Two new programs at Fletcher Allen Health Care are changing the face of hospital care for older patients – and just in time. Right now over 30 per cent of all inpatient admissions to FAHC are persons over age 65. By 2020, the number of people aged 65 and over in the Burlington area is going to double.  In recognition of these stark facts, a team from Elder Care Services and Nursing Education and Research is training interested nurses from any service in geriatric nursing, and assuring that older patients get targeted interventions to prevent acute confusion or delirium, a common complication when old folks are ill or hospitalized.

A registered nurse for twenty-five years, Cathy Tatro has worked in home care, critical care, and medical-surgical nursing. Recently she has become a FAHC geriatric specialty nurse, as a result of attending classes in NICHE (Nurses Improving Care for Health System Elders), a program found in hospitals around the country. "My NICHE classes have helped me to avoid stereotypical approaches to elderly patients," Tatro says. "We don't automatically medicate or write off confusion or agitation to old age. We look for treatable reasons behind the behavior." When a patient is confused, for example, Tatro now tries dimming the lights or playing music. For agitation, she may investigate whether the patient is in pain or constipated or having a drug reaction and then act accordingly.

"Simple interventions can make a real difference in care for the elderly," says Sue Goetschius, a gerontological nurse practitioner, who initiated NICHE at FAHC three years ago. "We try to make nurses more aware of syndromes and conditions common to aging patients," she says. For example, when an older person comes into the hospital diagnosed with pneumonia, his or her care should involve more than just a course of antibiotics to treat the infection. A nurse trained in geriatrics would discourage bedrest and encourage pre-illness activity. She or he would look at potential problems, such as making sure that the patient can get up out of a chair safely and walk well before being discharged. Since these abilities are strong predictors of safety at home, declines here may lead the nurse to suggest physical therapy and home health assistance to the family. A nurse trained in geriatrics would understand the at-home service options available in the community from organizations like the Visiting Nurses Association and the Champlain Agency on Aging

In 2004, Goetschius used grant funding from the Frymoyer Scholarship Program to start NICHE at FAHC. At that time she was the only practicing geriatric nurse specialist at the hospital. Today, there are some 70 geriatric specialty nurses, at least one on each hospital floor. "The idea is that every GSN can be a source of geriatric information for the staff and nursing students on his or her floor," Goetschius says.

In three NICHE classes offered in both Spring and Fall semesters, nurses learn about the biology of aging and how older patients can present diseases differently than younger ones: how medications may affect them, how sleep patterns, eating, and skin resiliency change with age. They learn to be willing to explore problems, not just assume they are normal for old age. They learn that maintaining function is important, that cures are not always possible, practical, or necessary. "Get the ability to transfer from bed to chair back," says Goetschius. "De-emphasize the perfect blood sugar. Get that patient up and moving." Good geriatric care "is not so much about curing, as it is about caring," she says.

HELP (Hospital Elder Life Program) is FAHC's latest response to the specific challenges of older hospital patients. National studies show that from 34 to 50 per cent of these patients suffer physical and cognitive losses as a result of their hospital stay. These declines may be associated with delirium or acute confusion and are often caused by common hospital interventions, like pain medications, prolonged bed rest, and medical equipment such as indwelling bladder catheters. Like the NICHE approach, HELP focuses on care for the individual and simple and practical interventions.

Research has shown that there are six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, vision impairment, hearing impairment, and dehydration. HELP deals with these issues by providing vulnerable patients, 70 and over, with equipment for improving their hearing and vision; a non-drug sleep protocol promoting relaxation; therapeutic activities for mental and social stimulation; and a daily visitor to provide quality time for communication and social support.

Although these interventions seem simple, they are not usually available in a busy modern hospital. HELP, started in Yale and now used in 43 hospitals across the country, meets the challenge with an interdisciplinary team – hospital personnel with geriatric expertise linked to trained and supervised volunteers. Studies at other hospitals show that HELP reduces delirium and prevents functional and cognitive decline.

Volunteers are assigned to individual patients and work a three to four hour shift once or twice a week They visit and socialize, encourage patients to eat, and make sure that lighting is adequate for reading. They walk with patients, encourage them to move about and exercise in bed. Currently seven volunteers have signed up for the sixteen hours of intensive classroom and small group training required. Then they are paired with a staff member for another sixteen hours of "shadowing" a professional. After their training, Elder Life Specialist Shelly Barton, RN checks the competency of the volunteers in all of the interventions before they are cleared to work independently with patients.

Crystal Variava, a UVM senior, majoring in speech and hearing with a minor in gerontology, has finished her HELP training and has started to work with patients. "It's the small things that make a difference," she says. On her first day, she was assigned to a woman who needed to eat and drink more. When a nurse brought medications and a glass of water, the patient refused the water. After checking with the nurse, Variava asked the patient if she wanted ice in the water. With the ice, the patient finished the whole glass and asked for more.

"Hospitalization has been described as extended periods of boredom, punctuated by periods of discomfort," says Barton. "HELP tries to ensure that older patients remain as stimulated and independent as possible throughout their hospitalization."

Barbara Leitenberg writes on senior issues for the Champlain Valley Agency on Aging. This article originally appeared in the Burlington Free Press.