Telephone Nurses face a special challenge when assisting elderly clients with their health care needs. Nursing practice areas that often work with seniors include family practice and internal medicine offices and clinics, home care and hospice, health care services dealing with chronic illness and specific disease processes, and community service health lines.

The focus of this issue is Telephone Nursing with Seniors, emphasizing how the telephone is used to educate, support and counsel those patients who are over age 65, along with their caregivers and families. Caregivers often play a prominent role in health care decisions for the geriatric population, although some elderly live alone and/or a distance from family members. In fact, dramatic increases in the number of elderly living alone in the future is expected.

It should be noted that issues related to institutionalized elderly are not addressed in this ezine. Nursing home or hospitalized patients are normally managed by a primary care provider -- and thus are normally excluded from discussions of telephone nursing advice lines either in the community or after-hours setting.

The aging process and the circumstances of the older person are included in the field of study now known as Gerontology -- a multidisciplinary science that includes the biological, behavioral and social aspects of aging life. One of the goals of Geriatric nursing is to maximize the positive aspects of aging and improve quality of life.

Most older Americans have at least one chronic condition and many have multiple. Best health can be achieved by working with both healthy and ill clients, delaying the onset of chronic disease and maximizing function despite diseases that may occur.

Geriatric Telephone Advice Has Gray Areas

by: Kathi Webster BSN RN

As babyboomers move quickly toward age 65, the majority of Americans will soon be gray haired. According to one 1994 study, 33.2 million Americans (12.7% of the U.S. population) are 65 or older. By the year 2000, projections say 13% of the American population will be over 65, while by year 2030, 70 million or 20% Americans will reach that age group. Another study gives January 1, 2010, as the "day of reckoning" when the oldest boomers reach age 65.

This demographic trend indicates a future with an increasing demand for long-term care services with more health care and social support services to help maintain the physical, social, and mental health of older adults. Statistics show older Americans accounted for 36% of all hospital stays and 48% of all days of care in hospitals in 1993. The average LOS (length of stay) for older adults was 7.8 days, versus 4.9 days for people under age 65.

Nurses on almost all telephone health lines communicate regularly with elderly clients, unless their service is specifically focused on the pediatric or young adult populations. Disease counseling services target the senior population due to their use of health services.

Elderly callers pose special challenges to a Telephone Nursing advice service.

• Guidelines or protocols used for younger populations may not address the needs of the elderly. Assessment and intervention tools should include symptoms related to the most common acute and chronic complaints of elderly callers. The most frequently occurring chronic conditions in the elderly are: arthritis (49%), hypertension (35%), heart disease and hearing impairments (31% each), orthopedic impairments (18%), cataracts and sinusitis (15% each), along with diabetes, tinnitis and visual impairments (10% each).

• A medical history of chronic illness especially when multiple diseases exist can cloud the patient assessment so that symptom-based guidelines or protocols no longer fit. In this circumstance, the patient must be referred to their primary care provider for assessment and problem resolution.

• The list of prescribed and over-the-counter medications may be lengthy. Common problems seen with seniors and medication therapy include: non-compliance to prescribed medications, accidental overdosage, failure to recognize side effects or adverse drug reactions/interactions, inability to afford medications, and lack of knowledge about the dosage or purpose of medications.

• An older adult may attribute symptoms (such as pain or weakness) to the normal aging process, thereby delaying the diagnosis of a serious condition. In addition, fear of hospitalization or institutionalization may cause denial of problems. Health education with seniors is a vital part of telephone nursing.

• Mental health status may interfere with the patients ability to communicate their problems clearly and comply with advice given. Some studies estimate that 5% of people over 65 and 20% of people over 80 suffer to some degree from dementia, with the most common cause being Alzheimer's disease. According to the Institute of Brain Aging and Dementia, the problem of dementia affects over 4 million Americans, is the 4th major cause of death, and costs society $100 billion annually. In addition, depression in the aged is a major public health problem. Assessment of mental status is especially important with older patients.

• Poor historians are found in all age categories by advice nurses. With elderly clients cardiovascular disease, dementia, stroke symptoms, medication, mental problems or poor memory may contribute to a 'fuzzy story' during a telephone interview. Traditionally triage nurses have referred poor historians to their primary care providers or ensured they received a timely appointment for exam.

• Hearing impairments affect a large percentage of seniors. Good communication via telephone is difficult when the nurse must yell to be understood. Telephone equipment that allows an increase the volume for a hearing impaired caller can help. According to the National Institute on Deafness, age-related hearing loss affects 30 to 35 percent of the United States population between the ages of 65 to 75 years and 40 percent of the population over the age of 75. In addition, in order to be in compliance with the Americans with Disabilities Act and/or organizational policies, some health advice lines provide TTY/TTD (teletype/telephone text) telecommunications access to patients with hearing/speech impairments.

• Low vision or vision impairment can make it difficult for a telephone nurse to effectively help an elderly client. These patients may be hesitant or refuse to write down advice or referrals given (often requested by an advice nurse) as they know they will not be able to read their own handwriting later. Ability to read a thermometer or medication labels may be affected. Despite the availability of surgery in the U.S., cataracts remain an important cause of visual loss or blindness. One U.K. report states 66 per cent of people with impaired vision are over 75. In other words, more than one person in five over the age of 75 is blind or partially sighted. Most of these have lost their sight in later life, as their eyes deteriorate with age. Six out of ten visually impaired people have another serious illness or disability while many have more than one.

• A good assessment of the 'norm' becomes vital. When assessing a new complaint, the nurse must scrutinize how the activities of daily living (ADL) have changed. Questions like "What happened today that was different?", or "How has your problem changed that you are concerned now?" are helpful in determining changes in health status of an elderly caller.

• Transportation to needed health services may be an issue for senior callers. Although the number of elderly population holding driver's licenses increased from 45% in 1970 to 72% in 1990 according to a transportation study, seniors avoid driving at night, during peak hours, or long distances. Elderly with low incomes may no longer own their own car. Telephone nurses should develop lists of alternative transportation resources available in the community.

• "Ageist" and judgemental attitudes can impact good listening skills. Some health care providers may have a relative unwillingness to listen to older people, and sometimes an actual aversion to having older people as patients, per a National Institute of Health consensus statement. One Australian study found nurses may have negative attitudes toward elder care starting in nursing school. Educational programs for telephone nurses should stress the importance of a positive and caring approach to geriatric healthcare.

• Female caregivers are often the first contact for problems related an elderly family member. In a national VA study, 41% of homebound veterans were totally dependent on caregivers to place telephone calls. Caregivers often do not attend to their own health problems because of the demands of caregiving, and the advice nurse is often challenged to provide appropriate support and reassurance to the caregiver(s) as well as the elderly client.

  Senior care or “geriatric care management” is a rapidly developing and newly recognized profession -- as is Telephone Nursing. Nurses working with elderly patients should take advantage of all resources to understand the special problems of their clients, along with sharing in the rewards of assisting them to leading fuller lives.

  Kathi can be reached via email at: tnt@katsden.com

North Carolina Sends A Line

Dear TNT,

I've been "doing" telephone triage for two years now and love it! I live and work in Winston-Salem, NC. After 4 children I realized I couldn't afford child care anymore and found this career (don't want to call it a job). Our nurses are able to work from home in a quiet room. We utilize beepers and are paged through the answering services. In the summer, when we're not as busy, we can still enjoy family life, but in the winter, well, we all have "numb butts"!!!

"Our" triage company consists of approximately 15 RN's. We do solely after hour and weekend work from home utilizing beepers, phone and plain old paper forms. As of (hopefully) December 1st we will all be on computers. We take "first call" for the physicians we contract with for their patients. The MDs still are on first call for nursing home, MD, and hospital calls. We have standing orders from each individual practice that we follow and an extensive protocol manual which has been read and approved of by many MD's (don't know the exact number). The majority of the practices are family practice, but we do have some OB\GYN and Pediatric groups. The RN's that take Peds calls all have extensive experience in Peds. I work every W/E 8A-8P and help the family practice groups. We generally handle about 40 calls/day. Last winter my busiest was 70 calls in 12 hours. We ought to be able to handle more when we become computerized. We are very "patient teaching" oriented, going that extra mile to make sure everything is understood and all questions are answered before ending the call.

My employer has asked me to be responsible for continuing education for our nurses and I have found all your information to be of wonderful help. Thank you so much for all your hard work

Sincerely,

Jan Daniel
Email to:RNteletalk@aol.com
[Readers who wish to chat with Jan are encouraged to contact her personally]

More to Tell on Hospice

Dear TNT,

Until 1994 our Hospice provided its patients with afterhours support by having the caregivers call an answering service which then in turn paged one of the three hospice oncall nurses, the nurse then called the service obtained the phone number and called the PCG (patient caregiver) and determined whether a nursing visit was required, etc. Then in the fall of 1993 as part of a cost containment effort, the management proposed changing the format of afterhours care to a triage system. The result was phone line staffed by hospice nurses with hospice beeper nurses available to do home visits if situations warrented.

Quite frankly as one of the oncall nurses, we were against the idea. Until this point, we had been assigned to a specific primary care team (now a region) and attended team meetings at least monthly. The oncall staff identified with their patients and got to know the families quite well; we felt like an afterhours primary care nurse. But our objections were overrulled.

The sytem has evolved over the last three years. We began with 4 triage nurses, one per shift: M-F evening and night, Saturday/Sunday day and nightshift each of which is/was 12 hours. We had three hospice beeper nurses (1 per region), we now have 4 beepernurses on standby each shift, one for each regional office. We have 2 triage nurses on the phones now at peak times, Saturday/Sunday day shift (0800-1800) and M-F 1800-2200.

We support weekend admissions with special admission nurses assigned and scheduled by the region; we also obtain intake information from physicians, and the community at large; scheduling liaison and admission visits for the following week or if necessary over the weekend. Using our computer system we have access to a patient's file which includes med list, insurance information and in some cases nursing and social work notes. (Obviously, this data is only as good as it is current!)

Now after three years of triaging, I must admit that the system works -- and works well. PCGs are relieved to reach a nurse on the first call. For hospice families who may have just experienced the death of a loved one, making only one phone call is a relief. For patients in crisis, the voice on the other end is able to begin the process of symptom management immediately. Non-hospice medical professionas frequently are unaware that in hospice there are true medical emergencies; after all, isn't death the ultimate medical emergency? But there are emergencies: like pain out of control, respiratory distress, cord compression and superior vena cava syndrome. Also, because of the nature of our work, psycho-social issues are often an additional component. Dying has a way of magnifying family dysfunction, and caregiver stress is often present.

The emotional toll of hospice nursing is high and having been a primary care nurse for terminally ill pediatric patients, I find the stress of hospice triage nursing no less so. As a triage nurse you cannot change assignments your next shift or switch with another primary care nurse for a break, you never know who is going to be on the other end of the telephone line and what the next problem will be. We often must say difficult things to caregivers without the benefit of body language to signal when we need to stop. Often, it is listening between the words that is the most important part of the job.

I'd been a primary care nurse for three years before I came to triage, and it was six to a year before I had learned the nuances and instincts that took me toward the art of triaging hospice patients. I do know that I may not see my patients, but they have taught me an enormous amount with their words and silence, their legacy continues with me for each lesson I learn.

Well, that's just a slice of hospice triaging,

Sincerely.

Denise E. Skinner, RN BSN
Email: HATTERAS8@aol.com
[Readers who wish to answer and chat with Denise are encouraged to contact her personally]

Geriatric Assessments

Assessment in Telephone Nursing focuses on having organized and systematic way of obtaining health information. One Internet resource states that "about 85% of important information may be obtained through detailed questioning during the health history, and another 10% of information may be gained from the physical examination."

Several resources are available on the Internet to educate nurses on the best approaches to geriatric assessments.

The National Institute of Health (NIH) has sponsored the ongoing development of consensus statements from healthcare experts on a variety of topics. One such statement focused on geriatric assessment was issued in October 1987. The document is entitled Geriatric Assessment Methods for Clinical Decision Making. This is an excellent resource and is not to be missed.
URL is at: gopher://gopher.nih.gov:70/ORO-36818-/clin/cdcs/individual/65.geriat
[Most web broswers can access gopher sites by placing the above in the URL window]

University of Florida physicians have established some wonderful Geriatric Education resources on their Web page. The project is referred to as Geri-Ann and covers each of the five "I"s of Geriatrics (Iatrogenic Issues, Impaired Intellect, Instability, Impaired Homeostatis and Incontinence). An outstanding resource.
The URL is at: http://www.med.ufl.edu/medinfo/geri/topics.html

Physicians at Columbia University via the School of Dental and Oral Surgery have done an superb job with their MEGA site -- Multidisciplinary Education in Geriatrics and Aging. They developed these online modules to teach graduate and undergraduate students in the health sciences basic concepts in geriatric care. There are 12 modules covering topics including geriatric assessment and case management. Do visit.
The URL is at:
http://cpmcnet.columbia.edu/dept/dental/Dental_Educational_Software/Gerontology_and_Geriatric_Dentistry/introduction.html

Geriatric Nursing on the Net

The Internet offers a growing number of excellent resources for Geriatric Nurses. Email addresses are provided where available for those nurses without World Wide Web access.

Gerontological Nurses Connect

The National Gerontology Nurses Association is a US nursing specialty organization dedicated to helping you realize your full potential as a gerontological nurse. This web site offers membership information.
The URL is at: http://www.ajn.org:80/ajnnet/nrsorgs/ngna/
No email address listed.

GSA is A-OK

The Gerontological Society of America was established in 1945 to promote the scientific study of aging, to encourage exchanges among researchers and practitioners from various disciplines related to gerontology, and to foster the use of gerontological research in forming public policy.
The URL for this site is at: http://www.geron.org/
GSA staff are eachable by email at: geron@geron.org

Bo Graham

Bo Graham is a well-known Nurse and Canadian personality on the Internet with a long-standing interest in geriatric nursing and health care. His nursing web site includes a Gerontology page that is a useful resource for nurses caring for older patients. Bo has just moved his web page so if all senior links aren't available, please DO check back with him regularly.
The URL is at: http://bgraham.com/
Bo is reachable by email at: bgraham@istar.ca

2 Nurses at Nurse2

Gary Blatch at Nurse2 has a special interest in the problems of Elders, especially with Alzheimers Disease. Both Gary and his wife Tracey work with the elderly in the area of mental health near Southend on Sea in Essex, England. His page includes
Their website is found at: http://ourworld.compuserve.com:80/homepages/GaryBlatch/nurse2.htm

Ethical Nurses Line Up

The Nursing Ethics Network is a regional organization of professional nurses committed to the advancement of nursing ethics. Although not specific to geriatrics, care of the elderly population along with death and dying issues often has ethical implications in light of modern technology. NEN is supported by the Boston College School of Nursing through the Henry R. Luce Professorship in Nursing Ethics.
The URL is at: http://www.bc.edu/bc_org/avp/son/ethics.html

In the Video Eye

Recent abstracts helpful to Geriatric Nursing can be found at Geriatric Video Productions website. This award winning video productions company also includes an index of links to relevant web sites. Don't forget to check their lengthy archive of past abstracts.
The URL is at: http://www.geriatricvideo.com

An Aging Library for Surfers

The Andrus Gerontology Library at the University of Souther California maintains one of the foremost collections on the subject of life-span development and aging in the U.S. This informational site includes indexes to web sites for nurses and other health professionals. You can also search their disseration list via the Web.
The URL is at: http://www-lib.usc.edu/Info/Gero/index.htm

Elders Get Physical

The American Physical Therapy Association has a website on Geriatrics. The online resource includes copies of research articles related to seniors, plus selections from GeriNotes, a quarterly newsletter. Well worth a visit.
Surf to the URL at: http://geriatricspt.org/

The Administration on Aging, a US government resource, offers info on AOA and its programs for the elderly, resources for practitioners who serve the aged, statistical information on the aging, and information for consumers. Joyce Post, Librarian from the Philadelphia Geriatric Center maintains an index of comprehensive gerontology resources on and off the WWW (over 650 of 'em) located at the AOA website.
The main URL is at: http://www.aoa.dhhs.gov/
Joyce's web resources are at: http://www.aoa.dhhs.gov/aoa/pages/jpostlst.html

From the Gero-Informatics Workgroup at Wayne State University, GeroWeb is an online resource for researchers, educators, practitioners and others. Excellent site for links and information resources.
For a tour check out URL: http://www.iog.wayne.edu/GeroWebd/GeroWeb.html

For more senior surfing, try Huffington's Center on Aging in Houston Texas, at Baylor College of Medicine. The Center was created in 1988 through philanthropic generosity. This website includes both information about the center, along with some wonderful insights into the accomplishments of senior citizens. Check it out.
The URL is at: http://www.bcm.tmc.edu/hcoa/

Professor Michael C. Kearl from Trinity University in San Antonio Texas offers Web surfers an amazing dialogue and tour in cyberspace with Social Gerontology and the Aging Revolution. Only one in a series of highly educative webtours from Kearl. His observations are as insightful as his selection of accompanying web pages.
The URL for Social Gerontology is at: http://WWW.Trinity.Edu/~mkearl/geron.html
For more of Kearl's efforts checkout: http://WWW.Trinity.Edu/~mkearl/index.html

IAN is a non-profit corportation dedicated to serving organization involved with older adults. Also known as the Interactive Aging Network, their online resource has valuable links to a wide-range of senior oriented services and information.
IAN can be found at: http://www.ianet.org/

The American Association of Retired Persons has a delightful website for seniors with information and links to a variety of relevant topics.
The URL is at: http://www.aarp.org/

ARC or the Aging Resource Center is an Internet resource dedicated to research on aging. The focus is the biology and science of the aging process. Real Audio connections, theories on aging, papers, and more can be found here.
Find them at the URL: http://www.hookup.net/mall/aging/

SeniorNet is an international community of computer using seniors. This non-profit organization started as a research project in 1986 by Dr. Mary Furlong. Check out their chat area, library and more.
For SeniorNet use URL: http://www.seniornet.org/

And next visit Seniors-Site with webmaster Walter J. Cheney. A well done collection of Internet resources for seniors.
The URL is at: http://seniors-site.com/

The ElderCare Web is both a consumer and professional oriented web-site focusing on seniors and their care -- created by Karen Stevenson Brown. Though still under construction, it has the beginnings of a wonderfully detailed site.
The URL is at: http://www.ice.net/~kstevens/elderweb.htm

Not specific to geriatrics but certainly relevant, Mental HealthNet from Dr John Grohol, this Psychologist's work features a comprehensive guide to mental health resources online. Subjects covered include depression and suicide, both topics important to senior care.
The URL for this site is at: http://www.cmhc.com/

For those with legal interests, SeniorLaw is a website for senior citizens, families, social workers and anyone else interested in the topic.
The legal URL is at: http://www.seniorlaw.com/index.htm

The Caregiving OnLine newsletter shares information that can assist caregivers of an aging relative with wellness related issues. Samples from the hardcopy issue are provided at this web site.
The URL is at: http://www.caregiving.com/

AARP's Caregiving web page includes sections on caregiver support, long-term care financing, help with home care, assistive devices and more.
The URL is at: http://www.aarp.org/caregive/00-home.htm

Need the answers? Answers is a magazine for the Adult Children of Aging Parents. A small number of selected articles are available online.
To visit use the URL: http://www.service.com/answers/

Today's Caregiver with publisher Gary Barg, is a magazine "written FOR caregivers BY caregivers." You can find a Caregiver's Bill of Rights here.
The URL is at: http://www.caregiver.com/

The global format of the Internet offers nurses and health care professionals information about geriatric activity around the world.

The Canadian Health Network has created a web site called Aging and Seniors. Available in french or english, this it serves as a valuable resource for elderly from the Canadian community on the Internet.
The English URL is at: http://www.hwc.ca/datahpsb/seniors/seniors/english/health.htm
The Canadian Health Network is found at: HTTP://www.hwc.ca/

Try SeniorsNet if you're in the mood for over 5,000 links to folks over 50, especially geared toward Canadians. This webmaster includes a link section for Americans too.
For more, go to the URL at: http://www.seniorsnet.com/

The University of Queensland in Australia offers Internet-based information on Geriatric Anaesthesia and what to consider with aged patients. Hop this sleeping link to OZ!
The URL is at: http://gasbone.herston.uq.edu.au/teach/su602/docs/b9geriat.html

The Faculty of Basic Medicine at Moscow State University (Russia) has a telemedicine studio and projects. Learn more about the Spacebridge to Moscow project, aimed to provide an opportunity to design, build, test, verify, and evaluate an Internet-based testbed which has the capability to support NASA's medical personnel in remote locations, and one that could be used for world-wide coverage to provide expert consultation and education to remote populations afflicted by disaster, disease, or lack of sufficient medical care.
The URL is at: http://www.fbm.msu.ru/

Singapore has programs for it's elderly population as noticed in this speech by Mr Lim Hng Kiang, Minister for National Development at a Senior Citizens Home. Government efforts include hotline and counseling services.
The URL is at: http://www.gov.sg/mita/pressrelease/archives/96110201.htm

The Gerontological Society of America is having it's 49th Annual Scientific Meeting on Nov 17-21, 1996 at the Sheraton Washington Hotel in Washington DC. The theme will be "Economic and Health Security for the Aging" with over 375 sessions planned. Both AMA and ANA continuing education credits are planned.
For more information contact the GSA at (202) 842-1275.

"Self-Care & Demand Management" is the title of a conference sponsored by the Partnership for Prevention at the Sheraton City Centre Hotel from Dec 3-4, 1996 in Washinton DC.
Contact: Partnership for Prevention, (202) 833-0009, Fax: (202) 833-0113

Global Business Research, Ltd brings you "Transitioning Long-Term Care Into Managed Care." at the Renaissance Orlando Hotel, Orlando, FL from December 9-10, 1996.
Contact: Global Business Research, Ltd. at (800) 868-7188 for more info.

A Conference on Elder Abuse and Domestic Violence Among Older Couples will be happening at Arizona State University, Phoenix, AZ from January 13-14, 1997.
Contact: Jeff Calvert, (602) 264-2255

"Vital Aging" is the theme of the National Council on the Aging's 47th annual conference at Chicago Hilton and Towers, Chicago, IL from March 14-18, 1997.
Contact: NCOA, (202) 479-6991 for more info.

For more conferences related to Geriatrics, check out the Gerontological Society of America's web page at: http://gsa.iog.wayne.edu/calendar.html

Geriatric Education On Line

The American Journal of Nursing is a great resource for Internet or hardcopy education on geriatric nursing topics. They regularly publish articles related to nursing and elder care. All issues of AJN should be checked for relevant articles. Here are a few examples:
September 1996 issue - "Six Tips for Caring for Aging Parents" by Susan Stocker
August 1996 issue - "Back to Basic: Assessing Orthostatic Vital Signs" by Mitch Roper
July 1996 issue - "Drugs and the Elderly: Do you Know the Risks" by Mary Lee
June 1996 issue - "Osteoporis: It Steals More than Bone" by Theresa Galsworthy and Patricia Wilson.
The URL for AJN is at: http://www.ajn.org/
[A tidbit: For those nurses who don't know, Lippincott-Raven Publishers now owns AJN]

SpringHouse Corporation's CE Connection section has relevant material for nurses in eldercare. Articles worth your attention include:
November 1996 - "Chest Pain Emergencies: Making the Right Call When the Pressure is On"
October 1996 - "A Woman's Cancer: Straight Talk about Breast Cancer"
October 1996 - "Primary Care Dx and Pharmacologic Treatment of Depression in Adults"
September 1996 - "Avoiding Adverse Drug Reactions in Elderly Patients"
July 1996 - "Acute Confusion in the Elderly: What to Do with the Clouds Roll In"
The URL is at: http://www.springnet.com/ce/ceartlst.htm

NURSEWEEK offers continuing education credits for nurses via use of online articles. One entitled "How Transtelephonic Cardiac Event Recording Helps Patients" is highly relevant to telephone nurses. Written by Elizabeth Charuvastra RN and Dorothy D. Dance RN, this course describes the use of telephonics, nursing and ECG analysis.
The URL for this article is at: http://www-nurseweek.webnexus.com/ce/ce1115a.html

Michigan State University plans on offering a Advanced Practice Nursing (APN) course via the Internet entitled "NUR591 - The APN in a Re-engineered Managed Health Care Environment". The offering is planned for the spring semester (Jan 8 to May 2 1997). The focus will center on an analysis of the role of the nurse focusing on the Managed Care system, clinical guidelines, performance, outcome indicators and interdisciplinary functioning.
The URL for this course is at: http://web.msu.edu/dig/NUR591/

Aging in the Media