Today's obituaries aren't what they used to be. Nellie Bradley passed away peacefully in her bed March 11 at an English nursing home. At 112 years, she was the oldest living Briton.

Two days later, Delvina Dahlheimer died in Elk River, Minn., at age 113.

Maud Farris-Luse died in a Michigan hospital March 18 from complications of pneumonia. She had seven children and outlived six. She had cared for herself until 1991, when she broke a hip and moved into a nursing home. She left behind a Guinness World Record as the oldest verifiable living person. She lived for 115 years and 56 days.

We are getting older, living longer and changing the face of health care. According to a January California Healthline report, 20 percent of Americans will be 65 or older by 2030. Older adults now account for 60 percent of adult ambulatory primary care visits, 80 percent of home care visits, 48 percent of hospital patients and 85 percent of nursing home residents, according to the John A. Hartford Foundation Institute for Geriatric Nursing at New York University.

Such weighty numbers spark concern about having enough nurses to care for the aging patient population. "I think we are 20 years behind," said Gracie Wishnia, Ph.D., MSN, RN, an associate professor at Spalding University in Louisville, Ky.

The numbers keep growing. "This is going to be the demographic group driving the economy," said Susan Scanland, MSN, GNP, RN, president of Geriscan Geriatric Consulting in Clarks Summit, Pa.

And the nation needs specialists. The California Healthline report notes that the country needs 36,000 geriatricians-far more than the 9,000 now working.

The Hartford Institute reports that only 0.005 percent of the nation's RNs are certified gerontological nurses.

Some point to poor image as a root cause. "There are no television shows demonstrating the exciting and dramatic profession of gerontological nursing," said Carol Baird, DNS, RN, an assistant professor at Purdue University. "Grade school, high school and college students want to be part of the excitement and quick pace-assess and cure in 15 minutes or less on TV-that gerontological nursing does not offer."

These statistics raise questions about patient care, nurse training, age bias and the price tag on geriatrics.

Gaps in patient care

"Because of the shortage of gerontological nurses, long-term care facilities are understaffed," Baird said. "The care and safety of the elderly in long-term care may be in jeopardy." The shortage can cause shorter hospital stays, problems with health care assessment, and patient discharge and rehospitalizations that could have been prevented.

"There are very few geriatricians," Baird said. "Elderly are cared for by family practitioners or internists who generally do a good job," but geriatricians are more attuned to older adults and the newest, safest treatments for chronic disease. They often spend more time with the patient's family to determine the appropriate actions.

The situation led Scanland to start her consulting company after years as a nurse practitioner. She found that medical schools offered physicians little geriatrics training. "There were tremendous gaps in geriatrics assessment and management."

Education suffers

Experts agree that gerontological education has suffered. "I don't know how well the educational system is dealing with the geriatrics population," said Lori Costa, MSEd, RN, a lawyer and regulatory consultant for the California Association of Homes and Services for the Aging.

Simply put, "The educational process hasn't caught up with the proliferation of the specialty," said Shirley Travis, Ph.D., RN, professor of nursing and president of the National Gerontological Nursing Association. "Lots of nurses say 'I work with older people, therefore I'm a gerontological nurse.' " But the field requires special training, and NGNA advocates certification.

That happens through the American Nurses Credentialing Center, Baird said. RNs can take a gerontological specialist exam, and advanced practice nurses can be certified as clinical specialists in gerontological nursing or as gerontological nursing practitioners.
"However, many nurses are caring for the elderly without graduate degrees," Baird said. "Nurses often learn on the job, sometimes from nurses who do not practice the best gerontological nursing."

Travis said that the NGNA's mission is to maintain "high-quality clinical care of older people, regardless of the setting." Gerontological nurses work in varied environments, bringing numerous specialties to the field-acute, critical, long-term, primary and home health care.

"But we'd like gerontology to be at least a subspecialty within their specialty," she said.

Most specialized gerontological education occurs at the graduate level, Travis said. "Many, but not all, undergraduate nursing programs have some gero nursing content." That training can take three forms: didactic courses of theory, theory combined with clinical experience or gerontology integrated into the regular program-for example, looking at a particular disease among young people, middle-aged and older people.

Gerontological courses cover a wide range: assessment, functional capacity, quality of life, chronic illness, long-term care, ethics, finances and daily living activities.

Geriatric patients' needs differ from others, and nurses must "recognize the older adult is a different species," said Wishnia, who teaches gerontology.

"I do a whole unit on housing for the older adult," covering chronic illness at home, caregiving, depression, losing touch with society and dementia, Wishnia said. For example, "Women do better than men at living alone with chronic illness," she said, perhaps because many women have spent their lives raising children, organizing households and adapting to new circumstances.

Sometimes, older patients present atypical signs of disease, Travis said, such as fever that doesn't occur in younger patients. Medications differ, too. "The body doesn't use medications the same way that it does when you're younger," she said.

Continuing education is key for geriatrics nurses, Scanland said, but budgets are tight. It also varies regionally. "There are differences between states and whether RNs need continuing education to maintain their licenses," she said. "If it's not required, it might not be budgeted.

Mary Anne Filo, MS, RN, a nurse educator for the Milwaukee County Department on Aging, said most of the 50-plus population has at least one long-term illness. "Eighty percent of all health care is managing chronic health care problems. That's a pretty high statistic," she said.

Age biases

Gerontology and Alzheimer's care are "pretty much the wave of the future," said Susan Gilster, RN, executive director of the Alois Alzheimer Center in Cincinnati. Wherever nurses are, "they're going to be working with older adults," she said. But the field isn't as glamorous as others. "As a society, I'm not sure how much we value aging," Gilster said.

It's a common sentiment. "I think the age bias is terrible," Costa said. "It's kind of like they're all lumped into this big 'aged' group," and not seen as individuals. "We're not a culture that values the aged like some of the Eastern cultures. People are very impatient with the aged."

For example, Costa recently heard of an elderly man with bypass surgery, and her instinctive reaction was, "What are we doing?" Then she immediately thought, "Now wait a minute, you don't even know this person." In this society, "people key in to the age rather than the condition of the person."

Ethical questions

That can raise ethical questions, too. Travis pointed to the example of a 90-year-old man who refused to sign a DNR order. The patient was fully cogent. "It was just a perfect example," she said, because it veered from previous notions that 70, 80 or 90 was the end of the road. "Our life spans are so variable," she said. "There can be a 90-year-old who's very vibrant and vital."

Today, some older adults can be cured, particularly when health problems relate to conditions that can change: stress, weight, inadequate housing, abuse. Baird said that gerontological nurses also help patients live with chronic conditions such as arthritis, heart disease, renal insufficiency and neurological difficulties.

Christine Peterson, NP, works in a Philadelphia primary care office that serves seniors who "would benefit much if we could teach them to understand their medical condition and how they can live with it successfully and how behavioral choices they make may make it better or worse." Her practice is piloting a program to do just that.

It's part of a philosophical change. Should an 88-year-old woman get a mammogram? Such decisions should be based first on patient preference, and second on patient function, Scanland said. "Look at the whole person and not just the age."

Travis agreed. "Limiting care just because someone is over the chronological age of 65 is no longer acceptable. As the boomers reach retirement age, the concept of limiting care based solely on some arbitrary age will seem ridiculous."

Cost of care

All of that, of course, costs money. "Over 80 percent of the health care dollar spent on a patient is often spent in the last 20 days of life when the individual is on life support," Peterson said. "As a society, we need to devote more effort to educating people of all ages to discuss and write down their wishes and feelings regarding life support."

Sometimes, families try to do "too much" for a dying relative whose outcome won't change, she said. "The nation's health care money is misspent, and mom suffers."

Peterson is writing a book for families of seniors with chronic disease. "Efforts like this can shift the way health care dollars are spent," she said.

Still, problems persist. "This year, many states are near financial catastrophe and are not planning for the future," Baird said.

Older patients and longer life spans mean more long-term care needs. "There is no answer to the financial quagmire in sight."

Despite the difficulties, gerontological nurses stress the rewards of working with the aged. Such patients offer a wealth of life experience, and gerontological nurses can develop long-term relationships with older adults and their families.
"I wish somehow we could really emphasize to nurses the rewards you get from working with the elderly patient and the chronic patient," Costa said. Long-term care offers nurses the opportunity to do what they do best, caring for people. "It personifies nursing," she said.

Contact Karen J. Coates at redcoates@hotmail.com.