Reconceptualizing Geriatric Care in a Sub-Saharan African Context

Abstract

Population ageing is very fast catching up worldwide and with a resultant rise in demands for health services and medical costs. This is because older adults are typically more vulnerable to falls and chronic diseases. It is estimated that by 2025, 57% of the world’s population aged 80 years or older will be living in less developed regions. By 2050, there is an estimated increase of more than 70%. Although, Africa, on average, has the lowest life expectancy in the world, in virtually every country, the section of people aged 60 years and over is developing faster than any other age group, because of both longer life expectancy and declining fertility rates. Older adults have recommended that nurses should receive some training for improving their behaviour and attitude. Older adults and their significant health needs are different from that of an adult or a child and should be considered to meet SDG Goal 8: “ensuring equitable access to, and utilisation of, health and long-term care services …”. Their intense use of health services puts older adults at greater risk of receiving fragmented or poor-quality care. The sheer number of people entering older ages is bound to challenge national structures, particularly health systems. This chapter seeks to review the literature on geriatric health care by specialists.

1. Introduction

The former Secretary-General of the United Nations (UN), Kofi Annan, at the second UN World Assembly on Ageing quoted: ‘In Africa, it is said that when an old man dies, a library vanishes’. This is because older people in Africa have traditionally been celebrated and respected, although they accounted for a minority of the population. With increasing life expectancy globally and specifically in developing countries, the older adult population constitute a bigger proportion of society than previously. Ashirifi et al. [1] estimate that approximately two-thirds of the world’s population aged over 60 years are living in developing countries, and by 2050, 212 million of those will live in Africa. As the ageing population continues to grow exponentially, their demand for hospital care also increases.

2. Life expectancy

Across the globe, various initiatives have been put in place to improve the health outcomes of the elderly, to lengthen their life span and decrease the rate of morbidity and mortality of the older adult which in turn increases their numbers among the population [2, 3, 4]. The use of comprehensive geriatric assessment (CGA) for assessment, goal setting and care delivery has been adopted in the United Kingdom to improve relational working [5, 6]. CGA has been shown to improve outcomes for older people including improved physical and cognitive function, reduced mortality, and readmissions of the elderly to hospitals [6]. Over the years, geriatric care has received a lot of attention, from specialised training of healthcare professionals in the field of practice, to care given to the aged by their families till the end of life [7, 8].

Other factors that have accounted for the increase in the population of older adults in developed countries also include favourable social policies, geriatric care facilities, elderly retirement incentives and insurance schemes to facilitate a comfortable life for the elderly before their demise occurs. All communities in the world are advocating for healthy ageing. The United Nations (UN) and the World Health Organisation (WHO) for several years have been encouraging governments to promote policies aimed at the healthy and successful ageing of their people [9]. Additionally, the American Geriatrics Society (AGS) recently, made recommendations to guide federal, state and local governments in making decisions about the best care for older adults residing in assisted living facilities (ALFs) during the coronavirus disease 2019 (COVID-19) pandemic [10].

3. Geriatric care

Geriatric populations are prone to a wide variety of disorders; physical, psychological and social, which require specialised care [11, 12]. Over the years, the maintenance of a healthy body system for the aged has been of utmost importance, with information being sent forth to the public, families and health workers on how to combat physiological, biological, social as well pathological changes among the older adult.

These are all factors that account for the rise in the number of the ageing population across the globe, as their standard of living is improved, prolonging their length of stay as active or thriving members of the world’s population. Taking into view some common problems that affect the elderly, several reforms have been made in the health system to fend for the needs of the aged, for example, the guidelines put in place by the National Health Service of the United Kingdom towards the care and surgery of aged patients with hip fractures [13]. A multidisciplinary approach to caring for older adults is highly recommended and in the United Kingdom, national guidelines have been published in this regard. For example, between orthopaedic surgeons and geriatricians in the United Kingdom. This approach to modern hip fracture management aims at achieving the goals of coordinated multidisciplinary care, early surgery and facilitated discharge [13]. Over the years literary works educating the public, families and individuals are published centred on the care of older adults to build upon the public’s knowledge of geriatrics.

3.1 Age-friendly world

According to the WHO [14], an age-friendly world enables people of all ages to enthusiastically participate in communal activities being treated with respect, irrespective of one’s age. An age-friendly world enables older people to be with people they love promoting healthy living and appropriate support for those who can no longer engage in activities of daily living.

In recent years, international organisations and governments have developed age-friendly community models that incorporate aspects of the natural built, and social environment and optimise opportunities for well-being in old age.

Given the growing aged population, the WHO [15] called for special attention to the older adult friendliness of hospitals. Physical aspects of an elder-friendly hospital are defined as features of environmental design including the safety, physical, social and psychological needs of older adults [16, 17, 18].

Creating awareness about the need to improve care and support for older people and building agreements within all segments of society on the nature of care and its delivery in the most economical way [19] is vital. In most sub-Saharan countries, older persons are cared for in general wards with no geriatric specialist. However, evidence from developed countries shows this is not healthy for the vulnerable aged population as they have specific needs.

3.2 Specialist geriatric care

Internationally, interprofessional education (IPE) models have been used for geriatric syndromes, but not specifically for geriatric health policy. An IPE model has been used in presenting geriatric syndromes, palliative care, dementia care management, teaching the M Framework and fall-risk assessments [20]. IPE offers health profession learners opportunities to learn from, with and about each other. The World Health Organisation recognised IPE in the Ageing 2020 Report proposing that the interprofessional model will ensure optimal health care for the elderly [21].

Amidst the efforts put forth to improve the quality of life of the elderly in society, there are persisting gaps in the number of specialised healthcare professionals in the field. Nurses are recognised as the single largest health service professional who takes care of the aged population [22, 23]. Caring for older people is complex and challenging due to their physical, psychological and social needs. According to the John A. Hartford Foundation [24], there is a scarcity of specialist nurses who take care of older persons, for instance, less than 1% of the 2.56 million registered nurses in the United States, are certified gerontological nurses, and only 3% of the 111,000 advanced practice nurses, are gerontological nurses. In sub-Saharan Africa, this is non-existent. A few geriatric doctors are being trained by the College of Physicians in Ghana but none for the nurses. There is not enough training rendered in primary training institutions. The preparation of future nurses to meet this need is a critical concern for the nursing profession. Currently, there is no dedicated career pathway or exposure to geriatric care in undergraduate nursing programmes in Ghana. Many nurses and doctors have had little if any, specialist education in the care of older people and therefore do not understand the extent of their needs [18].

In some countries, there is still a struggle to provide adequate health facilities needed to meet the health concerns of older adults. Outlined principles for age-friendly hospitals by the WHO [15], include the following (i) Information flow through education, communication and training [training of staff in clinical geriatrics and patient education]; (ii) Healthcare management systems and (iii) Physical environments with clean and comfortable centres that are user friendly irrespective of an individual’s age or disability. The number of older patients admitted to acute hospitals has increased; however, with their varying needs, there is no gold-standard method of triaging them towards practising comprehensive geriatric assessment [25]. A recent systematic review of negative health outcomes in older people attending EDs (Emergency Departments) identified adverse events, including under triage of illness severity, lack of recognition of geriatric syndromes, suboptimal drug therapy and adverse communication-related events [26]. Concerns about overcrowding in emergency departments are furthered by the growing population of older adults with increasingly complex healthcare needs. Emergency department (ED) backlogs, and long waits for in-patient beds, diagnostic tests and procedures among older adults. This has raised concerns about patient safety, the timeliness of ED services and the quality of care provided in this acute care treatment setting [27, 28].

Policymakers face a key challenge: how best to allocate fitted resources, improve the quality and fitness for purpose of the workforce, increase recruitment and retention, and ensure efficient ways of working with wider health and social care systems [29].

The publication of a major critique of the neglect of older people in the United States stimulated public concern that led to the creation of the National Institute on Ageing with a multi-million-dollar research budget [30]. Gerontology and geriatrics training in Ghana are limited, but the issues facing the ageing society are enormous due to the limited information available to families. Designing an advanced gerontological system as found in the United States to meet the growing needs of Ghana would be difficult due to the lack of trained professionals and resources [31, 32].

Many strategies can be put up by local governments and health-centred institutions to deal with the persisting gaps. The idea of trying to put up nursing homes and aged facilities is a good idea however a simplified social support system, which is community-based, would be an ideal prototype for providing services to older adults [33]. There is considerable diversity among different communities’ needs for specific strategies to become age-friendly. Each approach needs to be rooted in the expressed needs of its residents, both older and younger [34]. One important factor that allows people to age in place comfortably is having the right housing in terms of available facilities, location, size, affordability and tenure [35, 36, 37].

4. Strategies for a reconceptualisation

In dealing with the gap of the reduced number of health professionals who are specialised in the healthcare of the elderly, supportive initiatives can be put up by the government to build the interest of health workers in the field of gerontology. With the increasing number of older adults in sub-Saharan Africa, it is prudent that nurses require sound gerontological knowledge and skills that permit them to provide quality care to this population. Studies have shown that nurses who are adequately prepared in gerontological nursing, provide quality care which leads to better outcomes [22, 38, 39]. International research evidence suggests a positive association between registered nurse staffing levels and better-quality care and quality of life for nursing home residents [29]. To meet the challenges of building an age-friendly community, policymakers and planners are encouraged to take a proactive approach and engage with multiple stakeholders as well as empower older people themselves to create the conditions for active ageing [40].

The current models of care for frail older adults in sub-Saharan Africa have been heavily hospital-based. Given that hospitals can do more good than harm for frail older adults, this is not unproblematic nonetheless, being cared for by specialist geriatric nurses, will be more appropriate. Additionally, if efforts are made to keep them out of the hospital in the first place (public health nurses trained in geriatric care will play a critical role here), making care less unsafe in the hospital. Furthermore, given current pressures on the NHIS, we must strive to practice health promotion and prevention of diseases rather than curative care. Bringing care closer to people’s homes, focusing as much on wellness as on responding to illness [41].

The best way to ensure quality geriatric care is to use evidence-based guidelines and professional standards to guide the practice environment [42]. Nurses consider institutional practices that support the use of evidence-based policies and guidelines, adequate and appropriate resources, administrative commitment and support of specialised geriatric nursing knowledge and skills as essential to quality geriatric care [43]. It is necessary to reconceptualise geriatric care in the African sub-region as this will improve health outcomes among the older adult population leading to an increased life expectancy.

5. Conclusions

With the aim of improving the quality of care given to older persons, there is an urgent need to reconceptualise the current geriatric care rendered in sub-Saharan Africa. In view of the numerous evidence from developed countries, of improved outcomes when geriatric health professionals are involved, the African continent can align with the strategies described in this chapter.

Acknowledgments

We are grateful to the authors of the literature reviewed during the writing of this chapter.

Conflict of interest

The authors declare no conflict of interest.