Older Adult Relocation: Considerations for Nurse Practitioners

The projected trends of the senior and baby-boomer population represent a demographicchange that is nothing short of astounding. Thenations older adult population will continue to swelland, by 2035, they will make up approximately 18% to23% of the total population, nearly doubling this currentage segment.1 With this significant and inevitable shift indemographics, individual, family, and community needswill increase proportionally. Nurse practitioners (NPs) in

ABSTRACTThe projected trends of the senior andbaby-boomer population represent a pro-jected demographic change that is nothingshort of astounding. The nations older adultpopulation will continue to swell and, by2035, will make up approximately 18% to23% of the total population, nearly dou-bling this current age segment. With thissignificant and inevitable shift in demo-graphics, individual, family, and communityneeds will increase proportionally. Nursepractitioners in primary care settings needto be cognizant of these trends and provideproactive assessments and health promotionadvice to older patients and their families.

Keywords: community, family, individual,older adult relocation, population trends 2010 American College of Nurse Practitioners

Joseph Kirst andSue Peck

Older Adult Relocation: Considerations for Nurse Practitioners

206 The Journal for Nurse Practitioners - JNP Volume 6, Issue 3, March 2010

www.npjournal.org The Journal for Nurse Practitioners - JNP 207

primary care settings need to be cognizant of thesetrends, and provide proactive assessments along with list-ings of community resources accessible to older adultsand their families.

POPULATION TRENDSNational trends indicate that the dramatic increase in theolder adult population will either age in place ormigrate to other parts of the country. Aging in place isdefined as remaining within a relatively confined geo-graphic region in which one has resided for most ofones life. Slower growing metropolitan areas in theNortheast and Midwest will become disproportionatelyolder and will have marginal financial and wellnessresources. Additionally, projected demographic phenome-na will involve the movement of particular segments thatwill migrate to the suburbs from metropolitan areas. Eventhough they relocate within a region, they will nonethe-less change the demographics of that region. These sub-urbs will become considerablyolder than the cities them-selves. Suburbs projected to beaffected by this shift willinclude those around NewYork, Philadelphia, Chicago,and Los Angeles.2

Significant changes indemographics will occur asseniors move into otherregions in the United States.The rapidly growing, eco-nomically dynamic areas ofthe Sun Belt, such as Las Vegas, Austin, Atlanta, andDallas will see a significant aging of their population.Additionally, the Intermountain West and SouthAtlantic states will experience high-growth influxes ofthe senior population. The Western portion of theUnited States will experience up to an unbelievable140% increase in growth of seniors 65 years and olderthrough 2030.2

Regardless of which region, the upcoming anddramatic demographic surge of seniors will impact allaspects of society. Adjustments of individual, family,and community will be experienced. A basic under-standing of each of these areas is necessary to begin tomeet the demands and create an environment of opti-mal health promotion.

INDIVIDUAL CONSIDERATIONSPsychosocial ConsiderationsThe process of relocation may be precipitated by a multi-tude of factors. A staged, gradual process may serve as thebasis of a move, or a move may be precipitated by an illness,resulting in a precipitous relocation. Regardless, this humanexperience will affect quality of life and living satisfaction.Attachment of personal meaning in the decision-makingprocess and the subsequent life changes will influence fac-tors of adjustment.3 Gaining an understanding of the mean-ings attached to a relocation event through astute interview-ing may positively influence the adjustment process.Additionally, helping to generate interventions to enhancepositive thinking and fostering learned resourcefulness mayhelp to create favorable responses to the relocation process.4

Health Care DeterminantsThe older adult population, some 70-million strong by2030, presents unique challenges and medical needs that

are different from youngeradults.5 As an example, theaverage 75 year old has 3chronic conditions and uses 5prescription drugs. After a relo-cation event, as older adultspresent to primary clinical set-tings to establish care, impor-tant areas of assessment need tobe considered. Older adultfunctional status, such as self-care behaviors associated withhealth and hygiene needs

(activities of daily living [ADLs]), as well as abilities toremain independent (instrumental activities of daily liv-ing [IADLs]), are vital assessments that need to be madeby NPs. Within these areas, we can assess a milieu ofelements that will help facilitate health promotion.Physical, emotional, cognitive, family, social, and culturalneeds and concerns can be assessed within these 2 func-tional frameworks. The national report of the MerckInstitute of Aging and Health5 identifies 15 indicatorsthat relate to general health status, health behaviors, pre-ventive care and screening, and injuries (Table 1).Additionally, the 3 agencies (Merck Institute of Agingand Health, Centers for Disease Control, andGerontological Society of America) of this report col-laborate and collect data, providing a report card that

Generating interventions to enhance positive

thinking and foster learnedresourcefulness may help

to create favorableresponses to the

relocation process.


measures state against state. Interestingly, no state meetsall targets; however, a majority of states are meetingstandards for pneumonia vaccine and colorectal cancerscreening. There is certainly room for improvement.These indicators can add to an NP's overall history-recording process

During a short office visit, it is important to direct ques-tions that assess various aspects of the function framework.The practitioner might find it helpful to develop a templatecontaining a few questions that will assess the general healthstatus, ability to perform self-care, preventive care andscreening, and family involvement. These templates can bemade assessable in each exam room.

FAMILY CONSIDERATIONSThe relocation of an older adult may often result inchanges in family and household dynamics. It is estimat-ed that 18 million adults4.9 million householdspro-vide some form of care for someone who is older than65. Because of the ensuing older adult demographicchanges, these numbers are expected to increase dramati-cally through 2030.6 It is estimated that the value of theservices family caregivers provide amounts to $306 bil-lion a year, which amounts to twice as much as thatspent on home care and nursing home services com-bined.7 Specifically, a phone survey of 1000 family care-

givers found that the average yearly out-of-pocket cost ofproviding care was $5531. This represented approximately10% of the $43,026 median income of the respondents.Common cost expenditures were: household goods, foodand meals (42%), transportation and travel (40%), andmedical care co-pays and pharmaceutics (31%).8 Informalcare provided by children of older adults helps provide avast quantity of elderly long-term care in the UnitedStates, thus prolonging and often preventing placementof older adults into long-term facilities, as well as fre-quent hospitalizations. The most recent data indicateapproximately 66% of Medicare enrollees 65 and olderreceive personal care for a chronic condition by an infor-mal care process. Informal care is defined as care provid-ed by family, whereas formal care is care provided bytrained individuals, such as home health care and nursinghome care.9 Approximately 26% receive care from bothinformal and formal modes. The remaining percentagereceives formal care only.10 From these data, one couldextrapolate that, in any given family situation of elderrelocation, it is likely that care would be provided by afamily member.

Along with older adult relocation, families oftenundergo definitive stages or phases when transitioninginto caregiving responsibilities. These stages and phaseslead 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 fam-ilies make the transition to caregivers. Marital disagree-ment and psychological well-being can be affected, notsurprisingly, by becoming a parent caregiver. The overallwell-being of a caregivers marriage is thought to be con-tingent upon baseline marital role quality as well as thenature of the caregiver transition and the context inwhich the process occurs.11

COMMUNITY CONSIDERATIONSThe understanding of available resources can be dauntingfor the older adult who has relocated to a new commu-nity. Within the clinic setting, assessing previous integra-tion and use of community resources by the older adultin his or her previous community may provide an NPwith an understanding of the individuals willingness touse various available resources. Whether relocating from arural setting or a large metropolitan setting, understand-ing how reliant the individual(s) were on communityelements such as church, health care, transportation, and

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


social services may prove helpful in future provider deci-sions. Moreover, determining receptiveness to use exist-ing community resources will give insight of likelihoodof the older adults use of community resources.Developing a readily available list with appropriateagency phone numbers may prove useful for the olderadult and family members.

Communities will no doubt feel the strain ofincreased demands created by the dramatic graying ofour population. Issues relating to health care access,payment ability, and long-term care represent someareas that will encounter significant system burdens.Current data from 2003 indicate that Medicareaccounts for approximately 53% of all sources of pay-ments for those 65 and older, Medicaid payments makeup 9%, out-of-pocket payments 19%, and other sources19% of total health care service payment sources. Theavailable statistics that examine health care expendituresexplore past data but provide no forecasting of futureexpenditures of federal and state programs.12 Onewonders if the system can endure the demands of theimpending changing demographics.

HEALTH CARE CONSIDERATIONSHealth care considerations are one of the most importantelements in an older adults decision-making regardingwhere he or she would relocate.13 Given the knownchanges in population dynamics that will soon be upon ourcommunities and probable demands that will ensue, it isimperative that NPs partner with community organizationsto ensure optimal community health. An example of aunique grant-derived program that helps communitiesdevelop leadership, innovation, solutions and options thatmeet the needs of older adults over the long term is theCommunity Partnership for Older Adults Project spon-sored by the Robert Wood Johnson Foundation.12 Thisproject currently has provided $28 million to fund 16 com-munities around the United States to improve the long-term care system through engaging community-basedorganizations, older adults, policy makers, and other stake-holders to create a proactive plan to best meet the needs ofolder adults. Broome County, New York, provides a com-prehensive report outlining its strategic plan that was creat-ed from this project.14 Ten themes were identified by par-ticipants as critical elements for optimal older adult (Table2). These key indicators serve as the foundation for com-munity planning and actions.

The Community Partnership for Older Adults Projectin Broome County exemplifies how a core of concerned,motivated individuals can partner with multiple organiza-tions to create a common vision and ultimately createmutually beneficial solutions that would ordinarily bebeyond the scope of any single organization. The begin-ning of the process involved 110 individuals includingseniors, caregivers, service providers, and practitionerswho convened in a forum. The forum highlighted locallyconducted qualitative and quantitative research.

Twelve small groups responded to the data present-ed, asked probing questions about community needs,and then identified the above-stated critical issues.Surveys then queried seniors and their caregivers in thecounty to prioritize these items. The top 4 concernswere: caregiver support through transitions, managingchronic disease, staying socially connected, and under-standing and accessing services. Afterward, during this18-month project, 3 work groups addressed how these4 top issues could be addressed by the community.

A second forum was held to identify and addressany additional community issues. For each issue, short-,intermediate-, and long-term objectives were estab-lished for future evaluation purposes. Moreover, whilethe above-described activities were taking place, anoth-er group was working to procure grant monies forimplementation of the identified concerns. Overall, thisproject can serve as a template for local proactive serv-ices that can ensure healthy older adult communities inthe face of significant changes in older adult popula-tions. It emotes opportunities for communities.

Table 2. Important Issues that Enhance Older AdultHealth12

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


For the NP in a primary care setting, understandingand developing social networks within the community is invaluable; its importance cannot be understated.Granted, this is a process that takes time, but neverthelessrepresents an integral part of a practitioners arsenal ofreadily available resources that help the patient and familyadjust to this unfamiliar part of lifes journey. Specificexamples of helpful listings might include key contactswithin the local county Department of Aging, mentalhealth counselors, legal service representatives, churchcontacts, reputable home improvement contractors, andpublic and private transportation carriers.

EXEMPLARThe following scenario represents general issues that maybe revealed at any given encounter with an older patient.Actively listening, along with directed querying, will helpthe stories unfold, ultimately allowing the provider,patient, and family to effectively optimize the health ofthe newly located older adults.

Consider a couple in their early 80s who havemoved to the city after spending all of their lives liv-ing in a small rural town. Their story unfolds as youare assessing the 84-year-old husband, accompanied bya family member who is con-cerned his father may bedepressed. The patients symp-toms include excessive sleep-ing, apathy of daily activities,and emotional apathy. As youbegin the questioning toassess for depression, they pro-ceed to relate the events ofthe last 6 months.

The decision to move wasmet with excitement and antic-ipation by the wife, while thehusband longed to stay. Finally,after family discussions, the reluctant spouse agreed toproceed with the move. Selling the house, downsizingpossessions, finding housing in a new city, moving, andsettling into a new abode all represented incredible chal-lenges for the couple and their family.

Once the move was completed, the couple and familyfound new unanticipated challenges. Considerations ofdriving (ie, heavier traffic and unfamiliar locations) besetthe couple with a degree of social isolation. The couple was

comfortable enough to drive to a close grocery store, buthesitant to venture any further into the city; thus, theyrarely drove beyond the safety of a few familiar roads.Further exploration of the city was not practical. Publictransportation is available, but neither has ever ridden a busand neither is receptive to learning how to ride. A sense ofuncertainty also prohibits them from using a taxi service.Subsequently, the closest family member becomes responsi-ble for transporting either parent to locations not previous-ly traveled. The burden for the family will seemingly grow.As the patient and family members talk, their sense of frus-tration shows. As the visit concludes, your patient is willingto try a course of antidepressant medication but is unwill-ing to seek counseling. You are left with a sense that thisindividual and family needs additional resources to helpfacilitate the adjustment of the relocation.

NP RESPONSESThe inevitability of the burgeoning older adult popula-tion and probable relocation occurrences will create significant challenges for the NP working in primarycare settings. Data that address best-practice interven-tions for this population, within the context-popula-tion-based interventions, are limited. Instead of viewing

the paucity of data as a limita-tion, the NP needs to embracethis impending situation as anincredible opportunity.

As providers striving to pro-mote optimal health of individ-ual, family, and community, suchas those presented in HealthyPeople 2010, it becomes apparentthat NPs need to recognize andbecome an active part of thegreater community.15 NPs willneed to arm themselves with theknowledge and understanding

needed to confront the demographic changes that willtake place, in order to partner with various communityagencies, work with and develop relationships with keycommunity individuals, and network with policy makerslocally and beyond. In particular, strengthening and devel-oping new collaborations will aid in care interventionswhen providers are confronted with relocated older adults.

The need to gain a better understanding of thehealth needs of older adults who relocate requires

In particular, strengtheningand developing new

collaborations will aid incare interventions whenproviders are confronted

with relocated older adults.


further research from the NP. The opportunities forresearch abound. Use of primary, secondary, and terti-ary preventative practices can provide platforms forresearch activities.

CONCLUSIONSOlder adults who relocate will make up just one segmentof a dramatic demographic phenomenon that will impactus as providers and consumers. The older adult popula-tion will present many challenges for NPs as we attemptto deliver holistic and highly individualized health care.Involving the patients family in the process will lend to ahealthier environment for all involved. Lastly, the onus ison us as a profession to actively partner with our com-munities to proactively develop solutions that creativelyaddress the needs of the older adult population.

References

1. U.S. Census Bureau (2006). 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. AccessedOctober 10, 2008.

2. Frey WH. Mapping the Growth of Older America: Seniors and Boomers inthe Early 21st Century. The Brookings Institution: Metropolitan PolicyProgram Living Cities Census Series; 2007:1-27.

3. Armer JM. Elderly relocation to a rural congregate setting: personalmeaning and perceptions related to decision to move and overalladjustment. J Nurs Sci. 1996;1(3-4):105-114.

4. Bekhet AK, Zauszniewski JA, Wykle ML. Milieu change and relocationadjustment in elders. West J Nurs Res. 2008;30:113-129.

5. Merck Institute of Aging and Health (MIAH), Centers for Disease Control andPrevention (CDC), and Gerontological Society of America (GSA). The Stateof Aging and Health in America. Available at: http://www.cdc.gov/aging/pdf/State_of_Aging_and_Health_in_America_2004_pdf. 2004. Accessed October21, 2008.

6. Scharlach A. Historical overview: lessons from the past, challenges for thefuture in family caregiving. Am J Nurs. 2008;108(9):16-22.

7. Harold Van Houten C, Norton EC. Informal care and health care use of olderadults. J Health Econ. 2004;23:1159-1180.

8. Evercare study of family caregiverswhat they spend and what theysacrifice: 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.

9. Harold Van Houtven C, Norton EC. Informal care and health care use ofolder adults. J Health Econ. 2004;(23):1159-1180.

10. Firbank OE, Johnson-Lafleur J. Older persons relocating with a familycaregiver: processes, stages, and motives. J Appl Gerontol. 2007;26(2):182-207.

11. Choi H, Marks NF. Transitions to Caregiving, Marital Disagreement, andPsychological Well-Being. Center for Demography and Ecology- A NationalSurvey of Families and Households, University of Wisconsin-Madison. NSFHWorking Paper No. 90; 2004.

12. Agingstats.gov. Available at: http://www.agingstats.gov/aging/statsdotnet/main_site/data/2006_documents/health_care.pdf. Accessed October 20, 2008.

13. Community Partnerships for Older Adults. A National Program of TheRobert Wood Johnson Foundation. Available at: http://www.partnershipsforolderadults.org/aboutcpfoa/indexx.aspx. Accessed October 20, 2008.

14. Aging Futures . . . Older Adults Living Well as They Define it. A CommunityPartnership for Older Adults Project. Available at: http:/www.gobroomecounty.com/agingfutures/demographic.php.Accessed October 29, 2008.

15. United States Department of Health and Human Services. Healthy People2010, 2000. Available at: http://www.health.gov/healthypeople.Accessed October 5, 2008.

Joseph Kirst, RN, BSN, MS/ANP, practices as a nurse practi-tioner in spine and neurological surgery at Luther Midelfort-MayoHealth System, Eau Claire, WI. He can be reached [email protected]. Sue Peck, RN, PhD, GNP, BC,CHTP/I, is a professor and nurse practitioner in the College of Nursing & Health Sciences at the University of Wisconsin in Eau Claire. In compliance with national ethical guidelines, theauthors report no relationships with business or industry thatwould pose a conflict of interest.

1555-4155/10/$ see front matter 2010 American College of Nurse Practitionersdoi:10.1016/j.nupra.2009.05.015

Older Adult Relocation: Considerations for Nurse PractitionersPOPULATION TRENDSINDIVIDUAL CONSIDERATIONSPsychosocial ConsiderationsHealth Care Determinants

FAMILY CONSIDERATIONSCOMMUNITY CONSIDERATIONSHEALTH CARE CONSIDERATIONSEXEMPLARNP RESPONSESCONCLUSIONSReferences

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Older Adult Relocation: Considerations for Nurse Practitioners