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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].
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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. Music Therapy: An Introduction. 2000; Springfield: Thomas
Publishers. P 36.
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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
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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
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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.
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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)
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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.
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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
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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.
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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
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.
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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:
March 2013
ELDERCARE
Canes
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.
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19
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.
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.
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.
Page
20
Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging
Sponsored by:
August 2012
ELDERCARE
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
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.
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.
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.
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
ThisediƟonofElderCareaddressesmanyofthequalityindicatorscreatedbytheRandACOVEHealthProjecttoassessthequalityofcareofvulnerableadults.Space
limitsprecludeafulllisƟng,asnumerousindicatorsapplytothecomponentsofgeriatricevaluaƟon.ThereaderisdirectedtotheRandwebsitehƩp://www.rand.org/
health/projects/acove/acove3.htmlforalisƟngofthecomponentsofgeriatricevaluaƟonforwhichtherearecorrespondingACOVEqualityindicators.
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
Page
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Sponsored by:
August 2012
ELDERCARE
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.
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ELDERCARE
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
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.
Lynne Kirk, MD; Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH
Page
24
Sponsored by:
February 2012
ELDERCARE
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.
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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
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/
Page
26
Sponsored by:
April 2012
ELDERCARE
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
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
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/
Page
28
Sponsored by:
March 2012
ELDERCARE
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
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.
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.
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.
Page
30
Sponsored by:
July 2011
ELDERCARE
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
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
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.
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.
Page
32
Sponsored by:
April 2013
ELDERCARE
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
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.
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
Page
34
Sponsored by:
January 2013
ELDERCARE
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
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.
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.
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.
Page
36
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]

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