Life expectancy in Australia is at an all-time high: pre-school-aged girls can expect to live to 84 years, around five years longer than their healthy brothers. By 2041, the 65-plus age group is expected to make up more than one fifth of the population, posing a number of inter-generational planning challenges.
Although disease and disability are far from synonymous with old age, chronic and debilitating diseases become more prevalent as we age. In 2009, for instance, more than 70% of Australians aged 90 years or older experienced profound difficulties getting around, caring for themselves and/or communicating.
In particular, the chances of developing dementia increase substantially with ageing. In those aged 95 years and over, prevalence of dementia escalates to 37% for men and 47% for women.
Dementia occurs because of changes in the brain, mainly from Alzheimer’s disease or vascular deterioration. Communication, in particular, is generally affected. Cognitive and functional deterioration tends to progress slowly, but inexorably, to death.
Concurrent illness in old age is now a major issue in health care and its impact crosses care settings. There is a growing group of older people who are frail and unwell in the years when they draw close to death; our challenge is to meet their care needs.
Caring for the aged
When concurrent illness occurs, care complexity increases. For example, recognising angina when a person has dementia requires special skills. Also, old age brings about physiological changes that impact upon treatment choices such as medication dosages. Therefore, there’s a growing need for health professionals with appropriate expertise.
Nurses have a key role to play in the health-care team. In particular, they aim to enhance quality of life and minimise suffering. To achieve this end when caring for older people, especially when there are complex care needs, two critical nursing skill sets are required.
Firstly, nurses must have a good understanding of normal age-related changes and the illnesses and conditions most likely to occur in older people, along with related treatments. This is known as gerontological nursing expertise.
Secondly, nurses need a thorough understanding of the principles of palliative care and how these may be applied in the care of older people. Palliative care is appropriate in any life-limiting condition and aims to holistically and proactively address quality of life and dying; it doesn’t attempt to lengthen or shorten life. Importantly, it includes supporting the patient’s family through the illness and in bereavement.
Palliative care can be delivered by appropriately skilled and knowledgeable care teams in any setting with support from specialist palliative care services when needed. Australian evidence-based guidelines inform the delivery of this approach in both residential and community aged care.
Getting the right care
Older people receive care in hospitals, residential aged care, and in their own homes. Ensuring sufficient and appropriate nursing expertise across all these settings is one key step towards attaining excellence in aged care delivery. To neglect this issue puts us all at risk as we grow old.
A number of recent budget announcements recognised the fundamental importance of aged care. One widely welcomed measure was the projected increase in the number of packages to provide care in older peoples’ homes. But questions remain about whether we have the workforce to provide this care.
Ensuring that suitably qualified nurses are available on every shift to coordinate, oversee, and drive quality must be a minimum standard wherever care is delivered. But it’s arguably more difficult to attain the same level of professional input across multiple home care settings than in a hospital or residential facility.
There is a danger, therefore, that nursing shortages will lead community aged care, in particular, to become a poorer quality option, and unduly reliant on family carer oversight of support workers.
To avoid this situation, we need to look closely at nursing workforce planning. As the Australian Nursing Federation has highlighted, pay differentials between the hospital and aged care sector, the shortage of nurses, and the need for appropriate education and training for nurses are all key and interdependent issues.
While recognising the need for an increasing emphasis on aged care nursing as a specialty area in hospital settings, there is also an urgent need to address professional nursing practice models in residential and community aged care. In particular, we need to redefine the role of the nurse in such long-term settings and recognise the extensive nursing expertise required to care for ageing patients with complex care needs.
While some positive changes are already occurring, including initiatives to promote teaching and research in aged care services, further nursing-specific initiatives are essential.
One suggestion is to mirror the American Nurse Credentialing Centre’s Magnet Program, which recognises hospitals meeting key criteria as centres for nursing excellence. Such a step would encourage and help empower aged care nurses to take leadership roles in the promotion of clinical excellence.
A credentialing program would also help ensure more widespread recognition of the extensive nursing knowledge and skills required to provide care to frail and unwell older Australians well into the future.