AGING

 

Course Objectives

1.  Identify the physical changes that are associated with aging.

2.  Describe common psychological disorders found in aging individuals.

3.  Identify signs of aging that may require additional care.

4.  Describe the types of care available to aging adults.

5.  Describe the unique issues and concerns associated with substance abuse and aging.

6.  Describe intervention techniques that minimize trauma to elderly patients and their families.

 

Introduction                                                                                                                                                               

Until a person is in their fourth or fifth decade of life, the finality of aging may not mean a lot, even though it's a lifelong process. Childhood, adolescence and young adulthood are typically filled with feelings of immortality. It's often only when a person starts to notice physical changes that they accept that they are actually getting older.

So what exactly is aging — what causes it, how does the body change and how long can a person expect to live?

Some of the physical effects of aging are wrinkles, gray hair and slower reflexes, but what else is going on that you're not seeing? As individuals age, time takes its toll on the organs and systems in the body. How and when this occurs is unique to the individual. And everyone doesn't undergo the same changes. Still, in general, some of the age-related changes that occur include changes in:

Bones - As one ages, the bones become less dense as they slowly lose mass and minerals. Gradual loss of density weakens the bones and makes them more susceptible to fracture.

Brain - The number of neurons (cells) in the brain decreases. However, in some areas of the brain, the number of connections between cells increases, perhaps helping to compensate for the cellular decrease and maintain normal brain function.

Cardiovascular system - The size of the heart increases slightly. The blood pressure increases, the maximum heart rate decreases and the heart may take longer to return to its normal resting state after physical activity.

Hearing - The normal wear and tear of sounds over the years can damage the cells of the inner ears. The walls of the auditory canals also thin, and the eardrums thicken. Some will have greater difficulty hearing higher frequencies.

Kidneys - The size of the kidneys shrinks, and the amount your bladder can hold decreases. The kidneys also become less efficient at removing wastes from the blood.

Muscles - Muscle mass and strength decrease, though increased physical activity can reduce this effect. As the amount of water in the tendons and ligaments decreases, stiffness increases.

Reproductive system - Women produce less estrogen, progesterone and testosterone as they age. The uterus and the vagina shrink, and there's less vaginal lubrication. Men produce less sperm, and their levels of testosterone decrease.

Skin - The skin thins, and the nails grow at about half the pace they once did.  The sweat and oil (sebaceous) glands become less active, and the moisture in the skin decreases.

Vision - The eyes are less able to produce tears, the retina thins and the lenses yellow. In ones 40s, focusing on objects that are close-up becomes more difficult due to changes in the lenses. Later, the irises stiffen, making the pupils less responsive. This can make it more difficult to adapt to different levels of light. Further changes to the lenses can make an individual sensitive to glare.

Falls - In the United States, one of every three persons, aged 65 years and older, falls each year. Among older adults, falls are the leading cause of injuries, hospital admissions for trauma, and deaths due to injury. In 1999, about 10,097 seniors died of fall-related injuries.  Fractures are the most serious health consequence of falls.

Approximately 250,000 hip fractures, the most serious fracture, occur each year among people over age 65.  Many of these falls and resulting injuries can be prevented. Strategies to prevent falls among older adults include exercises to improve strength, balance, and flexibility; reviews of medications that may affect balance; and home modifications that reduce fall hazards such as installing grab bars, improving lighting, and removing items that may cause tripping.

Driving - While rates of motor vehicle related death and nonfatal motor vehicle related injuries among older adults vary by state, there are some consistencies. In most states, the fatality rates for men are twice those for women. In all states, motor vehicle-related fatalities are higher among adults 75 years and older, as compared with adults between 65 and 74 years of age. Among older adult drivers, the number of motor vehicle-related fatalities increased 30% and the number of nonfatal injuries increased 21% between 1990 and 1997.

How Long Do People Live?

One hundred twenty-two years is the longest documented human life span. Though a life span this long is rare, improvements in medicine, science and technology in the last century have helped more people live longer, healthier lives. In the early 1900s the average life expectancy in the United States at birth was only about 50 years. Today, it's close to 77.

Moreover, the 85-plus group is the fastest-growing demographic segment in the United States, although the number of people 100 and older has exploded as well. The U.S. Census Bureau projects that the number of people age 85 and older could increase from 4 million in 2000 to 19 million by 2050. And the number of people age 100 and older is projected to more than quadruple from 65,000 in 2000 to 381,000 in 2030.

In the last 10 years, scientists have made great progress in the study of aging. Currently, thousands of research projects on how to slow aging are under way in numerous medical specialties throughout the world. Scientists are studying a variety of topics including everything from cloning for spare parts to how DNA mutations affect aging to fighting cancer with viruses.

But longer lives also mean that some people may spend more time in an incapacitated state at the end of their lives, in part because the United States has done too little to promote healthy aging. Rates of obesity, sedentary lifestyle, smoking and alcohol abuse are still too high. However, researchers say it's never too late to clean up your act. For example, if an individual quits smoking, their risk of heart disease begins to fall almost immediately. Living a healthy lifestyle can improve how an individual ages. No matter the age, an individual can begin preparing now for their later years. An individual is the master of their own quality of life.

Clearly, old isn't what it used to be. And as more than 70 million baby boomers approach their retirement years, the definition continues to evolve.

ELDERLY, ALCOHOL AND ALCOHOLISM

While alcoholism has been increasingly diagnosed and treated in the general population as a whole, older persons, and 60 years of age and over, still constitute a "hidden" group with a significant number having medical problems associated with alcoholism and excessive drinking. The primary care physician can be the front line identifier of alcoholism and/or excessive drinking in the elderly. They need not be an expert or specialist in alcoholism or addiction medicine to assess the elderly patient, diagnose the disorder and provide for treatment. Physicians can update their own awareness in assessing and establishing a diagnosis, and in referring the elderly patient for on-going treatment for alcoholism and for any medical or psychiatric complications.

ELDERLY ALCOHOLIC/EXESSIVE DRINKERS DISPLAY:

  • Severe memory loss.
  • Inability to concentrate.
  • Defensiveness or irritation when asked even routine, general questions about alcohol use.
  • Extreme mood swings, even during a single office visit.
  • Undo concern about physical ailments, sometimes bordering on hypochondria.
  • Suicidal ideation.

ACUTE PRESENTING PROBLEMS IN THE ELDERLY

ALCOHOLIC/EXCESSIVE DRINKER PRESENTS:

  • Severe gastrointestinal complaints.
  • Loss of consciousness.
  • Panic attack.
  • Renal and bladder complications.
  • Hypoglycemia.
  • Aspiration of vomitus.
  • Angina and other cardiac involvement.
  • CNS intoxication effects, including ataxia and dyskinesia.
  • Blackouts.

Treatment of Alcoholism

The treatment of substance abuse and dependence in older adults is similar to that for other adults. Treatment involves a combination of pharmacological and psychosocial interventions, supplemented by family support and participation in self-help groups.

Pharmacotherapy for substance abuse and dependence in older adults has been targeted mostly at the acute management of withdrawal. When there is significant physical dependence, withdrawal from alcohol can become a life-threatening medical emergency in older adults. The detoxification of older adult patients ideally should be done in the inpatient setting because of the potential medical complications and because withdrawal symptoms in older adults can be prolonged. Benzodiazepines are often used for treatment of withdrawal symptoms.   In older adults, the doses required to treat the signs and symptoms of withdrawal are usually one-half to one-third of those required for a younger adult. Short- or intermediate acting forms usually are preferred.

 Alzheimer’s Disease

Alzheimer’s disease is one of the most feared mental disorders because of its gradual, yet relentless, attack on memory. Memory loss, however, is not the only impairment. Symptoms extend to other cognitive deficits in language, object recognition, and executive functioning.  Behavioral symptoms, such as psychosis, agitation, depression, and wandering are common and impose tremendous strain on caregivers.  Diagnosis is challenging because of the lack of biological markers, insidious onset, and need to exclude other causes of dementia.

Alzheimer’s disease is the most prevalent form of dementia. However, many of the issues raised also pertain to other forms of dementia, such as multiinfarct dementia, dementia of Parkinson’s disease, dementia of Huntington’s disease, dementia of Pick’s disease, frontal lobe dementia and others.

Counseling Alzheimer’s Patients and their Families

DURING THE EARLY STAGE

 The first (mild) stage of AD generally lasts two to four years. Among the signs and symptoms (which may be mistaken for manifestations of aging) are loss of recent memory, inability to retain new information, subtle personality changes (including abandonment of interests and activities, and increasing stubbornness), and difficulty communicating. Depression is common and may be the presenting symptom; first-time depression in a patient older than 65 should be investigated as possible dementia. Patients begin to lack judgment and insight.

 After diagnosis, the patient and family need straightforward information about the disease and the cognitive and functional changes to expect with each stage. Patients should be discouraged from driving, as even mild cognitive deficits are associated with increased risk of accidents.

 Families will benefit from a list of community resources. The Alzheimer's Association, for example, offers invaluable information about support groups, respite care, individual and family counseling, and other services that can help ease the caregiver's physical, emotional, and financial concerns. The National Institute on Aging funds nearly 30 hospital- and university-based AD centers in the United States.

 Patients and family caregivers also need information and advice about available medical treatments. Although medications approved to treat AD are expensive, their early use is an important means of prolonging the first stage--and preserving the patient's ability to participate in creating an advance directive and making other important decisions. Effective early treatment may also make it possible to delay institutionalization.

 At each contact, patients should be evaluated for depression. Short-term treatment with selective serotonin reuptake inhibitors that have limited anticholinergic effects (eg, citalopram, sertraline) may be indicated for AD patients with depression. The family should be told to watch for and report symptoms such as apathy, irritability, refusal to eat, and weight loss, with the understanding that these may simply be symptoms of the dementia itself.

 Caregivers should be reminded that attending to the patient's comorbid conditions can help slow the progression of disability and maintain function. Hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, arthritis, genitourinary conditions, and hypothyroidism are common concerns, as are vision and hearing impairment.

 Additional Considerations

 Early attention to the patient's environment is important (ie, consistency and structure, safety, moderate stimulation, and contrasting colors). Familiar items, including photographs and souvenirs, and orientation cues, such as clocks and calendars, can help stimulate memory and cognition. Some patients benefit from therapy using music, art, exercise, or pets, reminiscence therapy, and psychotherapy (emotion-oriented, supportive, and/or interpersonal).

 The earliest stage of AD is an ideal time to broach the subject of advance care planning with the patient in the presence of the family or caregiver. More than one study has found that patients with early dementia can participate in completing advance directives. Considerations should include use of artificial nutrition and hydration, hospitalization, antibiotic use, and do-not-resuscitate orders.

 THE MIDDLE STAGE

 The moderate second stage of AD may last from two to 10 years. Patients require full-time supervision because of increasing confusion, declining ability to care for themselves, wandering tendencies, belligerence, and, for many, psychotic episodes. Communication skills continue to decline and delusions, agitation, and paranoia are common.

 As symptoms progress, many caregivers begin to think about placing their loved ones in a long-term care facility. Behavioral strategies and appropriate pharmacologic management (discussed below) may help to delay this step. Families should be made aware of the available adult day care and community-based programs. They should also be directed to contact the Alzheimer's Association or the appropriate constituent unit of the National Council on Aging for information on financial resources.

 Practical Coping Strategies

 A safe, predictable environment and a consistent daily routine are the mainstay of managing potentially troublesome behaviors and the starting point for all other interventions. Safety measures include removing throw rugs and other obstructions over which patients may trip, and securing medicine, firearms, keys, toxic substances, and dangerous tools and utensils. Also, caregivers should be taught specific techniques to maintain optimal communication with the patient, such as those outlined by the Alzheimer's Association.

 Apathy--manifested as loss of interest, poor persistence, blunted emotions, and lack of social interaction--may occur in 90% or more of AD patients. Apathetic patients may be mistaken as lazy or resistant, because they seem to expect others to initiate activities they themselves are still capable of performing. Functioning may be improved by regular exercise, increased social stimulation, prompt encouragement to begin activities, a structured activity routine, and use of visual cues to expected behaviors.

 About 90% of patients also experience psychiatric manifestations, particularly behavioral disturbances. These include agitation (aggressiveness, combativeness, repetitious questioning, shouting, cursing, disinhibition) and wandering. The caregiver should look for physical or environmental stressors--such as pain or discomfort, anxiety, lack of sleep, noise, clutter, and presence of large numbers of people--that may be triggering or exacerbating the behavior, and these should be removed wherever possible. Caregivers can calm the patient better with an easygoing attitude than by challenging him or her.

 Spending time outside with the patient when the weather permits, incorporating exercise into the patient's daily routine, and limiting the patient's caffeine intake are ways caregivers can help the patient avoid sleeplessness. A regular sleep schedule should be maintained, with naps limited to 30 minutes and use of the bed restricted to sleep only.

 Wandering is a significant problem because it can be persistent and is inherently dangerous. Yet ambulation is considered an important factor in maintaining the AD patient's quality of life. One strategy is to provide a controlled environment where the patient may wander safely, rather than to try to eliminate the behavior. Wandering can be restricted by using child-proof doorknobs, mounting locks or latches higher or lower than eye level, obscuring doors with a scenic poster or curtains, and placing signs on doors with the words "stop" or "do not enter." Another effective technique is to keep outdoor clothing (symbols of departure) out of sight.

 Required Reading:   Alzheimer’s disease

PBS: A Portrait of Alzheimer's

Required Reading:   Guidelines for Alzheimer's Disease Management

Mental Disorders and Aging

Older adults are encumbered by many of the same mental disorders as are other adults; however, the prevalence, nature, and course of each disorder may be very different. This section provides a general overview of assessment, diagnosis, and treatment of mental disorders in older people. Its purpose is to describe issues common to many mental disorders.

Sleep Disorders

Sleep disturbances are common and pharmacologic intervention should be considered only when other non-pharmacologic interventions have failed (American Psychiatric Association, 1997). The sleeping area should be free of distractions and might contain nightlights if helpful to the patient. Caregivers should be instructed to try to limit the amount of sleep during the day. Naps should be kept short and there should be increased exercise or activity in the morning/early afternoon. Patient should be dressed during daytime hours. Caffeine and nicotine should be avoided and nighttime fluids and diuretics should be restricted. Warm milk and tryptophan before sleep may be successful, as may a tepid bath or light snack high in carbohydrates (Warshaw, et al., 1995). Pharmacologic treatment of other sleep disorders must take into account whether depressive symptoms, fear, pain, or side effects from other drugs underlie the insomnia (Warshaw, et al., 1995). Great caution must be exercised and caregivers warned because of reactions (incontinence, instability/falls, agitation) with major tranquilizers. Antidepressants (e.g. Trazadone), minor tranquilizers or benzodiazepines may suffice in intermittent short-term doses, but should be terminated at the earliest possible time (Warshaw, et al., 1995). Use of various dopamine agonists has been described in case reports, but the efficacy of these drugs has not been demonstrated in controlled studies. Simple remedies, such as use of melatonin, may help insomnia. For stronger sedation, a low dose of antipsychotic is preferable to a longer-acting benzodiazepine, which often has lingering effects. Diphenhydramine hydrochloride (over-the-counter) should be avoided because it may increase confusion due to its anticholinergic effects (Inouye, 1998).

Schizophrenia in Late Life

Although schizophrenia is commonly thought of as an illness of young adulthood, it can both extend into and first appear in later life. Diagnostic criteria for schizophrenia are the same across the life span, and DSM-IV places no restrictions on age of onset for a diagnosis to be made. Symptoms include delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, as well as affective flattening, alogia or avolition. Symptoms must cause significant social or occupational dysfunction, must not be accompanied by prominent mood symptoms, and must not be uniquely associated with substance use.

Prevalence and Cost

One-year prevalence of schizophrenia among those 65 years or older is reportedly only around 0.6 percent, about one-half the 1-year prevalence of the 1.3 percent that is estimated for the population aged 18 to 54.

Misuse of Prescription and Over-the-Counter Medications 

Older persons use prescription drugs approximately three times as frequently as the general population and the use of over-the-counter medications by this group is even more extensive. Annual estimated expenditures on prescription drugs by older adults in the United States are $15 billion annually, a fourfold greater per capita expenditure on medications compared with that of younger individuals. Not surprisingly, substance abuse problems in older adults frequently may result from the misuse, that is, under use, overuse, or erratic use—of such medications; such patterns of use may be due partly to difficulties older individuals have with following and reading prescriptions. In its extreme form, such misuse of drugs may become drug abuse.

Pharmacological Treatment

The special considerations in selecting appropriate medications for older people include physiological changes due to aging; increased vulnerability to side effects, such as tardive dyskinesia; the impact of polypharmacy; interactions with other comorbid disorders; and barriers to compliance.

The aging process leads to numerous changes in physiology, resulting in altered blood levels of certain medications, prolonged pharmacological effects, and greater risk for many side effects. Changes may occur in the absorption, distribution, metabolism, and excretion of psychotropic medications.

As people age, there is a gradual decrease in gastrointestinal motility, gastric blood flow, and gastric acid production.  This slows the rate of absorption, but the overall extent of gastric absorption is probably comparable to that in other adults. The aging process is also associated with a decrease in total body water, a decrease in muscle mass, and an increase in adipose tissue. Drugs that are highly lipophilic, such as neuroleptics, are therefore more likely to be accumulated in fatty tissues in older patients than they are in younger patients.

The liver undergoes changes in blood flow and volume with age. Phase I metabolism (oxidation, reduction, hydrolysis) may diminish or remain unchanged, while phase II metabolism (conjugation with an endogenous substrate) does not change with aging. Renal blood flow, glomerular surface area, tubular function, and reabsorption mechanisms all have been shown to diminish with age. Diminished renal excretion may lead to a prolonged half-life and the necessity for a lower dose or longer dosing intervals.

Pharmacodynamics, which refers to the drug’s effect on its target organ, also can be altered in older individuals. An example of aging-associated pharmacodynamic change is diminished central cholinergic function contributing to increased sensitivity to the anticholinergic effects of many neuroleptics and antidepressants in older adults.

Because of the pharmacokinetic and pharmacodynamic concerns presented above, it is often recommended that clinicians “start low and go slow” when prescribing new psychoactive medications for older adults. In other words, efficacy is greatest and side effects are minimized when initial doses are small and the rate of increase is slow. Nevertheless, the medication should generally be titrated to the regular adult dose in order to obtain the full benefit. The potential pitfall is that, because of slower titration and the concomitant need for more frequent medical visits, there is less likelihood of older adults receiving an adequate dose and course of medication.

Increased Risk of Side Effects

Older people encounter an increased risk of side effects, most likely the result of taking multiple drugs or having higher blood levels of a given drug. The increased risk of side effects is especially true for neuroleptic agents, which are widely prescribed as treatment for psychotic symptoms, agitation, and behavioral symptoms. Neuroleptic side effects include sedation, anticholinergic toxicity (which can result in urinary retention, constipation, dry mouth, glaucoma, and confusion), extrapyramidal symptoms (e.g., Parkinsonism, akathisia, and dystonia), and tardive dyskinesia.

What is a Geriatric Psychiatrist?

A geriatric psychiatrist is a medical doctor with special training in the diagnosis and treatment of mental disorders that may occur in older adults. These disorders include, but are not limited to, dementia, depression, anxiety, and late-life schizophrenia.   Older adults have special physical, emotional, and social needs. Understanding this, the geriatric psychiatrist takes a comprehensive approach to diagnosis and treatment, including listening and responding to the concerns of the older adult, helping families, and when necessary, working with other health care professionals to develop effective approaches to treatment. Co-existing medical illnesses, medications, family issues, social concerns, and environmental issues are integrated into a comprehensive program of care.

Ageism

Never has there been an era more conscious of chronological age than this one. People will go to extraordinary lengths to maintain a youthful appearance, from elaborate beauty preparations, to plastic surgery, vitamin cocktails and much more besides. Retirement is often seen as a withdrawal from usefulness and active participation in communities.

Yet in some cultures (like the Hunza and Vicabamba), there seems to be no concept of retirement; people remain active in farming, teaching and walking long distances all their lives. In other cultures, especially where oral traditions are strong, older people have played an important role in society by passing on knowledge to younger generations.  This suggests that in contexts, such as modern western culture, where the status of older people is low, it is because attitudes determine that it will be low, not because it is a natural consequence of the ageing process.

A definition of ageism is: 'a set of attitudes that generate fear and denigration of the ageing process and stereotyping presumptions regarding competence'. Ageism is reflected in unjustified age discrimination in employment, in patronizing or denigrating attitudes, negative (or non-existent) media images, and the widespread expectation that retirement from full-time employment means the end of usefulness and of active participation in society.

Cultural Competence

Long Term Care

Most elderly individuals are independent. But later in life, individuals in their 80s and 90s may begin to need help with everyday activities like shopping, cooking, walking and bathing. For many people, regular or “long-term” care may mean help from family and friends or regular visits by a home health aide. For others who are frail or suffering from dementia, long-term care may involve moving to a place where professional care is available 24 hours a day.        

The good news is that families have more choices in long-term care than ever before. Today, services can provide the needed help while letting you stay active and connected with family, friends, and neighbors. These services include home health care, adult day care, and transportation services for frail seniors as well as foster care, assisted living and retirement communities, and traditional nursing homes.

Successful long-term care means planning ahead –

If a patient is having trouble with things like bathing, managing finances, or driving, make sure they consult with a doctor. 

You probably will need to get other family members involved. A special type of social worker, called a geriatric case manager, can help the family through this complex time by developing a long-term care plan and locating appropriate services. Geriatric case managers can be particularly helpful when family members live a long distance apart.

  Talk about the best way to meet his or her needs. For instance, if he or she is having trouble making meals, would they want meals delivered by a local program or would they like family and friends to help? Would they let a paid aide in their home? If they don’t drive, would they like a friend or bus service to take them to the doctor or other appointments?

Learn about the types of services and care in your community. Doctors, social workers, and others may have suggestions. The Area Agency on Aging and local and state offices of aging or social services can give you lists of adult day care centers, meal programs, companion programs, transportation services, or places providing more care.

Find out how they may, or may not, be covered by insurance. The Federal Medicare program and private “Medigap” insurance only offer short-term home health and nursing home benefits. Contact your state-run Medicaid program about long-term nursing home coverage for people with limited means. Also, your state’s insurance commission can tell you more about private long-term care policies and offer tips on how to buy this complicated insurance. These agencies are listed in your telephone book, under “Government.”

Be aware that figuring out care for the long term isn’t easy. Needs may change over time. What worked 6 months ago may no longer apply. Insurance coverage is often   very limited and families may have problems paying for services. In addition, rules about programs and benefits change, and it’s hard to know from one year to the next what may be available.

Facts about long term care:

  • 80% of Long Term Care is received in a home-like setting.
  • The average cost of a semi-private nursing home bed is $50,000 per year or more!
  • Home care costs average $20,000 per year or more!
  • Medicare will NOT pay for Long Term Care.
  • Medicare HMOs will NOT pay for Long Term Care.
  • Caring for the caregiver is just as important as caring for the aging adult.

Signs that one may need additional care:

Elderly adults often are reluctant to accept help from loved ones for fear of losing their independence. 

Communicate with elderly patients in a non-threatening manner if you believe they need help for their physical or mental limitations.  Ability, not age, is the best way to judge if a person needs daily assistance. Watch for these warning signs:

Difficulty doing basic tasks, such as walking, dressing, eating and cooking may be signs that one needs additional care. 

Poor remembering skill are a sign that help may be needed.    If the elderly person is unable to remember familiar names, places, or recent events he or she needs extra attention.  Poor hygiene and/or an inability to fulfill responsibilities can be signs that extra help is needed. If you spot unopened mail, unpaid bills and bank account overdrafts, you should be concerned.

Changes in health including weight loss, incontinence, changes in appetite and bruising from falls can be signs.  

Signs of isolation including lost of interest in friendships and activities are warning signs. You should be concerned with alcohol or drugs use.  Paranoia and depression are common signs of dementia and other chronic disorders.

Residential Care:  

At some point, support from family, friends, or local meal or transportation programs may not be enough. If they need a lot of help with everyday activities, they may need to move to a place where care is available around-the-clock. There are two types of residential care:   

 Assisted living - arrangements are available in large apartment or hotel-like buildings or can be set up as “board and care” homes for a small number of people. They offer different levels of care, but often include meals, recreation, security, and help with bathing, dressing, medication, and housekeeping.    

Skilled nursing facilities – “nursing homes” – provide 24-hour services and supervision. They provide medical care and rehabilitation for residents, who are mostly very frail or suffer from the later stages of dementia.

Sometimes, health care providers offer different levels of care at one site. These “continuing care communities” often locate an assisted living facility next to a nursing home so that people can move from one type of care to another if necessary. Several offer programs for couples, trying to meet needs when one spouse is doing well but the other has become disabled.

Adult Day Care

Over the past few decades, adult day centers have developed as an important service delivery approach to providing community-based long-term care. Adult day centers, although heterogeneous in orientation, provide a range of services, usually during standard “ 9 to 5” business hours, including assessment, social, and recreation services, for adults with chronic and serious disabilities. They represent a form of respite care designed to give caregivers a break from the responsibility of providing care and to enable them to pursue employment.

Over the past 30 years, adult day centers have grown in number from fewer than 100 to over 4,000, under the sponsorship of community organizations or residential facilities. A large national demonstration program on adult day centers showed that they can care for a wide spectrum of patients with Alzheimer’ s disease and related dementias and can achieve financial viability. There also is evidence that adult day centers are cost-effective in terms of delaying institutionalization, and participants show improvement in some measures of functioning and mood.

Ombudsman Program

Long-term care ombudsmen are advocates for residents of nursing homes, board and care homes, assisted living facilities and similar adult care facilities. Since the Ombudsman Program began in 1972, thousands of paid and volunteer ombudsmen working in every state and three other jurisdictions have made a dramatic difference in the lives of long-term care residents. LTC ombudsmen advocate on behalf of individuals and groups of residents, provide information to residents and their families about the long-term care system, and work to effect systems changes at the local, state and national level. They provide an on-going presence in long-term care facilities, monitoring care and conditions and providing a voice for those who are unable to speak for themselves.

The Ombudsman Program is established under the Older Americans Act, which is administered by the Administration on Aging (AoA). Local ombudsmen work on behalf of residents in hundreds of communities throughout the country.

About one thousand paid and 14,000 volunteer staff (8,000 certified) investigate over 260,000 complaints each year. They provide information to more than 280,000 people on a myriad of topics including how to select and pay for a long-term care facility.

While the vast majority of frail and homebound older people receive quality care at home, abuse does occur. Estimates vary, but most studies find rates of abuse by caregivers, either family or non-family members, to range up to 5 percent.  Abuse is generally defined in terms of being physical, psychological, legal or financial. The abuse is most likely to occur when the patient has dementia or late life depression, conditions that impart relatively high psychological and physical burdens on caregivers.

A recent report by the Institute of Medicine describes the range of interventions for protection against abuse of older people, including caregiver participation in support groups and training programs for behavioral management, especially for Alzheimer’s disease, and social services programs (e.g., adult protective services, casework, advocacy services, and out-of-home placements). While there are very few controlled evaluations of these services, communities need to ensure that there are programs in place to prevent abuse of older people.

REPORTING?

Mandated reporters must report actual or suspected physical and sexual abuse, abandonment, isolation, financial abuse, mental abuse, or neglect of an elder or dependent adult. Failure of a mandated reporter to report abuse is a misdemeanor, punishable by a jail sentence or fine.  Report the abuse immediately by telephone followed by a written report within two working days using the standardized abuse reporting form.

Normal Life-Cycle Tasks

With improved diet, physical fitness, public health, and health care, more adults are reaching age 65 in better physical and mental health than in the past. Trends show that the prevalence of chronic disability among older people is declining: from 1982 to 1994, the prevalence of chronic disability diminished significantly, from 24.9 to 21.3 percent of the older population. While some disability is the result of more general losses of physiological functions with aging (i.e., normal aging), extreme disability in older persons, including that which stems from mental disorders, is not an inevitable part of aging.

Normal aging is a gradual process that ushers in some physical decline, such as decreased sensory abilities (e.g., vision and hearing) and decreased pulmonary and immune function. With aging come certain changes in mental functioning, but very few of these changes match commonly held negative stereotypes about aging. In normal aging, important aspects of mental health include stable intellectual functioning, capacity for change, and productive engagement with life.

Cognitive Capacity

Cognition subsumes intelligence, language, learning, and memory. With advancing years, cognitive capacity with aging undergoes some loss, yet important functions are spared. Moreover, there is much variability between individuals, variability that is dependent upon lifestyle and psychosocial factors. Most important, accumulating evidence from human and animal research finds that lifestyle modifies genetic risk in influencing the outcomes of aging. This line of research is beginning to dispel the pejorative stereotypes of older people as rigidly shaped by heredity and incapable of broadening their pursuits and acquiring new skills.

Retirement often is viewed as the most important life event prior to death. Retirement frequently is associated with negative myths and stereotypes. However, most people fare well in retirement. They have the opportunity to explore new interests, activities and relationships due to retirements liberating qualities. In the Retirement phase, new feelings of freedom, courage, and confidence are experienced.

Those at risk for faring poorly are individuals who typically do not want to retire, who are compelled to retire because of poor health, or who experience a significant decline in their standard of living. In short, the liberating experience of having more time and an increased sense of freedom can be the springboard for creativity in later life. People can change the course of an individual, family, community, or culture.

Prevention of Excess Disability


Prevention efforts in older mentally ill populations also target avoidance of excessive disability. The concept of excess disability refers to the observation that many older patients, particularly those with Alzheimer’s disease and other severe and persistent mental disorders, are more functionally impaired than would be expected according to the stage or severity of their disorder.  Medical, psychosocial, and environmental factors all contribute to excess disability. For example, depression contributes to excess disability by hastening functional impairment in patients with Alzheimer’s disease. The fast pace of modern life, with its emphasis on independence, also contributes to excess disability by making it more difficult for older adults with impairments to function autonomously. Attention to depression, anxiety, and other mental disorders may reduce the functional limitations associated with concomitant mental and somatic impairments. Many studies have demonstrated that attention to these factors and aggressive intervention, where appropriate, maximize function.

Prevention of Premature Institutionalization

Another important goal of prevention efforts in older adults is prevention of premature institutionalization. While institutional care is needed for many older patients who suffer from severe and persistent mental disorders, delay of institutional placement until absolutely necessary generally is what patients and family caregivers prefer. It also has significant public health impact in terms of reducing costs. A randomized study of counseling and support versus usual care for family caregivers of patients with Alzheimer’s disease found the intervention to have delayed patients’ nursing home admission by over 300 days. The intervention also resulted in a significant reduction in depressive symptoms in the caregivers. The intervention consisted of three elements: individual and family counseling sessions, support group participation, and availability of counselors to assist with patient crises.

Caregivers

What is caregiving?

Caregiving means caring for others, whether friends or relatives, who have health problems or disabilities and need help. Caregivers provide many kinds of help to care receivers, from grocery shopping to helping with daily tasks such as bathing, dressing, and eating. Most people who need help from caregivers are elderly.

Caregiver and Stress

Caregiver stress is a daily fact of life for many caregivers. Caregiving often takes a great deal of time, effort, and work. Many caregivers struggle to balance caregiving with other responsibilities including full-time jobs and caring for children. Constant stress can lead to "burnout" and health problems for the caregiver. Caregivers may feel guilty, frustrated, and angry from time to time.

Caregivers often need help caring for an elderly or disabled care receiver. Sometimes other family members or friends and neighbors are able to help, but many caregivers do most or all of the caregiving for a loved one alone. Research has shown that caregivers often are at increased risk for depression and illness. This is especially true if they do not receive enough support from family, friends, and the community.

Caring for a person with Alzheimer's disease or other kinds of dementia at home can be overwhelming. The caregiver must cope with declining abilities and difficult behaviors. Basic activities of daily living often become hard to manage for both the care receiver and the caregiver. As the disease worsens, the care receiver usually needs 24-hour care.

What can caregivers do to prevent stress and burnout?

Caregivers can call upon others for support and assistance. Other family members, friends, and neighbors may be able to help in different ways. It may not be easy to ask for help, and they may need to make very specific requests. But getting help from others will benefit the caregiver and the person being caring for.

Respite care can be a good way to get a break (respite) from constant caregiving. If other caregivers aren't available to fill in for the main caregiver, respite care services may be available in the community.

Caregivers can take steps to take care of their own health: Caregivers should eat a healthy diet rich in fruits, vegetables and whole grains and low in saturated fat. They need to get enough sleep and rest.   Caregivers need time for some exercise most days of the week. Regular exercise can help reduce stress and improve a person’s health in many ways.  They should see a health care provider for a checkup if they have symptoms of depression or illness. Caregivers should seek counseling if needed.  Caregivers should stay in touch with friends. Social activities can help keep a feeling of being connected and should help with stress. Faith-based groups can offer support and help to caregivers.  Caregivers should find a support group for other caregivers in their situation (such as caring for a person with dementia). Many support groups are available online through the Internet.

References

Theo B. Sonderegger, Janis E. Jacobs; Psychology and Aging, Psychology, 1992

Ian Glover, Mohamed Branine; Ageism in Work and Employment, Social Science, 2001

The Forgetting: A Portrait of Alzheimer's, PBS, 2004

Marcela I. Feria; Alzheimer: A Human Experience, Health & Fitness, 2006

 

 

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