The Role of Advanced Practice Nurses in Alzheimer’s Disease Prevention
1. Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; 2. Inserm UMR1027, Université de Toulouse III Paul Sabatier, Toulouse, France; 3. Divisions of Geriatric Medicine, University School of Medicine, St Louis, MO, USA
Corresponding Author: B. Fougère: Saint Louis University School of Medicine – Division of Geriatric Medicine, 1402 South Grand Boulevard, Room M238 – St Louis, MO 63104, USA, E-mail: firstname.lastname@example.org.
J Prev Alz Dis 2018;inpress
Published online February 20, 2018, http://dx.doi.org/10.14283/jpad.2018.7
To the editor, Worldwide, the population of older adults is increasing. The global population aged 60 years or over numbered 962 million in 2017, more than twice as large as in 1980 when there were 382 million older persons worldwide. The number of older persons is expected to double again by 2050, when it is projected to reach nearly 2.1 billion (1). The United Nations reports that by the year 2045, the number of individuals aged 60 years and older will exceed the number of individuals under 15 years of age (1). The nations experiencing the largest increase in this age group include Europe and North America. By the year 2050, adults 65 years and older will comprise nearly 30% of the European population (2) and 20% of the American population (3). To meet the healthcare needs of aging patients, governments and international health care organizations endeavor to increase the number of practitioners to provide direct clinical care. However, many geriatric residency programs continue to have unfilled posts. Indeed, in the United States (US), 56% of geriatric fellowships were unfilled in 2015 (4). Moreover, the number of general practitioners continues to decline globally (5). At the same time, recent years have seen an increased interest and use of advanced practice nurses (APNs). Models of best practices of supervision and collaboration have been promulgated by many organizations.
The Need to Detect Alzheimer’s Disease
With aging, the prevalence and incidence of Alzheimer’s disease (AD) has increased exponentially. According to the Alzheimer’s Disease International, dementia is considered a major public health problem of epidemic portion, affecting more than 47 million people worldwide. Approximately 5.4 million people in the United States have AD or a related dementia (6). AD is the sixth leading cause of death in the United States (7). The disease impacts individuals and families and has been estimated to cost the U.S. health care system in 2016 an estimated $236 billion, including $160 billion in costs to Medicare and Medicaid (7). As the number of older adults increase in proportion to the total U.S. population, it can be expected that these costs will increase exponentially. This number is expected to increase to an estimated 13.8 million by 2050 because of the United States aging population (7).
Although there is currently no cure for AD, early diagnosis has particular advantages. For example, current treatments can help slow the progression of AD (8), and an early diagnosis may improve quality of life over the course of the disease and provide earlier opportunities for family education, planning, and assistance (9). Another benefit of early diagnosis is that in some cases AD can be ruled out in lieu of another, treatable condition (8). However, clinicians do not readily diagnose dementia during clinic visits using routine history and physical examination. Thus, more than 76% of persons with dementia, including many with mild but some with moderate dementia, have never received a diagnosis of dementia from a general practitioner (10,11). The lack of diagnosis of dementia suggests insufficient current screening practices. The reason for the inadequacy of detection is uncertain and may be associated with multiple factors such as time constraints during visits, unawareness of current guidelines, insufficient knowledge of available instruments, and uncertainty by providers in the administration and evaluation of these instruments. One possible solution to these barriers is to utilize tools administered by a third party such as APN.
Involvement of Advanced Practice Nurses in Alzheimer’s Disease Prevention
The need for APNs is increasingly recognized around the world. Today numerous countries have well established advanced practice nursing programs and approximately 70% of hospitals in the world have some form of advanced practice nursing (12). The evidence is plentiful that APNs are contributing significantly to improving patient care and outcomes and lowering hospitalization and readmission rates and thereby lowering costs (13). The demand for advanced practice nurses has grown as their clinical expertise, leadership and effectiveness as change agents has been recognized and built into nursing career ladders (14). The awareness that these nurses are an important human resource for improving access to high-quality, cost-effective and sustainable models of healthcare has positively facilitated integrating advanced practice nursing in government and academic policies in many countries (15).
Prevention is traditionally divided into three levels: primary, secondary, and tertiary prevention. Primary prevention refers to reducing the incidence of the disease by eliminating or treating specific risk factors, which may decrease or delay the development of a specific disease. In the case of AD, people currently without any signs or symptoms of AD could remain without AD through the primary prevention strategy. Secondary prevention aims to detect the disease at an early stage, before any symptom has emerged, when treatment could halt or limit its progression. Tertiary prevention ameliorates the impact of complications and disability of long-term diseases; thus, it allows patient to maintain an acceptable quality of life. These preventive approaches must start in integrating advanced practice nurses (APNs).
Prevention by targeting modifiable risk factors can reduce disease incidence of AD (16). A prevention approach can start by making general recommendations to a large, diverse population (e.g., those age 50 years or older with normal cognition) on diet, physical and cognitive exercise, and risk factor control; then identify decliners through longitudinal cognitive markers; and finally test interventions targeted specifically. APNs provide a unique dimension of healthcare for this chronic and complex disease and incorporate education into patient visits and working with patients and families as partners in healthcare. APNs can be also the first line providers in situations where adults present with symptoms of memory loss and forgetfulness. Thus, APNs play a critical role in Alzheimer’s disease prevention, beginning with risk assessment for older patients.
APNs have to play an important part in AD prevention. There is a need for all nurses to help transform healthcare in the 21st century to meet the needs of an aging population and a rising prevalence of AD. Unfortunately, the diffusion of innovation in healthcare is challenged by a number of translational roadblocks that limit the implementation of discoveries into clinical practice. As such, despite decades of evidence, there is a lag in public understanding and acceptance of APN roles. Therefore, academics, nursing leaders and clinical champions alike must continue to educate, promote and validate advanced practice nursing roles to overcome these barriers.
Authors’ contributions: BF has made substantial contributions to conception and design. BF wrote the manuscript.
Conflict of interests: The author declares that there is no conflict of interests regarding the publication of this paper.
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