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SIGN Vol 19, Issue 3 May/June 2012

President's Message
Celebrating Older Americans

By Amy Cotton MSN, GNP-BC, FNP-BC, FNGNA

Each year, the month of May is designated as Older Americans Month, a perfect time to celebrate the lives of our eldest community members.  It provides a great opportunity for gerontological nurses to recognize the contributions and influence that this growing population has had on our country. 
 
The heart of NGNA’s purpose is to improve nursing care given to older adults.  Gerontological nurses stand apart from other nursing specialties, because we value aging and recognize the importance of the individual as we care for aging community members.  
 
I am excited to share the news that  NGNA has joined with 3.1 million other nursing professionals to support Joining Forces, which is a comprehensive initiative led by First Lady Michelle Obama. Joining Forces is a nationwide effort to mobilize all sectors of the community for service members and their families, specifically supporting their employment, education and wellness opportunities. We have committed to increasing the body of knowledge leading to improved health care and wellness for service members, veterans and their families.  As Americans continue to live longer, we know the numbers of aging veterans will grow.   Nurses need state-of–the-art education to understand the unique clinical challenges and best practices associated with caring for current service members, veterans and their families.   
 
To that end, NGNA continues our commitment to grow our online member education resources with the addition of The Advancing Excellence Campaign Webinar, which is  hosted by national leaders,  showcasing the resources and tools gerontological nurses have available in long term care to improve quality and clinical outcomes.    
 
NGNA’s board of directors, committee leaders and members, special interest groups and Fellows are working diligently to take action to improve the health care older adults are receiving.    On behalf of your Board of Directors, I thank each of you for the work you do to honor the lives of older Americans and to ensure that quality nursing is delivered to those who need it.  
 
I wish you peace, health and happiness.  
 
     


 Arkansas Chapter of NGNA Partners with Arkansas Gerontological Society

Mrs. Kathie Gately, the State Long Term Care Ombudsman, Department of Health and Human Services/Division of Aging and Adult Services presents Carol Enderlin with the AGS Award.

The Arkansas Chapter of NGNA (Ar-NGNA) partnered with the Arkansas Gerontological Society (AGS) on March 28 and 29 at their annual spring meeting in Ferndale, Arkansas. 
 
Carol Enderlin, Ar-NGNA Education Officer, worked with fellow AGS board members Priscilla Pittman, of Alzheimer’s Arkansas, and LaVona Traywick, of the U. of A. Extension Service, to plan presentations for the two-day conference, which focused on improving quality of life in older adults. 
 
Members of Ar-NGNA drew from their collective nursing expertise and offered  a wide variety of presentation topics, including Promoting Personhood in Nursing Home Residents with Dementia, Grandparenting, Pet Therapy, Getting a Good Night’s Sleep, Bone Health, Activities for Persons with Dementia, Polypharmacy, and Resident-to-Resident Violence in the Nursing Home. 
 
Ar-NGNA presenters included Dr. Bill Buron, Dr. Susan Ball, Mrs. Joy Jennings, Dr. Carol Enderlin, Mrs. Riesa Gusewelle, Dr. Melodee Harris, Mrs. Jan Rooker, and Dr. Susie Sifford-Snellgrove. 
 
The conference was attended by approximately 160 professionals from a variety of fields involved with the care  for older adults, including state employees, social workers, gerontologists, nurses, nursing home and home health representatives, students, and retirees. 
 
During the awards luncheon, Carol Enderlin, Assistant Clinical Professor at UAMS College of Nursing, was honored with an AGS Fellow Award for her work and service in the field of aging. Dr. Enderlin is pictured receiving the award from Kathie Gately, Arkansas State Long Term Care Ombudsman.
 
The partnership between Ar-NGNA and AGS proved to be successful as the informative event drew to a close. Dr. Melodee Harris, Associate Professor of Nursing at Harding University Carr College of Nursing and current President of ArNGNA expressed her hopes that collaboration between the two organizations would continue to grow in the future for the common goal of enhancing the lives of older Arkansans.
 


NGNA Fellows Applications Now Being Accepted

Fellow status is an honor conferred by the National Gerontological Nursing Association (NGNA).  This distinction recognizes outstanding leadership in gerontological nursing, as well as  distinguished contributions to the field.  Contributions should include participation/leadership in the Association, along with significant achievements in the areas of consultation, research, teaching, practice, administration, and/or public service.
 
Individuals at all stages of career development are eligible to apply for Fellow status.   All who have been a member of NGNA for five years or more are encouraged to submit an application to become a Fellow. 
 
For more information about the NGNA Fellows status, and to download the Fellow application,  visit www.ngna.org/about/fellows.html.   The deadline to submit an application for Fellow status is June 1, 2012.  
 


NGNA Awards Committee Now Accepting Applications

The National Gerontological Nursing Association (NGNA) is proud to offer award and scholarship opportunities to NGNA members. Awards are presented each year at the NGNA Annual Convention.
 
Board of Directors Lifetime Achievement Award
The Lifetime Achievement Award is the highest honor given by NGNA. The award recognizes individuals whose contributions and accomplishments have had significant national or international impact on the care of older adults. The contributions of individuals who receive this award also should positively influence the public image of older adults and enhance healthcare delivery in a variety of settings. Nominations are accepted from the Board of Directors and NGNA Fellows. 
 
Chapter Award
The Chapter Award honors the regional chapter that best exemplifies the vision of NGNA through its member relationships, community activities and promotion of community health issues.  Each chapter is encouraged to submit an application for this award.
 
Cindy Shemansky Travel Scholarship
The Cindy Shemansky Travel Scholarship provides assistance to NGNA members who wish to attend the annual convention, but are in need of financial assistance with travel expenses.
 
Distinguished Service Award
The Distinguished Service Award is presented to a member of NGNA in recognition of outstanding leadership, participation, and contributions toward achieving the goals of NGNA.
 
Excellence in Gerontological Nursing Awards
The Excellence in Gerontological Nursing Award recognizes excellence in individuals who provide care to older adults. This award honors an advanced practice registered nurse, registered nurse, licensed practical nurse, and/or a certified nursing assistant who consistently provides outstanding care to older adults and is an inspirational role model and mentor to other healthcare workers.
 
Gerontological Nursing Student Leadership Awards
This award is sponsored by the NGNA Fellows. Three nursing students will be awarded a scholarship to attend the annual convention. This is an exciting opportunity for students who will be our next generation of gerontological nurses. 
 
Mary Opal Wolanin Scholarship
The Mary Opal Wolanin Graduate and Undergraduate Scholarships provides financial assistance to students intending to work with older adults. Applicants must intend to work in a gerontology/geriatric setting after graduation.  A $500.00 scholarship may be awarded for each category.
 
Visit http://www.ngna.org/resources/awards-a-scholarships.html to view the Awards Criteria and download application(s).
 


NGNA 2012 Election – Your Vote Counts!

The 2012 NGNA elections opened on May 1.  The 2012 election ballot includes the following candidates for office :
 
President-Elect:  
  • Mary Rita Hurley, RN, MPA
  • Barbara Raudonis, PhD, RN, FNGNA, FPCN
Treasurer:  This position serves for two years.
  • Jean Gaines, PhD, RN, FNGNA
Directors-at-Large:  Two positions are open.  Both positions serve for two year terms.
  • Jackie Close, RN, MSN, GCNS-BC
  • Melodee Harris, PhD, APN, GNP-BC
  • Linda Hassler, APRN-BC
  • Nancy King Rowe, PhD, RN, CNS
  • Wanda Raby Spurlock, DNS, RN, BC, CNS, CNE, FNGNA
Nominating Committee:  This position serves for two years.
  • Janice Crist, PhD, RN, FNGNA, FAAN
You may write in a candidate for each office, but please note that the write-in candidate must agree to the nomination and meet the position criteria.

An email was distributed to the NGNA membership on May 1, which included  candidate biographies and a link to the election ballot.  If you did not receive this email, please contact the NGNA National Office at 800-723-0560 or email at info@ngna.org.  Voting will close at 12:00am EDT on May 31, 2012.


 NGNA Fellows Update

Submitted by Martha S. Anderson, DNP, GCS-BC, FNGNA, Chair, Fellows Governing Council

It is an honor to be conferred the status of Fellow in the National Gerontological Nursing Association. This experienced and accomplished group of over fifty  individuals looks forward to meeting together at the annual conference, to discuss strategies and opportunities for the  advancement of the mission of NGNA.

Fellows are often leaders in the organization – serving on committees, writing or reviewing articles, participating in community and academic educational events across the country, and always advocating for the older adult. We display our FNGNA initials proudly after our RN and other educational designations.

During our meeting in Kentucky last year, many members expressed an interest in receiving more communication and additional opportunities for involvement throughout the year. The Fellows Governing Council met together on a conference call recently, and planned our first mid-year conference calls for all Fellows on May 2 and May 10!

We discussed the updated Fellows responsibilities, sent out the application for new Fellows, and discussed additional opportunities for student involvement at the 2012 convention in Baltimore. Last year, we had a wonderful group of students attend the Fellows reception. They were interested in our careers and experiences and eager to hear of the various career opportunities for gerontological nurses. We also discussed the Board’s request for donations to the Mission Advancement Fund. I have personally donated and totally support the goal of working with our new management company to improve the financial well-being of our wonderful organization.

Fellows take great pride in proposing eligible members for Fellow status. I encourage all NGNA members to review the qualifications and the responsibilities on the website, and let one of us know if you would like to be considered for proposal!


 Never Too Old to Play!

May is Older Americans Month, which offers us a perfect opportunity to show our appreciation for the older adults in our community. Since 1963, communities across the nation have joined in the annual commemoration of Older Americans Month — a proud tradition that shows our nation's commitment to celebrating the contributions and achievements of older Americans.

The theme for Older Americans Month 2012 — Never Too Old to Play! — puts a spotlight on the important role that older adults play for others, as they share their experience, wisdom, and knowledge with other generations in a variety of significant ways. This year's celebrations will recognize the value that older adults continue to bring to our communities through spirited participation in social and faith groups, service organizations, and other activities.

As large numbers of baby-boomers reach retirement age, many communities are increasing their efforts to provide meaningful opportunities for older adults—many of whom remain physically and socially active through their 80s and beyond. Current trends show that people over age 60 account for an ever-growing percentage of participants in community service positions, faith-based organizations, online social networking, and arts and recreational groups.

We know that lifelong participation in social, creative, and physical activities has proven health benefits, which include retaining mobility, muscle mass, and cognitive abilities. However, older adults are not the only ones who benefit from their engagement in community life. Studies show that their interactions with family, friends, and neighbors across generations enrich the lives of everyone involved. Young people who have significant relationships with a grandparent or elder report that these relationships helped shape their values, goals, and life choices and gave them a clearer sense of their own identities and roots.

NGNA encourages all members to join in this year's national celebration of Older Americans Month with activities and events to promote intergenerational engagement and recreation.

To find ongoing opportunities to celebrate and support older Americans, contact your local Area Agency on Aging by visiting www.eldercare.gov, or call 1-800-677-1116 for additional information.


 Palliative Care and Geriatrics: In Brief

Submitted by Tamara L. Burket, MSN, APN

“Palliative care (from Latin palliare, to cloak) is an area of healthcare that focuses on relieving and preventing the suffering of patients. Unlike hospice care, palliative medicine is appropriate for patients in all disease stages, including those undergoing treatment for curable illnesses and those living with chronic diseases, as well as patients who are nearing the end of life.”1

Palliative care is often confused with hospice care. In reality, hospice care refers to the terminal phase of an illness, and is only appropriate when death is anticipated within 6 months. Palliative care, however, can be provided from onset of a chronic ailment that may result in death months or even years later. “In contrast to hospice care, which precludes the use of any curative treatment at life’s end stages, (palliative care) seeks primarily to comfort patients and to keep them pain free, yet it does not necessarily preclude medical treatment.”2

The focus on a patient’s quality of life has increased greatly during the past twenty years. Palliative care offers the hope of quality of life during a time of physical suffering. “The goals of palliative treatment are concrete: relief from suffering, treatment of pain and other distressing symptoms, psychological and spiritual care, a support system to help the individual live as actively as possible, and a support system to sustain and rehabilitate the individual’s family.”3

In the United States today, 55% of hospitals with more than 100 beds offer a palliative-care program.4 The concept of a dedicated health care team that is entirely geared toward palliative treatment has led to the formation of palliative-care teams.

Palliative care and geriatric care teams share many common elements in the management of complex patients. In addition to focusing on health, illness, and symptom relief, both are subspecialties of internal medicine that focus on quality of life, functional status and family centeredness.5 Geriatric and palliative care teams address four dimensions of pain: physical, emotional, spiritual, and psychological.6 They recognize the patient and the family as the unit of care.7 Both disciplines focus on interdisciplinary models of care wherein professionals collaborate and work in teams to provide the best, specialized care for persons with complex medical problems.8

Most serious chronic illnesses occur in persons aged 65 years and older, and may cause long periods of physical and functional decline.9 Older persons who may benefit from palliative care include those with heart failure, some cancers, chronic obstructive pulmonary disease, pulmonary hypertension, end-stage renal disease, multiple sclerosis, and Alzheimer’s disease. In addition, older persons often require medically and ethically complex care driven by multiple comorbidities, quality of life, and the desire to preserve autonomy. 10 A major focus of palliative care is provision of comfort and relief of suffering through management of symptoms. Common symptoms remediated in palliative care include pain, nausea, limited activity, and fatigue. 11 Other conditions amenable to palliative management in the elderly include delirium, dyspnea, depression, dysphagia, oral health, urinary incontinence, and falls.12,13 Evaluation and management of symptoms for the elderly are often further complicated by cognitive and sensory impairments.14

There is a role for geriatric and palliative team partnerships in the management of chronically ill older adults. Organizations such as the End-of-Life Nursing Education Consortium (ELNEC), the National Priorities Partnership, the National Consensus Project, and the Center to Advance Palliative Care provide additional resources to support end-of-life care. The evidence-based geriatric clinical nursing website of The Hartford Institute for Geriatric Nursing, at New York University’s College of Nursing, is www.ConsultGeriRN.org. This site is an excellent resource for general assessment and screening tools, and for suggested intervention and symptom management.15

References
1 http://en.wikipedia.org/wiki/Palliative_care

2 http://www.tandfonline.com/doi/abs/10.1207/S15327027HC1502_9

3.4 Center to Advance Palliative Care, www.capc.org

5, 6, 7, 8 Goldsmith, J., Wittenberg-Lyles, E., Rodriquez, D., & Sanchez-Reilly, S. (2010). Interdisciplinary geriatric and palliative care team narratives: Collaboration Practices and barriers. Qualitative Health Research, 20, 93-104.

9,10,11,12,14 http://www.uptodate.com/contents/palliative-care-issues-specific-to-geriatric-patients

13,15 http://consultgerirn.org/topics/palliative_care/want_to_know_more
 


 Confusion Clarified

Submitted by Carol Tringali, MS, RN, AOCNS, Oncology Clinical Nurse Specialist, Penn State Hershey Medical Center

Let me shout it from the rooftop Let me scream it in your ear
Let me paste it on a billboard
I want the message to be clear
That Palliative Care is not Hospice.

They share some similarities
That most certainly is true
It’s because of this confusion
That some people have no clue
Why Palliative Care is not Hospice.

One can stand alone, you see
Palliative Care would be the name
Hospice, on the other hand,
Has Palliative Care in its fame
But Palliative Care is not Hospice.

Nausea and pain control
Diarrhea and fatigue
There should be no uncertainty
Hospice does attend to these,
Yet Palliative Care is not Hospice.

The difference comes when death draws near
And treatments are all done
Give comfort care and ease the grief
Now the two become as one
Behold, Hospice is Palliative Care!

Tringali, Carol A. (2006). Confusion Clarified. Wild Onions, a Penn State Milton S Hershey Medical Center Literary Journal, XX:39.


 Nurse In Washington Internship 2012

Submitted by Mary Rita Hurley, RN, MPA

The Nurse In Washington Internship (NIWI) experience is one I will remember for a long time. As nearly 100 nursing advocates gathered in our nation’s capital, we had several goals in mind. First, we always strive to be effective advocates for patients, residents, clients and communities, and this experience enabled us to broaden our capabilities to provide the best possible care at home. It also provided a national perspective and created a unified voice, which is essential to moving our causes forward.

After several days of engaging and listening to national nursing leaders, I was prepared to approach our elected representatives Capitol Hill, on behalf of the Nursing Alliance, the National Gerontological Association and the state of Oregon. I could feel the energy and power circulating as we wove our way through throngs of lobbyists, activists and CIA personnel. We were greeted enthusiastically and asked to be resources to our elected members of Congress.

The NIWI sessions gave me the additional confidence and tools to use my nursing voice effectively and professionally when engaging in policy change, whether on “The Hill” in Washington, D.C., or back home in my own state capitol, Salem, Oregon. I now know how to “make the ask”, be credible and tell the stories of the populations I serve.

My experience in Washington inspired me to join the 2012 class of Emerge Oregon, a chapter of Emerge America. This program is changing the face of American politics by identifying, training and encouraging women to run for office, get elected and to seek higher office. Since joining Emerge Oregon, I have been given some unique learning opportunities, such as shadowing a member of Oregon’s House of Representatives for a day. The combination of the NIWI training and the intensive seven-month Emerge training have given me a clearer understanding of the legislative process, as well as the roles that elected officials and constituents serve.

Learning and observing are the first steps toward creating positive, long-lasting change. Having the ability to discuss the national nursing agenda and then relate it to issues in my home state has been incredibly valuable for my career and for the patients I serve each day.


 Publishing Opportunity

Submitted by Sara Campbell, Geriatric Nursing

I am the Section Editor for the NGNA Section in the journal, Geriatric Nursing. This journal serves as the official publication of NGNA. If you are a member of NGNA, you automatically receive Geriatric Nursing as part of your membership benefits. Something that you may not be aware of is that you are also given publishing priority for the NGNA Section that is housed inside of each Geriatric Nursing journal. The NGNA Section exists for YOU.

What type of articles can you submit?
  • Findings from pilot projects or full research projects
  • Description of clinical project
  • Description of an educational project (nursing education or clinical education)
  • Evidence based projects
  • Descriptions of new initiatives aimed at improving clinical care and/or services
  • Conceptual articles related to older adults and/or geriatric nursing practice
  • Reflective pieces related to older adults and/or geriatric nursing practice
  • Articles by nursing students that relate to geriatric nursing
If you have presented a poster or paper at a conference, that presentation can be turned into an article. Use the presentation format as the outline for your article. If you are unsure about how to do that, we can help.

If you have never published before…the NGNA Section is for YOU! Writing mentors are waiting to help you prepare your first manuscript. If you have published before…the NGNA Section is for YOU!

What should be included in an article and what format should be used?

There is a link on the NGNA website that takes you to a worksheet to use in guiding your manuscript preparation: Click here to view the worksheet.

How do you submit an article? How do you talk with someone about an idea or how do you obtain a writing mentor?

Email the article or questions to Sara L. Campbell, PhD, RN, NEA-BC, NGNA Section Editor, Geriatric Nursing. I can be reached at sarac@usca.edu. We look forward to hearing from you!


 NGNA Encourages Members to Celebrate National Nurses Week by Nominating Exceptional Nurses for Excellence in Gerontological Practice Awards

The National Gerontological Nursing Association (NGNA) encourages you to celebrate National Nurses week! This year, the American Nurses Association (ANA) selected “Nurses: Advocating, Leading, Caring,” as the 2012 theme—a theme that exemplifies NGNA’s purpose to improve the quality of nursing care given to older adults.

National Nurses Week begins on May 6th, which is National Nurses Day, and ends on May 12th, the birthday of Florence Nightingale, founder of nursing as a modern profession. During this week, nurses will be recognized and honored at events throughout the country.

NGNA encourages members and constituents to specifically recognize gerontological nursing by nominating a peer, colleague or mentor for the NGNA Excellence in Gerontological Practice Awards. The Excellence in Gerontological Nursing Awards recognize excellence in individuals who provide care to older adults. These awards honor an advanced practice registered nurse, registered nurse, licensed practical nurse, and/or a certified nursing assistant who has consistently provided outstanding care to older adults and have been inspirational role models and mentors to other healthcare workers. Please click here to view complete eligibility requirements.

The deadline for Excellence in Gerontological Practice Awards submissions is June 1st!


 Convention Planning Update

Submitted by Jane Hannah Herin, MSHS, BSN, RN BC, PHN, CDE, CHES, FNGNA Chair, Convention Planning Committee


 
We are excited to share an update about the plans for this year’s annual convention, which will be held October 4-6, 2012, at the Sheraton Inner Harbor Hotel in Baltimore.

We are in the process of selecting the concurrent sessions for our convention. What a process! We received over 45 submissions for the general concurrent sessions and 16 for research. That is wonderful. We will give additional details of these submissions in the next issue. We also received a great turnout of poster session submissions , including some student posters.

Our much requested gerontological certification pre-conference with Deborah Conley is being planned for Wednesday, October 3 and Thursday, October 4. We have scheduled another pre-conference session on Thursday, which will be a one day pharmacology track with credits available for GNPs.

The Advance Practice Nurses are planning a half-day palliative care session, and a half-day session with a dementia related topic is also planned by the Evidence Based Practice/ Education group. Both sessions will take place on Thursday. The time for each will be determined at a later date. Please plan to arrive early for these sessions.

The annual conference will begin on Thursday evening at 5:30 pm. The opening agenda will include a welcome and President’s remarks, our opening session, followed by the welcome reception and poster session.

Plans are in the works for several more special activities for our guests to enjoy while in Baltimore These include a Crab Fest on Friday evening at a nearby local establishment. We will also have our ever popular Dinner for Eight at local restaurants. Registration details for these events will be available as the convention draws closer.

The committee is also discussing the possibility of several off site visits on Thursday afternoon, which will be available for a select number of people who will choose to pre-register for these visits. Sites include various senior living facilities and retirement homes throughout the Baltimore area. Further details will be communicated as the sites are finalized.

Some of you may want to extend your stay to visit the many attractions of Washington, DC. If you would like to visit your local Senator or Representative while in Washington, take the following steps to schedule a meeting. These tips are courtesy of NGNA member Colleen Steinhauser of Nebraska.
  • Call your Representative and/or Senators’ offices.For contact information, visit www.senate.gov, or www.house.gov. You can also call the US Capitol switchboard at (202) 224-3121, and ask for the member by name.
  • When you reach the office, explain that you are a constituent who will be in the area, and that you would like to schedule a short meeting. Please note that members of Congress are most likely available Monday – Thursday. Local transportation is available from Baltimore to Washington, DC.
Stay tuned for further updates on the NGNA website, SIGN, and the convention brochure, which will be mailed this summer. The members of the Convention Planning Committee are looking forward to an event full of great opportunities for networking, education, and fun!


 Looking Harder: Improving Recognition of Hypoactive Delirium in Elderly ICU Patients

Submitted by Alexander T. Wolf, BSN, RN, CCRN, Medical Intensive Care Unit, Denver Health Medical Center

Background
Delirium is defined by the text revised Diagnostic Statistical Manual of Mental Disorders (2000) as an acute disturbance of consciousness occurring within hours to days, with features of inattention, perceptual and cognitive disturbances, and a fluctuating course.

Delirium is markedly prevalent in the intensive care unit (ICU), with reports of up to 80% of mechanically ventilated patients and greater than 70% of patients in ICU step-down units (Page & Ely, p. 14). Additionally, it is well known that advanced age and preexisting cognitive impairment are both significant risk factors for developing delirium.

Although delirium was once considered to be a relatively benign sequella of critical illness, recent literature has proven otherwise; delirium has been independently associated with a threefold increase in mortality within six months of ICU discharge, adjusting for covariates such as severity of illness, comorbidities, age and sex (Ely & Page, 2011, p. 95-96). More specifically, delirium is associated with increased one-year mortality in elderly ICU patients (Pisani MA et al., 2009). Ely & Page (2011) have theorized that each additional day spent in delirium increases death risk by 10%. In some ICU patient populations, delirium is the strongest predictor of increased length of hospital stay (Page V & Ely EW, 2011, p. 106). Recently, the American Association of Critical-Care Nurses issued a nursing practice alert regarding the importance of detecting, preventing, and treating delirium in the ICU (Bell, L., 2011).

Identifying Hypoactive Delirium: The CAM-ICU
The motoric subtypes of delirium are hypoactive, hyperactive, and mixed symptom, and they are largely self-defining (p. 28). In hypoactive delirium, the delirious patient will often exhibit a flat affect, appear withdrawn, lethargic, and a reduced number and speed of spontaneous movement. In the ICU, these symptoms can be missed as symptoms of delirium. Hyperactive delirium, on the other hand, has far more appreciable symptoms such as restlessness or agitation, increased motor activity, yelling, pulling out invasive tubes and lines, severe disorientation, and violent behavior towards others or themselves (Meagher D et al, 2008). In a study of over 600 patients (Peterson et al., 2006), only 2% of delirious patients could be characterized as hyperactive; 44% of delirious patients had hypoactive symptoms, and the majority of patients (54%) had mixed symptoms of hypoactive and hyperactive delirium. Additionally, hypoactive delirium is associated with worse patient outcomes (Meagher D., 2009).

Regardless of the subtype, the common denominator in all delirious patients is inattention. In a survey that we conducted at a large urban teaching hospital in Colorado, forty-eight medical intensive care nurses were surveyed about the basic features of delirium; only 26% (n=11) were able to identify inattention as delirium’s requisite feature.

In hypoactive delirium, a patient’s inattention, concomitant with decreased level of activity, can be inaccurately dismissed as simply being exhausted, sedated, or even introverted. While any of those three adjectives could describe an older critically ill patient, the fact of the matter is that a patient with a decreased level of consciousness and inattention has already met criteria for delirium. Simply dismissing these symptoms as something benign can have negative consequences for the patient.

A delirious patient can be oriented to person, place, or time, but still be inattentive. Perhaps the most validated tool for detecting ICU delirium is the Confusion Assessment Method for the ICU (CAM-ICU). This tool, adapted from the original Confusion Assessment Method (CAM), is highly sensitive, has high specificity, and can even be used in patients who cannot speak or move their extremities (Guenther et al., 2010) (Mitasova et al., 2012).


CAM-ICU Flowsheet. © 2002 E. Wesley Ely MD, MPH and Vanderbilt University. All rights reserved. Retrieved from www.icudelirium.org
Assessing wakefulness is a key part of monitoring for delirium. The CAM-ICU uses the Richmond Agitation and Sedation Scale (RASS) to quantify how awake a patient is. Because sedation is often necessary, multidisciplinary teams can use the RASS on an hourly basis, implement a “target RASS” and assess the patient’s “actual RASS”. If a patient’s RASS score is lower than the target RASS, sedation could be excessive. Special attention must be given to older patients, as it is well known that they are dose-sensitive to many sedation and analgesic agents.

Richmond Agitation & Sedation Scale (RASS). Printed with permission from Sessler CN et al. Image retrieved from ccn.aacnjournals.org/content/23/2/25/T3.large.jpg

In the absence of sedative agents, hypoactive delirium can be more challenging to determine, especially in the elderly. Many critical illnesses yield some type of insult to the brain – for example, septic shock or decompensating congestive heart failure, and expectedly result in delirium or other cognitive changes. In these situations, the obvious priority for the patient is to treat whatever is causative. Additionally, preventing loss of mobility and encouraging patients to participate in care activities can keep a patient from developing preventable hypoactivity. Fortunately,the ICU culture seems to be shifting away from bed rest and sedative infusions towards “sedation vacations” and rapid progressive mobility. Even immediately after intubation, reports of adverse events are rare when ambulating patients who are mechanically ventilated (Pohlman et al., 2010).

The cardinal feature of inattention must be present for delirium to be diagnosed. If the patient has an altered level of consciousness (measured by RASS not equal to 0) and fails the “SAVEAHAART” test of inattention, they are CAM-ICU positive for delirium – plain and simple. While other scales rate the degree or severity of delirium, the CAM-ICU simply detects for the presence of delirium.

Importance of Recognizing Hypoactive Delirium
As previously mentioned, patients with mixed symptom or hyperactive delirium can have more easily observable features that are consistent with diagnosing delirium; they are often much more memorable as they may hit, yell, cry, or attempt to exit the bed. But hypoactive delirium can be easily missed altogether or miscategorized as something else, so patients with hypoactive delirium can go longer without having the condition recognized. As a result, the investigation of potential causes for the patient’s delirium can be delayed, and the hypoactive delirious patient is at high risk for potential iatrogenic complications such as falls, nosocomial infections, and skin breakdown (Page & Ely, 2011, p. 98).

In the ICU, the progress of many critical illnesses can be measured through specific hemodynamic numbers and serum biomarkers, but there is no serum biomarker for delirium, and no magic vital sign. However, because delirium has been made a more sensitive and objective finding by scales such as the CAM-ICU, it is much less complicated to determine whether a drowsy patient is just drowsy, or if it is delirium.

Hypoactive Delirium and the Older Adult
Recent literature has shown that nurses frequently fail to recognize the features of delirium in older hospitalized patients (Rice et al., 2011). While no one cause can fairly be pinpointed, it should be noted that hypoactive delirium in the ICU has the potential to not only be missed, but also ignored. Elderly patients with critical illness may have severe mobility problems, malnutrition, preexisting cognitive impairment, end organ dysfunction, severe pain, and a poor hospital environment in which to sleep – all risk factors for delirium. As a result, a patient who appears to be sleeping may actually be experiencing hypoactive delirium; and no nurse will know unless a sensitive assessment tool like the CAM-ICU is used.

Put simply, no nurse can afford to assume a patient’s mental status without assessment. While assessing for ICU delirium can actually be very quick and efficient with tools like the CAM-ICU, it also requires training, energy, and a positive attitude not just on a clinician-to-clinician level, but on an organizational level. Organizations can develop delirium initiatives to improve their competency and compliance regarding delirium (Szymanski et al., 2006). For instance, our hospital’s medical ICU started an “ICU delirium journal club”, comprised of a group of nurses, physicians, and clinical researchers who are interested in improving the unit’s outcomes for delirious patients.

Hypoactive delirium is particularly dangerous in the elderly because of the inherent issues of functional decline faced by the elderly, which are exponentially worsened after episodes of delirium. This decline, such as lack of mobility, can be compounded by critical illnesses and made even worse by hypoactive delirium. It is well known that decreased mobility in the hospitalized elderly is associated with skin breakdown, muscle deconditioning, poor nutrition, atelectasis and pneumonia, and other systemic complications – not to mention death. Among older medical patients, delirium is independently associated with a doubled risk of dying in 12 months (Ely et al., 2004). Conversely, early initiation of physical and occupational therapy exercises in the ICU, combined with daily sedation interruption, is associated with a decreased duration of delirium and improved functional status (Banerjee et al., 2011) (Morris et al., 2008).

Studies differ in the prevalence of the delirium subtypes, specifically in elderly patients. Nevertheless, it should be noted that hyperactive delirium is associated with considerably better outcomes than hypoactive and mixed symptom delirium (Page & Ely, p. 42) (Meagher D., 2009). Regardless of specific prevalence in the elderly, any nurse who cares for an older adult should be aware of the potential for severe long-term functional and cognitive decline following an ICU stay.

Pharmacologic Treatment: Still Much to Learn
This article aims to emphasize the importance of delirium assessment. The paradigms of delirium treatment are still controversial and the subject of several recent studies. After a diagnosis of delirium is made, the priority treatment for delirium is to identify and treat any possible causes. Although metabolic abnormalities and severity of the patient’s illness are influential factors in delirium, another common cause is medication. In the ICU, an obvious common culprit is sedation; benzodiazepines are associated with delirium, especially in elderly populations, and they should be avoided when possible. The efficacy of antipsychotics such as haloperidol or ziprasidone to treat delirium of all subtypes remains unclear. Regardless of the indefinite nature of delirium treatment, the fact is that there is no treatment at all if the condition is not assessed for, documented, and discussed.

Conclusion
Delirium is acute organ dysfunction that has been associated with significantly increased mortality and functional decline, most notably in the elderly. While hyperactive and mixed delirium can have features that are easily recognizable as an acute change from baseline mental status, hypoactive delirium is considerably more dangerous due to its easily overlooked symptoms and poorer associated outcomes. The topic of medical treatment and prevention of delirium continues to be a challenging topic of research, but the first step that must be taken if delirium is to be treated is to be able to detect it; heightened clinical awareness and validated, sensitive screening tools such as the CAM-ICU are the best weapons to detect even the most subtle symptoms of hypoactive delirium. Because the elderly are at particular risk for delirium, cognitive impairment, and functional decline, their levels of activity should be routinely monitored using a sedation scale such as the RASS.

No assumption should be made regarding a patient’s decreased activity level. Even in the presence of critical illness, nurses should seize every opportunity to increase mobility and activity in the elderly when appropriate. There are many elements that remain unknown about delirium, but for now, all we can do is continue to research, observe and provide the best possible quality of care.

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Bell, L. (2011, Nov). AACN Practice Alert: Delirium assessment & management. Retrieved from /www.aacn.org/WD/practice/docs/practicealerts/delirium-practice-alert-2011.pdf>.

Page, V. & Ely, E.W. (2011). Delirium in critical care. Cambridge, UK: Cambridge University Press.

Peterson JF, Pun BT, Dittus RS, Thomason JW, Jackson JC, Shintani AK, Ely, EW. (2006). Delirium and its motoric subtypes: a study of 614 critically ill patients. Journal of the American Geriatric Society; 54(3): 479-84.

Meagher D, Moran M, Bangaru R, Leonard M, Donnelly S, Saunders J, Trzepacz, P. (2008). A new data-based motor subtype schema for delirium. Journal of Neuropsychiatry and Clinical Neurosciences, 20: 185-93.

Meagher D (2009). Motor subtypes of delirium: past, present, and future. International Review of Psychiatry, 2009; 21: 59-73.

Pisani, MA, Murphy, TE, Van Ness, PH, Araujo KLB, Inouye SK (2007). Characteristics Associated with Delirium in Older Patients in a Medical Intensive Care Unit. Arch Internal Med, 167(15): 1629-34.

Boettger S & Breitbart W (2009). Phenomenology of the subtypes of delirium: Phenomenological deifferences between hyperactive and hypoactive delirium. Palliative and Supportive Care, 2011, 9: 129-135.

Rice, KL, Bennett, M, Gomez, M, Theall, KP, Knight, M, Foreman, MD (2011). Nurses’ Recognition of Delirium in the Hospitalized Older Adult. Clinical Nurse Specialist, 25(6): 299-311

Pohlman, M.C.., Schweickert, W.D., Pohlman, A.S., Nigos, C., Pawlik, A.J., Esbrook, C.L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G.A., Bowman, A., Barr, R., McCallister, K., Hall, J., Kress, J.P. (2010). Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med, 38(11): 2089-2094.

Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr., Inouye SK, Bernard GR, Dittus RS (2004). Caring for the critically ill patient. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American Medical Association 2004; 291: 1753-62.

Guenther U, Popp J, Koecher L, Muders T, Wrigge H, Ely EW, & Putensen C (2010). Validity and reliability of the CAM-ICU flowsheet to diagnose delirium in surgical ICU patients. Journal of Critical Care, 25(1): 144-151.

Mitasova A, Kostalova M, Bednarik J, Michalcakova R, Kasparek T, Balabanova P, Dusek L, Vohanka S, & Ely EW (2012). Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical Care Medicine, 40(2): 484-490.

Sessler CN, Gosnell MS, Grap MJ, Brophy, GM, O’Neal PV, Keane KA, Tesoro, EP, Elswick RK (2002). The Richmond Agitation-Scale: validity and reliability in adult intensive care unit patients. Journal of Respiratory and Critical Care Medicine 2002; 116: 1338-44.

Banerjee A, Girard TD, & Pandharipande P (2011). The complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit. Current Opinion in Anesthesiology 2011, 24: 195-291.

Morris PE, Goad A, Thompson C, et al. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36: 2238-2243.

Szymanski G, Krumm S, Olsen, M, Hoofring, L, Mock V, Paine L (2006). Improving recognition of delirium in oncology patients: a nursing screening initiative. Oncology Nursing Forum, 33(2): 405-6.
 



 NGNA Releases Position Paper on Gerontological Nursing Education

NGNA: Position Paper on Mandatory Gerontological Nursing Education in all Registered Nursing Programs and Gerontological Nursing Continuing Education for all RNs in the US

Introduction/Problem Statement
The intent of this position statement is to affirm the need to mandate that all registered nursing education programs offer stand-alone didactic and clinical courses in Gerontological nursing as part of the undergraduate curriculum. Further, that all registered nurses should be required to participate in a geriatric continuing education event for continued licensure. All nurses will care for older adults during their career either professionally or personally regardless of their specialty. The challenge of the 21st century for nursing is to educate the profession about the geriatric population for best practice.

Rationale and Supporting Information
The 21st century brings a dramatic gain in the aging population globally. Anticipation of the aging population has spawned numerous concerns for health care. Health care professionals need to be prepared educationally to care for the older adult population and their unique needs. The normal process of aging tends to be complicated with the atypical presentation of diseases which often are under detected with poor outcomes. With a third of baccalaureate nursing programs offering a stand-alone didactic course in Gerontological nursing, two-thirds of nurses are missing the knowledge they need to understand and care for this unique population. Gerontological nursing must be a required element of training for the next generation of health care professionals.

In the early part of the 20th century, pediatrics gained approval to be taught as stand-alone didactic and clinical courses. The institutions that trained health care workers in the 20th century responded to the demographics and embraced the need to prepare the health professional in pediatrics – it was a requirement for all nursing and medical programs to have pediatric rotations and courses. The time has come for a similar commitment to recognize gerontology and its uniqueness with the appropriate course and clinical for all nursing students to experience.

To date, there are approximately 1% of registered nurses and 3% advanced practice nurses certified in Gerontological nursing in the U.S. Since nurses play a critical role in the care of older adults in various settings of health care, it is vital to promote education in this specialty area. Nursing schools must raise the profile of Gerontological nursing to attract the new nurses in this field and create collaborative relationships with community healthcare facilities and institutions. There is an essential need to be proactive in the approach to moving evidence-based clinical knowledge into practice settings.

The age of 65 has traditionally been considered the beginning of the “senior” years in the U.S because of Social Security and Medicare. The U.S. Census Bureau reported that Americans over the age of 65 years make up 13% of the population today. By the year 2030, older adults will be 20% of the total population. The growth in the numbers of older adults is unprecedented in the history of the US and the world. This flourishing of growth is due to the Baby Boomer generation entering 65 years of age in 2011 and continuing to infiltrate older age through 2030 with a doubling in numbers, becoming one in five Americans.

An aging population means that nursing has an obligation to understand aging and the older adult. Understanding of normal physiology of aging along with chronic illness and disabilities is vital in the care of this population. Approximately, 80% of older adults have one chronic health condition with 50% having at least two. Medicare has begun to hold healthcare facilities responsible for the errors made with the older population. In 2008, Medicare issued a list of number of health care mistakes and other preventable situations they will no longer pay for if the claims are submitted. Medicare will not pay for complications that are preventable. This is a strong financial indicator that health professionals must be educated in the proper care of this population.

The American Association of Colleges of Nursing noted that approximately 63% of newly licensed registered nurses work predominately with older adults in their patient load. Further, older adults’ care represents 50% of hospital days, 60% of all ambulatory adult primary care visits, 70% of home care visits, and 85% of skilled care facilities residents. It is anticipated that strong job opportunities in clinical practice will be with the older population. We are woefully unprepared to care for the older population in health care due to the lack of clinical knowledge and education for the uniqueness of their health-related needs.

In general, graduate nurses need the Gerontological nursing perspective to practice successfully with the older population to avoid errors in care. Best practices are formed in the undergraduate nursing programs and must include mandatory didactic and clinical in Gerontological nursing. Education at the basic level of nursing education and on-going continuing education must be mandatory for best clinical practice in Gerontological nursing. Research shows that nurses with preparation and education in geriatrics/gerontology provide measurably improved care to older adults. When nurses are prepared in both geriatrics and other specialties such as medical-surgical nursing, this becomes profitable to hospitals and the community.

All Registered Nurses should and must recognize the physiological, cognitive, psychological, social changes, and atypical presentations of disease associated with aging and understand that age alone puts older adults at risk for complications. Since older adults’ care is complicated due to usual aging physiological changes coupled with increased incidence of chronic health conditions, Registered Nurses and Advanced Practice Nurses need to achieve competency in Gerontological nursing to deliver best practice care. It is strongly advised for Registered Nurses to seek National Certification to benefit the population of patients served. Raising the standards of nursing care for older adults through undergraduate education and continuing education for practicing nurses will ensure that older adults will age with optimal function, comfort, care and dignity.

The Affordable Care Act’s goal is to improve the delivery of health care for every American. The financial incentive and dignified quality care are two motivating constituencies to set this position in motion. To move forward, American Nurses Association, Board of Nursing in each state, Medicare and Medicaid (CMS), health care organizations stakeholders (hospitals, clinics, community agencies), and all professional nursing organizations must strive to adopt this position and demand gerontological/geriatric knowledge and skills for the improved care of older adults by nurses and must provide incentives for adoption for best practices. Together, we can improve care for this older population and allow dignity and best care practices for all older adults.

Recommendations
  • Registered Nursing Programs institute a 3 hour didactic Gerontological stand-alone nursing course for all undergraduate nursing students by 2013.
  • Registered Nursing Programs institute a 3 hour clinical course in geriatrics for all undergraduate nursing students by 2013.
  • All practicing nurses in the U.S. participate in a 2 hour minimum continuing education class on a geriatric topic every year for relicensure in each state.
  • Registered Nursing Program Faculty teaching adult/geriatric course participate in a Geriatric continuing education program are encouraged to seek national certification in Gerontological nursing or annual continuing education in Gerontological nursing.
References
American Association of Colleges of Nursing /John A. Hartford Foundation (March 2006). Caring for an Aging America: A Guide for Nursing Faculty. Washington, D.C. http://www.aacn.nche.edu/geriatric-nursing/monograph.pdf

Census, U.S. (2011). Facts for features: Older Americans Month: May 2011. http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb11-ff08.html

Fagin, C., Franklin, P. (2005). Why Choose Geriatric Nursing? Geriatric Nursing, September/October 2005, 72-76. http://www.nsna.org/Portals/0/Skins/NSNA/pdf/Imprint_SeptOct05_geriatric_fagin.pdf

Hartford Institute for Geriatric Nursing. (2011). Hartford Geriatric Nursing Initiative (HGNI). New York. http://consultgerirn.org/resources/hartford_geriatric_nursing_initiative_hgni/ Mezey, M., Fulmer, M. (2002). The Future History of Gerontological Nursing. Journal of Gerontology: Medical Science, Vol. 57, No. 7, 438-441.

National Center for Chronic Disease Prevention and Health (2009). Healthy Aging Improving and Extending Quality of Life Among Older Americans. http://www.cdc.gov/nccdphp/publications/aag/pdf/healthy_aging.pdf

Medical Negligence: The Role of America’s Civil Justice System in Protecting Patients’ Rights. ( 2011). http://www.justice.org/resources/Medical_Negligence_Primer.pdf

Department of Health and Human Services: Office of Inspector General. (November 2010). Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf