AzGSJournal 5-16-12 LAYOUT TO POSSIBLY USE.indd
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AzGSJournal 5-16-12 LAYOUT TO POSSIBLY USE.indd
The Arizona Geriatrics Society an affiliate of the AMERICAN GERIATRICS SOCIETY In This Issue: Electroconvulsive Therapy (ECT): An Overview Music Therapy in Dementia Care Assessing the Quality of Life of People with Dementia Mentoring a Muse: A Story from the Interprofessional Senior Mentor Program Interprofessional Elder Care Provider Sheets: Frailty – Elders at Risk Canes Geriatric Evaluation Improving Communication with Older Patients Elder Abuse: Clinician Reporting Resilience in Aging Choosing the Correct Walker Sleep in Older Adults The ABDCs of Medicare Immunizations for Older Adults JOURNAL VOLUME 18 NO. 1 Summer 2013 CONTINUING TO MEET THE CHALLENGES OF PROVIDING QUALITY HEALTH CARE TO ARIZONA’S GROWING GERIATRIC POPULATION 25th Annual AzGS fall symposium 25th Annual Symposium 25th AnnualAZGS AzGS Fall fall symposium 25th Annual AzGS fall symposium Multimorbidity & the Interprofessional Healthcare Team: Keeping Patients at the Center of Care Friday-Saturday, November 8-9, 2013 at Desert Willow Conference Center in Phoenix Three out of four older Americans have multiple chronic conditions. Providing care for these patients is becoming ever more challenging as the entire landscape of healthcare changes: medications – new and old; the structure of healthcare delivery – “Obamacare”; technology – implanted surgical devices, remote sensors, EHRs Electronic Health Records; and population demographics. – Baby Boomers, traditional minority populations. The list goes on and on. The Arizona Geriatrics Society is pleased to present its 25th Annual Fall Symposium that will provide guidance on how to navigate the patient with multiple chronic conditions. This year’s conference presents a novel format with 100% general sessions. Topics to be presented are relevant to all disciplines and include: telehealth; ACOs and health care reform; case presentations highlighting multimorbidity and a stepwise approach to these patients; ethics; hospice vs. palliative medicine; and the role of non-medical home care, among others. The faculty includes a talented roster of interdisciplinary professionals who will prepare participants to better address the challenges of providing optimal care for older adults with multiple chronic conditions. Save the Date! Arizona Geriatrics Society 500 North 3rd Street ASU NHI-1 —Phoenix, Arizona 85004 www.arizonageriatrics.org Phone: 602-265-0211 Fax: 602-274-8086 CONTENTS Clinical Practice I Electroconvulsive Therapy (ECT): An Overview ............................. 3 Christopher Wiegand, MD, ABPN, FAPA An Affiliate of the American Geriatrics Society Music Therapy in Dementia Care ...................................................... 4 Robin Rio, MA, MT-BC BOARD OF DIRECTORS Assessing the Quality of Life of People with Dementia: A Marriage of Research, Practice and Technology............................................. 7 Perry Edelman, PhD; Tena Alonzo, MA Officers President: Edward Perrin, MD President-Elect: Sandra Brownstein, PharmD Past President/Treasurer: Joanne B. Gurin, MD Director-at-Large, Central: Carol Long, PhD, RN, FPCN Director-at-Large, Northern: Sam Downing, MD Director-at-Large, Southern: Patricia Dorgan, LCSW, ACSW Directors Senior Mentors Mentoring a Muse: A Story from the Interprofessional Senior Mentor Program ................................................................................ 13 Johnny Fenton, MA Clinical Practice II Elder Care Provider Sheets: Angela Allen, Geriatric Nursing Student, Arizona State University Frailty – Elders at Risk ..................................................................... 17 Rosemary S. Browne, MD; V. Ana Sanguineti, MD (student representative) Mindy Fain, MD Eileen Harris, BS, MS Paige Hector, LMSW Teri Kennedy, PhD, MSW, LCSW, ACSW Canes ................................................................................................. 19 Cameron R. Hernandez, MD; Tracy Carroll, PT, CHT, MPH; Barry D. Weiss, MD Mark E. Kiffer, DO, MBA Geriatric Evaluation.......................................................................... 21 Rosemary S. Browne, MD Jeannie Kim Lee, PharmD Carol McMullin, MD Karen Richards, RN, MBA, CPHQ Improving Communication with Older Patients ............................ 23 Jake Harwood, PhD Bob Roth, BS Staff Executive Director: Trudy Kiesewetter Project Coordinator: Iris Sumpter Special Projects: Sam Salinas Journal Editor: Mindy Fain, MD Co-Editor: Lisa O’Neill, MPH Inter-professional Associate Editorial Team: Rosemary Browne, MD; Jake Harwood, PhD; Karen D’Huyvetter, ND, MS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, CISW; Jeannie Lee, PharmD, BCPS; M. Jane Elder Abuse: Clinician Reporting ................................................... 25 Lisa M. O’Neill, MPH; Rae K. Vermeal, MA Resilience in Aging .......................................................................... 27 Erica S. Edwards, MSW; John Hall, PhD; Alex Zautra, PhD Choosing the Correct Walker .......................................................... 29 Cameron R. Hernandez, MD Sleep in Older Adults ....................................................................... 31 Joan L. Shaver, PhD, RN, FAAN Mohler, RN, MPH, PhD; Ana Sanguineti, MD; Barry Weiss, MD. The ABDCs of Medicare ................................................................... 33 Managing Editor: Trudy Kiesewetter VOLUME 18 NUMBER 1 - JULY 2013 We Welcome Letters to the Editor Barry D. Weiss, MD Immunizations for Older Adults ...................................................... 35 Doug Campos Outcalt, MD, MPA Letters must be submitted via email or in writing and include information on how to reach the writer. We reserve the right to edit for style, clarity and brevity. Send submission to: Letter to the Editor, Arizona Geriatrics Society, 500 North 3rd Street ASU NHI-1, MC 3020 Phoenix, Arizona 85004 l l Arizona Geriatrics Society Journal Published twice a year ---------------------------------Annual Individual Membership, Doctoral Level Dues - $160 Annual Individual Membership,Allied Professional Level Dues - $145 Annual Healthcare Affiliate Membership Dues - $325 500 North 3rd Street ASU NHI-1, MC 3020 Phoenix, Arizona 85004 Ph: (602) 265.0211 Fax: (602) 274.8086 www.arizonageriatrics.org The Arizona Geriatrics Society (AzGS) Journal assumes no responsibility for any injury and/ or damage to persons from any use of the instructions or ideas contained in the material herein. Statements reflect the views of the authors. All medication dosages should be checked. The information contained should never be used as a substitute for clinical judgement. The AzGS Journal is peer-reviewed publication. Those opinions expressed, and findings from research discussed in articles, however, are those of the author(s) and do not necessarily represent the views or positions of the AzGS. Page 1 From the Editor In this issue we continue to feature our Elder Care Provider Sheets – practical, evidence based short guides for health science students and clinicians, funded by grants from the Arizona Geriatric Education Center and the Donald W. Reynolds Foundation. Elder Care topics are highly relevant for health professionals caring for older adults and we encourage you to check them out! We welcome journal contributions on aging related topics from all of our readers, whether you are a student, researcher or a practicing clinician. Please contact us with any questions. As always, we hope you find this issue educational and valuable! Mindy J. Fain, MD The Arizona Geriatrics Society Journal, an official publication of the Arizona Geriatrics Society, is committed to publishing quality manuscripts representing scholarly inquiry into all areas of geriatrics. It is published twice a year. We encourage submissions of all research, best practice, review of literature, and essays. Manuscripts should be prepared according to the AMA Manual Style: A Guide for Authors and Editors, 10th Edition (2007) and emailed as a Word attachment to Mindy Fain, MD, Journal Editor, at [email protected]. The first page should include the title and a 50-100 word abstract. Manuscripts are generally limited to 4,000 words and should not be under consideration for publication elsewhere. Manuscripts are reviewed by members of our interprofessional editorial team whose evaluations will provide a basis for the publication decision. We are committed to a rapid review process. Thank you. American Geriatrics Society Journal Reviewer Information Name and Professional Degree(s)___________________________________ Position____________________________________ Work Institution_____________________________ E-mail address to which we should send manuscripts_________________________________ Have you reviewed manuscripts for medical journals before? _____Yes _____No If yes, how many times? _______________ List your areas of expertise/interest in which you would most like to review manuscripts 1._________________________________________ 2._________________________________________ 3._________________________________________ 4._________________________________________ Page 2 If there is a match between your topic(s) and the content of a manuscript, we will keep you in mind as a possible reviewer for the manuscript. Thank you! Please email responses to the questions on this form to [email protected] [email protected] or cut/copy this form and mail to: Mindy MD Carol L.Fain, Howe, MD, MLS University of Arizona on Aging Arizona Health SciencesCenter Library 1821 East Elm Street PO Box 245079 Tucson, AZ Arizona 85719 85724-5079 (520) 626-5800 520-626-2739 Thank you! ARIZONA GERIATRICS SOCIETY VOL. 18 NO.1 CLINICAL PRACTICE ECT: An Overview Christopher Wiegand, MD, ABPN, FAPA Electroconvulsive Therapy (ECT) has been practiced since 1937. In the late 19th and early 20th centuries, any patient with a brain illness that affected behaviors and/or emotions – bipolar disorder, schizophrenia, epilepsy, developmental problems, dementia, brain injuries – was sent to the same place, the asylum, for long-term confinement and care. Some of the physicians who cared for the patients in the asylums noticed that, when a patient who had both epilepsy and schizophrenia had a seizure from his or her epilepsy, the symptoms of schizophrenia improved for a time. This prompted the physicians to seek ways to give the non-epileptic schizophrenia patients seizures to treat their disorder. There are a few ways to induce a seizure in a person. It turns out that electrical stimulation of the brain is the safest and most reliable way to induce a therapeutic seizure. It also turns out that mood disorders respond better in general to ECT than schizophrenia, and that mood disorders in older patients respond best of all. Indications for ECT include: either unipolar or bipolar depression; mania; extremely severe behavioral disturbances in the setting of dementia; depression related to Parkinson’s disease; certain subtypes of schizophrenia (i.e., abrupt onset of positive symptoms); catatonia; and neuroleptic malignant syndrome. Pregnancy is not a contraindication for ECT; ECT is safe and effective for women who are pregnant or post-partum and suffering from one of the indicated disorders. Catatonia and neuroleptic malignant syndrome are two disorders for which ECT is indicated as a first-line treatment. For all the other disorders, ECT is reserved for severe illness that is resistant to medication management and psychotherapeutic interventions. Short-term memory loss and confusion are common side effects of ECT. It may seem counter-intuitive to treat patients with preexisting cognitive problems with ECT, but in the long-term, the cognitive side-effects subside in most cases and, overall cognitive functioning improves. An issue that can cloud the clinical picture is that, in up to half of Alzheimer’s disease cases, clinical depression is the first sign of the illness. There are emerging electricity-based and magnet-based treatment modalities that offer much to patients. At this time, ECT has the most robust beneficial effects for severe disorders. Culturally in the United States, ECT has been plagued by stigma and negative publicity. The negative portrayals in popular culture likely stem from the fact that, from 1937 until the 1950’s, ECT was performed without anesthesia. Also, the machines used in earlier times delivered the electrical stimulation in such a way that profound confusion and disorientation were common. In 2013, the procedure is safe, humane, and well-tolerated. Advances have been made in the technology and in the anesthetic agents used for the procedure. The tide is turning as far as the mainstream media’s portrayal and conceptualization of the procedure. In 2012, even Dr. Oz produced an episode of his widely-viewed TV show highlighting the potentially life-saving benefits of ECT. In conclusion, ECT is the best tool we psychiatrists have in our toolbox today for treating severe, treatment-resistant depression and catatonia. References are available from Dr. Wiegand through his website, www.doctorw.us, and by request via email [email protected]. We help you stay healthy at home ResCare HomeCare’s Life Management program is an individualized care plan that focuses on wellness and prevention. We educate the client and caregiver so they can monitor symptoms and successfully implement treatment and wellness plans to avoid hospital stays and live independently at home. We focus on wellness by: Educating our clients and caregivers to help monitor symptoms Creating a customized care plan Helping you manage meals and medication Acting as a communication link between you and healthcare providers Call today to learn about our Life Management program and set-up your free initial in-home RN assessment. 623.696.3749 ResCareHomeCare.com Page 3 24th ANNUAL AzGS FALL SYMPOSIUM THE NEW ERA OF ALZHEIMER’S DISEASE Music Therapy in Dementia Care Robin Rio, MA, MT-BC Literature Review Music therapists have been helping people with Alzheimer’s Disease (AD) and related dementias for many years. 1 In an extensive review of literature, Brotons, Koger and Pickett-Cooper found that music therapy was an effective way to manage symptoms of dementia involving social and emotional skills, cognition and behaviors. More recently, a group of French Experts 2 found that music therapy reduced anxiety, depression and aggressive behavior, significantly improving mood, communication and autonomy in people with AD. In a two-year study 3 to determine long-term effects of music therapy with residents of a care facility who had dementia, Takahashi et al (2006) found that the music therapy group maintained physical and mental health better than the non-music group. Lesta & Petocz 4 (2006) investigated the mood and behavior of women with dementia engaged in a music therapy group to help cope with the problems associated with sundowning. Study outcomes indicated that familiar group singing positively affected the social behavior and mood of those residents. When measuring the effectiveness of daily, seated dance exercises using familiar music, residents with moderate to severe dementia in the experimental group improved cognition scores on the Mini-Mental State Exam and the Amsterdam Dementia Screening Test 6, over the course of three months. Participants in the control group showed no improvement in cognitive scores. 5 Cervasco and Grant 6 found that a cappella singing garnered the greatest participation levels from people with AD. Holmes et al 7 found that the vast majority of moderately to severely affected people with AD were most engaged during live music compared with recorded music, and research by Gerdner 8 and confirms that the musical preferences of the individual are important in reducing agitation. The support and benefit that is provided by therapy with an experienced music therapist often increases the individual’s ability to communicate, express, and engage socially, improving mood and accessing memory through playing rhythms, vocalizing melodies, reminiscing and moving to music. The professional music therapist first completes a comprehensive assessment, whether in a formal manner prior to treatment, including cognitive-music tests and/or interview 9, 10 or less formally throughout the course of the first sessions. Once assessed, the individual’s care partners can work together to maximize the benefits of the individualized treatment program developed by the music therapist. Weekly music therapy sessions with a board certified music therapist can provide a foundation for subsequent music experiences to be provided by care partners, when given support and encouragement, to make music a part of daily social, exercise and recreational experiences. 11 Clair 11 and Hanser et al 12 describe successful programs established when Page 4 music therapists and care partners carry out an assortment of interactive music activities with the person(s) who have dementia. Applying Music Therapy Principles In both the residential facility and in the private home of the person with AD, it is helpful to define the role and responsibilities of the music therapist, outline the expected outcomes of the music therapy treatment, and to provide tools for the caregiver/partner to use outside of therapy sessions. Some of the techniques and principles provided in Connecting through Music with People with Dementia: A Guide for Caregivers 13 are included in the outline of music therapy strategies listed below. During the earlier stages of the illness, enhancing memory through singing, stimulating cognition and coordination through playing rhythmic patterns, and successful socializing is a primary goal. Helping a person who has recently been diagnosed to cope with the loss and use music to reflect and support those feelings is vital. Coping with mood, particularly anxiety and depression, upon learning of their diagnosis, can be supported through music that helps to calm and uplift. The therapist also wants to learn about the individual’s social history, family songs and meaningful music in these early stages while the individual is able to remember important details and life events. It is a time to build relationships, assess abilities and needs, share resources and develop support networks. How well does the individual communicate? What daily living skills are intact and where are the losses? For reminiscing 14 and stimulating memories through associations, try themes based on seasonal music, family, feelings, and pleasant pastimes. Intergenerational groups can provide a structure for older adults to have enjoyable time with youngsters, singing songs that are more firmly intact in the long-term memory, while still being “age appropriate” for the adult, making sure to keep music sophisticated enough that it isn’t insulting to adult sensibilities. Capitalize on associations with music from earlier life, particularly the teenage and young adult period, as it is often the bestpreserved and most meaningful music in the memory of the person with AD. When gathering information about a person’s music and related social history, ask the following: a. Did the person with AD play an instrument? Sing in a choir? b. c. d. e. Are there any particular dances known from young adult years? What was the individual’s favorite artist and/or style of music? Did the individual attend worship services? Sporting events? You can use music associated with those community events and spiritual life. Is there anything musically that could have been unpleasant or traumatic? Something as simple as being told “just move your lips, but don’t sing” in school can have a lasting negative impact. It is also important to find out if there is any serious trauma, such as being a veteran of a foreign war, a refugee, or similar situation where the associated music may produce a highly emotional response. Seeing how care-partners help facilitate independence in all manner of daily living skills can be applied to the therapeutic music setting. Setting up opportunities for success may involve simple but important environmental conditions. Reassurance will be needed. Lists and schedules will be appreciated. Putting things out in plain sight, such as music books, CDs, instruments, whatever will be used, and following a routine make a big difference for a person with dementia feeling secure enough to participate. When a person is facing memory challenges, they often have a “default mode” to save face. It can be a simple “no thanks” or “not today” or “I don’t know how” that keeps someone from participating in things they have previously enjoyed. As a rule, people don’t want to appear incapable, and are embarrassed when they are aware that they don’t remember. By offering choices and preparing the musical setting in an appealing and “easy to achieve” way, the person with AD can see the first simple step to what otherwise may look like a long and complicated procedure. Adapting materials, setting and procedures for independence helps the person with AD maintain musical engagement. The following are some suggestions for maximizing musical participation. a. b. c. d. e. f. g. h. Make available large print song sheets or sheet music. Give cues for turning pages, or organize music and lyrics so a page turn isn’t needed. Take out the instrument that the individual has played, and check it for proper working condition and repair it if needed. Find instruments that are easier to play if an original instrument is too difficult or unavailable (e.g., recorder instead of flute, autoharp instead of guitar, snare drum and cymbal instead of entire drum kit, etc.). If the individual with AD was an avid dancer, knowing the various dance music and steps will be helpful- you can reproduce simple dance rhythms on a drum if dancing isn’t safe or comfortable. Make sure that time in front of piano or whatever instrument was played is made a priority, and make it welcoming by having the music out. Invite the individual to come and play or sing often, and join them. Praise and encourage every effort. Self- esteem, confidence, and cognitive loss can make playing an instrument “too many steps” if the person doesn’t have assistance and support in “breaking down” the task. Invite the person with AD to attend a concert or participate in a community choir or music group that is at the appropriate level. Emotional Coping Anxiety and depression affect people who have dementia, and there is often a need for a release from this anxiety and stress, and for an improved overall mood state. Music can provide a welcome addition to traditional treatments. One can counter depression with opportunities to express sad feelings, acknowledge and validate them, and eventually lift the individual’s mood with up-tempo music. Music therapists refer to this technique as the iso principle based on the psychiatric work of Ira Altshuler. "Music therapists must first use music that matches the mood, activity level, or condition of the patients, before gradually changing the music to effect a change in these areas." 15 Dancing, movement, singing and instrument playing increases mobility and in return, deeper breath intake, which all helps to elicit a more positive mood. Social engagement through mutually enjoyed pursuits reduces isolation and provides much needed contact. When developing a music support group, include caregivers in the music experience as much as they are able and interested. Keep the group as homogeneous as possible, so that the pacing of the group is comfortable and the needs are similar. Facilitate so that each person has a chance to share, allowing for the solo voice in words or music when possible, intermingling discussion with music making. Group singing provides unity and support, and a shared repertoire can provide a bond. To further build community, celebrate life events and share memories. Some people with memory loss may like to perform, and this can be a very positive experience Some people prefer drum circles to song circles, and there are many benefits to drumming. Rhythmic patterns are easily created, and most people enjoy playing percussion even if they have no prior experience. It’s important to start with a smaller quieter sound and gradually build up. Sometimes people are highly sensitive to louder noises, and when unable to communicate effectively, it can be distressing to have loud or chaotic sounds. Many times, however, playing drums can be a great emotional release, and the rhythmic music making may naturally reduce tension and elevate energy levels. For those who like to create, songwriting and song parody or singing simple chants created in the moment can be a way to communicate important feelings. Saying, singing and repeating an affirmation, such as “I am feeling peaceful, I am calm” or other lyrics chosen by the participant can be a powerful way to achieve a sense of relaxation and well being. Songs of faith help renew, and music from one’s past can be familiar and comforting. In a more formal music therapy setting, life review with associated music helps in coping with losses. It allows the person with memory loss to share and preserve important personal history through the songs and music that accompany various life events. Informally, reminiscing naturally occurs when playing songs of one’s youth, and the memories associated with particular music may have even greater significance when shared with peers and those who care. Music Therapy in Middle to Later Stages of Dementia When a person is farther along in the progression of dementia, music therapy to manage symptoms becomes more connected with the stimulating and sedating properties of music, as they Page 5 have a direct impact on the nervous system and don’t rely on the intellect or verbal language to be felt and reacted to. Use music to energize the lethargic person. Take music with a slower tempo and increase the speed of the music to help create an atmosphere of excitement and alertness. Combine music with simple movement to help stimulate. With physical movement and engagement of the senses comes a person who is more aware and present in the moment. When the primary caregiver sings familiar songs, the person with dementia is comforted by hearing the familiar voice. Receptive music (listening) and physical contact are important to maintain togetherness for the caregiver and the person with dementia. Use music to calm the agitated person, and be aware of any triggers that may aggravate or over-stimulate. A few simple rules help to maintain an individual’s musical involvement in the later stages of dementia: a. Familiar music provides sense of security. b. Physical movement helps release tension. c. Seat people who get along near each other. d. Make sure to use any devices needed, such as glasses, hearing aide, walker, etc. e. Repeat music several times, especially the chorus or most well known part of a piece. f. Even if someone isn’t participating, they may be listening. g. Use visual cues and physical touch to help guide an individual back to the moment and the music. Last, it is important to have fun and enjoy the music experience with the person with memory loss. Music can capture a vast expanse of moods. It can be sentimental, deep, inspiring, heart wrenching, peaceful, silly, and every other emotion under the sun. Music therapy is a rewarding practice, has no known side effects, and is appreciated by people from all walks of life and represents a myriad of cultures across the globe. It is a cost effective way to manage many of the symptoms of dementia, from diagnosis to the end of life, and it offers solace and support for the care partner. Now is the time to provide this valuable treatment to the person you care for who has memory loss. References: 1. Brotons, M, Koger, SM, and Pickett-Cooper, P.. Music and dementias: a review of literature. Journal of Music Therapy. 1997; 34, 204–5. 2. Guetin, S, Charras, K, Berard, A, et al. An overview of the use of music therapy in the context of Alzheimer’s disease: A report of a French expert group. Dementia. 2012; 0(0): 1-16. 3. Takahashi, T, Matsushita, H. Long-term effects of music therapy on elderly with moderate/severe dementia. Journal of Music Therapy, 2006; 43(4): 317-333. 4. Lesta, B, Petocz, P. Familiar group singing: Addressing mood and social behaviour of residents with dementia displaying sundowning. Australian Journal of Music Therapy. 2006; 17: 2-17. 5. Van de Winckel, A, Feys, H, De Weerdt, W, Dom, R. Cognitive and behavioural effects of music-based exercises in patients with dementia. Clinical Rehabilitation. 2004; 18: 253-260. 6. Cevasco, A, Grant, R. Value of musical instruments used by the therapist to elicit responses from individuals in various stages of Alzheimer's disease. Journal of Music Therapy. 2006; 3:226-246. 7. Holmes, C, Knights, A, Dean,C, et al. Keep music live: music and the alleviation of apathy in dementia subjects International Psychogeriatric Association. 2006; 18:4, 623–630. 8. Gerdner, L. An individualized intervention for agitation. Journal of the American Psychiatric Nurses Association. 1997. P 177- 183. 9. Lipe, A, York, E, Jensen, E. Construct validation of two music-based assessments for people with dementia. Journal of Music Therapy. 2007; 44:4, 369-387. 10. Hintz, M. Geriatric music therapy clinical assessment: Assessment of music skills and related behaviors. Music Therapy Perspectives. 2000; 18, 33-42. 11. Claire, A. Mathews, M, Kosloski, K. Assessment of active music participation as an indication of subsequent music making engagement for persons with midstage dementia. American Journal of Alzheimer’s Disease and Other Dementias. 2005; 20:1, 37-40. Page 6 12. Hanser, S, Butterfield-Whitcomb, J, Kawata, M, et al. Home-based music strategies with individuals who have dementia and their family caregivers. Journal of Music Therapy. 2011; 48:1, 2-27. 13. Rio, R. Connecting Through Music with People with Dementia: A Guide for Caregivers. 2009. London: Jessica Kingsley Press. 14. Ashida, S. The effect of reminiscence music therapy sessions on changes in depressive symptoms in elderly persons with dementia. Journal of Music Therapy. 2000. 37:3, 170-182. 15. Peters, J. 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Orangewood Ave. Phoenix, AZ 85021 602-406-5600 ARIZONA GERIATRICS SOCIETY VOL. 18 NO.1 CLINICAL PRACTICE Assessing the Quality of Life of People with Dementia: A Marriage of Research, Practice and Technology Perry Edelman, PhD, Director of Wellness Research, Mather LifeWays Institute on Aging Tena Alonzo, MA, Director of Research & Dementia Programs, Beatitudes Campus June 19, 2013 Abstract Mobile observing quality of life in dementia (mOQOLD) is a non-invasive, non-pharmacological approach to improving person-centered dementia-care practice and the quality of life of people with dementia. The mOQOLD system enables researchers and practitioners to make systematic, reliable and valid assessments of the quality of life of people with dementia based on verbal and non-verbal cues, and indicators of engagement and affect. The challenges and benefits of using the system from the perspective of a practitioner from a skilled dementia care setting which was part of the National Institute on Aging-funded research study are described. Researchers and practitioners require reliable and valid methods for measuring the quality of life of people with dementia to assess the impact of interventions to identify activities that are most engaging and pleasurable and improve dementia care practice. In addition to useful measures, practitioners in particular require methods that are “usable” or practical in the dementia care setting. mOQOLD meets the needs of both researchers and practitioners across the spectrum of dementia care settings. Confusion regarding the relationship between quality of care and quality of life has been one obstacle to the development of an appropriate measure of dementia-specific quality of life. Jennings1 suggests that a commonly held belief is that quality of life is a goal of care. Lawton2 believes the term quality of care should be used in reference to concepts and issues like cleanliness, meeting physical needs, and treating or counteracting threats to life associated with illness and their effects on basic cognitive and physical function. On the other hand, quality of life refers to subjective states of individuals and “is the outcome toward which our efforts should strive.” (p. 143)2. Thus, while good quality of care is a necessary component of good quality of life, it is not synonymous with good quality of life. Care that is of good technical quality can be blind to critical components of quality of life such as engagement in meaningful and pleasurable activities. Efforts to improve the lives of people with dementia in residential facilities have focused on improving the quality of care; thus, the process of care, rather than outcomes of care, has been most carefully scrutinized. A well-accepted standard of care, personcentered care, can only be achieved by focusing on “the person”, which requires a new emphasis on assessing quality of life. Available Dementia-Specific Quality of Life Measures A number of dementia-specific measures have been developed over the past decade that attempt to assess quality of life from three different perspectives. Structured interviews are available that enable persons with mild to moderate dementia to self-report their quality of life.3-6 Questionnaires completed by family members and professionals have been developed to assess quality of life of persons who are too impaired to communicate on their own behalf.7-10 Measures of direct observation have been developed in which trained observers assess quality of life in congregate care settings.11-13 Strength and Weaknesses of Dementia-Specific Quality of Life Measures There are advantages and disadvantages to each type of quality of life measure. Interviews obtain information directly from persons with dementia, but as the disease progresses the reliability of the information becomes unclear, and interviews are not feasible with many individuals who are severely impaired. Staff and family member questionnaires can be used to assess a broader spectrum of individuals, but rely on the perspectives and perceptions of individuals with varying abilities to accurately report the person with dementia’s well-being. Systematic, trained observation is applicable to individuals with mild, moderate or severe dementia. Appropriate procedures and training minimize bias related to observer differences. However, in an applied setting a strength of observation – systematized and rigorous nature of the training and procedures – can also be a weakness if the method is too time-consuming or not userfriendly. George14 notes, practical constraints are inherent in service settings. Service providers have reported that time and cost constraints are a limited factor in adopting certain methods.15 mOQOLD takes advantage of the strength of observational procedures while avoiding their potential weakness by incorporating technological enhancements that reduce the time required by staff to collect data and produce reports. Development and Testing of OQOLD mOQOLD was developed in two stages. First, a three-phase program of research led to the development and testing of observing quality of life in dementia (OQOLD). The research was supported by staff and funds from Mather LifeWays Institute on Aging and a grant from the Alzheimer’s Association (award number: IIRG-05-13794). In Phase 1, six existing dementia-specific quality of life measures (two resident/client interviews, two staff questionnaires, and two observational procedures) were tested by researchers and service providers in three dementia-specific adult day centers, three assisted living facilities, and two skilled care centers to identify relationships among these measures and the usefulness and practicality of each measure. The researchers found that neither the staff measures nor the observational measures were significantly correlated with resident interviews. Although practitioners were most favorable to one of the Page 7 observational techniques, due to the time required to implement this method, the method was considered impractical for use. In Phase 2, OQOLD was developed and tested along with five of the previous measures (one of the Phase 1 observational procedures was dropped) in two dementia-specific adult day centers, two assisted living facilities, and two skilled care centers. OQOLD observers made systematic assessments of the quality of life of people with dementia based on verbal and nonverbal cues as well as indicators of engagement and affect. The coding system used by observers comprised a seven-point scale ranging from +3 (an extremely pleasant experience) to -3 (an extremely unpleasant experience). Definitions and examples were accompanied by illustrated faces that represent the experience. Verbal anchors are also attached to the midpoint and endpoints of the seven-point scale (+3 = excellent, 0 = neutral, -3 = terrible). Below is an example for the highest possible OQOLD score: +3 EXCELLENT. An extremely pleasant experience. A very enjoyable OR high level of verbal or non-verbal engagement with others or an activity. Examples: Having a very enjoyable conversation with another person(s), OR a very enjoyable interaction with a pet, OR a very enjoyable or high level of engagement in talking, singing or playing games. Observations are made in conjunction with activities which are broadly defined to include activities of daily living, stafffacilitated small and large group activities, and one-on-oneactivities. At the beginning of the activity, the staff person who is facilitating the activity enters the name of the activity being observed and the start time. At the end of an activity, the staff member enters three scores for each participant indicating: (1) the most frequently observed state, (2) the best experience observed (the highest score), and (3) the worst experience observed (lowest score). In addition to OQOLD scores, the primary and secondary areas of impact of each activity for each participant is recorded in terms of six dimensions of wellness – physical, social, intellectual, emotional, spiritual, and vocational.16 Identifying the areas of wellness impacted by each activity is critical to providing a holistic experience for participants across the six dimensions. Without this information, practitioners could be limiting participation to a small number of familiar activities, thus, denying participants a richer, more fulfilling experience. Finally, the stop time of the activity, location/traffic, distractions, and the presence of people (volunteers, staff and family members) during the observation period are recorded. Analyses comparing the use of the three types of measures indicated that OQOLD was significantly correlated with one of the staff questionnaires and the other observational procedure (correlation coefficients range from 0.55 to 0.98 (p <.0005). However OQOLD was the only measure significantly correlated Page 8 with any of the resident interviews (r= 0.50; p <.0005), suggesting that OQOLD tapped into the experience of people with dementia, whereas the other observational measure and staff questionnaires did not. Unlike Phase 1, where researchers collected most of the data, Phase 2 service providers collected all of the data. At the end of this phase, service providers identified OQOLD as the most useful and practical tool for assessing dementia-specific quality of life. Phase 3 research findings from two dementia-specific adult day centers, two assisted living facilities and two skilled care centers documented a number of benefits including improving staff knowledge of the impact of their behavior on participants (e.g., observations during lunch time have been used to inform the dietary and nursing staff regarding methods of improving participants’ food consumption), and motivating a change in care plans by using OQOLD to assess the impact of two different dining settings. Additionally, OQOLD has been used as an outcome measure to obtain a grant to assess the impact of a pilot massage therapy intervention, and to provide quantitative feedback to family members that complements the qualitative perspective of practitioners. Development of the mOQOLD System: Technological Enhancements to OQOLD The second stage of this research was funded by two grants from NIA. Mather LifeWays Institute on Aging and Benten Technologies collaborated over three years to improve the usability of OQOLD by developing and testing technological enhancements including data entry via an iPod Touch, wireless transmission of quality of life data to a website and intuitive, user-friendly software which enables practitioners to download 13 reports that can enhance the dementia care practice and the well-being of participants. The technology-enhanced system is called mOQOLD or mobile OQOLD. The mOQOLD system provides critical information regarding the impact of specific activities on specific participants that enables staff to match activities to individuals’ needs, abilities and interests. The mOQOLD system provides reporting with enough flexibility to answer a variety of practice-relevant questions. This information can be used to develop/revise participants’ care plans, and collection of mOQOLD data on a regular basis can be used to assess the success of changes instituted. mOQOLD data could be especially helpful to determine the most beneficial activities for new participants or for individuals whose condition and abilities are changing. Testing the mOQOLD System: Practitioners’ Experience The initial feasibility study was conducted with funding from the NIA at one dementia-specific adult day center, one assisted living facility, and one skilled care center. The second grant from NIA enabled large scale testing of the mOQOLD system with six dementia-specific adult day centers, two assisted living facilities, and two skilled care centers in Illinois, Florida and Arizona. The Beatitudes Campus in Phoenix, Arizona was one of the dementia-specific skilled care centers that participated. The experience at this site is instructive in terms of the obstacles that had to be overcome, as well as the success staff eventually experienced using mOQOLD. Adopting the mOQOLD System at Beatitudes Campus “I look at ways to improve each person’s experience now that I’ve learned to use the mOQOLD.” Stacy, Beatitudes Campus Adopting new tools can be difficult, but the choice to adopt mOQOLD was a relatively easy one because both staff and people with dementia stood to benefit. mOQOLD ensured input from the person with dementia even though their ability to verbalize was compromised, and provided staff with systematically collected data based on their knowledge of the residents and observational skills. The use of the tool enabled staff to see beyond the impairments of dementia and helped them to focus on specific strategies to create pleasurable experiences for the person while also creating awareness that all interactions were not equal. In addition, the experience of using mOQOLD strengthened the concept that staff members, especially front-line staff, have the power to change a no response or negative response to a positive one. An unanticipated result of adopting mOQOLD was that it encouraged staff members, regardless of their role, to have continuous dialogue about quality of life for people with dementia. Initial Implementation In preparation for the project, the research team from Mather LifeWays and Benten Technologies trained a core group of Beatitudes Campus skilled nursing center staff to use the OQOLD tool and collect data using the iPod mobile device. Training, including a component to develop reliability using the mOQOLD system requires approximately six hours. Initially, the healthcare administrator, the dementia program director, an activity professional and a nursing assistant received training. Once the training was completed, nine older adults diagnosed with moderate to advanced dementia were consented to participate in the study which occurred over a seven month period. The dementia program director, activity professional and certified nursing assistant were responsible for observing the older adults in the study during a variety of events and activities, and collecting the mOQOLD data. After the mOQOLD data were collected, a variety of reports were downloaded and discussed with staff. Group Summaries and Individual Reports The reports created by the mOQOLD system were useful in determining which types of activities/resident-staff engagements resulted in the most positive or negative responses for people participating in the study. A number of reports provided similar data, the difference being the focus – a single participant or group of participants (aggregate scores). The aggregate mOQOLD scores were used at Beatitudes Campus to enhance the Engagement/Recreation program, and individualized reports were used to improve each person’s plan of care, complete the Minimum Data Set (MDS) 3.0 and demonstrate levels of engagement and activity participation for a group of people where engagement is difficult to measure. Two examples of reports were the Trend Reports and the Top 10. Figure 1 displays an individual and a group trend report (data are contrived). These reports can be used to identify patterns of responses (i.e., the most, best and worst scores) over time, and additional information recorded during observations can be used to help interpret these patterns. Figure 1. Trend Charts (contrived data used in graph) Y axis represents scores on the OQOLD Scale. Y axis represents scores on the OQOLD Scale. Table 1 (data are contrived) describes the Top Ten activities in terms of the highest average most score across multiple observations of a single individual. The table to the left displays activities from highest to lowest average most scores observed. The table to the right displays the same information but the order of activities is from most frequently to least frequently observed. Knowing the number of observations that contributed to each average most score is important to appropriately interpret findings. Page 9 Table 1. Individual Top 10 Activity Report (contrived data used in table) One final example of a report is the Red/Green Flag Report. This report enables users to identify cut-off scores for displaying data. In Table 2 (data are contrived), the cut-off score was set at 3, the highest possible score. Thus, staff can use the information to identify which activities resulted in the highest quality of life for participants. This report also indicates the impact of each activity in terms of six dimensions of wellness. Table 2. Red/Green Flag Report (contrived data used in table) Page 10 Project Lessons Learned The requirement of a wireless local network that would enable transmission of data from the handheld data collection device to the website presented a challenge in a building constructed of cement nearly 50 years ago. There was considerable difficulty in the installation of the network, but it was finally competed a few months into the project. Prior to the installation of the network, data were collected by hand. The challenge with technology continued as some members of the Beatitudes Campus team initially experienced difficulty using the iPod. As with most new technology, the challenge with using the iPod soon abated. As the project was rolled out to additional staff, some were initially resistant to learn and adopt the mOQOLD as a way of evaluating engagement. Over two months, staff became proficient in using the tool and comfortable with recording observations using the iPod, and mOQOLD acceptance was achieved. During this time, staff - regardless of their role began discussing ways to help people have more +3 experiences. The myth that people with dementia can not find enjoyment was dispelled, as well as the idea that staff were powerless to create enjoyable moments. Collectively, the staff recognized that improving quality of life for the person with dementia improved their own work experience. Enhancing quality of life for people with dementia by using mOQOLD has now become common place and is exemplified in Eddie’s story: Eddie was an accomplished wife, mother and teacher who lived in Arizona all of her life. Eddie was diagnosed with dementia 10 years ago after her husband had noticed changes in her memory. Unable to ambulate independently or speak more than a few words, Eddie spent much of her time in the skilled nursing center seated in a recliner or resting in bed. Although, Eddie had trouble thinking, she loved small children. Whenever she saw a young child she smiled broadly and tried to speak. During a mOQOLD observation, a staff member noticed how happy Eddie looked when preschool children were visiting. The staff member noted this was the happiest Eddie had ever looked; generally she had little expression or response to events but she was a “plus three on the OQOLD scale!” The staff member wanted to see Eddie have “a plus three” response more often so she asked Eddie’s family if they had any pictures of babies or were there young children who could visit. Other staff members got involved by bringing their children to see Eddie and by donating pictures of their children for her to look at. Eventuality a collage of baby pictures was created for her room which made Eddie smile every time she saw it. Beatitudes Campus Next Steps During the project, the skilled care staff recognized that mOQOLD was beneficial for everyone involved with people with dementia. A plan was developed to educate staff serving in the skilled care and assisted living centers. Education was made available to staff from all departments working for Beatitudes Campus. Additionally, a plan to educate families about mOQOLD was developed for implementation. Finally, the opportunity to further integrate the information gathered through mOQOLD was considered. It was determined that using the mOQOLD system to assess individuals’ responses to opportunities for engagement can have a profound impact on how care and service is delivered. The process of integrating the tool continues as staff and families embrace the opportunity to enhance quality of life for people with dementia. Summary A decade of research and development has resulted in mOQOLD, a reliable, valid and practical observational tool for assessing the quality of life of people with dementia. The mOQOLD system includes the OQOLD scale and technological enhancements that maximize the usability and practicality of the tool by enabling ease of data entry and production of practicerelevant information. The portable device for recording data, carried by a staff member in his/her pocket with wireless synchronization minimizes disruption to daily routines of staff and participants. With real-time information collected throughout the day on a mobile device, mOQOLD data are continuously transferred to the mOQOLD website for storage, management and report-generation. Staff members who use the system are key to its successful implementation, because staff knowledge of the meaning of the behavior and affect of people with dementia is the foundation for using the OQOLD scale. A toolkit exists for training staff to reliably use mOQOLD, and interested parties can contact the first author for more information. Years of privately and NIA-funded research conducted with dementia-specific adult day centers, assisted living facilities and skilled care settings have documented benefits of using the mOQOLD system. References: 1. Jennings B. A life greater than the sum of its sensations: Ethics, dementia, and the quality of life. In: Albert SM, Logsdon RG eds. Assessing quality of life in Alzheimer’s disease. New York: Springer; 2000. 2. Lawton MP. Quality of care and quality of life in dementia care units. In: Noelker S, Harel Z eds. Linking quality of long-term care and quality of life. NY: Springer; 2001. 3. Brod M, Stewart AL, Sands L, Walton P. Conceptualization and measurement of quality of life in dementia: the dementia quality of life instrument (DQoL). The Gerontologist. 1999;39:25-35. 4. Kane RA, Kling KC, Bershadsky B, Kane RL, Giles K, Dehgenholtz HB, et al. Quality of life measures for nursing home residents. Journal of Gerontology: Medical Sciences. 2003;58:240-248. 5. Logsdon RG, Gibbons LE, McCurry SM, Terri L. Quality of life in Alzheimer’s disease: patient and caregiver reports. In: Albert S, Logsdon RG eds. Assessing quality of life in Alzheimer’s disease. NY: Springer Publishing Co; 2000:17-30. 6. Logsdon RG, Gibbons LE, McCurry SM, & Terri L. Assessing quality of life in older adults with cognitive impairment. Psychosomatic Medicine. 2002;64:510-519. 7. Logsdon RG, Gibbons LE, McCurry SM, & Terri L. Quality of life in Alzheimer’s disease: patient and caregiver reports. In: Albert S, Logsdon RG eds. Assessing quality of life in Alzheimer’s disease. NY: Springer Publishing Co; 2000:17-30. 8. Logsdon RG, Gibbons LE, McCurry SM, & Terri L. Assessing quality of life in older adults with cognitive impairment. Psychosomatic Medicine. 2002;64:510-519. 9. Albert SM, Castillo-Castenada C, Sano M, Jacobs DM, Marder K, Bell K, et al. Quality of life in patients with Alzheimer’s disease as reported by patients’ proxies. Journal of the American Geriatrics Society.1996;44:1342-7. 10. Rabins P, Kasper JD, Kleinman L, Black BS, Patrick DL. Concepts and methods in the development of the ADRQL: An instrument for assessing health-related quality of life in persons with Alzheimer’s disease. Journal of Mental Health and Aging. 1999;5:33-48. 11. Bradford Dementia Group. Evaluating dementia care: The DCM method. 7th ed. Bradford, England: University of Bradford; 1997. 12. Kitwood T, Bredin K. A new approach to the evaluation of dementia care. Journal of Advances in Health and Nursing Care. 1992;1,41-60. 13. Lawton MP, Van Haitsma K, Klapper J. Observed affect in nursing home residents with Alzheimer’s disease. Journal of Gerontology: Psychological and Social Sciences. 1996;51:3-14. 14. George, LK. Choosing among established assessment tools: Scientific demands and practical constraints. Generations. 1997;XXI:32-36. 15. Fulton BR, Edelman P, Kuhn D, Cislo A. Observing quality of life in dementia (OQOLD): A new tool for improving dementia care practice. Seniors Housing and Care Journal. 2006;14. 16. Montague JM, Peters K, Poggiali T, Piazza W, & Eippert G. The wellness solution. The Journal on Active Aging. 2002;2. Page 11 Arizona Geriatric Education Center Arizona Geriatric Education Center The Health Resources and Services Administration (HRSA), an agency of the US Department of Health and Human Services, funds Geriatric Education Centers (GEC) across the nation to provide interdisciplinary training of health professions faculty, students and practitioners in the diagnosis, treatment and prevention of disease, disability and other health problems of the elderly. Due to our innovative programs, renowned interprofessional faculty and statewide partnerships we have successfully competed for a GEC in Arizona 4 times!! The primary goal of our Arizona Geriatric Education Center (AzGEC) is to help build an expanded, diverse, and prepared interprofessional geriatric workforce in Arizona to meet the special healthcare needs of older adults, especially the frail. There is a great need for this project, as Arizona is rapidly growing, with growth especially pronounced among older adults in ethnic minority groups and those living in rural and underserved areas. Many of these elders have multiple complex health problems, and poor function and quality of life, and will use a disproportionate share of health care resources with high associated costs. The AzGEC is integrally involved in geriatric education and training, clinical demonstration and care, biology of aging and aging health services research, community engagement, and aging policy integrating linkages to the Administration on Aging, National Institute on Aging, Department of Veterans Affairs, and other Health Resources and Services Administration programs. Our AzGEC is a statewide consortium, including the University of Arizona Health Sciences Center, Arizona State University, and the Southern Arizona VA Healthcare Center. Through these partnerships we provide interprofessional education and training of health science students, nurses, NPs, PAs, physicians, pharmacists, public health and social workers to provide quality care of seniors in Arizona, across the continuum. •Are you committed to improving and developing health care best practices for older adults? •Are you serious about advancing your knowledge of geriatric health care? If so: Join the AzGS Today!!! AzGS membership offers a wide array of resources to help you succeed in your health care profession — three annual continuing medical educational opportunities, accreditation options, professional networks, a highly recognized peer-reviewed Journal, and dinner programs that offer educational and networking opportunities. For more information or to register: Visit our website at: www.arizonageriatrics.org Email us at: [email protected] Give us a call at: (602) 265-0211 Page 12 ARIZONA GERIATRICS SOCIETY VOL. 18 NO.1 CLINICAL PRACTICE Mentoring a Muse: A Story from the Interprofessional Senior Mentor Program Pharmacy student, Cassia with her senior mentor, Johnny Fenton The surprise dilemma: How do you teach a teacher? The taste had gone out of food—and life in general when I was widowed several years ago. With a background of volunteerism and as a University of Arizona (UA) alumna, I signed on for the Interprofessional Mentoring Program within The UA Center on Aging. Then Mondays with Cassia were, once again, delicious with ideas and events! Briefly, what I brought to the mentoring process as a mother, grandmother and widow was a background including stints as an NBC reporter, lobbyist, sorority house mother, grant writer and currently, a concierge and travel writer for a statewide magazine during the past 13 years. As the daughter of a lawyer and judge, I grew up in a small town south of Kansas City, Missouri, spending most of my childhood Thanksgivings serving dinners at the Salvation Army and living a family philosophy most succinctly described by a poet from my birthplace, Maya Angelou, “If you get, give—If you learn, teach.” Cassia energized me with a short list of her right-and-left-brained interests and accomplishments from our first schmoozing over smoothies at a sandwich shop in February across from our meeting spot at my parish St. Philips in the Hills Episcopal Church (where I met and married the love of my life). A disarming example was learning of her project to sew a dress for her Mother’s birthday while Cassia is in the midst of her medical studies as a pharmacy student. Then, when I asked what her favorite web apps included, her first response was her banking app! I was fascinated by her childhood tales of growing up in the Marshall Islands surrounded by several generations of doctors in the family—including an uncle whom I learned, is my ophthalmologist! These were surprising responses that encouraged a self-described “cranky optimist” – yours truly. One of my most instructive interludes was at a Pima Community College fashion show in which Cassia had to model a black cocktail dress she made to receive her grade in a sewing class she took (as a practical measure) in addition to her UA classes. I was invited to this, almost professional, showcase for the needlecraft of 87 models, enhanced by the interdisciplinary programs of theatre and music. What a great venue, getting me out of my routine, to meet her supportive family of doctors and engineers and Anthony, her significant other who is off to medical school in Indiana in the fall. And primarily, to see her creative side and sense of fun, driven by her Type-A personality stunningly played out on a runway in an arresting little black dress, where she briefly stopped on her way to her chosen profession in a white lab jacket! It was evident this night that Cassia will succeed in any endeavor she undertakes. A bonus gift from Miss Griswold included a tutorial in computerese during a luncheon at my home. She instructed me in how to catalog recent photos and send them as attachments, which delighted my daughter who attempts to fast forward me in these skills on her brief but nurturing holiday visits. Thank you Cassia, for this and enrichments too numerous to recount. Page 13 Hiking in Catalina State Park This summary would not be complete however, without a final story. Cassia and I decided we would go on a hike for our last assigned Monday together. When she suggested Catalina State Park for a trail head, I had a “crossroads moment.” You see, Catalina State Park in the shadow of the Catalina Mountain Range beneath Pusch Ridge, was where my husband trained each year for the 111mile perimeter bicycle tour for charity and where he took his life after a diagnosis of terminal prostate cancer. I had not returned to—could not drive by—this area since his death in 2008. But because Cassia issued the invitation, I said “yes.” Cassia was the muse—my inspiration—for seeing with new eyes this destination. And indeed, we saw cardinals, horny toads, streamed arroyos and sunny vistas of the Tortolitas, all purple in the distance, and chatted about the dogs in her life, Sebastian and Nuri; the excitement of stepping out of one’s comfort zone and the definitions of success on a personal and professional level. That evening I phoned my daughter in Virginia with tears of relief and a profound victory that Cassia (unaware) helped me achieve through her prescription. About the Author Johnny Fenton is a University of Arizona Alumna with an M.A. in Journalism. A former NBC reporter, magazine editor, and lobbyist, she is currently a travel writer for Arizona Key Magazine and a concierge at Omni Tucson National Resort. Interprofessional Senior Mentor Program The Interprofessional Senior Mentor Program (IPSMP) is offered to University of Arizona and Arizona State University health science students, and is designed to increase their exposure to healthy older adults by allowing them to get to know an older adult in a non-clinical environment. This out-of-classroom experience pairs each student with a socially and physically active 65+ year-old community-dwelling adult who will be their senior mentor for a semester. They meet 3-4 times for approximately 2-3 hours each visit. Each meeting has activities aimed to increase the student’s geriatric knowledge, reduce stereotypes about aging and add meaning to their geriatric curriculum content, thus improving the way future health professionals care for older adults. The students also participate in one Interprofessional Team Meeting for a case review. This relaxed and engaging roundtable discussion allows them to increase their knowledge of the roles and expertise of other health professionals and learn the importance of team health care. During the spring semester of 2013, our program brought together 40 mentor/student pairs in Tucson and 11 mentor/student pairs in Phoenix. We received glowing reviews from all parties and are continuing to expand this very successful program. Page 14 The University of Arizona Center on Aging strives to improve the quality of living and function of Arizona’s older adults through innovative programs in research, education and clinical care We are proud to collaborate with our partners across the state Research: Combining cutting-edge research through our biology of aging, clinical, epidemiologic, and health services programs, we bring the bench to the bedside and back again to improve the quality of life and functional longevity of older adults. Of special note are our Immunobiology and GeriMetrics Programs: Immunobiology research explores age-related changes in inϐlammation, immunity, bone, muscle, and fat biology. GeriMetrics uses innovative bioengineering tools to address common geriatric conditions and syndromes including imbalance and falls, cognitive deϐicits, pressure ulcers, polypharmacy management, self-care deϐicits and frailty. Education and Training: We provide training and continuing education in aging issues to health science students and working professionals across the state. Our Interprofessional Arizona Geriatric Education Center and Reynolds Program in Applied Geriatrics help to prepare our state’s workforce in caring for Arizona’s older adults. Clinical Care: We connect older adults with geriatricians and palliative care specialists – providers who are trained to meet the speciϐic needs of aging adults. University of Arizona Center on Aging 1821 East Elm Street Tucson, AZ 85719 (520) 626 -5800 www.aging.arizona.edu Page 15 Graduate Education Opportunities The 2012 U.S. News & World Report survey of America’s best graduate schools ranks the College of Nursing and Health Innovation 21st out of 467, or the top 4%, of graduate nursing programs in the nation. x Master of Healthcare Innovation (MHI) is a fully online program that brings together information from innovation and change theory, leadership, entrepreneurship, application technology, and system design programs, to create innovative solutions to the challenges in health care. x Master of Science, Clinical Research Management (MS-CRM) is a fully online program that prepares graduates to lead complex global clinical research operations at multiple types of employer settings in the rapidly growing clinical research industry. x Master of Science, Nurse Educator is a pathway designed to prepare the new and experienced nurse to meet demands of the changing health care environment. The program is learner-centered, clinically focused, population-specific, and designed for those who initially choose a career as a nurse educator, as well as for nurses in practice who want to make a change. x Doctor of Nursing Practice (DNP) program is focused on improving health care through facilitating a culture of best practice, and providing the additional skills necessary to develop advance practice nursing leaders for the future. Post x Baccalaureate and Post Master’s DNP advanced practice specialties include: o Adult-Gerontology Nurse Practitioner o Family Psychiatric Mental Health Nurse Practitioner o Family Nurse Practitioner o Neonatal Nurse Practitioner o Pediatric Nurse Practitioner o Women's Health Nurse Practitioner o Innovation Leadership PhD degree in Nursing & Healthcare Innovation is designed for scholars who wish to pursue careers as leaders in health policy, education and research. The degree will also help to address a national need for faculty and researchers who are increasingly in short supply. For additional information, https://nursingandhealth.asu.edu/programs Page 16 Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center May 2013 ELDERCARE A Resource for Interprofessional Providers Frailty – Elders At Risk Rosemary S. Browne, MD, College of Medicine, University of Arizona V. Ana Sanguineti, MD, College of Medicine, University of Arizona Frailty is a clinical state of increased vulnerability and decreased ability to maintain homeostasis that is seen in older adults. It is characterized by declines in functional reserves across multiple physiologic systems. Frailty is agerelated, with the prevalence reaching 30% among those over 90 years. It is now considered to be one of the geriatric syndromes and, as the population ages, is emerging in importance because of its associated morbidities, such as falls, disability, and dependency. The physiology of aging is still not fully understood, but all cells undergo a decline in function as a person ages. Whether through the mechanism of somatic mutations, waste accumulation, collagen cross-linking, immune dysregulation, oxidative damage, and/or programmed cell death, the end result is that aging cells function less effectively and efficiently. Growing evidence points to the accumulation of pro-inflammatory responses to cell death and senescence, including secretion of interleukin-6 and others, as particularly important in the etiology of frailty. This age-related functional decline happens predictably in all organ systems, and is distinct from the loss of function that occurs from disease. Frailty occurs when this agerelated deterioration in cellular function becomes extreme. The result is a loss of functional capacity and limited energy reserve at both a cellular level and in day-to-day activities. From a clinical perspective, a frail elder will experience a disproportionate decline in health as compared to non-frail peers, even from a minor medical insult. When faced with stressors such as illness, hospitalization, or surgery, frail older adults lack the capacity to right themselves (i.e., to regain homeostasis). Unable to recover equilibrium, the individual often spirals into further decline and disability. Homeostenosis is the term used to describe this inability of frail elders to regain a steady state, and stands in contrast to the normal ability to maintain homeostasis. What Happens in Frailty? There currently are no biomarkers or imaging tests that provide a measure of frailty. Frailty, however, is associated with a number of findings which, in effect, create a clinical syndrome. The findings typically include sarcopenia (see next paragraph), changes in body mass, and exhaustion, entering into a cycle (Figure 1) that can lead to a decline in strength, increased disability, and decreased activity. Dependency eventually develops. Figure 1. The Frailty Cycle Malnutrition/ Weight Loss Decreased Activity Sarcopenia Decreased Strength/ Exhaustion Falls and Disability Sarcopenia Sarcopenia is the gradual loss of skeletal muscle mass that occurs with normal aging. Severe sarcopenia, however, often defined as a muscle mass >2 standard deviations below the average muscle mass of a same sex-young adult, suggests the presence of frailty. Weight Loss Weight loss is a common precursor to frailty, usually developing in a “pre-frailty” stage. Weight loss is considered extreme when it results in a low body mass index (BMI <18.5), and such low BMI values are often present in individuals with frailty. But, it is important to keep in mind that frailty, as defined by the various measures in Table 1, can also occur in individuals, most often women, who are obese (BMI >30). Despite their high BMI, obese individuals can still lose weight due to malnutrition, and that can worsen the decline in muscle mass. Obese individuals also commonly limit their physical activity, which further contributes to loss of muscle mass. TIPS FOR DEALING WITH FRAILTY IN OLDER ADULTS x Perform frailty assessments routinely on older adults, including those who are obese. Obesity does not prevent frailty. x Ask about unintentional weight loss, weakness and exhaustion. x Recommend a healthy diet such as the Mediterranean diet, along with adequate intakes of protein and vitamin D x Recommend resistance exercise and aerobic exercise to slow development of sarcopenia. x Optimize management of medical conditions. Page 17 Continued from front page ELDERCARE The combination of poor nutrition, weight loss, and decreased activity in obese individuals can result in severe sarcopenia, just as it does in those with a low BMI. The Frailty Cycle Once severe sarcopenia and weight loss develop, patients have limited strength and become exhausted easily. They walk more slowly and are prone to falls and injuries that can lead to disability, further limiting mobility and physical activity. The decreased physical activity leads to yet more loss of muscle mass that contributes to further loss of function. An older adult can enter this cycle at any point, although weight loss and malnutrition are a common entry point. Diagnostic Tools Multiple validated scoring systems are available to aid in the clinical diagnosis of frailty. Two of the most commonly used scoring systems are shown in Table 1. These scoring systems can be used during formal interprofessional comprehensive geriatric assessments and also during geriatric evaluations performed by individual clinicians in practice (see Elder Care on Geriatric Evaluation). Both scoring systems use objective and subjective measures. A downside to the CHS index is that it includes research measures that are often not assessed in everyday clinical practice (e.g., grip strength). The SOF, in contrast, is easier to use in clinical settings, and its accuracy has been validated against the CHS. Implications of Frailty Frailty is an independent marker for poor outcomes following surgery, including increased morbidity and mortality, longer lengths of hospital stay, and the need for discharge to nursing facilities. Including a frailty assessment as part of the preoperative evaluation of older adults contemplating elective surgery can better identify individuals at risk for these poor outcomes and may help guide peri-operative decision making (see Elder Care Preoperative Assessment). Prevention and Treatment The interventions that have been shown to be most effective for prevention and treatment of frailty are resistance exer- cise, aerobic exercise, and optimal nutrition to prevent both weight loss and obesity. Building muscle mass through hormonal therapy (e.g., testosterone, growth hormone) has not shown benefit and is not currently recommended. Table 2 lists practical interventions aimed at maintaining strength and mobility. They may be helpful for preventing and treating frailty. Table 1. Scoring Systems to Assess Frailty in Older Adults Cardiovascular Health Study ICHS) Index - Fried Criteria Frail = 3 of the following findings present Pre-frail = 1 or 2 of the following findings present x Weight loss (5 percent of body weight in last year) x Exhaustion (positive response to questions regarding effort required for activity) x Weakness (decreased grip strength) x Slow walking speed (>6-7 seconds to walk 15 ft) x Decreased physical activity. Males expending <383 kcals/week and females <270 kcal /week in physical activity. (For reference, walking 4 miles in 1 hour = 300 kcal) Study of Osteoporotic Fractures (SOF) Index Frail = 2 out of 3 criteria positive x Weight loss of >5 percent in last year x Inability to rise from a chair five times without using arms Table 2. Interventions Recommended to Prevent and Treat Frailty and its Complications x Resistance and aerobic exercise x Physical therapy, if needed, to facilitate exercise x Optimal nutrition (e.g., Mediterranean diet, adequate protein) x Obesity prevention x Fall prevention x Optimize calcium and Vitamin D intake x Optimize treatment of medical illnesses x Treat depression References and Resources Ahmed N, Mandel R, Fain M. Frailty: An emerging geriatric syndrome. Am J Med. 2007; 120:748-53. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet. 2013; 381:752-62. Fedarko NS. The biology of aging and frailty. Clin Geriatr Med. 2011; 27:27-37. Kiely DK, Cupples LA, Lipsitz LA. Validation and comparison of two frailty indexes: The MOBILIZE Boston Study. J Am Geriatr Soc. 2009; 57:1532-9. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010; 210:901-8. Wenger, NS, et al. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. Journal of the American Geriatrics Society, 2007. 55: p. S247-S252. Xue QL. The frailty syndrome: definition and natural history. Clin Geriatr Med. 2011;27:1-15. ACOVE Quality Indicators x IF a vulnerable elder has involuntary weight loss of greater than or equal to 10% of body weight over 1 year or less, THEN weight loss (or a related disorder) should be documented in the medical record as an indication that the physician recognized malnutrition as a potential problem. x ALL vulnerable elders should have documentation that they were asked at least annually about the occurrence of recent falls. Interprofessional care improves the outcomes of older adults with complex health problems Page 18 Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Tracy Carroll, PT, CHT, MPH; Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center March 2013 ELDERCARE Canes A Resource for Interprofessional Providers Cameron R. Hernandez, MD, Mount Sinai School of Medicine Tracy Carroll, PT, CHT, MPH, College of Medicine, University of Arizona Barry D. Weiss, MD, College of Medicine, University of Arizona A previous issue of Elder Care discussed the use of walkers as an ambulation aid. This issue will discuss canes, which are used by one in ten older adults. Canes are primarily used to improve balance and stability. Although some types of canes can be used for limited weight bearing, individuals whose ambulation requires major weight-bearing support generally need to use a walker or hemi-walker. Two-thirds of patients who use a cane obtain it on their own, without any professional guidance about the proper type or sizing of the cane, or even about whether a cane is the appropriate walking aid for their needs. Even fewer, about one in five, receive proper education on how to use their cane. The three main types of canes are standard canes, offset canes, and multiple-legged canes. Each has variations, plus advantages and disadvantages. Standard Canes Figure 1. Standard Cane A standard cane, also called a single-point cane (Figure1), is usually made of wood or aluminum, and is the most widely used type of cane. It’s main purpose is to improve balance by widening an individual’s base of support. Standard canes are not appropriate for individuals who need assistance with weight bearing (i.e., who need to lean heavily on the cane because they can’t bear weight on their legs). Aluminum canes typically have an adjustable length, so perfect fitting before purchase is not always critical. Aluminum canes Figure 2. are also available as a “folding” Folding Cane cane that can be collapsed for compact storage when traveling (Figure 2). In contrast to aluminum canes, wooden canes are lightweight and inexpensive. But, they have a fixed length and thus require proper fitting prior to purchase. Offset Canes Offset canes (Figure 3) are similar to standard canes except the shape positions the patient’s weight over the axis of the cane. This allows the cane to be used for occasional weight bearing. Offset ca nes are often recommended for patients who have arthritis in the hip or knee and occasionally need to decrease the weight borne on a painful lower extremity. Figure 3 . Offset Cane Multiple-Legged Canes Multiple-legged canes typically have four, though sometimes three, short legs attached to a rectangular base at the lower end of the cane’s shaft. Depending on the number of legs, they are referred to as quadripod or “quad” canes, or tripod or “tri” canes (Figure 4). Because they have multiple legs, these canes provide more support than standard or offset canes and are capable of bearing more of a patient’s weight. They can be used by patients who have an antalgic gait due to osteoarthritis and Figure 4. Multiple-Legged Cane by patients with hemiplegia. TIPS FOR RECOMMENDING CANES x Recommend standard canes when there is need for assistance with balance, but not weight bearing. x Recommend an offset cane for patients who require occasional limited weight bearing support. x Recommend a multiple-legged cane for patients who require more substantial weight bearing support. x Proper fit: when arm dangling at side cane should reach wrist crease; when holding cane handle, elbow flexed ~20o x Be sure the patient receives proper instruction on how to use the cane. Page 19 Continued from front page ELDERCARE In addition to weight bearing, another advantage of a quad cane is that it can stand upright by itself when not in use. This frees the patient’s hands to do other things until they need to resume walking, and the cane can be retrieved without the need to bend down. In addition, a modification known as a “sit-to-stand cane” combines the stability of a multi-legged base with a bent handle that can be gripped at two levels (Figure 5). This allows the patient to put weight on the cane via the lower part of the handle when rising from a sitting position. Despite these advantages, quad and tri canes are sometimes challenging to use. The principal challenge arises from the fact that for proper use, all the legs should strike the ground simultaneously, Figure 5. Sit-To-Stand Cane particularly if the device is to be used for weight bearing. This requirement is sometimes awkward, particularly for individuals with a relatively rapid gait. The solution to this challenge in some cases is to change from a quad cane to a tri cane, or to change the multi-legged bottom to a smaller size in which the legs are closer together. The faster an individual walks, the fewer legs and the closer together the legs can be, though the trade off is some loss of stability during weight bearing. A variety of handle styles Figure 6. Padded Horizontal Palm and grips are available, and Grips patients with certain hand and wrist problems may find some more comfortable than others. For example, carpal tunnel syndrome has been reported with the umbrellastyle handle often used on standard canes, while foampadded horizontal palm grips (Figure 6) are less likely to cause this problem. Patients who need wrist support or who have a need to decrease stress on the wrist may benefit from an ergonomic handle, which is used as if one is shaking hands with the handle (Figure 7). These handles are also available for right-hand or left-hand use. When walking with a cane, it is generally held by the arm on the same side as the patient’s stronger leg. Advance the cane simultaneously Figure 7. Ergonomic Handle with the opposite (affected) leg. If the patient’s gait is affected bilaterally, then the cane is usually held in the dominant or unaffected upper extremity. Canes should be fitted with non-skid rubber tips. These tips should be checked frequently and replaced when worn out. Fitting and Using a Cane For walking, the unaffected lower limb should assume the Two key considerations in fitting a cane are elbow flexion first full weight-bearing step on level surfaces and going and cane length. The elbow should be flexed at about 20 up a step. The affected limb should descend a step first, degrees when the tip of the cane is positioned on the floor, balanced in line with the cane. about 6 inches from the lateral edge of the toes. A proper Walking safely with a cane takes practice. Patients being cane length is the distance from the floor to the crease of the considered for a cane may benefit from a referral to a wrist when the patient’s arm is dangling loosely at the pa- physical therapist for gait analysis, postural and strength tient’s side. training, and selection of an optimal ambulatory aid. References and Resources American Geriatrics Society. Health in Aging. Choosing the right cane or walker. http://www.healthinaging.org/files/documents/tipsheets/canes_walkers.pdf Bradley SM, Hernandez CR. Geriatric assistive devices. Am Fam Physician. 2011; 84:405-411. Lam R. Choosing the correct walking aid for patients. Can Fam Physician. 2007; 53:2115-2116. Silva J. How to use a cane. (Video from CaregiversTraining.com). http://www.youtube.com/watch?v=fRn8ZZJMzno Van Hook FW, Demenrueun D, Weiss BD. Ambulatory devices for chronic gait disorders in the elderly. Am Fam Physician. 2003; 1717-1724. Wenger, NS, et al. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. J Am Geriatr Soc. 2007. 55: 247-S252. ACOVE Quality Indicators 1. All vulnerable elders should have documentation that they were asked about or examined for the presence of balance or gait disturbances at least once. 2. IF a vulnerable elder reports or is found to have new or worsening difficulty with ambulation, balance, or mobility, THEN there should be documentation that a basic gait, mobility, and balance evaluation was performed within 6 months that resulted in specific diagnostic and therapeutic recommendations. 3. IF a vulnerable elder demonstrates decreased balance or proprioception, or increased postural sway, THEN an appropriate exercise program should be offered and an evaluation for an assistive device performed. Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Tracy Carroll, PT, CHT, MPH; Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page 20 Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center August 2012 ELDERCARE A Resource for Interprofessional Providers Geriatric Evaluation Rosemary Browne, MD, College of Medicine, University of Arizona The practice of medicine traditionally centers on an organ system and disease-based approach to illness. For older adults, however, this method can often lead to inadequate and suboptimal care. Many “geriatric” problems are multifactorial in etiology, span conventional organ system boundaries, and therefore cannot be treated as a single organ system disease. For example, falls can result from deficits in a variety of systems, including musculoskeletal, neurologic, cardiac, and/or the special senses. Additionally, many geriatric issues are not covered during a traditional disease-based history and review of systems. As a result, common geriatric conditions can go unrecognized and untreated. Furthermore, disease processes do not exist in isolation in the geriatric population. Rather, illness is experienced in the milieu of concurrent co-morbidities, multiple medications and treatments, and often in vulnerable patients, i.e., older adults with little functional reserve, decreased cognitive capacity, and inadequate social support. Attempting to cure one component of dysfunction without an appreciation of the state of the whole patient can often lead to treatment failure, further loss of independence, and ultimately a decline in health related quality of life. Optimizing the health of older adults, therefore, requires a broad and systematic evaluation. Beyond addressing organ-based diseases, geriatric evaluation assesses the condition of an older adult across a spectrum of domains, including functional and cognitive status, mental health, and social support. Additionally, a geriatric evaluation looks for common, multi-factorial syndromes which influence wellbeing, including urinary incontinence, malnutrition, polypharmacy, gait instability and falls. Managing and minimizing these problems can improve health and prolong independence. Lastly, an all-inclusive geriatric evaluation provides a natural opportunity to raise end-oflife issues when a patient is not seriously ill. Geriatric assessment performed as a multidimensional diagnostic approach and management plan undertaken by a trained geriatric interprofessional team is termed a comprehensive geriatric assessment. Financial constraints and lack of personnel, however, often preclude such a complete approach. This issue of Elder Care offers a way for individual clinicians to assess for geriatric vulnerabilities during routine outpatient medical practice. Table 1. Components of the Geriatric Evaluation Physical Health: Resources/Tools Co-Morbidities Routine History including review of systems, focused physical (be aware of signs of elder abuse), targeted laboratory and imaging studies Special Senses Hearing: Whisper test, Brief Hearing Loss Screener: www.consultgerirn.org/uploads/File/trythis/try_this_12.pdf (From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing) Vision: Ophthalmologic referral q1-2 years Functional Status ADLs - Katz scale: www.soapnote.org/elder-care/katz-adl/ IADLs - Lawton scale: www.soapnote.org/elder-care/lawtoniadl/ Vulnerable Elders Scale-13 (VES-13): www.rand.org/health/ projects/acove/survey.html Screening Tests US Preventive Services Task Force (USPSTF) www.ahrq.gov/ clinic/uspstfix.htm USPSTF Electronic Preventive Services Selector http:// epss.ahrq.gov/PDA/index.jsp Geriatric Review of Systems During an outpatient encounter, a geriatric evaluation begins during the review of systems, by assessing an older adult’s ability to perform the activities of daily living (ADLs) essential for independence: dressing, eating, ambulating/transfers, toileting and hygiene. If the patient is functional in these areas, evaluate the next higher level of function, the instrumental activities of daily living (IADLs) which include shopping, cooking, doing household chores, managing finances, using the telephone, and managing medications. Deficits in any of these areas can TIPS FOR PERFORMING GERIATRIC EVALUATION x Remember to perform a complete geriatric review of systems regularly during an outpatient clinical encounters with older adults. x Remember to ask about geriatric syndromes, including polypharmacy. x Use an all-inclusive geriatric evaluation as an opportunity to address end-of-life issues. Page 21 Continued from front page ELDERCARE provide guidance for further history taking and focus the physical exam. The next step is to evaluate special senses and nutrition. Ask about vision and hearing. Perform a nutritional assessment by checking on the status of taste and smell, oral hygiene and weight loss. Assessing for geriatric syndromes is especially important, as older adults generally do not offer complaints in these areas. Include screening questions to evaluate for pain, dementia, depression or other mental health problems, incontinence, immobility and falls. Reviewing medications is also paramount, and should be part of every geriatric medical encounter. See Table 2 for a list of Geriatric Syndromes resources and tools. Table 2. Components of the Geriatric Evaluation Geriatric Syndromes: Resources/Tools Polypharmacy Updated Beers Criteria: www.americangeriatrics.org/files/ documents/beers/2012BeersCriteria_JAGS.pdf Drug-Drug Interactions - multiple online applications available Balance and Falls Get up and go test: http://www.reynolds.med.arizona.edu/ EduProducts/podcasts/GetUpAndGo.cfm POMA: www.hospitalmedicine.org/geriresource/toolbox/pdfs/ poma.pdf Incontinence www.reynolds.med.arizona.edu/EduProducts/providerSheets/ Urinary%20Incontinence-Diagnosis.pdf Nutrition Body Mass Index: www.nhlbisupport.com/bmi/ DETERMINE: www.hospitalmedicine.org/geriresource/toolbox/ determine.htm Oral Hygiene www.guideline.gov/content.aspx? id=34447&search=geriatric+oral+health www.reynolds.med.arizona.edu/EduProducts/podcasts/ oralhealth.cfm Pain http://www.healthcare.uiowa.edu/igec/tools/ categoryMenu.asp?categoryID=7 Lastly, include a series of questions to assess social support, safety, financial stressors, and end-of-life considerations. See Table 3 for Psychosocial resources and tools. Table 3. Components of the Geriatric Evaluation Psychosocial: Resources/Tools Cognition Montreal Cognitive Assessment: www.mocatest.org/ St. Louis University Mental Status Exam: www.stlouis.va.gov/ GRECC/SLUMS_English.pdf Minicog: http://www.hospitalmedicine.org/geriresource/ toolbox/pdfs/clock_drawing_test.pdf Mood Two question depression screen: "During the past month, have you been bothered by feeling down, depressed or hopeless?" and "During the past month, have you been bothered by little interest or pleasure in doing things?" Stanford Geriatric Depression Scale: www.stanford.edu/ ~yesavage/GDS.html Substance Abuse Screen for alcohol misuse http://pubs.niaaa.nih.gov/ publications/inscage.htm Ask about smoking and provide tobacco cessation interventions Social Support Ask about financial problems, loneliness and support systems, spiritual needs, caregiver burnout, elder abuse - refer for further social services as needed and available End of Life Five Wishes: www.agingwithdignity.org/five-wishes.php POLST (selected states): www.ohsu.edu/polst/ Evidence Base The evidence to support the above recommendations varies. The U.S. Preventive Services Task Force indicates good evidence in support of screening and treatment for fall prevention, and screening for depression if there are systems for intervention. Screening for hearing deficits is currently under review. At present, there is insufficient evidence to validate screening asymptomatic older adults for impaired visual acuity, dementia, or elder abuse. References and Resources Rosen, L, Reuben, DB. Geriatric assessment tools. Mt Sinai J Med. 2011; 78:489–497. Elsawy B, Higgins KE. The geriatric assessment. Am Fam Physician. 2011; 83(1):48-56. The U.S. Preventive Services Taskforce. August 2010. http://www.uspreventiveservicestaskforce.org/index.html ACOVE Quality Indicators ThisediƟonofElderCareaddressesmanyofthequalityindicatorscreatedbytheRandACOVEHealthProjecttoassessthequalityofcareofvulnerableadults.Space limitsprecludeafulllisƟng,asnumerousindicatorsapplytothecomponentsofgeriatricevaluaƟon.ThereaderisdirectedtotheRandwebsitehƩp://www.rand.org/ health/projects/acove/acove3.htmlforalisƟngofthecomponentsofgeriatricevaluaƟonforwhichtherearecorrespondingACOVEqualityindicators. Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page 22 Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center August 2012 ELDERCARE A Resource for Interprofessional Providers Improving Communication with Older Patients Jake Harwood, PhD, Department of Communication, University of Arizona Older adults often experience sub-optimal communication during their visits to clinicians. This issue of Elder Care provides recommendations for effective communication with older patients who are not suffering from serious cognitive decline or hearing loss, emphasizing how to make appropriate accommodations while avoiding those that can impair communication or result in patient dissatisfaction. The December 2010 issue of Elder Care discussed communicating with adults who have hearing loss. Older adults typically experience three main problems that contribute to miscommunication with clinicians: (a) memory-related problems, (b) problems caused by companions, and (c) patronizing speech delivered by health care providers. Memory Problems Older people often suffer from declines in working memory. Working memory is what we use when we try to hold a number of thoughts in our mind at the same time and integrate or manipulate them. Even a mild decline in working memory can cause challenges in understanding complex sentences. The more complex the grammar, the more likely it is that some portion of the sentence will be forgotten while listening to another portion of the sentence. What should you do about this? x Recommendation 1: Avoid complex sentences involving multiple clauses. This does not mean restricting language to short sentences. It means avoiding sentences that contain multiple thoughts that are inter-related. See Table1 for examples. x Recommendation 2: When possible, information presented verbally should be supplemented with written material prepared at an appropriate reading level. x Recommendation 3: Repeat and rephrase critical material to ensure effective transmission. x Recommendation 4: Pay extra attention in checking for comprehension with the patient. Pay attention to verbal cues and ask patients to state their understanding of what you have told them. x Recommendation 5: Talk at a normal or slightly slower rate. Avoid talking fast or extra-slow. Table 1. Effective Rephrasing of Complex Sentences Complex Sentences Effective Rephrasing “The medication that I’ll be prescribing to treat your condition may have a couple of side effects.” “I’m going to prescribe you some medication. This medication may have a couple of side effects.” “When you feel dizzy and have to sit down suddenly, are there things that happen right before that which you think might cause it?” “Are there things that happen right before you feel dizzy?” Problems Caused by Companions Older adults are frequently accompanied on health care visits by a companion – often a family member or close friend. While companions can serve positive functions, such as providing additional information or helping remember what the clinician has said, those companions can cause several problems in communication between patients and clinicians. First, research shows that patients talk substantially less when companions are present in the health care encounter, reducing the amount of information that a health care provider can receive “first hand” from the patient (Figure 1). Second, clinicians and companions sometimes talk about the patient as if the patient was not TIPS FOR IMPROVING COMMUNICATION WITH OLDER ADULTS x Reduce grammatical complexity of spoken language. x Avoid using “baby talk” or addressing the patient with endearing or cute names, such as “Sweetie” or “Honey.” x Don’t speak extra loud, or with an exaggerated or high-pitched intonation. x Speak at a normal conversational pace. Avoid speaking very quickly or very slowly. x Repeat and elaborate on important points. x Provide written information to supplement what you tell the patient orally. Page 23 ELDERCARE Continued from front page Figure 1. Proportion of Patient and Physician Talk During Encounters With and Without Companions 60% Talkbypatient 50% Talkbyphysician 40% Talkbycompanion 30% 20% 10% 0% Encounterinvolvingonlyphysicianandpatient Data from Ishikawa et al. Soc Sci Med, 2005 cognitive variables among older adults than is seen in younger people. Furthermore, older adults who themselves internalize ageism’s concepts about old age are less likely to seek medical care and they die younger than older adults who resist ageism. Hence, attitudes towards older adults should not be patronizing, nor should clinicians assume decline: x Recommendation 1: Resist the temptation to use pet names and baby talk with older adults. x Recommendation 2: Remember that older adults are a diverse group, and that communication should be tailored to individual patients’ needs, not to a health condition or the age of a patient. Figure 2. Biological and Cognitive Diversity with Age % research studies there, and the patient becomes excluded from the discussion. Third, the companion may sometimes provide incorrect information. On rare occasions, that incorrect information might be purposely provided to conceal elder abuse. What can you do about this? x Recommendation 1: Double-check directly with patient symptoms and concerns that have been presented by a companion. x Recommendation 2: Address as much communication as possible to the patient, and avoid referring to the patient as “him/her” or “he/she” while talking with companions. x Recommendation 3: If a companion is impairing effective and direct communication with the patient, or if patient appears uncomfortable with the companion’s presence, arrange to talk with the patient one-on-one. Patronizing Speech Ageism is a set of beliefs, deeply ingrained in society, about the inevitability of declining health, limited capabilities, and impaired intellect of older people. As a result of these beliefs, many clinicians instinctively use patronizing speech when talking to older adults. Examples of patronizing speech include using pet names (“sweetie,” “honey”), using very short and simple sentences (baby talk), and using exaggerated or high-pitched intonation. Such speech modifications impair older people’s comprehension. Research shows that the concepts of ageism are incorrect (Figure 2). There is more diversity in biological and Encounterinvolvingphysician,patient,and companion 90 80 70 60 50 40 30 20 10 0 Studies showing more diversity with Biological variables Cognitive variables Studies showing less diversity (or no change) Data from Nelson and Dannfer, Gerontologist, 1992 References and Resources Dreher BB. Communication skills for working with elders. New York: Springer, 2005. Harwood J. Understanding communication and aging. Thousand Oaks, CA: Sage, 2007. Nussbaum JF, Fisher CL. A communication model for the competent delivery of geriatric medicine. Journal of Language and Social Psychology, 2009; 28:190-208. Ryan EB, Meredith SD, MacLean MJ, Orange JB Changing the way we talk with elders: Promoting health using the communication enhancement model. International Journal of Aging and Human Development. 1995; 41:87-105. Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Lynne Kirk, MD; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page 24 Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center February 2012 ELDERCARE A Resource for Interprofessional Providers Elder Abuse: Clinician Reporting Lisa M. O’Neill, MPH, Arizona Center on Aging, University of Arizona Rae K. Vermeal, MA, District Program Manager, Arizona Department of Economic Security, Adult Protective Services A previous edition of Elder Care detailed the different types of elder abuse and identified risk factors for and warning signs of abuse. This edition will focus on reporting of elder abuse by clinicians. It is estimated that each year, about 2 million American adults age 65 or older are victims of some type of elder abuse. Though data collection methods vary across the country, it is thought that nearly 85% of these cases are never reported to Adult Protective Services (APS) agencies. Under-reporting of elder abuse is thought to stem from a variety of causes, including differences in reporting guidelines, varying definitions of elder abuse, and patient/ provider concerns (Table 1). Variation in guidelines is due to the fact that APS agencies are funded by each state, and governed independently by varying state statutes and regulations. Clinicians are Elders’ Frontline Protectors As our older population grows, it is likely that the number of elder abuse cases will also increase. Thus, it is important for clinicians to be alert for signs of abuse. Many abusers will go to great lengths to present themselves as dutiful caregivers. They will make doctor appointments for the older adult in their charge, stay by the elder’s side during the office visit, even answer questions on behalf of the patient - the latter making it easy for the caregiver to give answers that hide abusive behaviors. Indeed, having an “extra set of ears” at a doctor appointment with older adults is standard practice today, so the presence of a caregiver who answers all the questions might not seem inappropriate. It is important, however, for clinicians to spend a few minutes alone with each patient, as this may be the patient’s only opportunity to freely discuss any personal concerns and honestly answer questions about how they are treated. Cultural Differences Cultural, religious, or ethical beliefs can add to the complexity of identifying abuse because the perception of abuse can vary in different cultural and ethnic communities. While clinicians should be sensitive to these differences, it is also important not to ignore abuse that endangers patients. Screening Although the US Preventive Services Task Force has concluded that there is insufficient evidence to recommend for or against routine elder abuse screening, clinicians should be familiar with available screening tools (Table 2) and determine which might be most suitable for use in their practice when elder abuse is suspected. Data on these tools’ reliability and validity in primary care settings is lacking, so it is not possible to recommend one tool over another. What is important, however, is to be alert for abuse and use these tools when needed as an aid to determining if a report should be filed with APS. Table 1. Common Reasons Why Health Care Professionals Do Not Report Elder Abuse x Concerns about making the situation worse for the patient x Denial of mistreatment by patient and/or family x Insufficient understanding of reporting process - don’t know whom to call x Lack of awareness of warning signs of elder abuse x Loyalty to patient and/or family x Patients are adults who may refuse intervention, thus making the effort of reporting seem useless x Potential damage to rapport with patient and/or family Source: Ahmad, M. and Lachs, M. Elder Abuse and neglect: What physicians can and should do. Cleveland Clinic Journal of Medicine, Oct 2002, Vol. 69 Number 10, p. 801-808. TIPS FOR REPORTING ELDER ABUSE x Spend a few minutes alone with each patient - this may be your patients’ only time to freely discuss any concerns/ issues/fears about their current living arrangements and concerns about their safety or financial security. x Be aware of any cultural differences that may prevent a patient from disclosing issues regarding caretakers’ behaviors that might indicate abuse. x Know the reporting laws in your state. x Remember that it is not up to you to prove abuse. But, it is up to you to protect your patient and report any suspicions of elder abuse. The authorities will follow up and determine the proper course of action. Page 25 Continued from front page ELDERCARE What Happens After Making a Report? Clinicians often wonder what happens after they file a report with APS. Because of APS confidentiality rules, information may seem to flow one way and the clinician often cannot find out if an investigation was started or the outcome of that investigation. This should not discourage reporting of suspected abuse. Healthcare professionals need to know the reporting laws in their state. They also need to have knowledge of what APS can and cannot do. In particular, they should know that legal and ethical requirements often prevent APS from releasing information about investigations. That understanding should increase confidence in the investigation process. More information about elder abuse and reporting can be found via the resources in Table 3. Finally, remember it is not up to you to prove abuse, but it is up to you to protect your patient and report any suspicions of abuse. APS and other appropriate agencies will follow up and determine the proper course of action. Table 3. Elder Abuse Resources x Administration on Aging www.aoa.gov x Clearinghouse on Abuse and Neglect of the Elderly www.cane.udel.edu x National Adult Protective Services Association www.napsa-now.org x National Center on Elder Abuse www.ncea.aoa.gov x National Committee for the Prevention of Elder Abuse www.preventelderabuse.org What information is needed to make a report to Adult Protective Services? When calling or reporting online you will be asked: x Reason for concern regarding suspected abuse; provide as many details as possible x Name, address, contact information, and other identifying information (e.g., date of birth) of potential victim x Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) screening device to identify people at high risk of the need for protective services. Information about the victim’s health such as a disability or mental illness that increases vulnerability to abuse, neglect, or exploitation x Name, address, and contact information of the alleged perpetrator, if available Questions to Elicit Elder Abuse - specific questions to determine if abuse is occurring. x Screen for Various Types of Abuse or Neglect (American Medical Association) - general questions to screen an older person for various types of abuse or neglect. Any issues that might affect the safety of the APS field investigator x Your name, address and contact information Table 2. Elder Abuse Screening Tools * Brief Abuse Screen for the Elderly (BASE) - to help practitioners assess the likelihood of abuse. Elder Abuse Suspicion Index (EASI) - to raise suspicion about elder abuse to a level where reporting might be necessary. Suspected Abuse Tool - designed to help recognize common signs or symptoms of abuse. * These screening tools can be found at: http://www.medicine.uiowa.edu/familymedicine/ emscreeninginstruments/ Not all of this information is mandatory, but it can be extremely helpful to the agency investigating the case. To find your state’s reporting phone number, go to Eldercare Locator - www.eldercare.gov or call 1-800-677-1116 References and Resources Ahmad M, Lachs M. Elder abuse and neglect: What physicians can and should do. Cleve Clin J Med. 2002, 69:801-808. American Psychological Association, Elder Abuse and Neglect: In Search of Solutions, www.apa.org/pi/aging/resources/guides/elder-abuse.aspx Arizona Department of Economic Security, Help Stop Adult Abuse, Neglect and Exploitation Informational Brochure. Elder Abuse: A Public Health Perspective. Editors, Summers R and Hoffman A. American Public Health Association. 2006. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington DC: National Research Panel to Review Risk and Prevalence of Elder Abuse and Neglect. 2003. Jayawardena, K, Liao, S. Elder abuse at the end of life. J Palliat Med. 2006. 9: 127-136. University of Iowa Hospitals and Clinics, University of Iowa Health Care, Elder Mistreatment Screening Instruments. http://www.medicine.uiowa.edu/familymedicine/emscreeninginstruments/ Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page 26 Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center April 2012 ELDERCARE A Resource for Interprofessional Providers Resilience in Aging Erica S. Edwards, MSW, Morrison Institute for Public Policy, Arizona State University John Hall, PhD and Alex Zautra, PhD, Resilience Solutions Group, Arizona State University moving forward. No matter how resilience is viewed, the resources that lead to resilience can result in positive outcomes. (Table 1). Although resilience is seldom associated with older adults because they experience loss and decline, older adults actually have a higher level of subjective well-being than individuals in any other age group. “Resilience thinking” in older adults gives them the ability to recover from adversity, thrive with a sustained purpose, and grow in a world of turmoil, change, and chronic illness. It is a regenerative capacity that maintains health and function in the face of loss, disability, or disease. The three hallmarks of resilience are shown in Table 2. Resilience thinking allows older adults to accept the wear and tear of aging, while also dealing with problems and crises – like losing a loved one, spousal caregiving, or acquiring a disability – in ways that leave them feeling stronger than they would have been if they had not encountered those crises. In resilience thinking, failure leads to growth. Assessing Resilience Table 1. Examples of Resilience Resources and Hypothesized Outcomes By assessing older adults using a resilience perspective, strengths of Resilience Resource Hypothesized Outcome an individual can be highlighted. Psychological The goal of such an assessment is to determine if an individual has the Coping capacity Prevention of disability following injury characteristics that predict positive Emotional awareness and clarity High levels of emotion differentiation and complexity outcomes when dealing with stressors Sense of purpose Sustained elevations in positive emotion and hope and calamity, and to suggest the need to encourage resilience if those Social connection/affiliation Social meaning and value sustained under stress characteristics are absent. Several Supportive social network Less depression and anxiety following loss of these characteristics are shown in Physiological Table 3. Specific questions that can be asked to help assess an Cardiac health Recovery following stress individual’s resilience are shown in Immune competence Rapid immune response to acute illness/injury Table 4. The concept of resilience in aging was born out of the “paradox of old age.” The paradox is that in spite of losses and physical declines experienced in later life, older adults report feeling content, and they have lower rates of psychopathology than the general population. Researchers have argued that this is due to resilience, and that an understanding of resilience can lead to new health promotion strategies that yield healthier, happier people and communities. What is Resilience? Resilience is the result of successful adaptation to adversity. It is revealed by an individual’s ability to cope and recover from crises, sustain a sense of purpose and vitality, and emerge stronger from stressful experiences. Resilience is a dynamic characteristic that may shift according to the circumstance. Indeed, it can be manifest in many forms: as an outcome of physical or mental recovery from a traumatic event; as a trait that describes an individual’s enduring ability to cope; or as a process of recovering from a stressful event and TIPS ABOUT RESILIENCE IN OLDER ADULTS x Despite losses and physical decline, older adults report feeling content and have less psychopathology than the remainder of the population. This is thought to be due to resilience: the successful adaption to adversity. x An individual’s “resilience thinking” can be assessed by asking questions about life philosophy, and about characteristics and behaviors that lead to resilience (Tables 3 and 4). x Older adults should be encouraged to participate in activities that build resilience, like joining a social group, developing a family communication plan, starting a stress management program, exercising, and/or beginning a volunteer position, job, or new hobby. Page 27 Continued from front page Continued from front page ELDERCARE What Happens After Making a Report? Clinicians often wonder what happens after they file a report with APS. Because of APS confidentiality rules, information may seem to flow one way and the clinician often cannot find out if an investigation was started or the outcome of that investigation. This should not discourage reporting of suspected abuse. Healthcare professionals need to know the reporting laws in their state. They also need to have knowledge of what APS can and cannot do. In particular, they should know that legal and ethical requirements often prevent APS from releasing information about investigations. That understanding should increase confidence in the investigation process. More information about elder abuse and reporting can be found via the resources in Table 3. Finally, remember it is not up to you to prove abuse, but it is up to you to protect your patient and report any suspicions of abuse. APS and other appropriate agencies will follow up and determine the proper course of action. Table 3. Elder Abuse Resources x Administration on Aging www.aoa.gov x Clearinghouse on Abuse and Neglect of the Elderly www.cane.udel.edu x National Adult Protective Services Association www.napsa-now.org x National Center on Elder Abuse www.ncea.aoa.gov x National Committee for the Prevention of Elder Abuse www.preventelderabuse.org What information is needed to make a report to Adult Protective Services? When calling or reporting online you will be asked: x Reason for concern regarding suspected abuse; provide as many details as possible x Name, address, contact information, and other identifying information (e.g., date of birth) of potential victim x Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) screening device to identify people at high risk of the need for protective services. Information about the victim’s health such as a disability or mental illness that increases vulnerability to abuse, neglect, or exploitation x Name, address, and contact information of the alleged perpetrator, if available Questions to Elicit Elder Abuse - specific questions to determine if abuse is occurring. x Screen for Various Types of Abuse or Neglect (American Medical Association) - general questions to screen an older person for various types of abuse or neglect. Any issues that might affect the safety of the APS field investigator x Your name, address and contact information Table 2. Elder Abuse Screening Tools * Brief Abuse Screen for the Elderly (BASE) - to help practitioners assess the likelihood of abuse. Elder Abuse Suspicion Index (EASI) - to raise suspicion about elder abuse to a level where reporting might be necessary. Suspected Abuse Tool - designed to help recognize common signs or symptoms of abuse. * These screening tools can be found at: http://www.medicine.uiowa.edu/familymedicine/ emscreeninginstruments/ Not all of this information is mandatory, but it can be extremely helpful to the agency investigating the case. To find your state’s reporting phone number, go to Eldercare Locator - www.eldercare.gov or call 1-800-677-1116 References and Resources Ahmad M, Lachs M. Elder abuse and neglect: What physicians can and should do. Cleve Clin J Med. 2002, 69:801-808. American Psychological Association, Elder Abuse and Neglect: In Search of Solutions, www.apa.org/pi/aging/resources/guides/elder-abuse.aspx Arizona Department of Economic Security, Help Stop Adult Abuse, Neglect and Exploitation Informational Brochure. Elder Abuse: A Public Health Perspective. Editors, Summers R and Hoffman A. American Public Health Association. 2006. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington DC: National Research Panel to Review Risk and Prevalence of Elder Abuse and Neglect. 2003. Jayawardena, K, Liao, S. Elder abuse at the end of life. J Palliat Med. 2006. 9: 127-136. University of Iowa Hospitals and Clinics, University of Iowa Health Care, Elder Mistreatment Screening Instruments. http://www.medicine.uiowa.edu/familymedicine/emscreeninginstruments/ Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page 28 Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center March 2012 ELDERCARE A Resource for Interprofessional Providers Choosing the Correct Walker Cameron R. Hernandez, MD, Mount Sinai School of Medicine Assistive devices, such as walkers, are being used more often as the population ages. If you’re looking for something to provide minimal help for your patient, a cane might be a better solution. Canes improve one’s ability to get up from a chair or can help with balance. Canes will be discussed in a future Elder Care issue. Walkers, however, provide even more stability. In general, walkers are given to patients to keep them stable when walking. If the correct type of walker is prescribed, and if patients are taught how to use the walker correctly, walkers can decrease the risk of falls. But, if used inappropriately they can make falls more likely. Thus, knowing when to prescribe a walker and which type to prescribe is important to patient safety. This issue of Elder Care will discuss the three most commonly used walkers: the standard walker, the two-wheeled walker, and the four-wheeled walker. Standard Walker The standard walker does not have wheels and, therefore, it is the most stable type of walker (Figure 1). It is used for patients who need to bear a significant amount of weight on the device. Standard walkers are used in older patients who are very unstable with a cane and who do not have the ability to control a rolling walker. For maximum stability when using this walker, the patient should place all four legs of the walker on the ground before taking a step forward. Besides stability, another advantage of the standard walker is that it that folds quickly and is easy to transport. The disadvantages of the standard walker are that 1) it truncates the patient’s walk, 2) it needs to be lifted with every step, 3) it makes the patient slow, and 4) patients can fall when lifting the walker. Patients who stop using this type of walker tend to state that they stopped because they get tired of picking it up with every step. Figure 1. Standard Walker Two-Wheeled (Rolling) Walker Rolling walkers have two front wheels and two back sliders (Figure 2 on back page). They are used for patients who have gait instability but who do not need to bear a substantial amount of weight on the device. A key advantage of rolling walkers over standard walkers are that they provide a more normal walking pattern, as they do not need to be lifted off the ground with each step. Furthermore, the wheel-and-slider combination makes it easy to maneuver on many different surfaces. And, just like a standard walker, they can be easily collapsed. The disadvantages of a rolling walker relative to a standard walker are that 1) it is less stable, 2) it requires more cognition, and 3) the front wheels are fixed (i.e., do not rotate), which makes for a large turning arc. Because of the large turning arc, many patients will pick up the walker during the turning process and this creates the possibility of a fall. The correct way to turn with a rolling TIPS FOR CHOOSING THE CORRECT WALKER x Recommend a standard walker for patients who have an unstable gait and need to bear a significant amount of weight on the walker. x Recommend a two-wheeled (rolling) walker for patients who have an unstable gait but do not need to bear a substantial amount of weight on the walker. x Recommend a four-wheeled (Rollator) walker for patients who need a walker only for balance but not for weight bearing. x Be sure patients receive and understand instructions for how to use their walker, as improper use can lead to injury. Page 29 Continued from front page ELDERCARE walker is multiple small turns until the patient and the device are facing in the new direction. Figure 2. Two-Wheeled (Rolling) Walker Finally, patients may fall when attempting to use the seat. The proper way to sit on a Rollator is to abut the walker against a sturdy surface like a wall, apply the permanent brakes, and then sit down. Patients should never be transported on the seat of this walker as this is a setup for a serious fall and possible head injury. This walker does not collapse very compactly. It is thus more difficult than other walkers to transport. Figure 3. Four-Wheeled Walker (Rollator) Four-Wheeled Walker (Rollator) The Rollator has four fully-rotating wheels, brakes, a seat, and often a basket (Figure 3). It is used for patients who need a walker only for balance but not for weight-bearing. It is easier to propel than the rolling walker. It is also easier to maneuver around turns and typically does not need to be lifted when turning. The seat is helpful for people with diseases that require resting (e.g., heart failure or COPD). The basket allows carrying items hands-free. Most of these advantages can be disadvantages, too. Easy to propel means that the Rollator can roll away from a patient. Easy to maneuver means that the patient needs to have good abdominal strength to keep from falling. Furthermore, the brakes do not necessarily stop the walker. Rather, when the brakes are pressed the Rollator essentially turns into a rolling walker; it may slow the patient but it is not going to stop a runaway patient and Rollator. If the patient is dependent on the brakes to stop when using this walker, then this is not the appropriate walker choice. When assessing the need for a walker, it is important to take into account the various features available, as specified in the following table. Weight Take into account the patient’s height, weight, and lifting capability. There will be times that the patient will need to lift or shift the walker away from uneven surfaces, so models that are lightweight are important. Foldability Does the patient travel outside of their home frequently? If so, choose a walker that folds down for easy storage and travel. Wheels The patient should be able to control both the wheels and brakes effectively. Seat Many of the rolling walkers, or rollators, come with seats. If a patient tires easily and needs sitting breaks, rollators with seats and storage baskets are a good choice. “Wheelchair” Rollator/transport chair combination products are useful if patients wish to walk part of the time and be pushed at other times. References and Resources Bradley SM, Hernandez CR, Geriatric Assistive Devices. Am Fam Physician. 2011;84(4):405-411. Faruqui SR, Jaeblon T. Ambulatory assistive devices in orthopaedics: uses and modifications. J Am Acad Orthop Surg. 2010;18(1):41-50. Kaye HS, Kang T, LaPlante MP. Mobility device use in the United States. Vol 14: National Institute on Disability and Rehabilitation Research, US Dept. of Education; 2000. Wenger NS, Roth CP, Shekelle P. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. J Am Geriatr Soc. 2007;55 Suppl 2:S247-252. ACOVE Quality Indicators IF a vulnerable elder demonstrates decreased balance or proprioception, or increased postural sway, THEN an appropriate exercise program should be offered and an evaluation for an assistive device performed. Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page 30 Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center July 2011 ELDERCARE A Resource for Interprofessional Providers Sleep in Older Adults Joan L. Shaver, PhD, RN, FAAN, Dean, College of Nursing, University of Arizona With healthy aging, sleep becomes less consolidated, which people experience as frequent awakenings and perceptions of sleep loss or inadequacy. At least half of older adults report poor or worsened sleep. The Daily Sleep/Wake Cycle The daily sleep/wake cycle is governed by three interacting processes: (1) sleep drive, (2) circadian rhythm, and (3) environmental and behavioral factors (Figure). With aging, sleep drive weakens due to changes in neurochemical receptor sensitivity. Various circadian rhythms, most importantly levels of melatonin and its sensitivity to the light-dark cycle, also change with aging. Indeed, many older adults experience a ‘phase advance’ of the sleep/wake rhythm, with earlier positioning of the night sleep period within the 24-hour light/dark cycle, leading to earlier bedtimes and arise times (the phase advance can be normalized using an early evening dose of bright-light therapy). Decreased sensitivity to the light/dark cycle can be further aggravated by environmental factors, such as living circumstances in which there is more time spent indoors and thus less exposure to adequate bright light. The Nighttime Sleep Cycle Each night’s sleep is characterized by recurring cycles lasting roughly 90 minutes each, which on polysomnogram reveal the sequential stages of a cycle from awake to transitional, light, deep, and rapid-eye-movement (REM) sleep. Observed changes with aging include more light sleep, less deep-stage and REM sleep, and a gradual reduction in total sleep time each night. When individuals report waking at approximately 1-2 hour intervals, they are probably waking between sleep cycles. If return to sleep is relatively rapid, sleep cycles likely are being completed with little overall sleep loss or effect on daytime function. In otherwise healthy older adults, simply explaining this normal phenomenon can help alleviate undue anxiety about poor sleep. On the other hand, when individuals truly have inadequate sleep, they can experience impaired physical performance (e.g., slower reaction times), poor cognitive performance (e.g., impaired memory), and a propensity to fall. Indeed, poor sleep efficiency and decreased total sleep time have been associated with higher risk of death, even after controlling for other factors. Sleep in Chronic Disease Chronic health conditions produce a myriad of disease changes which, along with the many medications prescribed, can induce insomnia - the inability to fall or stay asleep or get restful sleep. Chronic insomnia can be primary (i.e., occurring in the absence of a clear causative condition), but more frequently poor sleep emerges secondary to chronic disorders, such as arthritis, chronic pain, diabetes, heart failure, cancer, chronic lung disease, stroke, Parkinson’s disease, or dementia. Insomnia is also strongly associated with depression. Indeed, there is growing evidence that insomnia is prodromal to depression and depression predicts insomnia. Therefore, reports of chronic insomnia should trigger an evaluation for symptoms of depression. Alternatively, depressive mood states should raise concern about the possibility of poor sleep. Many medications used to manage common chronic diseases can affect sleep and contribute to insomnia. These include nervous system stimulants, antihypertensives, respiratory medications, chemotherapy, decongestants, steroid hormones, and many psychotropic medications. TIPS FOR DEALING WITH SLEEP DISORDERS IN OLDER ADULTS x When an older adult reports problems with sleep, consider depression as a possible contributor. x Also consider the possibility that medications are causing or aggravating a patient’s insomnia. x Avoid using sedative-hypnotic medications for chronic treatment of insomnia. Cognitive and behavioral approaches (Table 1) are better for long-term treatment. x Always consider sleep-related breathing disorders, movement disorders, and rapid eye movement disorders as possible contributors to a patient’s insomnia or daytime sleepiness. Page 31 Continued from front page ELDERCARE Prescribe medications with stimulating or activating effects earlier in the day, and sedating medications near bedtime. Treating Insomnia A 2005 National Institutes of Health consensus panel concluded that chronic use of benzodiazepines is not effective and poses risks to patients, especially older adults. Medications, including over-the-counter products, containing diphenhydramine or similar medications, should also be avoided in older adults. There are, however, several new nonbenzodiazepine hypnotics, such as eszopiclone, ramelteon, zaleplon, and zolpidem. These allow insomnia in older adults to be managed initially with hypnotics, and then longer term with cognitive and behavioral therapies (Table 1). Table 1.Cognitive and Behavioral Treatments for Insomnia Cognitive x Discuss sleep expectations, misconceptions, and sleeppromoting behaviors Behavioral – the 4 Rs Regularize sleep wake pattern x No daytime napping x Restrict time in bed to current sleep duration; gradually lengthen time in bed x Arise at consistent time Ritualize cues for sleeping x Quiet, dark environment x Lie down only when sleepy x If not asleep in 20 min, get up x Use bedroom only for sleep and sex Relaxation techniques x Comfortable posture x Clear the mind – concentrate on breathing or scenery x Use biofeedback, deep relaxation Resist sleep interference (sleep hygiene) x Avoid heavy meals before bed x Avoid heavy exercise 2-3 hours before bed x Avoid tobacco, alcohol, caffeine Important Sleep-related Disorders Adding to risk of sleep disturbance with aging are the sleep-related conditions of sleep-disordered breathing; sleep-related movement disorders (restless leg syndrome and periodic limb movements), and rapid eye movement sleep-behavior disorder (Table 2). A key manifestation to these disorders is excessive daytime sleepiness (EDS), most often seen as unintentional napping. As part of a sleep history, assessing for EDS is warranted. Symptoms of these disorders should trigger in-depth assessment and possible referral to a sleep center. Table 2. Important Sleep-Related Disorders Disorder Key Findings Sleepx Complete sleep history – especially snoring, Disordered unintentional daytime dosing, excessive dayBreathing time sleepiness (Snoring, x Bed partner testimony Sleep Apnea) x Risk factors (male, obesity, use of sedatives, alcohol, smoking, thick neck (men), narrow upper airway (women), family history x Confirm with overnight polysomnography Restless Legs Syndrome x Discomfort in legs (crawling sensation), urge to move x Most prominent at rest, in relaxed state, during inactivity, usually evening or night Periodic Limb Movements in Sleep x Clusters of repetitive limb movements during sleep - can cause arousal x Bed partner testimony x Confirmed by overnight polysomnography Rapid Eye Movement Sleep Behavior Disorder x Absence of usual muscle atonia during REM x Gross movements occur during sleep, e.g., running, kicking, yelling, punching (complex motor movements while dreaming) x Can be dangerous or injurious x Confirmed by recording intermittent muscle tone and movements during REM sleep References and Resources Crowley, K. Sleep and Sleep Disorders in Older Adults. Neuropsychol Rev. 2011;21:41–53. Neikrug, AB, Ancoli-Israel, S. Sleep Disorders in the Older Adult –A Mini-Review. Gerontology. 2010;56:181–189. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults. Wenger, NS, et al. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. Journal of the American Geriatrics Society, 2007. 55: p. S247-S252. ACOVE Quality Indicators If a vulnerable elder presents with new onset of one of the following symptoms: sad mood, feeling down, insomnia or difficulties with sleep, apathy or loss of interest in pleasurable activities, complaints of memory loss, unexplained weight loss greater than 5% in the past month or 10% over 1 year, or unexplained fatigue or low energy, THEN the patient should be asked about or treated for depression, or referred to a mental health professional within 2 weeks of presentation. Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging 32 Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center April 2013 ELDERCARE A Resource for Interprofessional Providers The ABCDs of Medicare Barry D. Weiss, MD, College of Medicine, University of Arizona Medicare is a US government-sponsored program that provides health insurance coverage for adults over 65 and qualified individuals with disabilities. This issue of Elder Care will focus on Medicare for older adults. The Medicare program has evolved since the first enrollees began receiving coverage in 1966. Part of that evolution has been the introduction of different categories of coverage, known as Parts A, B, C, and D (Table 1). There are now two types of Medicare programs: “original Medicare,” which is the standard program that has existed since the program began, and “Medicare Advantage Plans.” Advantage Plans are governed by Part C. ORIGINAL MEDICARE - PART A Part A covers hospital care, skilled nursing facility care, hospice care, home health services, and non-custodial nursing home care. Part A is an automatic benefit of Medicare enrollment (i.e., there is no fee or premium). Hospital care is covered in hospitals that accept Medicare. Coverage includes a semi-private hospital room, meals, nursing care, drugs and other treatments administered in the hospital, including rehabilitation. Private rooms are covered only if medically necessary (e.g., isolation for infection control). Patients on original Medicare must pay a portion of the costs of hospital care (Table 2) unless they have purchased supplemental Medigap insurance that may cover all or some of those costs. Skilled Nursing is covered in facilities that accept Medicare payments. As with hospital care, patients pay a portion of the cost of skilled nursing facility (SNF) care unless they have supplemental Medigap insurance. Without Medigap insurance, there is no cost to the patient for the first 20 days in a SNF. But, the cost is $148/day for days 21-100 and after day 100, the patient is responsible for all costs. Table 1. Parts A, B, C, and D of Medicare Part Services Covered A Hospital care, skill nursing facility care, hospice, home health services, nursing home care (as long as custodial care is not the only care required) B Doctor visits, lab tests, medical supplies and equipment, ambulance transport, inpatient and outpatient mental health care, second opinions before surgery C Medicare Advantage Plans D Prescription drugs Hospice Care is also covered at no charge, including physician care if the physician is employed by the hospice. If not, Part B applies to physician care. There is also a small copayment ($5) for prescription drugs used for pain relief and symptom control, and the out-of-pocket cost to the patient for respite care varies from $5-$12/day. Table 2. Patient Costs for Hospital Care on Original Medicare (2013) Length of Hospital Stay Patient Out-of-Pocket Costs Days 1-60 $1,184 deductible Days 61-90 $296/day Days 91 and beyond (lifetime reserve days) $592/day up to a lifetime maximum of 60 days Beyond the 60 lifetime reserve days Patient pays all costs From: www.medicare.gov/coverage/hospital-care-inpatient.html ORIGNAL MEDICARE - PART B The essence of part B is coverage for physicians’ fees and outpatient services such as lab tests, and other services (Table 1) from providers that accept Medicare payment. TIPS ABOUT MEDICARE x Be aware of your patients’ Medicare coverage. Are they in a Medicare Advantage Plan in which they must see providers with a defined network, or can they see any provider who accepts Medicare? x Be aware that for Medicare Part D, which provides drug coverage, the copay for medication can vary considerably depending on whether the medication is classified as Tier 1, 2, 3, 4 or 5. Tier-1 and Tier-2 medications are much less costly, sometimes only a few dollars per prescription. Tier-4 and Tier-5 medications can cost hundreds of dollars. Page 33 Continued from front page ELDERCARE Medicare Part B covers a variety of preventive services without copayments (Table 3), as long as the service providers accept Medicare payment. Several other services are not covered under original Medicare Part B. They include routine dental and vision care, dentures, cosmetic surgery, acupuncture, hearing aids, and routine food care. Table 3. Preventive Services Covered by Medicare Part B (2013) xAbdominal aortic aneurysm screening xAlcohol misuse screenings and counseling xBone density measurements xCardiovascular disease risk reduction counseling xCervical vaginal, and colorectal cancer screening xDepression screening xDiabetes screening and self-management training xGlaucoma tests for patients at high risk x HIV screening xHyperlipidemia screening xImmunizations (influenza, hepatitis B, pneumococcal) xMammograms (screening) xNutrition services for patients with diabetes or renal disease xObesity screening/counseling xOne-time “Welcome to Medicare” preventive visit xProstate cancer screening xSexually transmitted infection screening and counseling xTobacco cessation counseling xYearly "Wellness" visit Source: www.medicare.gov/coverage/preventive-and-screening-services.html In contrast to Part A, Part B is not an automatic benefit of Medicare enrollment. Rather, enrollees must pay a monthly premium that can be deducted from their monthly Social Security check. In 2013, the premium ranged from $105/ month for individuals with an annual income less than $85,000 to $336/month for those with an annual income above $214,000. ADVANTAGE PLANS - PART C Medicare Advantage Plans are health insurance plans offered by private companies that contract with Medicare. They provide all Part A and B services except hospice care, which is still covered by Medicare at no cost to the patient. Monthly premiums, which vary by plan and coverage, are less costly than for original Medicare and are typically deducted from the enrollee’s monthly Social Security check. A key difference between original Medicare and Advantage plans is where and from whom services can be obtained. With original Medicare, enrollees can receive services nationwide from any provider or institution that accepts Medicare payment. With Advantage Plans, care must be obtained through designated insurance plan networks such as preferred provider organizations (PPOs), health maintenance organizations (HMOs), or others. Depending on the specific Advantage plan, in-network care may be free or require a modest copay. Some plans require referrals from a primary care clinician before specialist services will be covered. Out-of-network care, other than emergency care, is typically not covered. Another difference between original Medicare and Medicare Advantage plans is that, depending on the specific plan, Advantage plans may cover hearing aids, dental care, and vision care (refraction and eyeglasses), even though these services are not covered by original Medicare. DRUG COVERAGE - PART D Medicare Part D covers prescription drugs, for which individuals enrolled in original Medicare pay a monthly fee that ranges from $12-67, depending on income. With Medicare Advantage plans, drug coverage is often included as part of the plan with an extra monthly premium. Available drugs are determined by a formulary that can vary between plans. The zoster vaccine, in contrast to other immunizations is covered under Part D. A copay is required when obtaining medications through Part D. It varies depending on the medication’s tier rating. Copays for Tier-1 (basic) drugs can be as low as $0-2 per prescription, while copays for Tier 4-5 (specialty) drugs can be hundreds or thousands of dollars. Part D currently has a coverage gap, referred to as the “donut hole.” In 2013, enrollee’s have a copay until the total cost of medications exceed $2970. Then the gap begins and enrollees pay most (up to 79%) of the real cost of the drug. Then, when these out-of-pocket costs exceed $6154, Medicare resumes payment and covers 95% of costs. The donut hole is being phased out and will be eliminated by 2020. References and Resources 2013 Medicare Costs. http://www.medicare.gov/Pubs/pdf/11579.pdf Barry P. Explaining the tier system of copays in Part D drug coverage. AARP Bulletin. March 3, 2011. http://www.aarp.org/health/medicare-insurance/info-03-2011/ask_ms_medicare_question_93.html Drug Coverage (Part D). www.medicare.gove/part-d/index.html What Does Medicare Part A Cover? http://www.medicare.gov/what-medicare-covers/part-a/what-part-a-covers.html What Does Medicare Part B Cover? http://www.medicare.gov/what-medicare-covers/part-b/what-part-b-covers.html Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Tracy Carroll, PT, CHT, MPH; Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Page 34 Sponsored by: Donald W. Reynolds Foundation Arizona Geriatric Education Center January 2013 ELDERCARE A Resource for Interprofessional Providers Immunizations for Older Adults Doug Campos Outcalt, MD, MPA, College of Medicine Phoenix Campus, University of Arizona Vaccines are among the most successful public health interventions, saving millions of lives and preventing millions of disabilities. While most vaccines are targeted at children and young adults, there are four recommended for routine use in adults aged 65 and older: influenza vaccine, pneumococcal vaccine, herpes zoster vaccine, and a vaccine against tetanus and diphtheria. The latter may include the addition of pertussis protection in a vaccine that combines tetanus toxoid, diphtheria toxoid, and acellular pertussis (Tdap). This issue of Elder Care will discuss these four vaccines. Other vaccines are also available for older adults, (Table 1) but will not be reviewed in this issue of Elder Care. They include vaccines for older adults with particular health risks (e.g., vaccines against hepatitis A and B and meningiococcus) and vaccines for individuals who travel outside of the US. Information on these and other vaccines is available from the Centers for Disease Control and Prevention (CDC). Influenza Vaccine While the highest rate of influenza infection is among children, the highest rate of serious illness and death occurs among older adults. Indeed, influenza causes an average of 36,000 deaths in the US each year, most of which occur in older adults. Thus, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommends that all older adults receive annual influenza vaccination. Several influenza vaccines are available in the US and they all contain the same virus strains. But, only two of them are approved for use in older adults – the standard intramuscular killed-virus trivalent influenza vaccine (TIV) and the newer high-dose TIV (Fluzone High-Dose). Neither the intranasal live attenuated influenza vaccine (FluMist) nor the intradermal trivalent killed-virus vaccine (Fluzone) is approved for use in people 65 and older. The standard intramuscular TIV has been used for years and continues to be recommended. The only alternative to this standard TIV for older adults is a higher antigen product (Fluzone High-Dose®), which is specifically licensed for adults age 65 and older. It contains four times the antigen as the standard vaccine and the hope is that it will lead to a more robust immune response in older adults which, in turn, will translate into less morbidity and mortality. Studies are ongoing to evaluate this product’s effectiveness and adverse reactions in comparison to standard TIV. The ACIP currently does not state a preference for which vaccine should be given to older adults. Table 1. Vaccines Recommended for Older Adults Routine Vaccines (for all adults) Influenza Pneumococcal 1 dose annually 1 dose (at age 65) Tetanus, diphtheria pertussis Td every 10 years. (Substitute 1-time dose of Tdap for one Td booster)* Zoster 1 dose (at age 60) Vaccines for Special Situations (based on medical, occupational, lifestyle, or other indications) Hepatitis A Hepatitis B Measles, mumps, rubella 2 doses 3 doses 1 dose Meningococcal Varicella 1 or more doses 2 doses * If close contact with infants or patient desires pertussis protection Source: http://www.cdc.gov/vaccines/schedules/downloads/adult/ adult-schedule.pdf Note that a history of egg allergy is no longer an automatic contraindication to influenza vaccine. ACIP now states that individuals who have experienced urticaria TIPS ABOUT VACCINES FOR OLDER ADULTS x Immunize all older adults annually against influenza, using the standard intramuscular trivalent vaccine or the new highdose trivalent vaccine specifically designed for older adults. Either is acceptable. x Do not automatically withhold influenza vaccine because of a history of egg allergy. Egg allergy, including urticaria, is no longer a contraindication to influenza vaccine. Those with egg-induced anaphylaxis should consult an allergist. x Assure that patients receive one dose of pneumococcal vaccine at age 65. However, if a patient received the vaccine prior to age 65, at least 5 years should elapse before administering the “post-65” dose. x Recommend a single dose of zoster vaccine, ideally at age 60. x Administer diphtheria-tetanus vaccine to older adults every 10 years. One time, however, the booster should also contain acellular pertussis antigen (Tdap vaccine) if there is close contact with infants or need for pertussis protection. Page 35 Continued from front page ELDERCARE following exposure to egg should still receive influenza vaccine, but only a TIV product and only from a clinician familiar with treatment of severe allergic reactions. People who have a history of anaphylaxis to eggs should be evaluated by an allergist prior to receiving influenza vaccine. Pneumococcal Vaccine Pneumococcal polysaccharide vaccine (PPSV) is recommended for all adults age 65 and older as a single dose, primarily to protect against invasive pneumococcal disease. If a dose was received before age 65 because of a high-risk medical condition, it is recommended that one more dose be given after age 65, at least five years after the first dose. PPSV is one vaccine where more than the recommended number of doses can actually be harmful by causing an impaired immune response to pneumococcal antigens. New pneumococcal vaccines are in development, and the 13 -valent pneumococcal conjugate vaccine (Prevnar13) was licensed by the FDA in 2011 for administration to adults aged 50. The ACIP, however, has not made recommendations about this new vaccine, and Medicare typically will not cover vaccines unless ACIP has recommended them. Herpes Zoster Vaccine Herpes zoster vaccine (Zostavax) is recommended as a single dose for adults aged 60 and older to prevent shingles. The vaccine is actually licensed for those age 50 and above but ACIP recommends starting at age 60 due to lower incidence of disease at age 50, uncertainty about duration of protection (and resulting need for revaccination), and limited vaccine supply. The vaccine is 50% effective in preventing shingles, but less effective with increasing age. It is 66% effective at preventing post-herpetic neuralgia in those who develop shingles. Zoster vaccine contains a modified live virus and is contraindicated in those with immune deficiency. It can, however, be given to individuals who have had shingles; the optimal interval between singles and the vaccine is unknown. Td or Tdap Vaccines All adults should receive a booster tetanus and diphtheria vaccine at least every 10 years, after a three-dose primary series (which is usually received as an infant or child). A new product that includes tetanus and diphtheria toxoid plus acellular pertussis antigen (Tdap) is available to provide adults protection against pertussis in addition to tetanus and diphtheria. This new product not only provides pertussis protection for the adult, but more importantly, can prevent an adult from passing pertussis to an infant. While the Tdap vaccine is FDA-approved only up to age 65, the ACIP recommends those over age 65 receive the vaccine if they are in close contact with infants. ACIP also states that it is acceptable for any older person to receive the vaccine should they desire it. Payment The payment system for adult vaccines is confusing because, as shown in Table 2, some vaccines are covered through Medicare Part B (physician office charges), others are covered through Part D Table 2. Medicare Coverage for (drug coverage), and Older Adults’ Vaccines in special situations Vaccine Part B Part D they are covered by Parts B and D. This Influenza D creates a problem Pneumococcal D for medical practices Tetanus-Diphtheria D in that they may have difficulty arZoster D ranging reimburseSource: http://www.gao.gov/products/GAO-12-61 ment through part D. As a result, some practices do not provide zoster vaccine or Td (or Tdap) for Medicare patients. Other locations at which to receive these vaccines include pharmacies, hospitals, and public health departments. Family and Intergenerational Aspects of Vaccines An often-overlooked benefit of vaccines is the protection afforded against intergenerational transmission of infection. For instance, influenza in children above the age of 4 years is usually not serious, but immunizing them against influenza can prevent transmission of the disease to grandparents who are at much higher risk of complications. Conversely, immunization of older adults against pertussis prevents them from infecting infants, who have much more severe reactions to this infection. Vaccines should thus be seen as both a personal and a family prevention strategy. References and Resources Fiore AE, Uyeki TM, Broder K, et al. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices ACIP), 2010. MMWR Recomm Rep. 2010;59(RR-8):1-62. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR Morb. Mortal. Wkly. Rep. 2011;60(1):13-15. Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1-30. Wenger NS, Roth CP, Shekelle P. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. J Am Geriatr Soc. 2007;55 Suppl 2:S247-252. ACOVE Quality Indicators 1. IF a vulnerable elder with no history of allergy to the pneumococcal vaccine is not known to have already received a pneumococcal vaccine or if the patient received it more than 5 years ago (if before age 65 years), THEN a pneumococcal vaccine should be offered 2. IF a vulnerable elder has no history of anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine, THEN the patient should be offered an annual influenza vaccination. Interprofessional care improves the outcomes of older adults with complex health problems Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu Page 36 Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging Arizona Geriatric Education Center EDUCATIONAL PROGRAMS Advances in Aging Lecture Series 3rd Friday of every month, 12:00pm – 1:00pm Schedule and location may be viewed at: http://www.azgec.med.arizona.edu/html/news_events.html View live at: http://streaming.biocom.arizona.edu/home/ Past lectures archived at: http://streaming.biocom.arizona.edu/categories/?id=5 Contact Laura Vitkus at [email protected] or (520) 626-5800 for more information Interprofessional Certificate in Aging Services Program Online, Self-Paced 4 Core Courses + 2 Electives or Internship This non-academic program is designed to provide knowledge of aging issues for anyone working with older adults Core Courses: The Aging Mind and Body Society and Aging Legal and Financial Issues of Aging Navigating the Health Care System and Aging Network Electives: Communicating Effectively with Older Adults Social Engagement: Keeping Older Adults Connected Healthy Aging http://outreachcollege.arizona.edu/programs-courses/professional-certificates Contact Karen D’Huyvetter at [email protected] or (520) 626-5808 for more information An Affiliate of the American Geriatrics Society 500 N. 3rd Street, ASU NHI-1, Phoenix, AZ 84004 Send name or address changes to Arizona Geriatrics Society, 500 N. 3rd Street, ASU NHI-1, Phoenix, AZ 84004 or email: [email protected]