老年心理护理在促进老年保健中的作用

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Introduction

In the United States, the number of older adults is expected to grow from 50 million today to >80 million by 2050 (U.S. Census Bureau, 2018). Older adults are frequent users of health care services—although adults aged ≥65 years comprise 16% of the population, they make up 37% of all hospitalizations and 32% of all primary care visits (Agency for Healthcare Research and Quality, 2022; Santo & Okeyode, 2018).

Older adults are particularly vulnerable to mental health conditions and changes in cognition—such as dementia, delirium, and depression—that lead to significant suffering for patients and caregivers. Age is the biggest risk factor for Alzheimer's disease and related dementias, which currently impact >6 million older adults (Alzheimer's Association, 2021). Delirium is a common occurrence among hospitalized older adults, affecting up to 53% of older patients postoperatively and 87% of older adults in intensive care (Inouye, 2006). Up to one in six older adults experiences clinically significant depressive symptoms annually and events such as bereavement, disability, and sensory loss may increase the risk of depression (Kok & Reynolds, 2017). All too often, there are gaps in care for older adults experiencing these symptoms and other mental health and cognitive disorders, with far too few providers trained in geriatrics or psychiatric care, let alone both. Moreover, our health care systems are not designed around the needs of older adults, placing older adults at risk for adverse events, missed diagnoses, and lost opportunities to provide treatments and supports for patients and caregivers (Fulmer et al., 2021).

The Age-Friendly Health Systems (AFHS) Initiative is working to address gaps in care for older adults. Started in 2017, this initiative is a collaboration between the John A. Hartford Foundation and Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association and Catholic Health Association. The initiative has developed an evidence-based framework for systems to reliably provide high-quality care to older adults, which includes the core components “What Matters,” “Mobility,” “Medications,” and “Mentation,” also known as the 4Ms (IHI, 2020). Although each component has its own set of actions and criteria for evaluation, the components are deeply intertwined and intended to complement each other. The AFHS Initiative is working to build capacity in U.S. health care institutions to better serve the needs of older adults. They achieve this goal by getting health care institutions to commit to quality improvement endeavors aimed at implementing the 4Ms in their systems. IHI and their partners provide training and community-building, and institutions can receive recognition for being an AFHS, with different levels of recognition depending on their level of engagement and commitment. More than 2,000 health care organizations across the United States have been recognized as AFHS to date (IHI, 2022).

The subspeciality of geropsychiatric nursing is well-positioned to advance the integration of mental health needs of older adults in health care settings. Geropsychiatric advance practice RNs (APRNs) possess expert knowledge of disorders that affect mental health and cognition, such as dementia, delirium, and depression, common syndromes that affect a large number of older adults across health care settings. Thus, geropsychiatric APRNs can serve as leaders for designing innovative ways to implement the 4Ms model, particularly in the area of mentation. The mentation component focuses on assessing and addressing three main conditions—dementia, delirium, and depression—across inpatient and outpatient health care settings. Examples of geropsychiatric APRN efforts include the early detection of delirium (Yevchak Sillner et al., 2020), delivery of individualized care to manage behavioral symptoms in persons with dementia (Massimo & Evans, 2014), and nonpharmaco-logical interventions for late-life depression (Wright, 2018).

It is our position that geriatric mental health care is a critical component of care models across all health settings and therefore is essential to integrate in the AFHS movement. Geropsychiatric APRNs can lead the effort of putting principles of geriatric mental health care in to practice, yet there a barriers to meeting the demands of the comprehensive health care needs of older adults, such as lack of formal training for geropsychiatric nursing (Harris et al., 2021). Although geropsychiatric nursing special interest groups and organizations, such as the Geropsychiatric Nursing Collaborative (Stephens et al., 2020) and Gerontological Advanced Practice Nurses Association (Harris et al., 2021), advocate for advancing behavioral health education and specialty training to develop the geropsychiatric nursing workforce, infusing principles of mental health care throughout nursing curricula will be important to meet the population demands of AFHS that incorporate high-quality mental health practices. Integrating geropsychiatric APRNs within the age-friendly movement is critical to enhancing the good work that currently exists. True comprehensive age-friendly care models cannot exist without careful consideration of behavioral and mental health care for older adults. We strongly encourage geropsychiatric nurses to actively participate in the age-friendly movement by joining the AFHS community.

全文翻译（仅供参考）

在美国，到 2050 年，老年人的数量预计将从今天的 5000 万增长到超过 8000 万（美国人口普查局，2018 年）。老年人是医疗保健服务的频繁使用者——尽管 65 岁以上的成年人占人口的 16%，但他们占所有住院治疗的 37% 和所有初级保健就诊的 32%（医疗保健研究和质量机构，2022 年；Santo ＆Okeyode，2018）。

老年人特别容易受到精神健康状况和认知变化的影响——例如痴呆、谵妄和抑郁——这会给患者和护理人员带来巨大的痛苦。年龄是阿尔茨海默病和相关痴呆症的最大风险因素，目前影响超过 600 万老年人（阿尔茨海默病协会，2021 年）。谵妄在住院的老年人中很常见，高达 53% 的老年患者术后出现谵妄，87% 的老年患者在重症监护室（Inouye，2006 年）。每年多达六分之一的老年人会出现临床上显着的抑郁症状，而丧亲、残疾和感觉丧失等事件可能会增加患抑郁症的风险（Kok & Reynolds, 2017）。很多时候，对于经历这些症状和其他心理健康和认知障碍的老年人的护理存在差距，接受过老年病学或精神病学护理培训的提供者太少，更不用说两者了。此外，我们的医疗保健系统并非围绕老年人的需求而设计，使老年人面临不良事件、漏诊以及失去为患者和护理人员提供治疗和支持的机会的风险（Fulmer 等人，2021 年）。

老年友好型卫生系统 (AFHS) 倡议正在努力解决老年人护理方面的差距。该倡议始于 2017 年，是约翰 A. 哈特福德基金会和医疗保健改进研究所 (IHI) 与美国医院协会和天主教健康协会合作开展的一项合作。该倡议为可靠地为老年人提供高质量护理的系统开发了一个循证框架，其中包括核心组件“重要事项”、“移动性”、“药物”和“心理”，也称为 4M ( IHI, 2020）。尽管每个组成部分都有自己的一套行动和评估标准，但这些组成部分是紧密交织在一起的，旨在相互补充。AFHS 倡议正在努力建设美国医疗保健机构的能力，以更好地满足老年人的需求。他们通过让医疗保健机构致力于质量改进工作来实现这一目标，旨在在其系统中实施 4M。IHI 及其合作伙伴提供培训和社区建设，机构可以作为 AFHS 获得认可，根据他们的参与和承诺程度，获得不同程度的认可。迄今为止，美国已有 2,000 多家医疗保健组织被认定为 AFHS（IHI，2022 年）。

老年精神科护理的亚专科可以很好地促进老年人心理健康需求在医疗保健环境中的整合。老年精神病学高级实践 RN (APRN) 拥有影响心理健康和认知的疾病的专业知识，例如痴呆、谵妄和抑郁症，这些常见综合征会影响整个医疗保健机构中的大量老年人。因此，老年精神病学 APRN 可以作为设计创新方法来实施 4Ms 模型的领导者，特别是在心理领域。心理治疗部分侧重于评估和解决住院和门诊医疗保健环境中的三种主要疾病——痴呆、谵妄和抑郁。老年精神病学 APRN 工作的例子包括谵妄的早期发现（Yevchak Sillner 等人，2020 年），提供个性化护理以管理痴呆症患者的行为症状（Massimo 和 Evans，2014 年），以及针对晚年抑郁症的非药物干预（Wright，2018 年）。

我们的立场是，老年精神卫生保健是所有卫生环境中护理模式的重要组成部分，因此对于融入 AFHS 运动至关重要。老年精神科 APRN 可以引领将老年精神卫生保健原则付诸实践的努力，但在满足老年人综合保健需求方面存在障碍，例如缺乏老年精神科护理的正规培训（Harris et al. , 2021 年)。尽管老年精神科护理特殊兴趣团体和组织，例如老年精神科护理协作组织 ( Stephens et al., 2020 ) 和老年学高级实践护士协会 ( Harris et al., 2021))，倡导推进行为健康教育和专业培训以发展老年精神科护理人员，在整个护理课程中注入精神卫生保健原则对于满足纳入高质量精神卫生实践的 AFHS 的人口需求非常重要。将老年精神病学 APRN 纳入关爱老人运动对于加强当前存在的良好工作至关重要。如果不仔细考虑老年人的行为和心理健康护理，就不可能存在真正全面的关爱老人护理模式。我们强烈鼓励老年精神科护士加入 AFHS 社区，积极参与关爱老人的运动。

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