作者：NursingResearch護理研究前沿
分享智慧
共同成長
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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.
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在美國，到 2050 年，老年人的數量預計將從今天的 5000 萬增長到超過 8000 萬《美國人口普查局，2018 年》。
老年人是醫療保健服務的頻繁使用者——盡管 65 歲以上的成年人占人口的 16%，但他們占所有住院治療的 37% 和所有初級保健就診的 32%《醫療保健研究和質量機構，2022 年；Santo ＆Okeyode，2018》。
老年人特別容易受到精神健康狀況和認知變化的影響——例如癡呆、譫妄和抑鬱——這會給患者和護理人員帶來巨大的痛苦。
年齡是阿爾茨海默病和相關癡呆症的最大風險因素，目前影響超過 600 萬老年人《阿爾茨海默病協會，2021 年》。
譫妄在住院的老年人中很常見，高達 53% 的老年患者術後出現譫妄，87% 的老年患者在重症監護室《Inouye，2006 年》。
每年多達六分之一的老年人會出現臨床上顯著的抑鬱症狀，而喪親、殘疾和感覺喪失等事件可能會增加患抑鬱症的風險《Kok & Reynolds，2017》。
很多時候，對於經歷這些症狀和其他心理健康和認知障礙的老年人的護理存在差距，接受過老年病學或精神病學護理培訓的提供者太少，更不用說兩者了。
此外，我們的醫療保健系統並非圍繞老年人的需求而設計，使老年人面臨不良事件、漏診以及失去為患者和護理人員提供治療和支持的機會的風險《Fulmer 等人，2021 年》。
老年友好型衛生系統 (AFHS) 倡議正在努力解決老年人護理方面的差距。
該倡議始於 2017 年，是約翰 A. 哈特福德基金會和醫療保健改進研究所 (IHI) 與美國醫院協會和天主教健康協會合作開展的一項合作。
該倡議為可靠地為老年人提供高質量護理的系統開發了一個循證框架，其中包括核心組件『重要事項』、『移動性』、『藥物』和『心理』，也稱為 4M ( IHI，2020》。
盡管每個組成部分都有自己的一套行動和評估標準，但這些組成部分是緊密交織在一起的，旨在相互補充。
AFHS 倡議正在努力建設美國醫療保健機構的能力，以更好地滿足老年人的需求。
他們通過讓醫療保健機構致力於質量改進工作來實現這一目標，旨在在其系統中實施 4M。
IHI 及其合作夥伴提供培訓和社區建設，機構可以作為 AFHS 獲得認可，根據他們的參與和承諾程度，獲得不同程度的認可。
迄今為止，美國已有 2,000 多家醫療保健組織被認定為 AFHS《IHI，2022 年》。
老年精神科護理的亞專科可以很好地促進老年人心理健康需求在醫療保健環境中的整合。
老年精神病學高級實踐 RN (APRN) 擁有影響心理健康和認知的疾病的專業知識，例如癡呆、譫妄和抑鬱症，這些常見綜合征會影響整個醫療保健機構中的大量老年人。
因此，老年精神病學 APRN 可以作為設計創新方法來實施 4Ms 模型的領導者，特別是在心理領域。
心理治療部分側重於評估和解決住院和門診醫療保健環境中的三種主要疾病——癡呆、譫妄和抑鬱。
老年精神病學 APRN 工作的例子包括譫妄的早期發現《Yevchak Sillner 等人，2020 年》，提供個性化護理以管理癡呆症患者的行為症狀《Massimo 和 Evans，2014 年》，以及針對晚年抑鬱症的非藥物幹預《Wright，2018 年》。
我們的立場是，老年精神衛生保健是所有衛生環境中護理模式的重要組成部分，因此對於融入 AFHS 運動至關重要。
老年精神科 APRN 可以引領將老年精神衛生保健原則付諸實踐的努力，但在滿足老年人綜合保健需求方面存在障礙，例如缺乏老年精神科護理的正規培訓《Harris et al. ，2021 年)。
盡管老年精神科護理特殊興趣團體和組織，例如老年精神科護理協作組織 ( Stephens et al.，2020 ) 和老年學高級實踐護士協會 ( Harris et al.，2021))，倡導推進行為健康教育和專業培訓以發展老年精神科護理人員，在整個護理課程中註入精神衛生保健原則對於滿足納入高質量精神衛生實踐的 AFHS 的人口需求非常重要。
將老年精神病學 APRN 納入關愛老人運動對於加強當前存在的良好工作至關重要。
如果不仔細考慮老年人的行為和心理健康護理，就不可能存在真正全面的關愛老人護理模式。
我們強烈鼓勵老年精神科護士加入 AFHS 社區，積極參與關愛老人的運動。
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