The past few months have brought several new studies and initiatives focused on improving the care of older adults, and I would like to share a few and leave you with some thoughts for the new year.
In September 2019, the Agency for Healthcare Research and Quality released a study on the use of anti-psychotic medications for the treatment of delirium (Oh et al., 2019) with an accompanying editorial by Marcantonio (2019) entitled, “Old Habits Die Hard: Antipsychotics for Treatment of Delirium.” The below quote from the editorial seems to send the message home:
Nikooie and colleagues concluded that the current evidence does not support use of antipsychotics to treat delirium in adult inpatients and called for continued research in this field…. With regard to use of antipsychotics for broad treatment of delirium, I believe the findings presented are sufficient to stop this clinical practice.
So, let's stop prescribing antipsychotic medications in persons with or at risk of delirium. Nurses are critical to the research and implementation of non-drug approaches to delirium and should be involved in creating order sets in their health systems that reinforce the use of evidence-based approaches for the care of persons with delirium and dementia. Stay tuned for more from the Journal of Gerontological Nursing (JGN) on this issue.
Closely related to the improper prescribing of these medications is a new report supported by the Gordon and Betty Moore Foundation with broad provider and consumer recommendations to address polypharmacy in older adults that will be forthcoming in 2020 by the LOWN Institute. Their 2019 report found that more than 40% of older adults take five or more medications (LOWN Institute, 2019). Overprescribing medications leads to harm, and over the past 10 years older adults were hospitalized more than 2 million times for adverse drug events (LOWN Institute, 2019). Again, let's stop overprescribing and support nonpharmacological approaches in research and practice while improving care for older adults at the bedside and point of care.
In July 2019, the Health Resources and Services Administration funded 47 Geriatric Workforce Enhancement Program (GWEP) grants focused on dementia- and age-friendly health systems (access https://www.americangeriatrics.org/programs/gwep-coordinating-center). The Penn State Center for Geriatric Nursing Excellence and the Center for Nursing Research in collaboration with Primary Health Network in Pennsylvania are recipients of one of these grants (principal investigator, J. Hupcey) and will be working with Federally Qualified Health Centers (FQHCs) to address age-friendly care in primary care. In November 2019, those who received GWEP grants joined together at the annual meeting of the Gerontological Society of America to learn from and teach each other. There was a speed dating session at which attendees learned about others' GWEPs, and I left wanting to collaborate with all of them! As Penn State launches its first quarter of the age-friendly grant, we are finding this work exciting. In January, we will launch our first case-based video spoke and knowledge learning hub using the ECHO Model™ (access https://echo.unm.edu). ECHO is a great format for learning and sharing, especially in rural areas. We encourage you to join the age-friendly movement and learn about the 4Ms (i.e., What Matters, Medication, Mentation, and Mobility) by visiting the Institute for Healthcare Improvement website (access https://www.ihi.org).
I recently had an experience that reminded me how important our work in research and practice (and in JGN) is to improving the care of older adults— but also how challenging it can be to reach the next generation of geriatric scientists and clinicians. In addition to the FQHCs, we are touching all types of learners and partners at Penn State and in our community.
I had the opportunity to speak with junior nursing students, and I started by asking how many were interested in gerontology and the care of older adults. Only two people sheepishly raised their hands in the class of approximately 100. Seeing this response, I switched gears and instead of hopping right into my topic of assessing and acting on delirium and the 4Ms, I talked for 5 minutes about how much joy being in the field of gerontology has brought me and how I have found it to be a complex learning adventure across all settings of care (e.g., intensive care, long-term care, homecare, industry). Research has shown that if we want to encourage young people to embrace gerontology we have to understand their perspective, get them excited about the field, and help them see how it will connect to them. I told them how it had opened many doors, allowing me to meet fabulous and wise older adults, caregivers, and industry partners, as well as travel the world because aging is a global issue. I shared with them that improving the care of older adults is my passion and my job, but it has also been a rich and rewarding ever-growing experience. I was trying my best to get more than one student to raise his/her hand 2 years from now or to think about graduate school or a career in gerontology. (Not to mention the fact that almost everyone in that room will be working with older adults regardless of whether they raise their hand.)
Some students were listening, as several came up to ask a question or thank me for sharing our work. At the end of class, I asked the students to do a brief written assignment, which was to define the 4Ms and comment on something new they had learned from our time together and would use in practice. Several wrote about delirium or not giving medications listed on the Beers Criteria® or knowing their patient and asking, “What matters”—all great responses. However, one student's comment caught my eye, having written, “Stay active, and George is the oldest person to run up Mount Washington.” This response reminded me of the importance of engaging students by showing passion for the care of older adults and sharing research by telling stories of real older adults. When I talk about mobility or any other topic, I use real cases of older adults I have known or cared for in my practice.
In this particular class, I showed students a picture of myself with George Etzweiler (Figure 1) who will turn 100 this year and is the oldest person to run the Mount Washington Road Race (Dawson, 2019). George runs with family and friends through the same forest roads I run, so I see him in the dead of winter and heat of summer. He also has an award-winning film, For The Love of Mary (Horton & Perkins, 2018), about how running helped him manage his depression after his wife died. This story is not to reinforce an ideal or successful idea of aging but one that encourages mobility and the power and evidence-base for staying active as we age.
George Etzweiler out for a run.
© 2020 Larry Etzweiler
There are many resources to improve mobility, including a Medicare-based program for older adults called SilverSneakers® (access https://www.silversneakers.com). Many of the benefits of programs like SilverSneakers go beyond increasing physical activity and exercise to include decreasing social isolation and providing a support network. Older adults talk about how they “watch out for each other” and even check on participants who are regulars and then suddenly do not show up for classes.
The evidence for cognitive and other benefits of physical activity is strong (Middleton et al., 2010). Encouraging physical activity and facilitating mobility in every setting where older adults live is critical to improving the care of these individuals. One instance is Johns Hopkins University's AMP Program™, which has patients ambulating in the hospital while on ventilators (access https://www.hopkinsmedicine.org/physical_medicine_rehabilitation/education_training/amp/index.html).
Two years ago, I decided to have my own daily mobility goal—run outside every day for at least 1 mile. Deciding to do this made physical activity easier for me, as I know I am going to run every morning regardless of rain, snow, or sun. This is how I met George.
So, if staying active is the most important thing my students learned that makes me happy and may also help them think about caring more for themselves. Telling them is one thing but seeing and hearing the story of a 99-year-old man may combat some of the ageism that gets in the way of choosing gerontology as a career.
I invite all of you to be inspired by George, take care of yourselves more this year, and consider having your own age-friendly daily mobility goal. I extend my gratitude and joy to our readers, authors, and reviewers as we welcome 2020. Happy New Year!
Donna M. Fick, PhD, RN, FGSA,
- Dawson, A. (2019, May5). At 99 years old, George Etzweiler can't stop running. Retrieved from https://www.runnersworld.com/runners-stories/a27305018/george-etzweiler-cant-stop-running/
- Horton, K. & Perkins, S. (Directors). (2018). For the love of Mary [short film]. United States: Sharptail Media.
- LOWN Institute. (2019). Report – Medication overload: How the drive to prescribe is harming older Americans. Retrieved from https://lowninstitute.org/medication-overload-how-the-drive-to-prescribe-is-harming-older-americans
- Marcantonio, E. (2019). Old habits die hard: Antipsychotics for treatment of delirium. Annals of Internal Medicine, 171(7), 516–517. doi:10.7326/M19-2624 [CrossRef]
- Middleton, L. E., Barnes, D. E., Lui, L. Y. & Yaffe, K. (2010). Physical activity over the life course and its association with cognitive performance and impairment in old age. Journal of the American Geriatrics Society, 58(7), 1322–1326. doi:10.1111/j.1532-5415.2010.02903.x [CrossRef]20609030
- Oh, E. S., Needham, D. M., Nikooie, R., Wilson, L. M., Zhang, A., Robinson, K. & Neufeld, K. J. (2019). Antipsychotics for preventing delirium in hospitalized adults: A systematic review. Annals of Internal Medicine, 171(7), 474–484. doi:10.7326/M19-1859 [CrossRef]