Older Adult Relocation: Considerations for Nurse Practitioners
Article Outline
- Abstract
- Population Trends
- Individual Considerations
- Family Considerations
- Community Considerations
- Health Care Considerations
- Exemplar
- NP Responses
- Conclusions
- References
- Copyright
Abstract
The projected trends of the senior and baby-boomer population represent a projected demographic change that is nothing short of astounding. The nation's older adult population will continue to swell and, by 2035, will make up approximately 18% to 23% of the total population, nearly doubling this current age segment. With this significant and inevitable shift in demographics, individual, family, and community needs will increase proportionally. Nurse practitioners in primary care settings need to be cognizant of these trends and provide proactive assessments and health promotion advice to older patients and their families.
Keywords: community , family , individual , older adult relocation , population trends
The projected trends of the senior and baby-boomer population represent a demographic change that is nothing short of astounding. The nation's older adult population will continue to swell and, by 2035, they will make up approximately 18% to 23% of the total population, nearly doubling this current age segment.1 With this significant and inevitable shift in demographics, individual, family, and community needs will increase proportionally. Nurse practitioners (NPs) in primary care settings need to be cognizant of these trends, and provide proactive assessments along with listings of community resources accessible to older adults and their families.
Population Trends
National trends indicate that the dramatic increase in the older adult population will either “age in place” or migrate to other parts of the country. Aging in place is defined as remaining within a relatively confined geographic region in which one has resided for most of one's life. Slower growing metropolitan areas in the Northeast and Midwest will become disproportionately older and will have marginal financial and wellness resources. Additionally, projected demographic phenomena will involve the movement of particular segments that will migrate to the suburbs from metropolitan areas. Even though they relocate within a region, they will nonetheless change the demographics of that region. These suburbs will become considerably “older” than the cities themselves. Suburbs projected to be affected by this shift will include those around New York, Philadelphia, Chicago, and Los Angeles.2
Significant changes in demographics will occur as seniors move into other regions in the United States. The rapidly growing, economically dynamic areas of the Sun Belt, such as Las Vegas, Austin, Atlanta, and Dallas will see a significant aging of their population. Additionally, the Intermountain West and South Atlantic states will experience high-growth influxes of the senior population. The Western portion of the United States will experience up to an unbelievable 140% increase in growth of seniors 65 years and older through 2030.2
Regardless of which region, the upcoming and dramatic demographic surge of seniors will impact all aspects of society. Adjustments of individual, family, and community will be experienced. A basic understanding of each of these areas is necessary to begin to meet the demands and create an environment of optimal health promotion.
Individual Considerations
Psychosocial Considerations
The process of relocation may be precipitated by a multitude of factors. A staged, gradual process may serve as the basis of a move, or a move may be precipitated by an illness, resulting in a precipitous relocation. Regardless, this human experience will affect quality of life and living satisfaction. Attachment of personal meaning in the decision-making process and the subsequent life changes will influence factors of adjustment.3 Gaining an understanding of the meanings attached to a relocation event through astute interviewing may positively influence the adjustment process. Additionally, helping to generate interventions to enhance positive thinking and fostering learned resourcefulness may help to create favorable responses to the relocation process.4
Health Care Determinants
The older adult population, some 70-million strong by 2030, presents unique challenges and medical needs that are different from younger adults.5 As an example, the average 75 year old has 3 chronic conditions and uses 5 prescription drugs. After a relocation event, as older adults present to primary clinical settings to establish care, important areas of assessment need to be considered. Older adult functional status, such as self-care behaviors associated with health and hygiene needs (activities of daily living [ADLs]), as well as abilities to remain independent (instrumental activities of daily living [IADLs]), are vital assessments that need to be made by NPs. Within these areas, we can assess a milieu of elements that will help facilitate health promotion. Physical, emotional, cognitive, family, social, and cultural needs and concerns can be assessed within these 2 functional frameworks. The national report of the Merck Institute of Aging and Health5 identifies 15 indicators that relate to general health status, health behaviors, preventive care and screening, and injuries (Table 1). Additionally, the 3 agencies (Merck Institute of Aging and Health, Centers for Disease Control, and Gerontological Society of America) of this report collaborate and collect data, providing a report card that measures state against state. Interestingly, no state meets all targets; however, a majority of states are meeting standards for pneumonia vaccine and colorectal cancer screening. There is certainly room for improvement. These indicators can add to an NP's overall history-recording process
Table 1. Modifiable Risk Factors of Older Adults5
| Physically unhealthy day |
| Frequent mental distress |
| Oral health: complete tooth loss |
| Disability |
| No leisure-time physical activity |
| Eating 5 or more fruits and vegetables daily |
| Obesity |
| Current smoking |
| Flu vaccine in past year |
| Pneumonia vaccine |
| Mammogram within past 2 years |
| Sigmoidoscopy or colonoscopy screening |
| Up-to-date on select preventive services |
| Cholesterol screening |
| Hip fracture hospitalizations |
During a short office visit, it is important to direct questions that assess various aspects of the function framework. The practitioner might find it helpful to develop a template containing a few questions that will assess the general health status, ability to perform self-care, preventive care and screening, and family involvement. These templates can be made assessable in each exam room.
Family Considerations
The relocation of an older adult may often result in changes in family and household dynamics. It is estimated that 18 million adults—4.9 million households—provide some form of care for someone who is older than 65. Because of the ensuing older adult demographic changes, these numbers are expected to increase dramatically through 2030.6 It is estimated that the value of the services family caregivers provide amounts to $306 billion a year, which amounts to twice as much as that spent on home care and nursing home services combined.7 Specifically, a phone survey of 1000 family caregivers found that the average yearly out-of-pocket cost of providing care was $5531. This represented approximately 10% of the $43,026 median income of the respondents. Common cost expenditures were: household goods, food and meals (42%), transportation and travel (40%), and medical care co-pays and pharmaceutics (31%).8 Informal care provided by children of older adults helps provide a vast quantity of elderly long-term care in the United States, thus prolonging and often preventing placement of older adults into long-term facilities, as well as frequent hospitalizations. The most recent data indicate approximately 66% of Medicare enrollees 65 and older receive personal care for a chronic condition by an informal care process. Informal care is defined as care provided by family, whereas formal care is care provided by trained individuals, such as home health care and nursing home care.9 Approximately 26% receive care from both informal and formal modes. The remaining percentage receives formal care only.10 From these data, one could extrapolate that, in any given family situation of elder relocation, it is likely that care would be provided by a family member.
Along with older adult relocation, families often undergo definitive stages or phases when transitioning into caregiving responsibilities. These stages and phases lead to changes in identity, the development of new roles, and redefinition of relationships and support strategies.11 Additionally, significant role strains can take place as families make the transition to caregivers. Marital disagreement and psychological well-being can be affected, not surprisingly, by becoming a parent caregiver. The overall well-being of a caregiver's marriage is thought to be contingent upon baseline marital role quality as well as the nature of the caregiver transition and the context in which the process occurs.11
Community Considerations
The understanding of available resources can be daunting for the older adult who has relocated to a new community. Within the clinic setting, assessing previous integration and use of community resources by the older adult in his or her previous community may provide an NP with an understanding of the individual's willingness to use various available resources. Whether relocating from a rural setting or a large metropolitan setting, understanding how reliant the individual(s) were on community elements such as church, health care, transportation, and social services may prove helpful in future provider decisions. Moreover, determining receptiveness to use existing community resources will give insight of likelihood of the older adult's use of community resources. Developing a readily available list with appropriate agency phone numbers may prove useful for the older adult and family members.
Communities will no doubt feel the strain of increased demands created by the dramatic “graying” of our population. Issues relating to health care access, payment ability, and long-term care represent some areas that will encounter significant system burdens. Current data from 2003 indicate that Medicare accounts for approximately 53% of all sources of payments for those 65 and older, Medicaid payments make up 9%, out-of-pocket payments 19%, and other sources 19% of total health care service payment sources. The available statistics that examine health care expenditures explore past data but provide no forecasting of future expenditures of federal and state programs.12 One wonders if the system can endure the demands of the impending changing demographics.
Health Care Considerations
Health care considerations are one of the most important elements in an older adult's decision-making regarding where he or she would relocate.13 Given the known changes in population dynamics that will soon be upon our communities and probable demands that will ensue, it is imperative that NPs partner with community organizations to ensure optimal community health. An example of a unique grant-derived program that “helps communities develop leadership, innovation, solutions and options that meet the needs of older adults over the long term” is the Community Partnership for Older Adults Project sponsored by the Robert Wood Johnson Foundation.12 This project currently has provided $28 million to fund 16 communities around the United States to improve the long-term care system through engaging community-based organizations, older adults, policy makers, and other stakeholders to create a proactive plan to best meet the needs of older adults. Broome County, New York, provides a comprehensive report outlining its strategic plan that was created from this project.14 Ten themes were identified by participants as critical elements for optimal older adult (Table 2). These key indicators serve as the foundation for community planning and actions.
Table 2. Important Issues that Enhance Older Adult Health12
| Caregiver support through transitions |
| Social connections |
| Home repair and modification |
| Legal and financial planning |
| Mental health |
| Managing chronic illness |
| Understanding of and access to services |
| Affordable and appropriate housing |
| Health and wellness maintenance |
| Transportation |
The Community Partnership for Older Adults Project in Broome County exemplifies how a core of concerned, motivated individuals can partner with multiple organizations to create a common vision and ultimately create mutually beneficial solutions that would ordinarily be beyond the scope of any single organization. The beginning of the process involved 110 individuals including seniors, caregivers, service providers, and practitioners who convened in a forum. The forum highlighted locally conducted qualitative and quantitative research.
Twelve small groups responded to the data presented, asked probing questions about community needs, and then identified the above-stated critical issues. Surveys then queried seniors and their caregivers in the county to prioritize these items. The top 4 concerns were: caregiver support through transitions, managing chronic disease, staying socially connected, and understanding and accessing services. Afterward, during this 18-month project, 3 work groups addressed how these 4 top issues could be addressed by the community.
A second forum was held to identify and address any additional community issues. For each issue, short-, intermediate-, and long-term objectives were established for future evaluation purposes. Moreover, while the above-described activities were taking place, another group was working to procure grant monies for implementation of the identified concerns. Overall, this project can serve as a template for local proactive services that can ensure healthy older adult communities in the face of significant changes in older adult populations. It emotes opportunities for communities.
For the NP in a primary care setting, understanding and developing social networks within the community is invaluable; its importance cannot be understated. Granted, this is a process that takes time, but nevertheless represents an integral part of a practitioner's arsenal of readily available resources that help the patient and family adjust to this unfamiliar part of life's journey. Specific examples of helpful listings might include key contacts within the local county Department of Aging, mental health counselors, legal service representatives, church contacts, reputable home improvement contractors, and public and private transportation carriers.
Exemplar
The following scenario represents general issues that may be revealed at any given encounter with an older patient. Actively listening, along with directed querying, will help the stories unfold, ultimately allowing the provider, patient, and family to effectively optimize the health of the newly located older adults.
Consider a couple in their early 80s who have moved to “the city” after spending all of their lives living in a small rural town. Their story unfolds as you are assessing the 84-year-old husband, accompanied by a family member who is concerned his father may be depressed. The patient's symptoms include excessive sleeping, apathy of daily activities, and emotional apathy. As you begin the questioning to assess for depression, they proceed to relate the events of the last 6 months.
The decision to move was met with excitement and anticipation by the wife, while the husband longed to stay. Finally, after family discussions, the reluctant spouse agreed to proceed with the move. Selling the house, downsizing possessions, finding housing in a new city, moving, and settling into a new abode all represented incredible challenges for the couple and their family.
Once the move was completed, the couple and family found new unanticipated challenges. Considerations of driving (ie, heavier traffic and unfamiliar locations) beset the couple with a degree of social isolation. The couple was comfortable enough to drive to a close grocery store, but hesitant to venture any further into the city; thus, they rarely drove beyond the safety of a few familiar roads. Further exploration of the city was not practical. Public transportation is available, but neither has ever ridden a bus and neither is receptive to learning how to ride. A sense of uncertainty also prohibits them from using a taxi service. Subsequently, the closest family member becomes responsible for transporting either parent to locations not previously traveled. The burden for the family will seemingly grow. As the patient and family members talk, their sense of frustration shows. As the visit concludes, your patient is willing to try a course of antidepressant medication but is unwilling to seek counseling. You are left with a sense that this individual and family needs additional resources to help facilitate the adjustment of the relocation.
NP Responses
The inevitability of the burgeoning older adult population and probable relocation occurrences will create significant challenges for the NP working in primary care settings. Data that address best-practice interventions for this population, within the context-population-based interventions, are limited. Instead of viewing the paucity of data as a limitation, the NP needs to embrace this impending situation as an incredible opportunity.
As providers striving to promote optimal health of individual, family, and community, such as those presented in Healthy People 2010, it becomes apparent that NPs need to recognize and become an active part of the greater community.15 NPs will need to arm themselves with the knowledge and understanding needed to confront the demographic changes that will take place, in order to partner with various community agencies, work with and develop relationships with key community individuals, and network with policy makers locally and beyond. In particular, strengthening and developing new collaborations will aid in care interventions when providers are confronted with relocated older adults.
The need to gain a better understanding of the health needs of older adults who relocate requires further research from the NP. The opportunities for research abound. Use of primary, secondary, and tertiary preventative practices can provide platforms for research activities.
Conclusions
Older adults who relocate will make up just one segment of a dramatic demographic phenomenon that will impact us as providers and consumers. The older adult population will present many challenges for NPs as we attempt to deliver holistic and highly individualized health care. Involving the patient's family in the process will lend to a healthier environment for all involved. Lastly, the onus is on us as a profession to actively partner with our communities to proactively develop solutions that creatively address the needs of the older adult population.
References
- . Population Estimates by Race, Hispanic Origin, and Age for States and Counties . Available at: http://www.cnesus.gov/press-release/www./releases/archives/population/007263.html 2006; Accessed October 10, 2008.
- . In: Mapping the Growth of Older America: Seniors and Boomers in the Early 21st Century . The Brookings Institution: Metropolitan Policy Program Living Cities Census Series; 2007;p. 1–27
- . Elderly relocation to a rural congregate setting: personal meaning and perceptions related to decision to move and overall adjustment . J Nurs Sci . 1996;1(3–4):105–114
- . Milieu change and relocation adjustment in elders . West J Nurs Res . 2008;30:113–129
- . The State of Aging and Health in America . Available at: http://www.cdc.gov/aging/pdf/State_of_Aging_and_Health_in_America_2004_pdf 2004; Accessed October 21, 2008.
- . Historical overview: lessons from the past, challenges for the future in family caregiving . Am J Nurs . 2008;108(9):16–22
- . Informal care and health care use of older adults . J Health Econ . 2004;23:1159–1180
- Evercare study of family caregivers—what they spend and what they sacrifice: the personal financial toll of caring for a loved one . Available at: http://www.caregiving.org/data/Evercare_NAC_CaregiverCostStudyFINAL20111907.pdf 2007; Accessed April 10, 2009.
- . Informal care and health care use of older adults . J Health Econ . 2004;(23):1159–1180
- . Older persons relocating with a family caregiver: processes, stages, and motives . J Appl Gerontol . 2007;26(2):182–207
- Choi H, Marks NF. Transitions to Caregiving, Marital Disagreement, and Psychological Well-Being. Center for Demography and Ecology- A National Survey of Families and Households, University of Wisconsin-Madison. NSFH Working Paper No. 90; 2004.
- Agingstats.gov. Available at: http://www.agingstats.gov/aging/statsdotnet/main_site/data/2006_documents/health_care.pdf. Accessed October 20, 2008.
- Community Partnerships for Older Adults. A National Program of The Robert Wood Johnson Foundation . Available at: http://www.partnershipsforolderadults.org/aboutcpfoa/indexx.aspx Accessed October 20, 2008.
- Aging Futures … Older Adults Living Well as They Define it. A Community Partnership for Older Adults Project . Available at: http:/www.gobroomecounty.com/agingfutures/demographic.php Accessed October 29, 2008.
- . Healthy People 2010, 2000 . Available at: http://www.health.gov/healthypeople Accessed October 5, 2008.
In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
PII: S1555-4155(09)00293-1
doi:10.1016/j.nurpra.2009.05.015
© 2010 American College of Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
