Starting this month, the Gastroenterology Nursing Journal will begin to feature a new column on the topic of geriatrics. The intent of this new column is to explore issues faced by gastroenterology nurses as you care for an aging population.
A review of current trends in aging illustrates the importance of including geriatric concepts in all fields of nursing care. In the United States (U.S.), individuals older than 65 years currently make up over 15% of the general population (Vespa, 2019). The generation born between 1946 and 1964 is known as the baby boomers. This generation began turning 65 in 2011 and will continue to do so until 2030, at which time, they will make up 21% of the population in the U.S. (Vespa, 2019). In 2060, one in four people will be older than 65 years. Currently, those older than 85 years make up the fastest-growing subset of the population and their numbers will triple by 2060 (Vespa, 2019). Despite making up just 15% of the population, those older than 65 years utilize over half of healthcare in the U.S. (Nurses Improving Care of Health System Elders, 2016). The future impact of these trends on an already stressed healthcare system will be substantial.
Trained individuals prepared to care for this growing group are in the minority. There are currently less than half of the needed geriatricians for the aging population in the U.S.; less than 1% of certified nurses have obtained their certification in gerontology, and less than 3% of advanced practice nurses have done the same (Rowe et al., 2016). Regardless of whether you obtain certification, nurses caring for older adults have a professional obligation to maintain at least a basic knowledge of the specialized care required for this population. According to the American Nurses Association (2010), "In order to meet The Joint Commission (TJC) criteria on patient safety, nurses working in accredited hospitals need to embrace the knowledge and skills required to identify geriatric syndromes and know-how to prevent iatrogenic complications."
Age-related changes will impact the presentation of illness, response to treatment, and overall outcome of the older adult patient. These age-related changes affect various elements of the gastrointestinal (GI) tract to varying degrees and are compounded by the presence of comorbid conditions (Baker & Blakely, 2017). It can often be difficult to distinguish age-related changes from pathologic gastroenterology conditions (Dumic et al., 2019). For instance, normal aging includes decay of dentition and atrophy of the muscles used to masticate, as well as a decrease in saliva production (Baker & Blakely, 2017). These changes impair nutrition and heighten the risk of dysphagia (though dysphagia is not considered a normal aging change) (Smith & Cotter, 2016). Gastric motility may slow, and absorption of certain vitamins decreases in the stomach and small intestine (Smith & Cotter, 2016). Constipation is more common in older adults but likely has less to do with age-related physiologic changes than other factors including decreased activity level, use of anticholinergic medications, and the presence of other health conditions (Dumic et al., 2019). Gallstone formation becomes more common and the body's response to infection is blunted, including in the GI tract (Smith & Cotter, 2016). The liver maintains day-to-day function but is less capable of metabolizing medications in older adults (Smith & Cotter, 2016).
Due to age-related changes, disease presentation tends to look vague and may lack the indicators on which we typically rely, such as elevated temperature or localized pain. Instead, change in function or an alteration in mental status may be the only clues we have to indicate that something is amiss (Resnick, 2016). Response to treatment will be impacted by decreased ability to respond to stress and less robust physiologic reserves (Gidwaney, Bajpai, & Chokhavatia, 2016). As a result, care of the older adult requires more comprehensive assessment and a lower threshold for suspicion.
Finally, a noteworthy subset of the older adult population is living with dementia. There are currently 5.8 million people in the U.S. living with Alzheimer's disease, the most common of many different types of dementia (Alzheimer's Association, 2019). Age is the greatest risk factor for developing this condition. It is projected that, by 2050, the number of people with Alzheimer's in the U.S. will increase to 13.8 million (Alzheimer's Association, 2019). For gastroenterology nurses, this again will dramatically impact the presentation, disease course, and outcomes for the patients you encounter. In brief, complications will arise for patients with dementia in both the outpatient and inpatient settings due to problems with recognizing and communicating symptoms, adhering to a treatment plan, coping with the stress of hospitalization, developing of delirium, and experiencing, and the not uncommon sequelae that follow such as use of physical and chemical restraints. Increased knowledge and awareness not only benefit your patients, but GI nurses as well. There is an art to caring for individuals living with dementia that can be cultivated with time and practice. If you have worked with this population before, you understand that the course of this condition impacts both the memory and the functional ability of these individuals. Strategies to enhance communication serve the patient, but also save nurses' time and prevent frustration. Methods for completing tasks that focus on gaining permission and promoting the abilities retained by the individual avoid a defensive and potentially violent reaction.
Future columns will dive further into age-related changes and atypical presentations as well as include more discussion of the role of dementia in gastroenterology nursing, the challenges of conducting gastroenterology-related research for this population, and the impact of polypharmacy, among other topics. I hope you will find this column useful to your practice!
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