Gerontology and Long-Term Care

Demographic and Social Issues

  • Healthcare for elders accounts for about one third of physician resources and one quarter of medication use in the United States.
  • As longevity increases, more people in their 50s and 60s will be tasked with caring for parents aged 85+ with multiple chronic illnesses or disabilities.

Demographic Information

  • Older Adult Population
    • Age 65 years or older: 55.8\ \text{million} people in the United States.
    • Age 85 years or older (the “oldest-old”): the most rapidly growing segment of the elderly.
  • Leading Causes of Death
    • 1. Heart disease
    • 2. Cancer
    • 3. COVID-19
  • Average Life Expectancy
    • Both sexes: 76.1\ \text{years}
    • At age 65, average years of life remaining (U.S.): 18.4\ \text{years}
    • Women: 79.1\ \text{years}
    • Men: 73.2\ \text{years}
  • Elderly women outnumber elderly men and are more likely to live alone; most elderly women are not married, while most elderly men are.
  • The aging of America is driven by the baby boomer generation; for the first time in U.S. history, older adults will outnumber children by the year 2034.

Ageism

  • Ageism is a belief in negative societal stereotypes about aging.
  • Speak with older/elderly adults without implying hearing loss or reduced mental capacity.
  • Avoid terms like “sweetie,” “granny,” or “old guy.”

Gerontological Nursing: Timeline Highlights

  • 1981: American Nurses Association (ANA) Division of Gerontological Nursing first published the scope of practice for the specialty.
  • 1987: Scope of practice of gerontological nursing revised.
  • 1998: ANA offers certification for geriatric nurse practitioners (NPs) and gerontological clinical nurse specialists.
  • 2008: The new specialty called the “adult-gerontological” nurse is introduced to replace “gerontological” nursing programs by 2015 (consensus by 40 organizations).
  • 2012 (December): First group to take the new certification exam was graduates from adult-gerontology NP programs.

Gerontological Nurse Practitioner (GNP)

  • A specialty area in advanced practice nursing focusing on the aged (healthy and ill).
  • Can work in hospitals, clinics, private practices, skilled nursing facilities (SNFs), long-term care facilities (LTCFs), hospices, homes, academic settings, and communities.
  • In 2008, the GNP and adult NP (ANP) roles were combined into “adult-gerontology” under the National Consensus Model for APRN Regulation.
  • Educational programs for the ANP and GNP were completely phased out in 2015.
  • NPs already certified in ANP or GNP may continue with their existing certifications.
  • Certification can be renewed every 5 years by:
    • Continuing education (CE) and clinical practice hours (AANPCB)
    • CE, presentations, and other categories (ANCC)

Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP)

  • APRN specialty focusing on the population from adolescence until death.
  • Practice settings include hospitals/clinics, private clinics, public health facilities, urgent care, internal medicine clinics, college health clinics, and more.
  • Roles: nurse, healthcare provider, patient advocate, teacher, consultant, case manager.
  • Result of the national Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (LACE), finalized in 2008 and fully implemented in 2015.
  • AACN published the Adult-Gerontology Primary Care Nurse Practitioner Competencies in March\ 2010.

New Regulatory Model: APRN Population Foci

  • Six population foci:
    • Entire life span (family NP)
    • Adult-gerontology (primary care, acute care)
    • Neonatal
    • Pediatrics
    • Women’s health
    • Psychiatric/mental health

Educational Requirements

  • Minimum of a master’s degree required.
  • For those with graduate degrees not in NPs, postgraduate NP certificate programs are available.
  • Doctorate options for NPs:
    • Doctor of Nursing Practice (DNP): clinical degree
    • Doctor of Philosophy (PhD): research-oriented

Professional Specialties in Gerontology/Geriatrics

  • Geriatrics: medical care of the aged; a medical specialty.

  • Gerontology: study of aging and the problems of the elderly; healthcare of the aged; preferred term among nurses.

  • Geropsychology: psychology/mental health of the aged; psychologists may hold PhD or PsyD.

  • Social gerontology: social aspects of aging; typically requires a degree in social work, sociology, or related fields.

  • Other specialty areas:

    • Adult-gerontology acute care NP (AGACNP): advanced nursing care for adults/older adults with acute, chronic, or critical conditions.
    • AGPCNP: see above.
    • GNP: see above.

Organizations for Aging and Older Adults

  • Administration on Aging (AOA): principal agency of DHHS/ACL; administers Older Americans Act of 1965; funds state programs for supportive services for individuals >60; mission to create a comprehensive, coordinated, cost-effective system of home- and community-based services.
  • American Bar Association Commission on Law and Aging (ABA): interdisciplinary group to strengthen legal rights and quality of care for elders.
  • Adult Protective Services (APS): state-administered social services program to ensure elder safety; APS caseworkers are often first responders to elder abuse reports; APS TARC provides resources and training.
  • Alzheimer’s Association: voluntary health org for Alzheimer’s research and support.
  • AARP: nonprofit, membership-based lobbying and services organization for people 50+; provides Medicare/insurance discounts, travel/other benefits; founded 1958 by Ethel P. Andrus.
  • American Geriatrics Society (AGS): multidisciplinary org for professionals in geriatrics to improve quality of life and independence in older adults.
  • Centers for Medicare & Medicaid Services (CMS): federal agency responsible for Medicare and Medicaid.
  • John A. Hartford Foundation / Institute for Geriatric Nursing: funds education/grants addressing elder care issues; hosts GITT resources.
  • LeadingAge (formerly AAHSA): nonprofit representing not-for-profit nursing homes, CCRCs, assisted living, and other eldercare facilities.
  • National Center on Elder Abuse (NCEA): national resource on elder abuse research, training, best practices, and resources.
  • National Council on Aging (NCOA): professional membership org promoting dignity, self-determination, well-being of older persons.
  • National Institute on Aging (NIA): NIH institute focusing on aging and Alzheimer’s research.
  • Office of Long-Term Care Ombudsman Programs: state-level offices to protect residents’ rights; ombudsmen investigate complaints and negotiate with facilities.
  • Elder Abuse and Neglect: interventions for community-living adults; APS handles reports and coordinates supports.
  • Mandatory Reporting: states have separate statutes on mandatory reporters (e.g., social workers, mental health professionals, nurses, school personnel, nursing home employees).
  • Gunshot wounds and sexual assault cases: reported to local police/ED; evidence preservation instructions.

Elder Abuse and Neglect; Interventions for Community-Living Adults

  • APS is charged with receiving and responding to elder abuse reports; casework includes emergency housing, medical care, legal assistance, housing, law enforcement, and other supports.
  • Mandatory reporting varies by state; professionals such as social workers, mental health providers, nurses, and others may be required reporters.
  • In LTCFs, document facts about incidents (scene, evidence) in the resident’s chart.

Types of Elder Abuse

  • Financial abuse

  • Neglect

  • Emotional abuse

  • Physical abuse

  • Sexual abuse

  • Use of excessive physical restraints

  • Caregivers under high stress are at higher risk of abusing elders; respite care is recommended for stressed providers.

  • Financial Abuse: clues include ATM withdrawals, large bank withdrawals, excessive credit card use, identity theft, mismatched signatures on checks/documents, strangers managing finances.

  • Potential perpetrators: family members, designated durable power of attorney, conservators, or in-home contractors.

  • Neglect: failure to respond to physical, emotional, or social needs; withholding food/medications/healthcare.

  • Signs of neglect: poor hygiene, dehydration, pressure sores, withholding medications/healthcare.

  • Emotional Abuse: frequent shouting, verbal threats, intimidation.

  • Physical Abuse: unexplained bruises/welts, burns, hair loss patches, bites, inconsistent explanations.

  • Sexual Abuse: coercive acts; signs include torn clothes, discharges, new STDs.

  • Restrictions: isolation, confinement to rooms, restraints to limit mobility, excessive drugging with psychotropic meds.

  • Abandonment: leaving an elder alone without planning for care.

Issues Specific to Long-Term Care Setting

Patient Rights

  • OBRA 1987: major reforms to address nursing home abuse; requires a Patient Bill of Rights poster in staff-accessible area; local ombudsman phone number must be listed.
  • Rights include:
    • Dignity and privacy
    • Self-determination
    • Review of care plan
    • Be informed when treatment changes
    • Voice grievances and communicate freely without fear of reprisal
    • Participate in resident and family groups
    • Be free from mistreatment and abuse

Restraints

  • Right to be free from physical or chemical restraints imposed for discipline or convenience, not required to treat medical symptoms.
  • A sound-minded resident can refuse restraints or any medical treatment.
  • Types:
    • Physical: vests, belts, wrist/ankle restraints, mitts. Prohibited unless medically necessary in Medicare/Medicaid-certified LTCFs.
    • Chemical: Excessive use of psychotropic medications.
  • Adverse effects: functional decline, contractures, pressure injuries, urinary incontinence, agitation, mobility loss, decreased self-image, potential for strangulation or death.
  • Prescribing: document safety interventions; write a prescription if restraints are medically necessary; specify device, indication, and usage; monitor vital signs and symptoms; reassess regularly; release at least every 2 hours and check incontinence.

Residences and Facilities for Older Adults

  • Facilities must be licensed and regulated by the state; most accept Medicare/Medicaid and must be CMS-certified.
  • Long-Term Care Facilities (LTCFs): 24-hour custodial care (nonmedical assistance with ADLs and IADLs).
  • Typical nursing home resident: female, multiple ADL impairments, age 80+, often with dementia.

Types of Long-Term Care Settings

  • Skilled Nursing Facilities (SNFs): provide transitional care after hospital discharge, rehabilitation (PT/OT), skilled nursing and medical care; not age-restricted; can serve chronic conditions (coma, spinal injuries, ventilator dependence).
  • Assisted-Living Facilities: minimal assistance with ADL/IADL; nursing aides available; residents are alert (not dementia patients).
  • Group Homes: residents live together in a residential setting; privately owned; varied ages.
  • Green House Model: 8–10 residents; CNAs form a family-like team; created by William Thomas in 2004; an alternative to traditional LTCFs.
  • Independent Living Retirement Communities: age 55+; minimal-to-no daily assistance; housing options from homes to apartments; amenities like clubs, golf, activities; high entry fees and ongoing fees.
  • Continuing Care Retirement Communities (CCRCs): spectrum of care in one campus; independent living to SNFs; single entrance fee plus monthly fees; flexibility for transitions within campus.
  • Subsidized Senior Housing: HUD programs for low-income seniors; long waiting lists; early planning advised.

Adult Care Services

  • Adult Day Care: for community-dwelling older adults who live with family but need supervision during the day; supports caregivers and reduces social isolation; improves quality of life for seniors.
  • Home Healthcare: care in the home; higher-skilled nursing by RNs/LPNs; ADL/IADL assistance by CNAs; may be temporary or permanent, sometimes termed a "medical home".
  • In-Home Care: provides caregivers/personal care assistants for home-dwelling elders needing assistance.
  • Respite Care (for Health Caregivers Only): short-term relief for the primary family caregiver; alternate caregiver is employed temporarily.

Payment Methods

Reimbursement Terms

  • Accelerated death benefit: life policy feature allowing use of some death benefit before death (e.g., to pay for long-term care).
  • Assignment of benefits: long-term care policy benefits can be paid directly to providers.
  • Authorized representative / representative payee: individual (often a lawyer) who represents an older adult with Social Security benefits in SSA dealings.
  • Benefit maximum: cap on a covered benefit (dollar amount, duration, or number of visits).
  • Benefit period: Medicare hospitalization insurance has a 60-day consecutive-day limit after discharge before a new benefit period begins; finite number of benefit periods.
  • Conservatorship: legal mechanism permitting a court to appoint someone to manage a person’s property if they cannot manage it themselves.
  • Copay (copayment): flat fee paid at each visit or prescription fill.
  • Deductible: yearly amount the patient must pay before insurance begins to pay.
  • Out-of-pocket expenses: costs not reimbursed by insurance (deductibles, coinsurance, copays, and non-covered costs).
  • Third-party administrator (TPA): organization that processes claims without assuming insurance risk.

Forms of Payment (Resources and Assets)

  • Most people fund nursing home or LTC facility costs with their own funds first (cash, bank accounts, stocks, assets).
  • If funds run out, eligibility for Medicaid begins; medical necessity must be demonstrated for Medicaid LTC coverage.
  • Other sources of funding:
    • Veterans benefits (armed services)
    • Long-term care insurance / policy
    • Life insurance settlement (life policy converted to cash)
    • Reverse mortgages (home value converted to cash/mortgage)

Government Programs

  • Medicare: federal health insurance for eligible individuals; administered by CMS; fee-for-service model; funded by payroll deductions (Social Security taxes).
    • Medicare does not pay for custodial care (nonskilled, nonmedical ADLs).
    • Medicare Part A covers inpatient hospital, SNF, hospice, home health; automatic eligibility at age 65 if taxes were paid; those who did not work may not be eligible.
    • Medicare Part B covers medically necessary services, supplies, preventive services; outpatient visits, labs, some screening; mental health; DME; ambulance; limited drugs and immunosuppressants; clinical research.
  • Services Not Covered by Medicare Part A or Part B: acupuncture, most dental care, dentures, routine eye exams, routine foot care, hearing aids, long-term custodial care.
  • Screening and Preventive Care under Part B: abdominal aortic aneurysm screening, alcohol misuse screening, bone density, cancer screenings, diabetes, heart disease, depression, vaccines (influenza, hepatitis B, pneumococcal).
  • Medicare Advantage Plans: private plans that provide Part A/B (and often D) benefits; voluntary enrollment; may pay through HMO networks; has formulary.
  • Medicare Part D: voluntary prescription drug coverage; requires enrollment in a plan.
  • Medicare Supplemental Insurance (Medigap): covers gaps in original Medicare (e.g., drugs) sold by private insurers; requires premium.
  • Medicare PACE (Program of All-Inclusive Care for the Elderly): comprehensive medical and social services for frail elders living in the community; interdisciplinary team; funded by Medicare/Medicaid; includes adult day care, home care, hospital care, labs, meals, rehab, transportation, etc.
  • Medicaid: federal/state program for low-income individuals; can pay for nursing home care; eligibility varies by state.
  • Veterans Health Administration (VHA): largest integrated health system; benefits for service members and eligible veterans.

Legal Terms

  • Living will: documents wishes about medical care if in a persistent vegetative state or terminal condition; activates when patient cannot decide.
  • Power of attorney (broad): designates a person to act on the patient’s behalf for healthcare, finances, and assets in case of incapacity.
  • Power of attorney for healthcare (durable): advance directive that names a healthcare proxy to decide medical care if incapacitated; requires two adult witnesses (proxy cannot act as witness).

Interdisciplinary Team in Geriatric Settings

Types of Clinical Teams

  • Multidisciplinary Team: members from different disciplines meet to discuss care plans; each member creates independent treatment plans and may have a case manager coordination.
  • Intradisciplinary Team: same discipline but different levels of training (e.g., NP, RN, LPN) working together.
  • Geriatric Assessment Interdisciplinary Team (GAIT): several professionals from different disciplines collaborate to maximize health outcomes, continuity of care, and quality of life; 3+ members recommended.

Geriatric Team Members and Roles

  • Geriatrician (MD/DO): physician with geriatrics specialty; medical director possible; manage admissions, prescriptions, rehab referrals, hospital transfers.

  • Physician, Nurse Practitioner (NP), Physician Assistant (PA): medical care providers; roles include admitting patients, prescribing meds, ordering labs/imaging, referrals for rehab, hospitalizations, chronic disease management.

  • Registered Nurse (RN): director or supervisor of nursing staff; handles admissions, transfers, discharge; medication issues; health problem signs; incident reporting.

  • Director of Nursing (DON): oversees nursing staff; hires/fires; interfaces with medical staff.

  • Licensed Practical Nurses (LPNs): trained in vocational/colleges; supervised by RNs.

  • Medical Assistant / Nurse’s Aide (CMA/CNA): basic patient care; vital signs; intake/output; mobility assistance; common duties in LTCFs.

  • Registered Dietitian: dietary assessment and consultations.

  • Physical Therapist (PT): evaluate walking/gross motor skills; design rehab plan.

  • Occupational Therapist (OT): assist with fine motor tasks; assess assistive devices.

  • Speech Therapist: address speech problems; therapy.

  • Nursing Home Activity Director: organizes activities for social engagement.

  • Clergy: visits for spiritual support (e.g., last rites for Catholic patients).

  • Social Worker (MSW): casework; knowledge of social programs, Medicaid/Medicare; helps locate resources.

  • Psychologist (PhD or PsyD): mental health therapy/consultation; cannot prescribe medications.

  • Psychiatrist or Gerontological NP/Adult-Geronontology NP/ Psychiatric NP: may prescribe psychotropic meds; mental health focus.

  • Neurologist: dementia evaluation, seizures, other neurological conditions.

  • Pharmacist: consults on drug interactions and prescription management.

  • Geriatric Interdisciplinary Team Training (GITT): a training program developed with the John A. Hartford Foundation to provide resources for geriatric team training; includes web-based course, manual, curriculum, case studies/videos; live programs available.

Phases of Team Formation (GITT)

  • Forming: group creation; conflict not discussed yet.
  • Norming: appoint leader; establish goals and ground rules; conflicts may arise but are not addressed yet.
  • Confronting/Storming: conflicts become unavoidable; power struggles and leadership disputes.
  • Performing: focus on productivity and problem-solving; regular attendance.
  • Leaving: team may disband; members withdraw.

Ineffective Team Behaviors

  • Interrupting others; late meetings; sarcasm; disrespect; unclear leadership; role ambiguity; beeper/cell phone use during meetings; long breaks.

Recommendations to Minimize Ineffective Behavior

  • Practice strong leadership; facilitator guides meetings and uses collaborative language.
  • Clarify roles and responsibilities.
  • Directly address conflicts; respect among members.
  • Schedule follow-up meetings as needed.

Notes on Relevance and Practice

  • The content emphasizes aging demographics, policy, health systems, and interprofessional collaboration critical for geriatric care.
  • Understanding these components supports ethical, patient-centered gerontological practice and policy advocacy.