Alzheimer's disease (AD) affects approximately 4 million older persons in the United States today, and it is estimated that more than half of all residents in nursing homes are victims of AD. Because persons aged 85 years and over constitute the festest growing age group in the United States (from 11.3% of the population in 1980 to 2 1 .6% by 2040), it is estimated that the incidence of AD will quintuple.1 Recent research by Evans and associates found that the incidence of AD is much higher than previously thought (10% rather than 4% of persons over age 65X suggesting an even more serious problem in terms of the number of cognitively impaired persons who will eventually reside hi long-term care facilities (LTCFs).2
A recently published report from the Agency for Health Care Policy and Research addressed the current and projected availability of special nursing home programs for Alzheimer's disease patients.3 This survey found that in 1987, there were 1.6 million nursing home beds in the United States. Approximately 53,800 (3.3%) of these were in specialty units for patients with AD or related dementias, and specialized staff training for the care of patients with AD was available only in facilities that had these specialized units. The number of nursing homes without specialized units and the population trends are stark reminders of the critical need to attract and retain skilled, knowledgeable personnel to care for persons with AD and other dementias.
Most educational programs for health-care professionals stress acute rather than chronic care.2'4,5 These programs provide little education or training related to the care of persons with dementia, the chronically mentally ill, or the elderly in general. Thus, caregivers in LTCFs, acute care hospitals, and the community often are not equipped with the knowledge and skills required to care for patients with dementia; dissatisfaction results and employment is frequently voluntarily or involuntarily terminated.6,7
THE PROBLEM OF EDUCATION
Persons with AD are most often cared for at home in the early stages of the disease. As the disease progresses, however, the family caregiver usually seeks professional help in an institutionalized setting.8 This is commonly anywhere from 2 to 10 years after diagnosis.
Thus, at some point, the majority of persons with AD are cared for by paraprofessional or professional caregivers. This care may occur in the home, hospital, or in LTCFs. Few caregivers in any of these settings have specific training concerning the care of the person with AD. Only a small percentage of LTCFs (7.7% nationwide) have special treatment programs for persons with AD in the form of dedicated care units, and only 26% of these LTCFs provide a formal training program for their staff. Currently, there is no standardized mechanism for ongoing training because of a lack of regulatory mandates.
The Omnibus Budget Reconciliation Act (OBRA '87) regulations have instituted or upgraded training programs for new nurse's aides working in LTCFs, and even mention that a portion of the training must be geared toward the care of persons with dementia. However, the amount of time needed to be spent on this topic is not addressed. OBRA '87 regulations regarding inservice training in LTCFs mandate that regular inservice training be offered by all LTCFs, but feil to address either the amount of time or information needed for competent care of the cognitively impaired older adult.
Education and training devoted to the care of persons with dementia have also been absent in most generic nursing programs for registered and licensed practical nurses.9 Student nurses may be tangentially exposed to these care problems through practicum experiences in hospitals or LTCFs, but with little theoretical background regarding effective nursing care. Because few nursing programs offer specific coursework regarding care of the cognitively impaired, the interested student is often left to pursue knowledge in elective or continuing education courses as they are available.
The recommendations for educational preparation set forth in this article were developed after a nationwide review of existing curricula by the authors, including the complete program for training of nurses' aides developed by the Alzheimer's Association.10
EDUCATION FOR NURSINGASSISTANTS
In a comprehensive report on the preparation of LTCF nurses and administrators to train nursing assistants (NAs), the Maryland State Office on Aging concluded:
* The morale of paraprofessional and nonprofessional staff members improves when their practice is based on knowledge rather than on tradition or belief
* Increased knowledge of gerontology is important for facilitating the evolution of new roles in care for the elderly.
* Certification and recognition are important incentives for and expressions of commitment to the importance of formal learning about gerontology for long-term care positions.
* Readily accessible films, books, and other resource materials are important stimuli and supplementary learning tools.9
Changes must be made in the treatment of nursing assistants if long-term care is to survive and be economically viable. Nurses' aides often lack autonomy and the respect of long-term care nurses and administrators.11 There are few opportunities for advancement, and NAs are characteristically undervalued, ignored by administration, and frequently treated as non-entities. Attitudes of administrators must be altered for long-lasting, positive changes to occur among nurses' aides. A new beginning must encompass appropriate education and training for these caregivers.
Ideally, curriculum for NAs should extend over a 6- to 8-week period. This allows NAs time to internalize new knowledge, apply that knowledge to their particular work situation, and be exposed to written educational materials with adequate time to read and digest them. Written objectives for care and a method to determine that the content was learned are essential. This could be accomplished by administering pre- and post-tests or by using other strategies (eg, observation, review of nursing notes, patient vignettes) that demonstrate application of the content in the practice setting.
At a minimum, curriculum for NAs should include an overview of normal and abnormal aging, as well as the dementias. When reviewing the dementias, it is important to include symptoms most commonly exhibited, probable causes of the symptoms, and nursing care. Management of behavioral problems should be taught in detail, and the area of caregiver stress and methods to prevent burnout should also be included (Figure 1).
It is recommended that the didactic training be combined with a return demonstration and clinical experience so that the content can be applied. 'Videotapes and discussion groups are effective means of initial orientation to the care of the AD patient. They also serve as a review of common concerns throughout the employment period. Standards for education as well as ongoing training and continuing education must be set for both institutional and home-based formal caregivers. Certification should be obtained following initial training, with renewals issued yearly for 6 contact hours of continuing education on topics related to AD.
Increased prestige, education, and feedback enhance the morale of the NA. Although not the topic of this article, wages and benefits are also important aspects of job satisfaction for NAs. All of these factors are important in the recruitment and retention of quality staff With education and experience, the NAs feelings of competence and self-worth are enhanced. It is also essential that supervisory staff recognize and appreciate the role of the NA in caring for the AD client and encourage NAs to participate in all aspects of care within the realm of their knowledge and experience.
EDUCATION OF NURSES
In 1984, only 7.7% (115,077) of employed nurses were working in LTCFs. In 1988, that number decreased to 6.6% (107,805) of nurses working in nursing homes.12 In addition, a recent survey by the National League for Nursing revealed that only 3% of all newly registered nurses will practice in long-term care.13 These data suggest a desperate need to have more expertly trained nurses in LTCFs, especially with the high level of acuity and special problems seen in these settings.
As noted earlier, associate degree, diploma, and baccalaureate programs, as well as those for practical nurses, have provided little formal preparation to care for the older generation. Minimal theoretical or clinical content regarding care of the elderly has been in place in the majority of entry-level nursing programs.5 Professional nursing organizations, such as the National League for Nursing, are continuing to examine the specific educational content and competencies for many specialty areas in gerontological nursing. There has been federal support for gerontological nursing education through different agencies. The Division of Nursing of the Bureau of Health Professions continues to support programs for developing nurse practitioners and clinical nurse specialists in gerontology. The National Institute on Aging supports research in centers for Alzheimer's disease, and these centers also develop curricula for training nursing staff hi the care of the AD patient. Despite these resources, there is a continuing need for additional support for curriculum development and educational opportunities for nursing staff.
CURRICULUM FOR NURSE7S AIDES
Important modifications of basic nursing curriculum to improve preparation of nurses to care for the geriatric and AD client were set forth in the comprehensive volume loosing a MilTion Minds1 and include:
* Differentiation of acute and chronic illness, including management of the chronically ill and rehabilitation potential.
* Assessment skills; in addition to physical assessment, includes assessment of self-care abilities, cognitive skills, living environment, and social interactions.
* Case management.
* Patient and family education.
* Training and supervising paraprofessionals.
* Working within a multidisciplinary team.
* Administrative and supervisory skills.
Despite the feet that they frequently have no formal preparation in administration, directors of nursing in longterm care facilities commonly have heavy administrative responsibilities, including staff development and documentation needed to comply with nursing home regulations.14·15 They are removed from direct patient care and many experience symptoms of burnout that cause them to leave these positions. The subsequent lack of stable leadership often leads to low motivation and high turnover among staff.7
Licensed practical nurses commonly work in LTCFs and are usually employed in supervisory positions. During the 11- to 24-month educational period required to become an LPN, curriculum devoted to the gerontologicai patient is most often absent or inadequate. As noted earlier, LPNs generally receive no specialized training regarding the care of the AD patient, and little emphasis on supervision. Although some states do require that LPNs working in nursing homes complete supervisory training courses, the average LPN is inadequately prepared to work effectively with the AD patient or to supervise others in this role.
Nurses who work with persons with AD must receive specific training related to their care (Figure 2). Minimal training for nurses can be completed in 12 contact hours, with time between sessions to review reading materials and internalize information. As with NAs, videotapes, hand-outs, and role playing can assist in the learning process. Because the role of licensed practical nurses in LTCFs is similar to that of a staff nurse, no differentiation in training content is deemed necessary. After the program is completed, certification should be granted based on successful completion of an examination. Mechanisms (such as 6 annual contact hours of continuing education related to the AD patient or involvement in research) should be developed to renew certification on a regular basis.
Nurses with all levels of educational background need specific preparation to care for geriatric patients in general and those with AD in particular. Generic curricula needs to include more specific content on the aged client. Nurses must gain knowledge of normal aging, diseases associated with aging, and medication usage.
More incentives are needed to encourage nurses to become experts in caring for the person with AD. Additional funding is needed for advanced education in the care of the aged, preparation of clinical specialists and geriatric nurse practitioners, as well as nursing administrators in long-term care. The poor image of nursing homes, low wages and benefits, and lack of welltrained professionals contributes to the instability and short supply of nurses and NAs willing to work in long-term care facilities. Enhancing the image and prestige of long-term care nurses by promoting educational preparation will help increase motivation and interest in gerontological nursing and care of persons with AD.
CURRICULUM FOR NURSES
It is evident that educational preparation is needed to train health-care workers who work with geriatric patients, and in particular with patients who have dementia. Based on the issues set forth in this article, educational preparation for nursing assistants should include a minimum of 6 hours of training specific to caring for the person with AD. Renewable certificates should be issued upon completion of training and renewable yearly after completion of six continuing education classes. Nurses should complete 12 hours of training specific to caring for the person with AD, renewable yearly upon completion of predetermined criteria.
In addition, basic nursing education curricula should include specific material related to care of the geriatric patient, with additional concentration on the client with dementia. Guidelines should also be developed for the educational preparation of directors of nursing in nursing facilities to ensure competency in administration and reduce turnover of this important staff member. If caregivers are adequately prepared to care for patiente with dementia, the quality of life of these individuals, as well as the job satisfaction of the caregivers, can be greatly improved.
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- 9. American Health Care Association. Trends and Strategies in Long-Term Care. Washington, DC: American Health Care Association; 1985.
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