Involvement of Advanced Practice Nurse in the Management of Geriatric Conditions: Examples from Different Countries.

The increasing demand for healthcare services is placing great strain on healthcare systems throughout the world. Although the older population is increasing worldwide, there is a marked deficit in the number of persons trained in geriatrics. It is now recognized that early detection and treatment of geriatric conditions (e.g., frailty, sarcopenia, falls, anorexia of aging, and cognitive decline) will delay or avert the development of disability. At the same time, recent years have seen an increased interest and use of advanced practice nurses (APN). Models of best practices of supervision and collaboration have been promulgated by many organizations. APN's roles and scope of practice have been expanded in many countries and the quality and cost-effectiveness of healthcare systems have improved. Nevertheless, in older people, evidence of advanced practice roles remains scattered, and there is little synthesis of evidence, and therefore it is not easy to visualize the different practice models and their components. The aim of this paper is to explain the need for advanced practice nurses to manage geriatric conditions.

Examining Differences in Recovery Outcomes between Male and Female Hip Fracture Patients: Design and Baseline Results of a Prospective Cohort Study from the Baltimore Hip Studies.

BACKGROUND: Incidence of hip fractures in men is expected to increase, yet little is known about consequences of hip fracture in men compared to women. It is important to investigate differences at time of fracture using the newest technologies and methodology regarding metabolic, physiologic, neuromuscular, functional, and clinical outcomes, with attention to design issues for recruiting frail older adults across numerous settings. OBJECTIVES: To determine whether at least moderately-sized sex differences exist across several key outcomes after a hip fracture. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study (Baltimore Hip Studies 7th cohort [BHS-7]) was designed to include equal numbers of male and female hip fracture patients to assess sex differences across various outcomes post-hip fracture. Participants were recruited from eight hospitals in the Baltimore metropolitan area within 15 days of admission and were assessed at baseline, 2, 6 and 12 months post-admission. MEASUREMENTS: Assessments included questionnaire, functional performance evaluation, cognitive testing, measures of body composition, and phlebotomy. RESULTS: Of 1709 hip fracture patients screened from May 2006 through June 2011, 917 (54%) were eligible and 39% (n=362) provided informed consent. The final analytic sample was 339 (168 men and 171 women). At time of fracture, men were sicker (mean Charlson score= 2.4 vs. 1.6; p<0.001) and had worse cognition (3MS score= 82.3 vs. 86.2; p<0.05), and prior to fracture were less likely to be on bisphosphonates (8% vs. 39%; p<0.001) and less physically active (2426 kilocalories/week vs. 3625; p<0.001). CONCLUSIONS: This paper provides the study design and methodology for recruiting and assessing hip fracture patients and evidence of baseline and pre-injury sex differences which may affect eventual recovery one year later.

Improving community ambulation after hip fracture: protocol for a randomised, controlled trial.

INTRODUCTION: After a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients. PRIMARY OBJECTIVE: To evaluate the effect of a specific multi-component physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation. DESIGN: Parallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants. PARTICIPANTS AND SETTING: A total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions. INTERVENTIONS: Participants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists' adherence to the treatment protocol, and the participants' receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period. MEASUREMENTS: The primary outcome (community ambulation) is the ability to walk 300 m or more in 6minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6minutes, cognitive status, and nutritional status. ANALYSIS: Analyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks. DISCUSSION: This multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.

Second-look laparotomy in stage III epithelial ovarian cancer: clinical variables associated with disease status.

Variables associated with a negative second-look laparotomy in patients with stage III epithelial ovarian carcinoma are analyzed. Fifty-six patients were clinically free of disease after systemic chemotherapy and were subjected to second-look laparotomy to assess tumor status. Eighteen of these patients (32.1%) had no evidence of malignancy. Eight (14.3%) additional patients with no gross evidence of disease at laparotomy had microscopic persistence; five of these had disease documented in the pelvic or para-aortic lymph nodes. Significant variables associated with a histologically and cytologically negative second-look operation were low tumor grade (P less than .01), the use of cis-platinum containing combination chemotherapy (P less than .01), patient age less than or equal to 50 years (P less than .02), small residual tumor (less than 0.5 cm) before chemotherapy (P less than .05), and metastatic tumor less than or equal to 10 cm before initial cytoreduction (P less than .05). Patients treated with six to nine cycles of combination chemotherapy had the same probability of a negative second-look laparotomy as those treated with ten to 12 cycles. Multivariate discriminate analysis indicated that patients with low tumor grade, those receiving cis-platinum containing combination chemotherapy, and those with minimal residual tumors (less than 0.5 cm) after primary cytoreductive surgery correctly classify second-look status in 78.6% of patients. Until a nonsurgical method of monitoring subclinical disease is available, a through second-look laparotomy, including a pelvic and para-aortic lymphadenectomy, should be performed.

A seven step approach to starting an exercise program for older adults.

There is strong experimental evidence to indicate that regular aerobic exercise can prevent disease, decrease the risk of failing, reduce physical disability, improve sleep, and enhance mood and general well being. Despite these benefits, approximately 50% of sedentary adults who start an exercise program stop them within the first 6 months of involvement. To help older adults initiate and adhere to a regular exercise program, a seven step approach was developed and implemented in a continuing care retirement community (CCRC). The seven steps include: (1) education; (2) exercise pre-screening; (3) setting goals; (4) exposure to exercise; (5) role models; (6) verbal encouragement; and (7) verbal reinforcement/rewards. Following implementation of the seven step approach, 40 (19%) of the 212 residents living in the CCRC exercise regularly.

Home blood pressure monitoring for mild hypertensives.

A clinical trial of 204 untreated patients with mild hypertension was conducted to assess the effect of home blood pressure monitoring on blood pressure level, pharmacologic treatment, reduction of risk factors, and use of health services. After 1 year, no statistically significant differences were found between the treatment and control groups. The findings indicate that, while home blood pressure monitoring may be useful, it has no measurable short-term impact on these aspects of blood pressure management for patients with mild hypertension.

Outcome expectations for exercise scale: utility and psychometrics.

OBJECTIVES: The purpose of this study was to develop a measure of outcome expectations for exercise specifically for the older adult (The Outcome Expectations for Exercise [OEE] Scale), and to test the reliability and validity of this measure in a sample of older individuals. This scale was developed based on Bandura's theory of self-efficacy and the work of prior researchers in the development of measures of outcome expectations. METHODS: The OEE scale, which was completed during a face-to-face interview, was tested in a sample of 175 residents in a continuing care retirement community. RESULTS: There was support for the internal consistency of the OEE scale (alpha coefficient of .89), and some support for reliability based on a structural equation modeling approach that used R2 estimates, although less than half of these were greater than 0.5. There was evidence of validity of the measure based on: (a) a confirmatory factor analysis in which the model fit the data (normed fit index [NFI] = .99, root mean square error of approximation [RMSEA] - .07, chi2/df = 2.8); (b) support for the hypothesis that those who exercised regularly had higher OEE scores than those who did not (F = 31.3, p < .05, eta squared = .15); and (c) a statistically significant relationship between outcome expectations and self-efficacy expectations (r = .66). DISCUSSION: This study provides some initial support for the reliability and validity of the OEE scale. Outcome expectations for exercise were related to exercise behavior in the older adult, and the OEE scale can help identify older adults with low outcome expectations for exercise. Interventions can then be implemented to help these individuals strengthen their outcome expectations, which may subsequently improve exercise behavior.

A prediction model of aerobic exercise in older adults living in a continuing-care retirement community.

OBJECTIVES: The purpose of this study was to test a model of exercise behavior in older adults. It was hypothesized that gender, marital status, chronic illness, mental and physical health, self-efficacy and outcome expectations, fear of falling, and past exercise behavior were directly and/or indirectly associated with current exercise behavior. METHODS: In this descriptive study, interviews were conducted with 201 older adults living in a continuing-care retirement community. RESULTS: Twelve paths were significant, and the model accounted for 40% of the variance in exercise behavior. Self-efficacy expectations, outcome expectations, and prior exercise were directly associated with current exercise; health status, gender, and marital status were indirectly associated with current exercise behavior through self-efficacy and outcome expectations. DISCUSSION: Recognizing and treating mental and physical health problems may directly influence self-efficacy and outcome expectations related to exercise. Moreover, interventions that strengthen self-efficacy and outcome expectations related to exercise may improve exercise behavior.

The effect of cognitive status on outcomes following rehabilitation.

BACKGROUND AND OBJECTIVES: Impaired cognition is a determinant of poor recovery following a hip fracture. Because of the risk of poorer outcomes, individuals with impaired cognitive function may be refused admission into a rehabilitation program. This study considered the impact of cognitive status on functional ability over time for older adults who participate in a rehabilitation program. METHODS: We studied a convenience sample of 200 consecutive patients who participated in an inpatient rehabilitation program following an orthopedic event. We obtained complete follow-up data on 181 participants. Baseline data were collected within 48 hours of admission and included demographics, rehabilitation diagnosis, living location prior to admission, the Mini-mental State Examination, and the Barthel Index (BI). Telephone follow-up was made at 3, 6, and 12 months after discharge from rehabilitation, and we obtained information about demographic data and functional status (BI). RESULTS: There were no differences in the demographic characteristics of the two groups except for race; a larger percentage of African-Americans were in the impaired group. There was a statistically significant main effect of time with functional ability of all participants, increasing over the 12-month follow-up period. CONCLUSIONS: This study suggests that rehabilitation of the older adult, both with and without cognitive impairment, can result in improvement in functional ability that is sustained over a 12-month period. Although the findings indicate that those with cognitive impairment have lower functional performance at each testing period, these individuals improved functionally during the course of rehabilitation and maintained their discharge level of functioning for 1 year after discharge.

Functional performance of older adults in a long-term care setting.

Motivation has been identified as an important factor in the older adult's ability to perform functional activities. The purpose of this study was to explore functional performance and factors that have an impact on functional performance in nursing home residents. Participants included 44 White older adults from two nursing homes. The majority of the participants were female (84%). The mean age of the participants was 88 +/- 6.4 years and, on the average, they had been institutionalized for 2.85 +/- 2.8 years. Following data reduction of the predictors, two factors--motivation (efficacy beliefs and intrinsic motivation) and lower extremity function (contractures and standing balance)--were identified. In a stepwise multiple regression analysis, these two factors were the only variables that significantly predicted functional performance and accounted for 81% of the variance in function.

Falls in a community of older adults: putting research into practice.

This study described the incidences of falls and injuries related to those falls in a community of older adults. It used a convenience sample of 220 older adults in a continuing care retirement community. Over a 2-year period, all residents who had a witnessed or reported fall were evaluated by a nurse or nurse practitioner and completed a Falls Data form. There were 154 falls, most of which occurred between noon and midnight, within the residents' apartments, when walking (63%) or transferring (19%). Only 16 (10%) of the falls resulted in a fracture. The number of falls was the only variable associated with having an injurious fall. Individuals who had atrial fibrillation or neurological problems, were not married, and did not adhere to a regular exercise program were more likely to have multiple falls. The findings were used by the nurse practitioner to educate residents about falls in their community and to develop interventions to decrease the risk and incidences of falls.

Functional performance and exercise of older adults in long-term care settings.

Performing functional activities and exercising are important for older adults living in long-term care settings. Participation in these activities not only improves and maintains function in older adults but also can improve physical and emotional health and quality of life. The purpose of this study was to explore the variables that influence functional performance and exercise activity in a group of nursing home residents. Participants included 59 residents in a long-term care facility. The mean age of participants was 88 +/- 6.9, and the majority were women (76%), White (97%), and unmarried (76%). Residents participated in a single face-to-face interview. Chart reviews for demographic and health information also were performed. Based on stepwise multiple regression analyses, upper and lower extremity contractures and cognitive status were the only variables that significantly influenced functional performance and accounted for 49% of the variance in function. Self-efficacy and outcome expectations were the only variables to significantly influence exercise behavior and accounted for 57% of the variance in this behavior. These findings can be used to help develop and implement effective restorative nursing care programs in long-term care settings.

Measurement tools. Do they apply equally to older adults?

1. The self-motivation inventory was developed and tested on young and middle-aged adults, and may not be appropriate for the older adult. 2. Areas of concern when considering the use of scales in the older adult should include a careful examination of the underlying assumptions on which the measure is based, as well as the appropriateness of questions, language and administration. 3. Measuring motivation in the older adult may be different from consideration of this concept in younger adults, as older adults are more concerned with conserving energy and surviving than achieving socially accepted goals.

Efficacy beliefs in geriatric rehabilitation.

Motivation is an important variable in older adults' ability to recover from any disabling event. The theory of self-efficacy states that efficacy beliefs affect behavior, motivational level, thought patterns, and emotional reactions in response to any situation. This study explored the impact of efficacy beliefs on older adults in a rehabilitation program and tested interventions to strengthen efficacy beliefs related to participation in rehabilitation and functional performance. An experimental pretest-posttest design was used. Participants were randomly assigned to: the usual care control group or the treatment group. The study was completed on an inpatient geriatric rehabilitation unit. The sample consisted of 77 participants, 55 women and 22 men with a mean age of 78 +/- 7.2. Individuals in the treatment group received three efficacy enhancing interventions: role modeling, verbal persuasion, and physiological feedback. Baseline data were collected within 48 hours of admission and included four investigator-developed efficacy measures: Functional Inventory Measure, Participation Index, Numeric Rating Scale for pain, amount of analgesic used for pain, and Health Status. With the exception of Health Status, these measures were again completed within 48 hours of discharge. Admission performance was the only statistically significant predictor of efficacy beliefs. All efficacy beliefs increased over time and were significantly correlated with performance behaviors and length of stay. The treatment group had stronger efficacy beliefs regarding participation, higher participation at discharge, and less pain than the control group. Efficacy beliefs, both self-efficacy and outcome expectations, are related to participation, functional performance, and length of stay. Interventions to strengthen these beliefs improved participation in rehabilitation and decreased pain. Consideration of motivation can facilitate rehabilitation and help older adults obtain and maintain their highest functional level.

Geriatric motivation. Clinically helping the elderly to comply.

1. Motivation must be considered separately from compliance. Compliance implies manipulation whereas motivation is not something we "do to" a patient. 2. Many factors can stimulate patient motivation. These include both internal (medication, nutrition, sensory, and cognitive changes) and external (social norms) factors, as well as beliefs and past experiences. 3. Many strategies can help motivate the elderly to comply. It is helpful to set goals with the patient, explore fears of failure, establish frequent rewards, set a low stress environment, use role models, and evaluate each patient as an individual.

Understanding what motivates older adults to exercise.

The purposes of this study were to explore the factors that influenced adherence to an exercise program for older adults, and compare differences in motivation, efficacy expectations, health status, age, functional performance, and falls between adherers and nonadherers. A combined qualitative and quantitative design was used. Participants included 23 of the 24 members of an existing walking group, with an average age of 81 +/- 7.2 years. Fourteen (60%) participants did not adhere to walking, while 9 (40%) adhered. Those that adhered had fewer functional limitations due to their health, (F = 7.7, p < .05), better functional performance (F = 4.0, p < .05), stronger self-efficacy expectations related to exercise (F = 4.3, p < .05), and fewer falls (F = 4.4, p < .05). Six major themes were identified that impacted adherence: a) beliefs about exercise; b) benefits of exercise; c) past experiences with exercise; d) goals; e) personality; and f) unpleasant sensations associated with exercise. Interventions that focus on teaching older adults about the benefits of exercise, establishing appropriate goals, and decreasing unpleasant and increasing pleasant sensations associated with exercise may be useful to improve adherence to a regular exercise program.

Health promotion practices of the old-old.

The purpose of this study was to describe the health promotion activities of older adults in a life care community. A total of 195 older adults participated in a health promotion survey. The old and old-old age groups demonstrated a decrease in cancer screening behaviors, aerobic exercise, and compliance with a low cholesterol diet. Moreover, these individuals indicated that they had lived a sufficient period of time, and were no longer interested in disease prevention and prolongation of life. Older adults may benefit from an individualized approach to health promotion that focuses on quality rather than quantity of life.

Promoting health in older adults: a four-year analysis.

PURPOSE: The purpose of this study was to consider the influence of selected health promotion and disease prevention interventions in elderly residents of a continuing care retirement community (CCRC) over a four-year period by comparing actual health promotion practices of the residents. DATA SOURCES: Original research using a descriptive design, face-to-face interviews of residents (N = 176-200), chart reviews, and administration of a mini-mental state exam (MMSE) and health survey administered annually. CONCLUSIONS: In each year the mean age of the residents was at least 85, the majority were female, Caucasian, and unmarried. With the exception of checking stools for occult blood, there was a statistically significant change in all health promotion behaviors over the four-year period. The most significant change was in the area of exercise behavior, which increased from 24% of the residents participating in regular exercise in year one to 61% by year four. IMPLICATIONS FOR PRACTICE: The purpose of health promotion and disease prevention in older adults is to reduce the potential years of life lost in premature mortality and ensure better quality of remaining life. In addition to regularly scheduled interventions (group education, on-site administration of pneumonia and flu vaccines, on-site exercise room and walking group), individualized counseling regarding the pros and cons of health-promotion activities was provided to help residents make an educated decision about engaging in these activities. These interventions can be used to help facilitate participation in health promotion activities as appropriate and desired for each older adult.

Partners for NP education: the 1999 AANP preceptor and faculty survey.

PURPOSE: To increase understanding of national trends in nurse practitioner (NP) clinical education, the Education Committee of the American Academy of Nurse Practitioners (AANP) conducted a survey at the 1999 National AANP Conference in Atlanta. DATA SOURCES: A convenience sample of preceptors (n = 87) and faculty (n = 42) out of the total attendance of 1,744 responded to a written questionnaire. CONCLUSIONS: Preceptor respondents provided data concerning the number of NP students supervised, influence of student supervision on productivity, and availability of incentives for precepting. Faculty reported placement and supervision issues, the extent of precepting in their clinical practice site, and recognition and support for this role. Faculty and preceptors disagreed about the types and number of incentives offered for accepting students as well as the congruence of clinical teaching activities and national teaching guidelines. Precepting did not appear to strongly influence preceptor productivity. External funding did not influence opportunities for clinical education. IMPLICATIONS FOR PRACTICE: In 1998, the graduates of NP programs rose by 15.8% and over half of all nursing students enrolled in graduate nursing programs were seeking a NP education. This increase in students may compromise the ability of schools of nursing to insure quality clinical education of NP students by increasing faculty workload and placing greater demands on expert preceptors in the community. Clinical education is also changing in light of changes in the health care system.