Similar to other rural regions, the health of rural community-dwelling older adults in eastern North Carolina is challenged by isolation, lack of transportation, and shortage of health care providers, which leads to decreased access to preventive health care services (Health Resources and Services Administration [HRSA], 2016). The rapid growth in numbers of older adults in North Carolina has led to significant population health concerns. This growth is correlated with the Baby Boomer population reaching retirement age and eastern North Carolina being a popular retirement destination (North Carolina Department of Health and Human Services, 2016). North Carolina ranks ninth nationally in total population and people aged ≥65. By the year 2025, one in five North Carolina residents will be ≥65 years old (Reddy, 2017). As the older adult population has increased in North Carolina, so has the number of individuals diagnosed with dementia. It is projected that by the year 2050, 1 million new dementia cases will arise in the United States and, even now, every 33 seconds an American is diagnosed with Alzheimer's disease (Alzheimer's Association, 2018). Another alarming issue that has recently become more apparent is late life depression. Depression has been increasingly diagnosed in adults age 55 and older, with resulting diminished quality of life (Kok & Reynolds, 2017). Depression and dementia screenings can identify those in need of further evaluation, prompting intervention and treatment (Vieira, Brown, & Raue, 2014).
Falls are also a significant cause of morbidity and mortality among older adults, causing 800,000 hospitalizations annually and 28,000 deaths each year (Centers for Disease Control and Prevention [CDC], 2017). Medicare estimates treatment for falls at $31 billion per year (CDC, 2017). In an effort to serve the older adult population by increasing health care access, improving quality of care, and promoting healthy aging, the U.S. HRSA awarded East Carolina University (ECU) College of Nursing the Geriatric Workforce Enhancement Program (GWEP) grant in 2015. The goals of the ECU GWEP were to positively impact rural older adult population health and specifically included the delivery of community-based programs that provide patients, families, and caregivers access to information that promotes healthy aging.
Older adults are faced with disproportionate risks unique to this age group, including fall risks/fall prevention, early detection and treatment of dementia, and chronic disease management (Kietzman, 2016). Depression and frailty are other major concerns among aging adults. The purpose of the current study was to assess the utility of providing community-based health screenings with ultimate goals to improve access to preventive health services that could later be shown to enhance quality of life, promote early detection with decreased morbidity, and result in long-term cost savings for community-dwelling older adults.
The ECU GWEP team of RNs was deployed to communities throughout eastern North Carolina to provide preventive health screenings and education using community-based services. The education provided was tailored toward the participant and may have included reading materials or tools for individuals who were unable to read. Partnerships were established with rural Federally Qualified Health-care Centers (FQHCs). ECU GWEP nurses were intentionally embedded into two separate FQHCs located in northeastern and southeastern North Carolina. The presence of team nurses in the communities targeted for the study allowed them to become familiar and trusted faces among residents in the study counties.
The assessments at the FQHCs included annual wellness visit screenings plus screenings for depression, cognitive impairment, and fall risk. As the work progressed at the FQHCs, subsequently more community-based contacts were made with older adult service agencies such as the Area Agency on Aging, Alzheimer's NC (now called Dementia Alliance of North Carolina), local senior centers, and churches. The ECU GWEP nurses moved into the communities to provide services. Partnering with known resources in the local communities further enhanced nurses' trustworthiness and provided access to perform screenings.
Due to the challenges of completing the clinic-level comprehensive assessments in some of the community sites, the assessments were shortened to a three-part community screening that included fall risk, depression, and cognition assessment along with collection of basic demographic information.
At FQHCs and community events, nurses originally planned to screen older adults, age ≥65, who were self-referred or referred by their primary care providers. There was a high demand of screenings requested by younger participants with numerous comorbidities; therefore, the sample age limit was lowered to ≥55 years. Eligible participants were community-dwelling older adults (age ≥55) attending FQHC appointments, senior centers, community outreach events, and faith-based events who were referred or self-referred to nurses for screening.
Screening tools used were the Centers for Disease Control and Prevention (CDC; 2016) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) fall risk screening, the Patient Health Questionnaire-2 (PHQ-2; American Psychological Association, 2018), and the Mini-Cog© (Borson, 2016). The current study was approved by the university and medical center institutional review board. Each participant signed an informed consent and an identifying number was given to each person. Demographic information collected included identifying number; initials; year of birth; race; gender; occupation; zip code; whether participants had a primary care practitioner (yes/no); and whether they identified as logger, farmer, fisherman, or none. The agricultural occupation was a separate aim of the larger ECU GWEP grant and this information was included to support service to agricultural residents. Blood pressures were taken as a complementary service to the community screenings. Nurses were prepared to deliver education and referral information based on screening results for each participant. The three screening tools used in the current study are evidence-based, well-accepted, and frequently used tools.
The STEADI is a multifactorial fall risk assessment tool developed by the CDC (2016) that was designed to be implemented along with strategies that reduce risk of falls. The National Health and Aging Trends Study used a logistic mixed-effects regression to estimate the association between baseline fall risk of individuals age ≥65 years and their subsequent falls and mortality. The STEADI fall risk screening tool has been determined to be a valid measure for predicting future falls. High and moderate fall risk were accurately predicted by the STEADI in >65% of the Lohman et al. (2017) study sample.
The Mini-Cog is a brief screening tool that was developed to differentiate persons with dementia from those who do not have dementia. Borson, Scanlan, Chen, and Ganguli (2003) tested the tool among a rural western Pennsylvania population finding it as effective in detecting dementia as longer tools. The Mini-Cog was compared to the established Mini-Mental State Examination and found to have similar sensitivity and specificity (76% and 89% compared to 79% and 88%, respectively) and was comparable to the psychological screening battery conventionally used (Li, Friedman, Conwell, & Fiscella, 2007). The Mini-Cog has since been tested in numerous settings and other countries and found to have good utility with older adult screening.
The American Psychological Association (2018) provides a brief screening tool for depression in the PHQ-2. The tool is attractive due to its ease of administration, construct, and criterion validity. A PHQ-2 score ≥3 has shown 83% sensitivity and 92% specificity for major depression (Kroenke, Spitzer, & Williams, 2003). When evaluated for criterion construct validity with adults age ≥65, the PHQ-2 had a sensitivity of 100%, a specificity of 77%, and area under the curve of 0.88 (Li et al., 2007). The PHQ-2 is considered a valid tool for screening for depression, but it should be followed by diagnostic processes that are more comprehensive (Li et al., 2007).
Nine hundred ninety-four individuals were screened during the study and were predominantly female, African American, and older than age 55 (Table 1). Among the sample, 568 at-risk scores were identified. Four hundred five individuals scored at risk with a score ≥4 on the STEADI questionnaire, 116 scored ≤2 on the Mini-Cog, and 47 individuals scored ≥3 on the PHQ-2 (Table 2). All individuals scoring at risk for falls and cognitive changes received individualized education and referral for appropriate intervention. For example, participants who scored at risk for falls received immediate discussion of their risk and strategies to reduce falls in the home. The discussion included ideas such as clearing pathways between the bed and bathroom and removing trip hazards such as throw rugs and clutter. Families were included in the education whenever they were present. Individuals with cognitive impairment were referred to family caregiver specialists from the local Area Agency on Aging and encouraged to follow up with health care clinicians. Individuals who screened at risk for depression were given educational information about depression and its management and referred as appropriate for medical care. Handouts on depression were read and discussed as well as given to participants.
Sample Demographics (N = 994)
Participants Who Screened at Risk for Cognitive Impairment, Falls, and/or Depression
The use of the screening tools and provision of education at point of contact were found to be efficient and feasible. Most participants received recommended education and referral based on the screening results. The current study provided access to resources for many participants who had been unaware of the need and/or location of resources. The results are a clear indication of the importance of screenings and the critical need in this region.
All individuals who scored at risk for falls in the current study were referred to their providers or to an evidence-based fall prevention program. Although this study was not designed to track completed referral visits, the importance of fall prevention is clear in the literature. It is estimated that the average hospitalization cost related to a fall is >$30,000 (CDC, 2017). If the referrals from the current study created interventions that prevented falls, an estimated cost savings of $1,485,337 could be realized. Falls are the number one cause of nonfatal and fatal injuries in older adults (CDC, 2017). Of older adults who fall, 37.5% will report a fall that resulted in injuries that required medical treatment (Bergen, Stevens, & Burn, 2016). The average cost of a medically treated non-fatal fall is conservatively estimated to be $9,780 per person (Burns, Stevens, & Lee, 2016). Additional impacts of fall prevention could include maintenance of independence, higher quality of life, and prevention of death.
In the current study, approximately 5% of participants scored at risk for depression on the PHQ-2 and approximately 12% had screening evidence of cognitive impairment. Although these are not large percentages, they are still worth the referral for care. The screening was easy to accomplish and could easily be replicated in other settings. Medical illnesses are often correlated with risk for depression and in turn, depression is correlated with poor physical health outcomes and increased health care costs (Smith et al., 2014). Depression is costly to individuals and society by way of reduced interpersonal relationships, emotional suffering, therapy and treatment costs, lost wages, reduced productivity, and even loss of life (Siu, 2016). Depressive symptoms are seen more often in the older adult population versus other age groups, causing decreased self-care ability, irritability, psychomotor retardation, and pseudodementia (Tusaie & Fitzpatrick, 2016). Further evaluation and effective management of depression in these individuals could yield qualitative improvement in physical, cognitive, and social function and reduce the risk of morbidity and suicide. There are indirect costs associated with depression that are difficult to quantify, such as caregiver burden, costs of medications and therapy, and loss of productivity (Zivin, Wharton, & Rostant, 2014). A community-dwelling older adult with depression who lives at home can cost an extra $1,330 annually, and the cost is further amplified by caregiver burden.
Screening for cognitive impairment allows for appropriate diagnosis, early intervention, and planning that would improve quality of life, maximize functional performance, and improve patient and caregiver outcomes. In 2018, the total costs of care in the United States for people with dementia were $277 billion (Alzheimer's Association, 2018). Through screening, early intervention, and early treatment, the onset of complex dementia symptoms can be delayed. Early intervention may lead to increased functionality that allows in-home care, delaying institutionalization. During the last 5 years of care for people with dementia, the estimated cost per person was $287,000. Early intervention can lead to reduced health care costs due to lower dementia care levels for a longer period of time and reduced time spent in costly higher-level dementia care. Estimated savings based on the number of positive screenings are approximately $33 million (Alzheimer's Association, 2018). Discovery of dementia, cognitive impairment, depression, and fall risk was needed among participants of the current study and the resulting evidence supports the ease and use of these screening tools in a community setting.
The current study was limited by using convenience sampling for the screenings. The service area was across 41 counties, many with little to no access to screenings; therefore, participants included anyone who wished to be screened. Results could not be generalized to other populations from this work. The study design did not allow for follow up with any given participant. Anecdotally, in subsequent work, referral agencies have reported participant use of their services, such as the family caregiver specialist, through various Area Agency on Aging. The intentional ability to follow such a population in a longitudinal study would provide further evidence of the impact of screening and education in each community. Costs savings were estimated based on known costs of falls, depression, and dementia care. To know the exact amount of cost savings, further longitudinal research is warranted. It should be noted that actual costs and savings are difficult to compute due to numerous other comorbidities and variation of injuries, type of depression treatments, and duration, as well as the numerous variables in dementia care.
Since the completion of this work, the current authors' team has been used to build on the needs identified to create community-based education for the region. Topics most often requested include the management of depression, anxiety, stress, and cognitive changes; strategies for aging in place; and effective caregiving. With the proportion of older adults expected to grow in the United States, it is vital that evidence-based care be implemented at the community level for early intervention and prevention.
The response to the ECU GWEP grant overall has been overwhelming and has demonstrated the need for screening and education in the authors' region. The use of evidence-based tools in screening assisted ECU GWEP nurses in this process and could be readily replicated in other settings by health care staff. The findings from the current study demonstrated that the health risks of the aging population in rural eastern North Carolina are consistent with known risk factors in the general older adult population for falls, depression, and cognitive changes. The authors' ability to complete the large number of screenings was due to having nurses travel to where older adults congregate and perform leisure activities. These findings indicate the importance of nurses meeting the needs of people where they live and work. According to the 2017 Gallup poll, nurses remain one of the top three most trusted professions (Brenan, 2017). Nurses were widely accepted in the community and readily able to act as advocates and navigators, bridging gaps in the access of preventive screenings and increasing the possibility of early intervention.
The grassroots work of the ECU GWEP nurses through community-based health screening empowered older adults through education, guidance, and support, and increased access by linking individuals to proper resources. The authors believe this work demonstrates the feasibility of community screening and suggests that having nurses readily available for community-based preventive screening could potentially increase early detection, early intervention, and cost savings in the areas of fall prevention, depression, and cognition.
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Sample Demographics (N = 994)
| Female||689 (69)|
| Male||284 (29)|
| Not reported||11 (2)|
| African American||540 (54)|
| European American||423 (43)|
| Native American, Latino, Pacific Islander, multiple ethnicity||31 (3)|
| 35 to 54||30 (3)|
| 55 to 64||223 (22)|
| 65 to 74||401 (40)|
| 75 to 84||261 (27)|
| 85+||72 (7)|
| Not reported||10 (1)|
Participants Who Screened at Risk for Cognitive Impairment, Falls, and/or Depression
|Screening Tool||n (%)|
|Mini Cog©a||116 (12)|