HCAD 222 Final

Data from National Crime Victimization Surveys show that people over age 65 are _________ than other age groups to be victims of serious crimes, such as robbery, personal theft, assault, and rape. Which of the following is NOT a risk factor for elder abuse? How is a case of potential elder abuse different from a case of potential child abuse? When a person can no longer manage to prevent harm to himself or herself or others, legal intervention (i.e., "protective proceedings") may be sought and may include which of the following processes? Older people are more likely to be victims of financial exploitation than physical abuse

1. less likely 2. Family caregiving 3.An adult, unlike a child, is always presumed mentally competent until proven otherwise 4.guardianship,conservatorship, and civil commitmen 5.True

1."Assisted suicide" is defined as: 2.Termination of life-sustaining treatement is not homicide, suicide, or assisted suicide according to court decisions. 3.U.S. common law holds that people have a right to accept or reject medical treatment. 4.Which state was the first in the United States to make physician-assisted suicide legal? 5.Which of the following groups has the highest rate of suicide?

1.A doctor or family member actively provides the means or carries out the instructions required for an individual to end his or her life. 2.True 3.True 4.Oregon 5.older White men

1.People of all ages were impacted by the expansion and availability of the Internet in 1990s. This is an example of what kind of effect? 2.Boomers were the first generation in American history where more than half achieved some level of higher education. 3.Boomers make up what proportion of the US population? 4.When considering any cohort, such as the Boomers, it is important to keep in mind not only age, period and cohort effects, but the impact of class, ethnicity, and gender as well in shaping individual experiences. 5.How much advertising does AARP estimate is aimed at the mature adult demographic?

1.Period effect 2.True 3.About one quarter 4.True 5.less than 25%

1.Older Americans possess which of the following resources that other age groups lack? 2.Between the 1950's and the 1990s, the average age of retirement has ______. 3.Older workers have less absenteeism, lower job turnover, and a lower accident rate than younger workers. 4.During the 20th century, free time increased in all of the following ways except through ____ 5.Which law forbade older workers from being limited or treated in any way that would harm their employment possibilities?

1.Time 2.Decreased 3.True 4. a reduction of the work week. 5.Age Discrimination in Employment Act of 1967

1.Social Security was never intended to be the sole source of income for people in retirement. 2.The Social Security Act of 1935 was a response to the Great Depression at a time when only ____ of the U.S. population was over age 65. 3.Even though Social Security benefits are derived from taxation, they are subject to taxation. 4.The age of eligibility for full Social Security benefits was ____ but between 2002 and 2007 rose to ____. 5.The inequities in Social Security are largely being ignored in current debates about changing the system.

1.True 2.5% 3.True 4.65,67 5.True

How Reimbursement Shaped Care

1960s -MC/MA -NHs Proliferate 1970s -Health care costs rise-esp. hospitals because of "cost-reimbursement"! 1980s -AL proliferates for private pay -Hospital DRGs (Diagnosis Related Groups) *A flat rate of diagnosis . How they determined the set prices *This led to quicker and sicker discharges. Fewer days in the hospital, less money we have to care you -Gov sets the "price" or reimbursement 1983-1997 -PAC (Post Acute Care) Proliferates 2000s -More care options for PP -Gov't expands care options -New payment models Cost reimbursement: When someone else is paying the bill. -providers charge what they want -Prices increase, no control -solution=Don't build anymore hosptials/nursing homes

Alcohol

3-10% of those 65+ Psychiatric consequences - depression - cognitive deficits Common/Major health problems - cardiovascular disease - cirrhosis of the liver - seizure disorders - pneumonia - urinary tract infections - gait and balance disorders Female abuse this more than man

Demographic trends of elder abuse

4% of 65+ are victims, only 1 in 14 cases are reported Estimate > 500,000 abused or neglected in domestic situations More victims of abuse are women 80+ suffer abuse and neglect 2 to 3 times their proportion of the older population Perpetrators: -47% adult children of victims -19% spouse of victims

Employment

61% of employed -FT 80% -30-39 hours per week 15% -less than 30 hrs a week 25% How long -4.5 years -3/10 for more than 5 years (this is a trend) keeps increasig than ever before What else? -53% is other unpaid help *often spouses -31% paid help

Religion and Spirituality

72% of U.S adults consider religion to be important in their lives, 50% are affiliated with the church, mosque, or synagogue, and 38% attend services weekly. This has declined in the last two decades.

What gives meaning to their lives?

90% said their live was meaningful 1)Most meaning came from human relationships 2)Services to others 3)Religion 4)Leisure activities

Financial Requirements Each state sets their eligibility rules

<$2000 in assets If married (with assets of >$100,000): -$50,000 for community spouse=if you have less than 52,000 with your spouse you qualify. The idea is you don't want to make a healthy spouse dessicated. Still need to provide for them self. $2,000 for institutionalized spouse What assets are counted - Which are not? Counted (add all this stuff up and if its less than $2,000 you qualify) Cash Checking Accounts Savings Accounts Certificate of Deposit Life Insurance Policies Not Counted Your home One vehicle Burial assets Household furnishings Clothing & other personal items

What is Medicaid?

A program that is federally mandated, but administered and partially funded by states originally designed to provide healthcare to disadvantaged, vulnerable members of society. Welfare program-social safety net to support people who can't provide to themself Who is eligible? -US citizen or eligible alien who meet financial eligibility requirements, and are: -65 -Blind or disabled -Under 19 -Pregnant *Federal and state program 50/50

What is LTC/LTSS

A range of services and supports to meet the health and personal needs of someone with a chronic illness or disability -Care based on functioning -Not person-place-age dependent -Continuum is blurring -Often linked to chronic disease &/or dementia Goals: -Improve or slow deterioration of health and functional abilities -Meet needs for care & assistance -Enhance social and psychological well-being -Maximize client idependent autonomy -Permit clients to live in most intergrated settings -Promote a meaningful life

Care Continuum/Care Cycle (it's not linear)

Acute care -Diagnosis and treat -Physician office - Acute Care Hospital -Immediate Care Center Post Acute Care -Heal, Rehab, and Recover -Long term acute hospital -Inpatient rehab -Skilled Nursing Facility Life -Wellness, prevetion, management -Home *Adult day care *Community based services -Assissted living -Hospice -Nursing home -Outpatient rehab -Home health Why PACS? -Effect of DRGs *showing the delivery of hc services over a period of time and covers all the phrases of illnesses from diagnose to end of life

Relationship of Acute and Long-Term Care

Acute care: require short-term, immediate care for illnesses or injuries -1940s hospitals built -Doctors, hospital services provided and clinic to get bettter and to get back to life as you know it -Medicare/Health Insurance Long-term Care: is given in long term care facilities, who need 24 hr skilled care -OG (Families before facilities)=Nursing homes -Castodial care=services ordinarily provided by personnel like nurses' aides. -Pernament regular care. stay the same or get worse -1960s compromise with medicare and medicaid -Private Pay, LTC Insurance, Medicaid -People got sent here from hospitals when they were too sick to go home but do not need to care done on them anymore through the hospitals Assisted living -start building homes for 16-30s residents -Homier, independent, newer look -Targeted to private payers -Same pay as Nurshing homes -Out of pocket Post acute care -Medicare/Health Insurance -Two types: Traditonal nursing home care or rehab -Through home care, based community services

Caregiver support resources

Administration on Aging -Designed to support families http:///www.dhs.wisconsin.gov/ltcare/adrc Providers-Community Outreach Grants Private Online

What kind of info is collected?

Administrative info, forms, signatures Clinical Assessment: -Identification Information -Hearing, Speech, and Vision -Cognitive Patterns -Mood -Behavior -Preferences for Customary Routine and Activities -Functional Status -Bladder and Bowel -Active Diagnoses -Health Conditions -Swallowing/Nutritional Status -Oral/Dental Status -Skin Conditions -Medications -Special Treatments, Procedures, and Programs -Restraints

Measures of late life intelligence

Are we measuring "real" intelligence? -Do cognitive developments come with age? *Measuring a lot more fluid intelligence vs crystalized Wisdom - "common sense"? -Reflective Judgment in face of uncertainty -Problem finding -Integrated thought about one's life -Intuition or empathetic ability to understand a concrete situation

Neuropsychological Evaluation

Assist in Diagnosis: ´Identify presence of dementia ´Differentiate various dementing processes Track Progression of Disease ´Make Recommendations for Treatment and Behavioral Management ´Individual variability in patterns and rate Commonly see impairments in: ´Memory and Learning ´Verbal Functions ´Visuospatial Ability ´Executive Functions -The last 3 do not need to present but are fairly common

Remediation of Cognitive Impairementm (people who havea stroke/brain innjuries) Cont

Attention: -Decrease distractions -Stimulants -Visual cueing (signs around rooms with steps) -Repetitive training games/exercises to increase Attn/Conc. Orientation: -Orientation Boards-be sure these are accurate!!! (Why are you there, date/time, who is your nurse etc) -Watches with Date & Time -Use of Log Books/Schedules -Alarms -Rehearsal

Age-Related Changes in Sleep

Basal Sleep needs remains stable (7-8 hours) until 80+, then increase slightly Patterns change: - Time in bed increases after age 65 - Sleep is lighter - Onset to sleep lengthens (esp. women) - Awakenings are more frequent (urination) - Naps more common - Frequency of respiratory disorders (i.e. sleep apnea) increases - "Early-to-bed-early-to-rise"

What are the major clues? Behavioral symptoms

Behavorial sysmptoms (The things people are doing) ´Crying ´Stooped Posture and/or Hand wringing ´Worried or flat expression ´Signs of social isolation ´Increased dependency ´Refusal of medical treatment ´Frequent doctor office visits ´Resistance to hospital discharge ´Minimization of symptoms ´Expression of Depressive Statements (if they straight up tell you, take them seriously) -Taking in the nonverbal observations

Back in the workforce

Benefits: -Health Insurance -Sense of Productivity -Occupy Time -Social Benefits Programs available to assist seniors to reintegrate -Employers are receptive to this reliable and often skilled workforce

Stress

Biological response to stress - "Fight or flight" Chronic stress can lead to: - heart disease- ulcers - loss of memory - diminished immune function - obesity - strokes - insomnia - backaches - headaches - depression Common stressors may include: - adjusting to widowhood or retirement - chronic illness and disability - decisions about driving a car, relocation - death of friends and family - Daily hassles *Coping styles will vary and can mediate the effects of stress *Kicking in our sympathetic nervous system: Adrenaline; stress essential response *Kicking in our parasympathetic nervous system: Relation response

Any tests that predict how long someone will live

Biological vs. chronological age Biomarkers-Nothing foolproof yet BUT... -FOXO CNS changes-brains Shrinks with age -Age at menopause -Telomere length -Genes?

Risk factors for depression

Biological: ´Genetic *Medical Illness *Vascular changes in the brain *Chronic/Severe pain ´History of depression ´Substance abuse Social: *Loneliness, isolation *Recent bereavement *Lack of a support '*Decreased mobility Psychological: ´Trauma/Abuse *Body image issues *Fear of death *Frustration with memory loss *Role transitions

Social and Economic Outlook for an Aging Society

By itself, population aging does not dictate the shape of things to come, and there is certainly no cause to be gloomy about the coming of an aging society. The point to remember is that the life one leads as a younger person will affect prospects for old age. The social and economic outlook for an aging society, then, is not simply something to be predicted but something to be constructed. The decisions we make today depend on thoughtful consideration of the controversies that will shape the aging society of tomorrow.

Fountains of youth? From the video

Caloric Restriction -Mixed science, some support that 30% less improves -health and life span -Human data is limited WHAT is eaten may matter as much as AMOUNT -In Primates: *CR may promote longevity or may simply lead to improved health * Improved health on healthier diets, even without CR Resveratrol Red wine? blood flow -Very promising in mice -Limited evidence in humans

What are the major clues? Cognitive symptoms

Cognitive symptoms: Are the thinking symptoms ´Slow to answer questions ´Forgetful, poor memory ´Inability to concentrate ´Guilt ´Negativism ´Suicidal Ideation ´Delusions I have dementia when I see these Qs

Cross Linkage Theory

Collagen (Protein) develops cross-links to one another -Accumulate *Decreases function *Skin, Cataracts, Arteries, Kidneys, Brain Component of aging, but lacks of other direct experimental evidence

Benefits of Cessation

Compared to people who still smoke, people who quit: - Regardless of age, live longer than people who continue to smoke - Before age 50 1/2 the risk of dying in the next 15 years - Substantially decrease cancer risk *lung, laryngeal, esophageal, oral, pancreatic, bladder, and cervical cancers - Also reduce risk for: *Coronary, cardiovascular, and respiratory disease- Harm Reduction...

Cost and Assistance

Cost -Value of informal caregiving: $470 Billion/Year -Impact on Business: $3.6Billion loss/Year -Caregiver loss: $303,880 /Lifetime Help -half have none -only 20-30% use formal services -Support for caregivers yields: ↓ caregiver stress & ↑ their psychological well-being delayed institutionalization ($)

How does the immune system change with age?

Declines in immunity with age -Weaker T cells and slower macrophages -Thymus shrinks with maturity -T Helper cells-fewer, less effective, aberrant -Mucosal antibodies decrease Bad news: Higher risk of risk of infectious disease, cancers, and autoimmune disease §Good News: Produce less IgE > "outgrow" allergies. Vaccines: Pneumococcal vaccine, Influenza vaccine, Tetanus, shingles, hopefully COVID-19!

Is financial planning enough?

Developing interests to pursue in retirement equally important as financial planning -40-50 hours "extra" free time post-retirement Develop interests and activities before retiring Retirement NOT commonly associated with depression/low-self worth, but IS adjustment period Couples -Plan separate activities to assure privacy -Develop some common interests -Keep your lines of communication open -Challenges when only 1 spouse retires-Cornell study

Why is recognition difficult?-Because you need to narrow down this list first, hard to get to the root of it

Differentiation from medical illness: ´Hyperthyroidism ´Parkinson's disease ´Carcinoma of the pancreas ´Dementia Bereavement ´~15% develop depression within 2 yrs of loss Stigma of mental illness ´Older people may not seek help because of a sense of worthlessness or burden Difficulty accessing care Cost and time constraints in medical delivery *A lot of senior depression is symptoms of somatic

Ethnicity

Differs across cultures and ethnicity Higher % of family caregivers from ethnic minority groups % GC age 45-55 % GC 18+ Caring for Ethnicity Caring for Parents Someone 50+ 19% White 24% 28% African Americans 29% 34% Hispanic Americans 27% 42% Asian Americans 32% In the 70+ age group, whites are most likely to receive care from their spouse, Hispanics from their children, and African-Americans from non-family member *Races other than white are more taking care of someone whereas white prefer paid care

The Human Genome

Early research - some "Longevity Assurance" genes detected e.g. foxo Longevity is likely a polygenic trait 10,000+ genes have been associated with specific diseases so far Epigenetics: the study of how your behaviors and environment can cause changes that affect the way your genes work

Impact on physical health Impact on emotional health

Elderly, spousal caregivers reporting mental or emotional strain have 63% increased risk of dying 31% of those caring for the elderly describe their own health as "fair" to "poor" Telomere health increased perceived stress = shortened telomeres by 10 years emotional heath: Caregivers experience depression, anxiety, and insomnia But rates of clinical depression are very high 46-59%, rates are higher for women vs. men Stress is inversely related to income, more than 70,000 not as happy Caregiving seemed to lead to less distress following loss of spouse

What protections are availble?

Every state... "APS" (Adult protective service agency) and own definition of "vulnerable adult"-if you are in a nursing home you are a vulnerable adult Most Health/Social Service workers must follow mandatory reporting guidelines What happens once reported? -APS screens for seriousness, violation of laws -Provide crisis intervention, more commonly work with agencies to ensure needs are met -Adult has right to refuse services - The case of Uncle Bert

Summary

Families, not social service agencies, nursing homes, or government programs are the mainstay underpinning long-term care for the elderly. Recognition of the role of the family in providing long-term care is moving to the forefront of national policy making. -Example: Family Medical Leave Act of 1993 -November is National Family Caregiver Month -Multiple Internet and Community resources -Various Ad Campaigns -Family plays primary role in caring for their loved ones

Feelings Reported by People Caring for Their Parent

Feeling % Reporting loving 96% appreciated 90% proud 84% worried 53% frustrated 37% sad or depressed 28% overwhelmed 22%

What are the major clues? Feeling symptoms

Feeling symptoms ´Anhedonia-inability to experience pleasure—FLAT (MEH) You see this more in facial expression ´Loss of reactivity ´Lack of motivation or drive ´Decreased interest in usual activities (hard to get up and go) ´Lack of interest in personal care ´Anxiety/worry (more females) ´General dissatisfaction or sadness ´Hopelessness, helplessness ´Irritability (more men have this associated with depression)

Generation study

Four issues underlie generalization equity: A cohort of people who progress in the life cycle. 1.Questions about the allocation of resources between older adults and children/ spending more on older adults than kids. 2.Concerns about large government deficits 3.Controversies over rationing health care resources 4.Questions about the fairness of how Social Security is financed

Cellular Theory

Hayflick Limit: the maximum number of divisions Cells from older organisms ® fewer divisions Freezing can halt the replication level Limits may occur as cells specialize -As limit is approached, genetic programming prevents replication -Cancer results from uncontrolled multiplication-HeLa cells

Important issues to consider

Health insurance availability (have to think about this if you retire before 65) Income - 70-80%? -SS -Pension -Other Retirement savings Part-time employment Family situation Early retirement impact on pension and Social Security benefits

Life satisfaction is _____ among those with high levels of religious commitment compared to those with no sense of religious commitment. "_____________ aging" is an idea based on an assumption that late life can be a period for positive spiritual growth.

Higher conscious

Home Health Care vs Home Care

Home Health Care: This is skilled care like nurses, ot, st. Criteara needs to be met under insurance. Education needed Home Care: This is more supported care. Someone who comes by a couple times a week to help bathe and make sure you have food. No educaion needed. More like a nursing aide. This is not paid by Meidcare or Health but paid by Medicaid. You will see the most growth in all the kinds of services that a person needs to stay in their home. *Biggest barrier is the cost to stay at home

Cargiving by numbers

How many? -53 million -21%, 1/5 of adults Who? -60% Female -49 years old -20% more than 1 -10% SpouseNearly 10% 75+ Who for? -61% females 46% 75+ -26% live alone and own/caregiver home What? -70-80% IADLs, 60% ADLs Nearly 60% medical/nursing tasks 40+% Transfers 33% Toileting/bathing What for? -63% LT (2/3), 30% ST, Memory 32% (1/3) **IADLs (Instruments of acitivities of daily living-managing money, help prep/cook/buy food, transportation **ADLs (Activities of daily living)-toileting, bathing, transfers, and eating. The hands on personal care **Sandwich genraton: Caring for children while in workforce, and still caring for their parents/grandparent

Obesity concerns

If obese, you have higher rates of -Chronic conditions -Disabilities -illness -depression -medical expenses

AD Treatment

Improve brain communication pathways The primary 3 treatments below which are best in earlier stages and slows down progression: -Cholinesterase Inhibitors (Aricept) -Aduhelm (aducanumab) -Memantine (Namenda) Experimental: -Lecanamab-breaking new clinical trials! First drug to potentially stop AD -Treatment - Intranasal insulin -Blood Pressure Medication-ACE inhibitors Symptom treatment (stuff to make you less agitated outside of treatment) Non-Medical: -Prevention - Strength Training Treatment -Behavioral -Supportive

LTC expensive

In home care: Based on 5 hours of care -Homemaker services $59,488 -Home health aide $61,776 Community and Assisted Living -Adult day health care $20,280 -Assisted living facility $54,000 less than half of the cost of SNF Nursing home facility -Semi private room $94,900 -Private room $108,405

Delirium and risk management

Increased vulnerability: ´Advanced age ´Functional impairments ´Malnutrition ´Sensory deficits ´Organ failure ´Dementia ´Severe physical Illness ´Mental Health difficulties ´Change in environment Management: ´ID and treat underlying causes ´Supportive measures/nursing care/mobility ´Correct fluids/electrolytes/nutrition ´Treat bowel/bladder/skin problems ´Use a sitter or family members to supervise ´Avoid restraints ´Encourage adequate sleep ´Restore sensory aids ´Manipulate environment/lighting/noise ´Consistency/continuity is important ´Reassure/reorient ´Bring in familiar items ´Other...

Elements of coginitive function

Intelligence -Fluild Intelligence : applied to new tasks, ability to creatively solve problems *Tends to be higher in younger people *Reflects more on creativity Crytalized Intelligence : reflects accumulated past experience and socialization *Tend to be stronger in older adults *Reflects more on Wisdom *Category (supermarket) fluency tests

Do life have meaning? To central qs are: 1) How do individuals actually experience their lives as meaningful in the last stages of life 2) Does old age have a meaning in society

It is only human beings who care for and honor the oldest members of their species, just as only human beings care and remember their dead. In both cases, we might ask: why? -Humans live in a symbolic world of shared meaning, and the power of meaning can be a matter of life and death. Individuals said connecting with people and forming relationships with others was a huge part in having a meaningful life. -For example: acts of bravery in crisis or wartime prove that people are willing to sacrifice their lives for what outlives of the individual self whether they act on the behalf of family, religion, patriotism etc

In summary

LTC encompasses a continuum of services LTC is expensive -Government is biggest payer of LTC -MANY people do not realize that LTC is not generally covered by Medicare -LTC is changing and will continue to evolve -Changes affect policy -Policy affects changes Will likely see resources, societal attitudes, and legislative decisions as major factors influencing what is available to consumers -Separate services from site? -How integrated with primary care? -Different goals for different clients?

In Conclusion

LTC is expensive! Currently the majority of LTC is paid for by government programs MANY people do not realize that LTC is not generally covered by Medicare Now may be the time to begin planning for your future!

Alcohol and Aging

Late-Onset vs. Lifelong Situations increasing vulnerability to alcoholism include: -Retirement -Death of spouse, family, or friend -Mental issue; pain and disability -Loneliness More dangerous as we age -Because of med changes etc -Most females were not long time drinkers

Aging in Humans

Life expectancy Life span -max life span is 120 years old Oldest person living in the world today -Jeanne Calment of France is 122 years old Compression of Morbidity -Enhance the quality of life -Extend life expectancy -Reduce health care costs Metformin -treat diabetes, lose wait -May be a solution to compression of morbidity

Lifespan vs Life course

Lifespan is the durations of life and characteristics that are closely related to age vs Life course is old age is a part of the entire course of human life

In summary retirement realities

Living longer, healthier lives & future of SS? -Individuals will need to supplement retirement income Retirement will continue to exist, but may "look" different -Society must answer some questions-policy changes may require people to work longer to afford retirement Early "life planning" has multiple benefits -With proper planning and action on the part of the individual, retirement can be a rewarding role

family responsibility

Long-term care largely a family responsibility in the U.S. -Spousal responsibility is deeply embedded in our culture -If spouse is unable, then other family members take responsibility or other extended family/friend Filial responsibility-The responsibility for the care of older adults by their adult children. Particulary asian culture play this role. -Many states have laws requiring, but rarely enforced -Commonly in other cultures. For example, China struggle to provide care for the older adults since they have that one child policy Unresolved Question: How should government interact with spousal and filial care giving duties and financial responsibilities?-Medicare and Medicaid. U.S has grown more a customed to paid care

Nutrition

Malnutrition -Over & Under nourishment problematic Factors contributing to Malnutrition: *Bad eating habit *Dental problems *lack of nutrition knowledge *depression *social isolation *poverty *sensory loses -16% of older adults living in the community are under nourished -60% of older adults who are hospitalized are under nourished *Note: you still can be undernourished and still be overweight

Epideniology

Many different illnesses cause dementia: -About to increase overtime because life expectancy goes up in developing countries. People are experiencing dementia for the first time. ´>70 illnesses have been found to cause dementia symptoms ´Prevalence of about 1% at age 60 ´Prevalence doubles every 5 years *65+: 1 in 14 *80+: 1 in 6 *Worldwide: - 50 million today -75 million in 2030 -130 million in 2050 -Many in developing countries -Alzheimer's Disease accounts for approximately 50% of dementias (most common)

Medicare Part A rules for coverage in SNF

Maximum number of Part A days that can be billed in a benefit period is 100 days. Resident is responsible for co-insurance starting on day 21, starting around $200 a day. Technical requirements: -Enrolled in Medicare A and have days available -3 day "qualifying" hospital stay. Admitted into hospital, if you are in the ER, 23 hr observation hold, a head in a bed overnight in order for it to count -Resident must have days left in their benefit period or qualify for a new benefit period -30 Day Transfer Requirement to a nursing home from hospital Why are they down 23 hour holds? -Now hospitals get punished if you come back after 30 days after discharge from hospital

Elements of Cognitive Function

Measuring Intelligence=Wechsler Adult Intelligence Scale: The most influential test of intelligence used today; includes a verbal part and a performance part, which combine to give an IQ score. Verbal: -Vocabulary -Similarities -Arithmetic -Digit Span -Information -Comprehension Performance: -Picture Completion -Digit Symbol Coding -Block Design -Matrix Reasoning -Picture Arrangement *Starts with simple Qs then gets harder and harder. Once you get a certain numberws of Qs wrong the test will stop and goes to the next *Classic Aging pattern: We expect the performance IQ to go down because of the time component, thinking speed goes down and verbal IQ to stay intact. Vocab will always stay most intact comparing to others cognitive abilities.

Primary payers of LTC For Seniors

Medicaid 57% Medicare (PAC) Out-of-Pocket 23% Health (PAC)/Long-Term Care Insurance 4% *No primary payer for LTC, use all your money then apply for M&M. Medcaid is the higheset payer for M&M *Do not have designated program to pay for LTC, comes out of taxes revenu. This is why we have less money to pay for other things.

Challenge for providers

Medicaid underfunds most care to most providers The Medicaid per patient day losses experienced by Wisconsin facilities ($52.11) are more than double the national average ($19.55) -cost shifting to private payers -this shift to medicaid as a payer source faster -Al has had a further impact *60-70% Medicaid decrease in money because getting under paid. It's going to be hard to stay in business for very long. Both medicaid and private insurance has increased in PAC *Private pay is the traditional LTC residents. This is the only group you have control to set prices want to attract this group for this reason

Long-Term Care $ Review

Medicare vs. Medicaid -Began as a "safety net" but now major payer of nursing home coverage even for middle-class -2/3 of all spending goes to long term care for the elderly, disabled, and developmentally disabled Annual nursing home cost ~$100,000 -70% of "private payers" reach poverty level after only 3 months, 90% within a year. Little money Americans have saved Medicaid = fastest-growing component of state budgets

How do seniors pay for health care?

Medicare: Acute & PAC Medicaid: Acute, PAC, LTC* Supplemental Insurance: Acute & PAC LTC Insurance: PAC & LTC Out of Pocket/Private Pay: Acute, PAC, LTC* Unpaid Care Family & Friends: LTC*

Remedation of cognitive impairemnt cont

Memory -Mneumonics *Don't work with Brain injuries, effective with seniors, but can take practice to learn *Method of Loci - http://en.wikipedia.org/wiki/Method_of_loci *Face-Name *Acronyms/Acrostics *Chunking/Grouping (phone # chucking) -External Aids -Rehearsal -Multiple Modalities (flashcards) -Pictures, Written instruction, Verbal instruction, Do it! lOrganization!

What does the research say?

Methodology - Cross Sectional vs. Longitudinal -Cross sectional Methodology: a research methology in which people at different ages ares studied at a single point in time. -Longitudinal Methodology: research in which the same study individuals are followed over time Seattle Longitudinal Study - Steepest declined after age 60 Cognitive changes seen in normal aging: -Processed speed (slows down) -Divided attention (More Difficult) -Memory (Changes Overtime) -Visual-spatial (declines with aging) -Executive abilities (Get more challenging, Frontal lobe develops last in brain) -But language stays intact Few show global decline in intelligence -However-Loss in cognitive reserve capacity *Degree of your unused potential for learning that can be used at anytime Draw on strengths, compensate for losses -Optimists: "Decrement with Compensation" *Even if we are declining, we can compensate for it

Payments from the old age, survivors, and disabilities insurance (OASADI) program

Most Social Security benefits go to retirees, but survivors and the disabled make up substantial shares as well. Reform centers on the retirement portion of Social Security. -Retirement 64% (2/3) -Survivors 21% -Disability 15% *Ran out of disibility pay so they took out of the retirement fund

Facts and myths of cognitive aging

Myths: -"You can't teach an old dog new tricks" -The elderly cannot adapt to change -Older people are bored Facts: -Older people do proceed slowly in new learning situations -Reaction Time slows with age *Neither likely to interfere with functioning Definition & measurement challenge -Intelligence: the ability to acquire and apply knowledge and skills. -Wisdom: the quality of having experience, knowledge, and good judgment; the quality of being wise. -Creativity: the use of the imagination or original ideas, especially in the production of an artistic work. *Do not have any good tests to measure wisdom and creativity *Addiing creativity increases life span

The Hayflick Limit refers to which of the following processes?

Normal human cells grown in tissue culture go through a limited number of cell divisions.

How? When is this done?

Often electronic (electronic submission is required) Admission & Discharge (have to do assessment at discharge) -Quarterly -Annually -Change of Status (have to redo assessment) -If an error is detected

LTC NH Residents- "sense of purpose" (2018)

Over 90% of people said their life had a sense of purpose -1) sense of community -2) activities -3) contributary service to community (job at nursing home)

Risk factos for elder abuse

Overwhelming burden of dependency -Physically dependent are at greater risk If caregiver has physical, functional, or cognitive problems Mental illness, alcoholism, or drug abuse of either Financial or other family problems Inadequate or unsafe conditions in the home Unrealistic expectations of the caregiver Overextension of caregivers with multiple responsibilities Social Isolation History of family abuse *The higher the care recipients care needs are, the higher chance of abuse

Retirement Views

Overwhelming majority retired by 65-generally positive for individuals Negatives -Society-practice of retirement comes with large hidden costs Funding required for pensions and retirement systems Loss of accumulated skills and talents -Individual-Work life less predictable, planning essential 85% of eligible workers participate in retirement contribution plan -Only about 2/3 are eligible though (so only about half of Americans) Defined benefit (e.g., pension) vs Defined contribution (e.g., 401K) plans -*know the difference! Current Trends: -COVID-19 -Economic instability/Volatility of labor market -Corporate downsizing *401k plan (less predictable): Most popular type of retirement and is a defined contribution plan. You put a portion of your check inm if you want to (cheap way). Most will have employee put money in and have their employer offer some type of a match. Depends on how generous of employer *Traditional pensions: Defined benefit plan. Lots of unions used to do this. The employer is kicking in some money and the employee is kicking in some money. Ex 30% ave monthly wages. Made retirement more predictbale. Not great for employers because people are living longer. Introduced 401k because of this.

Medicare Plan A,B,C,D

Part A: Hospital Insurance- Inpatient hospital, inpatient skilled nursing facility, hospice, and some home health services. Monthly premiem of $499 Part B: Medical insurance- physician services, outpatient care, durable medical equipment, home health services, and many preventive services. Richer people pay more. 95% qualify for this. 80/20 split. $170.10 $91,00 or less Part C: Medicare Advantage (MA)- Medicare approved private insurance companies that provide all Part A and all Part B services and may provide prescription drug coverage and other supplemental benefits. Part D: Prescription Drug Benefit- Medicare approved private insurance companies that provide outpatient prescription drug coverage.

Social Security Revenues

Payroll Taxes General Revenues1 Interest on trust fund2 Starting in 2018 SS needed to start calling in the Trust Fund IOUs, projected to run out by 2035, was 2-34, lost a lot of souls to covid and gained a year bacm. Number keeps running back. The benefit reduction to about 75-80% if nothing is done. (FYI-Disability Trust Fund would have run short in 2016, but Congress "solved" this by taking a higher %age of money from the SS Trust Fund and this is what made SS need to start calling in TF IOUs in 2018 vs 2020.) 1 Credited from income taxes on benefits. 2. Interest to the trust fund's bonds is paid by issuing new bonds *Cost of living adjustment 5.9% (2021), no increase in 2010, 2011, but increase in 2022 8.7% *Chained CPI:when economist sau when times are tough, you not necessarily going to buy the same food. Instead of buying steak, you buy ground beef. To reduce the cost of living adjustment, we use chained CPI.

How do patterns of leisure activity change over the life course?

People 65 and older continue to engage in the same activities with the same people as they did in middle age -Active engagement remains a key to life satisfaction and positive meaning in later in life -In addition, participating in intellectual and political leisure activities may have protective benefits for cognition during later life. *People who are still in the labor force after age 65 have time use patterns similar to those of younger people *People over 75 years of age and older engage in on average 7.8 hours of leisure time daily more than any other age group. Major of leisure time is spent watching tv, reading, relaxing and thinking and socializing *Americans over the age of 50- they command more than half of all discretionary income and account for 40% of consumer and demand.*help market grow into business *Half of their waking hours are spent alone, not counting personal care. This is why lesion time is important for older adults who struggle with loneliness and isolation.

A New view of retirement productive aging

People over age 65 are productive in many ways -Three-quarters of older people are engaged in unpaid work -Value of their contribution? Nearly 12 million full-time workers, including 7 million workers in caregiving Plasticity - the potential for retraining Role of society? Business? Individuals?

What about gene therapy and cloning

Permanently altering embryonic genes Anti-Aging gene therapy - DNA-modified virus -Telomerase AAV9-Tert gene therapy -Increased lifespan of mice 24% with single treatment -BioViva - telomerase and muscle mass Cloning holds promise holds promise of cell, tissue and organ regeneration

Retirement views overall

Positives Society- Job opportunity for younger Americans nIndividual- Expanded leisure and opportunities for self-fulfillment in later life nPersonal development and volunteer service nBUT-Retirement as time of leisure only possible with resources

What is the immune system?

Protects by distinguishing between "self" and "non-self" Response is why we experience symptoms such as fever, redness, swelling, phlegm, pus, pain, etc. Immune-related diseases: -Auto immune: MS, Lupus, IBD -Aids -Cancer and it's treatment

LTC Insurance

Public supports are taxes to help pay for a LTC Program Insurance that covers: Care Coordination, Home Modifications, Medical Alert, Caregiver Training Home Health Aides, Homemaker, Companion Assisted Living, Adult Day, Hospice Nursing Home Care Younger age at purchase = lower premiums but still very expensive and difficult to qualify. It's cheaper when you buy younger. Allows you to get LTC coverage without spending down your assets -Especially helpful when only one spouse needs care!

What is caregiving

Refers to anyone who provides assistance to someone else who is in some degree incapacitated and needs help -Types of "Care" can be quite varied -Informal Caregiver=unpaid -formal Caregiver=paid

Healthy ways with coping with stress

Relaxation Strategies: - Diaphragmatic Breathing - Progressive Muscle Relaxation - Neuromuscular Exercise (i.e. Yoga) - Visualization/Imagery - Massage - Others... * Support network *Eliminate stressors * Change cognitions/reactions *Take a break!

Defining quality of life and sense of purpose in LTC settings

Resident: 1. Staff and residents relationships 2. autonomy and respect 3. sense of community (didn't make it to top 5 in any other but really important to residents) CNA: 1. Staff and resident relationships 2. Autonomy and respect 3. Quality of care Admin: 1. Staff and residents relationships 2. Quality of care 3. Autonomy and respect **We shouldn't prezoom what our customers want, we are usually close but off the mark so talk to your customers.

Aging and the American Family -Abandonment or Independence?

Seniors NOT largely abandoned by their children -75% talk w/ children weekly, 40% daily Patterns have changed -Fewer extended family households than the past -"Intimacy at a distance" -Used to be the norm to have multignerational households

What's wrong with Divestment

Should it be legal? -Medicaid programs decentivize Should accountants be able to promote it? -If it's legal, why not do it What if everyone did this? -we would be in a world of hurt-unstainable medicare and medicaid in the rats in growing Should people on government programs have lower quality service as an incentive for people to not go onto Medical Assistance? -i.e. A 2-tiered system? -Some say that in Wisconsin, that's where we're headed...or even where we are already...

History of Retirement

Social Security Act of 1935 Majority 65+ retired -1965: 57% 2015: 40% of 55+ in workforce -2018: 18% of 65+ is in workforce n65+ has been fastest growing segment of workforce (currently 16.5% of workforce) Age Discrimination Act (1967). (cannot discriminate by age, stats at age 40. Still happens all the time even with this) Mandatory Retirement no longer legal (1986) Early retirement increased in popularity in 1990s, but has stabilized/declining-why? Women 55-65 in the workforce have actually increased - Why? *Making up for the gap they lost during having kids. *Divorce rates are increasing overtime Trends participation in workforce: -Fewer young people in workforce -55-64 increasing # in workforce -Greater % of people 75 and older in workforce than ever before why?-financial reasons, living longer, trying to prepare for retirement because most were underfunded.

What are the major clues?: Somatic symptoms

Somatic symptoms:physical symptoms in your body (faitgue, pain, headache, GI symptoms, diaherria etc) ´Persistent somatic complaints ´i.e. pain, fatigue, headache, GI ´Changes in sleep patterns ´Changes in appetite or unintentional weight loss/gain ´Low energy, sex drive ´Delayed recovery from medical illness -In primary care, physical symptoms are often the chief complaint in depressed patients

Medicaid planning

Some middle-class families have found ways of qualifying for Medicaid -Medicaid Spendown- impoverishing themselves by spending all income and assets to qualify for Medicaid coverage -Dinvestment Planning- appearing to be poor by taking advantage of legal loopholes to "avoid the Medicaid trap" Used to be a lot more population who would do this Rapidly growing body of "elderlaw" attorneys Deficit Reduction Act -Lookback Period=5 years. If your sold your house under fair market value to your kid 3 years ago, cannot be eligilible for medicaid for another 3 years. Used to make it harder for people to do divestment planning -Ineligibility Period Estate Recovery Initiatives -New inititaives states put in place= 2014, applicable to ages 55 and older -If you recieve any kind of assistance from the medicaid program and over the age 55, it means you still have to meet these guidelines. But then after you die, they sell your car and house and the one person who gets your stuff is the state, not your spouse or family memebers. Helps pay them back.

"Life Planning" and financial planning

Sometimes retirement is unexpected (when corps downsize or because of chronic illness) Social Security = MAJOR source of retirement income 2/3 of recipients, practically the ONLY source for 1/3 Among 30-50, > ½ plan to retire at 60 or younger & only 6% plan to work past 65 30 - 49 accumulated only 1/3 of what needed Only ~ 20% in 401(k)-types contribute max employer match 25% plan to use funds for other than retirement Retirement could last much longer than parents' Although Health Affairs says they are Sicker & More Cash-Strapped then other-country peers Roth IRA Planning for Retirement: -20% not saving or plan for retirement -64% expects to retire and they have less than $10,000 saved for retirement -20% preparing for retirement $10,000-$400,000 saved for retirement -The rest are in good shape 1/4 million+

How are your retirement benefit calculated

Step 1:SSA keeps track of wage history and converts your past earnings into a single number- Average Indexed Monthly Earnings (AIME). Step 2:SSA uses a formula to convert your AIME into a monthly benefit. Step 3:The monthly benefit amount is adjusted by whether you begin receiving before or after Normal Retirement Age. Step 4:After you begin drawing benefits, they are adjusted by a Cost of Living Allowance. -67: normal retirement age -Can collect as early as 62 (reduces by 25% or as late as 70 increases your check by 25%. If you are late, after 70, you get 125% reduction. *35 highest earning years. Women leaves the workforce due to children, caregiverm or disabled child. If you have gaps, have to go back to teenage job (lower worker paying job) which can impact your SS.

Cost of Depression (is big)

The direct and indirect costs - $236 billion each year (US) ´HC costs are 50% higher in depressed seniors ´3rd leading cause of global disease burden ´A leading cause of global disability Depressed persons experience/have: -Social and cognitive impairment -Higher rates of disability -Poorer physical health/medical conditions worsen -Longer to recover from medical illness and have less tolerance for pain -Poor compliance with medical treatment Depression increases the risk of death ´Comorbid physical disorders ´Suicide risk ´Treatment is available-why not feel better?

Life Course Perspective

The process of aging actually begins much earlier in life. We can not understand what old age means unless we understand it as a part of the entire course of a human life, and this approach is called -To make sense of old age, we need to understand the entire life history -People do not suddenly become old at the time we have defined as old age. -Aging is a gradual process, and many human capabilities survive long past when persons living in North America are considered of an age to retire.

Is Retirement Obsolete?

The time in which the primary means of financial support becomes pension income and not salary" The 20th century was "age of retirement" -Early retirement peaked in 1990s (pop because the economy was stellar) Decline in labor force participation à loss of productivity by older people With longer lives, more time in: -Education -Work -Retirement

Role loss

The transition out of social roles, such as widowhood and retirement

Age grading

The way people assign different roles in society depending on their age

Spiritual journey

Theologians who have reflected on the life course tend to view aging not as a problem that calls for a solution but as a existential condition that can provide an opportunity for personal growth

Where to go from here?

There is no easy solution ... Doing nothing is not an option. Without action, benefits will eventually be cut. If you don't have a reform plan, you're for benefit cuts, because that's what the law prescribes. 74% cut once Trust fund "runs out" on paper. Every congressman - and every American - needs to learn about Social Security, the problems it faces and the solutions that have been proposed.

Identical Earnings can mean different benefits

Tom and Beth Green (age 35) Tom earns twice the average wage, Beth doesn't work outside the home. •The Greens' monthly benefit: $2100 for retirement, plus $1050 spousal benefit = $3150 total. If Tom dies: Beth gets $2100 more than Sue Mike and Sue Smith (age 35) Mike and Sue both work and each earns the average wage. •The Smiths' monthly benefit: •$1450 for Mike plus $1450 for Sue, equals $2900 total. If Mike dies: Sue gets $1450 less than Beth) That's $250 less per month than the Greens, who have the same household income. *Disparity widens if Tom or Mike die post-retirement due to survivor benefits *If spouse dies you are eligible to keep your own SS check or partners check

Free Radicals

Toxic byproducts of normal cell metabolism. We are producing them right now Antioxidants neutralize -natural + diet -colored fruit and veggies Causes mutations, or damage to cell membranes, cross-linking, etc. Suspected link to many chronic diseases Parkinson's, cancer, stroke, heart disease, arthritis Anti-aging creams? -Not a whole lot of evidence it gets rid of free radicals

So what is the role of Medicaid in LTC?

Traditionally only covers Nurisng Homes Care Options for covering other providers across the continuum are fairly limited, but can come in the form of waiver programs or other pilot programs Are Medicaid Reforms (i.e. Wisconsin Family Care) working? 1) ADRC (Aging Disability Resource Center)-you can ask qs about mom/dad memory or about my kid having autism and going to be an adult soon 2) MCOS (Manage Care Organizatioins)-They can help put together a care plan for you in the most cost effective way -Woodwork effect-Before this, your only option was the nursing home under the Medicaid program. Then family can come along and say you can stay at home and have caregivers take care of you 10 hours a week. You can stay that AL and we will pay Typical scenario: SNF for rehab, then out of pocket until assets used up, then Medicaid

Types of elder abuse

Two types: domestic (occurs much more in home setting) and institutional (in a nursing home setting) Neglect=withholding a care and not doing something for someone -Passive neglect=occurs unintentially, male spouse taking care of wife and does not know how to cook so she is not getting enough nutrition which is putting her at risk for a uti -Active neglect=occurs intentially. husband is bed bound and dependent on you. When you bring him dinner he gets fiesty and says he wants something else and you decide not to feed him because of the way he was towards you about the meal you cooked -Physical abuse -Material or Financial Abuse -Psychological Abuse -Sexual Abuse -Violation of basic rights -Self Neglect

Assisted Living (paying private out of pocket) 1980

Typical demographic- 87 year old females, lower level of acuity but they are older, why?- because they lost their husband that they cared for at home, now have to go somewhere else Residential environment that enhances functioning and is homelike -Regulated at state level -Residential environment: private space and public space -Philosophy of consumer control over space, care and life-style -Service capability *Routine services *Specialized services -Term has many meanings *Housing with (separate) services i.e. RCAC vs. CBRF (only WI) *Congregate care with single staff i.e. Board & Care i.e. Adult Family Home (only in MN) *Need for uniform classification system to allow consumers to make informed comparisons

Documented Advance Directives

Upon enrollling: 35% Post enrolling: 75% ** Vast majority didnt want feeding tube and wanted to be DNR etc. Wanted to die at home.

Treatment-Basic evaluation

Use of screening tools Poor recognition by primary MD's Medical Evaluation -History -Physical -Laboratory -Current medications

Vitamins and Minerals

Vitamins: -D: Reduces Inflammation -B6: Keeps RBC healthy and nerves - B12: Keep RBC healthy and nerves -Folate: Treats anemia -Calcium: Keep bones strong Antioxidants: combating free radicals -Beta -carotene -Selenium -Vitamin C -Vitamin E What about caffeine?: Drinking 2 cups of coffee a day can increase your life expectancy

Aging Theory

Wear and Tear Theory: sees aging as the result of chance. The human body is constantly wearing out and being repaired Aging -Clock Pacemaker Theory (fate): aging is programmed into our bodies like a clock ticking away from the moment of conception. For ex menstrual cycle -Cross Linkage Theory: The changes we see result from the accumulation of cross-linking compounds in the collagen, which gradually become stiff -Free Radicals: contribute to physical aging. In waste products are ionized oxygen molecules that cause damage because they more readily bond with proteins and other physiological structures -Cellular Theory: argues that aging ultimately results from this progressive weakening of capacity for cell division, perhaps through exhaustion of the genetic material.

Advance Directives

What is AD: a legal doc authorizing decisions to be made, typically involving witholding lifesaving medical treatment, should circumstances arise in which a person has lost the capcity to make those decisions Place of Death in Relation to Advance Directive Status Advance Directive Status at Time of Death No Yes Total Residence 0 19 19 Place Of Hospital 2 4 6 Death Total 2 23 25 Statistical Significance of Differences: p = 0.009 *All who died at home had AD. Better chance getting your wishes followed if written down.

Leisure activities later in life

What is leisure? -as a realm in which human beings gain freedom for self-development when the necessities of life have been taken care of. Mainly happens after retirement. Affirming one's identity, a vital dimension of our phenomenological life at a time when other roles may be lost. Stereotypes include: Bingo -education and income= flexibility. This means more control over leisure time activities, the more flexibility you have.

Exercise

What? Why? Who? 20 Minutes 3X/Week: 40% none, 40% below, and 20% get it - Improved mood - Improved health * cardiac health *cholesterol levels *sugar metabolism - improved balance & decreased risk of falls and disabling fractures *muscle strength & joint flexibility *reduce age-related losses of bone mass Research & the "Oldest-Old" - Strength/Resistance training * Be careful! - There was a case study of 90 year old and older at a nursing home who did 8 weeks of HIT *gained strength 174% *thigh muscle increased density by 9% *walking speed increased density by 48% -Mortality rate 3x higher if sedentary (seated around all the time) -If you walk 1/4 of a mile in 15 mins you decrease your mobility issues by 25%

Public Policy on Aging

When today's elderly born, U.S. government paid no special attention to issues of old age vs. Now-30% -Social Security Act (1935) -Medicare and Medicaid (1965) -Employee Retirement Income Security Act (1974) -Age Discrimination in Employment Act (1967) -Older Americans Act (1965) -Medicare Prescription Drug Improvement and Modernization Act (2003) -Why? are we addressing imbalances as population ages.

Cognitive theory of aging

argues that it is perception of change, rather than actual objective change, that has the most impact on behavior. The importance of meaning we bring to situations encountered in life.

Activities of Daily Living (ADLs)

cognition has a greater effect than the other types of psychological functioning on the ability to perform the ADLs.

Learned helplessness

dependency and depression reinforced by external environment

Faith stages

describing how people move from simpler , more literate ideas of religion to levels where they see themselves and their lives in more universal terms

Age stratification

emphasizes that a person's position in the age structure affects behaviors/attitudes

Multidimensional disengagement

is that as people grow older, they may withdraw from some activities, such as attending church. But they show an increase in personal religious practice -The number of people who report praying a day seems to increase steadily from the age 55 to the highest levels among those over 75. -Most popular religion is Protestant by 38% -Women tend to have higher religious participation than men -Young adults are more likely to be religious unaffiliated than other cohorts were at the same age -Those with high level of religious commitment also have high levels of life satisfaction than those for whom religious commitment is not as important

The time-dependent biological process that involves functional loss and susceptibility to disease and death is called

normal aging

Generativity

outliving the self. This is not limited to acts of sacrifice The question whether old age has meaning is both a personal question and a challenging one. The personal question is ultimately a matter of values: What is it that makes life worth living into the last stage?

Ageism

stereotypes, prejudice, and discriminatory behaviors against older adults.

As people age, they tend to engage in ______. The most damaging threat to well-being in later life is ______. It was only in the 20th century that a sizable proportion of the population survived to experience old age

the same activities with the same people they knew from middle age boredom and loss of life purpose True

The ageless self

unless they were sick or depressed they didn't feel old

Age differentiation

what it means to "act your age"

"Compression of morbidity" refers to which of the following processes?

when illness is pushed further into old age

Who is involved? Where does the info come from?

who? -MDS Coordinator -Nurses & CNAs -All other members of interdisciplinary teams - Social workers, therapists, dietician, etc. -Physicians -Residents -Family members info come from? -Record review -Resident interviews and observation -Direct care staff on all shifts -Communication with physicians and families

Importance of Funding Sources to LTC Providers

~20-30% is Private Pay *Not subject to discounts or maximums *Competition for consumers ~70-80% is government funded *Large portion of market, BUT-many rules, regulations, and discounts Private Insurance and Managed Care likely to grow...

Depression associated with structural brain diseases

´Alzheimers disease: *20% of subjects with early AD have depression *40% have depressive symptoms ´Stroke *25% have major depression -History of heart disease and high bp

CAM ('integrative" or "behavioral") Treatments This is used if you have some depression symptoms

´Balanced diet ´Fluids ´Exercise ´Avoid alcohol ´Family support/social support ´Focus on positives ´Promote autonomy ´Promote creativity ´Alternate therapy: Pet therapy, horticulture therapy ´Pace appropriately ´Inform about depression ´Avoid stressors *CAM (complementary and alternative medicine)

Dementia vs Delirum

´Delirium is an acute state (short-term) of fluctuating consciousness (dehydration, UTIs, and Drug interactions) ´Onset and course of Delirium often differentiates it from Dementia ´Frequent causes include drug therapy, dehydration, pain, infections, etc.

Dementia (slower less easy to identify) vs. Depression

´Depressed individuals often complain of cognitive difficulties ´Symptoms of depression often have a well-defined onset ´Pts with depression often make little effort on formal testing. When Qs got hard on test, they would just give up. ´Pts with depression don't show same pattern of cognitive deficits on testing. People diagnosed with dementia put forth more effort (behavior perspective) *memory and attention, but not vocab -When did this start (major clue in telling the differences)

"Reversible" Causes of Dementia (means misdiagnosis)

´Depression ´Metabolic and Endocrine Disorders: i.e. hypothyroidism ´Nutritional Disorders: i.e. B12, folate ´Drug Toxicity: Psychotropic meds, steroids, etc. ´Intracranial Masses: tumor (like brain), trauma ´Infection *When someone has an infection, they get delirius

Dementia

´In DSM-5: Major (or Minor) Neurocognitive Disorder (new name for dementia and official diagnosis) ´Essential features: *Complex Attention *Executive Function *Learning and Memory *Language *Perceptual Motor function *Social cognition *The cognitive deficits must: *Represent a decline *Cause social or occupational impairment -Have to reprepsent a decline from where you have started to get diagnosis..

Diagnosis of Definite AD

´Largely a diagnosis of symptoms and exclusion ´Can only be confirmed at autopsy. Its a slow process and people live for about 10 years. ´With 90% accuracy, diagnosis can be made on clinical grounds by typical features and exclusion ´Medical History ´Physical Exam ´Laboratory tests ´Neuropsychological testing ´Brain imaging scans -PET Scans help diagnosed AD

Suicide risk in elderly

´Many have visited a primary care physician near time of suicide ´20 percent on the same day they saw docter ´40 percent within one week they saw docter ´12% of population, but 20% of suicides ´2-4 attempts per suicide vs 100-200 (younger). Certain meds can lift your energy but mood is not lifted so have to be closely watched. ´ Paradoxically ↑ as patient responds to treatment -Males are less likely to tell you they are depressed -Males tend to use more deadly attempts of suicide than females. Therefore, males have more deaths -When males turn 65 their suicide rate expontentially increases

Traditional Medical Treatments cont

´Medications (SSRIs, TCA, Others, St. John's Wort) *12-24 weeks *60% need a 2nd trial ´Combination therapy (#1 way to treat depression), It's a method of treating disease through the simultaneous use of a variety of drugs to eliminate or control the biochemical cause of the disease. ´Electro-Convulsive Therapy (only given after failed multiple treatments) *Severe or treatment-resistant *Response 70-90% *Most efficacious antidepressant *Contraindication: ICP, intracranial tumors *3x/wk with avg number of treatments *8-12, may need maintenance therapy *Side effects: Short term memory loss *Moreover, in all patient populations, the combination of medication and psychotherapy generally provides the quickest and most sustained response. Combination therapy has also been associated with significantly higher rates of improvement in depressive symptoms; increased quality of life; and better treatment compliance, especially when treatment is needed for longer than 3 months. *Combination best, but > 13 talk therapy sessions similar Drug treatment only also effective for man Faster once correct drug ID'd Multiple trials needed More side effects (more frequently than package label) *Electrical induction of a series of grand mal seizures to alter the neurotransmitter and neuroendocrine systems May be first choice in some elderly because it works fast, with fewer side effects than medications Helpful with delusions, drug resistance, life-threatening behavior Major side effect is retrograde amnesia and confusion, usually temporary Usually given in series of 3 treatments; 6-12 treatments effective 1/10,000 mortality—80-90% remission Psychotherapy *Help mild to mod *Slower response but less frequent relapse -CBT: (as effective as antidepressants) =antidepressants -IPT: (more effective than antidepressants intreating mood suicidal ideations, lack of interest. whereas antidepressants are more effective for appetite and sleep disturbances) >antidepressants <antidepressants -Indications: *Failure of antidepressant trials *Severe depression with catatonic or psychotic features *High risk of suicide *Poor tolerability of oral meds

Traditional "Medical" Treatments

´Medications (SSRIs, TCA, Others, St. John's Wort) *12-24 weeks *60% need a 2nd trial ´Psychotherapy *Help mild to mod *Slower response but less frequent relapse *CBT (congitive behavaior therapy): -antidpts: *IPT (interpretating therapy): ->antidepressants -<antidepressants ´Electro-convulsive therapy *Response 70-90% *Most efficacious ´Vagal Nerve stimulation *Implant ´Repetitive Transcranial Magnetic Stimulation (rTMS) *Newest, least invasive *Esp for vascular depression ´Combination therapy

Epidemiology: the study of how often diseases occur in different groups of people and why.

´Men: 5-12% ´Women: 10-25% ´Prevalence in elderly (only 10% get treatment [1999 study found 4-37%]) ´6-10% in Primary Care setting ´12-20% in Nursing home setting ´11-45% in Inpatient setting -More prevalent in females than makes -Majority of deperession is from seniors in care setting like nursing homes and hospitals

In summary

´Neither Depression nor Dementia are NORMAL parts of aging ´Depression can be treated successfully ´Dementia risk does increase with age ´Differentiating between dementia, delirium and depression can be challenging, especially since often co-morbid, but accurate diagnosis is critical to treatment

Common types of dementia

´Parkinson's Disease ´Progressive Supranuclear Palsy ´Diffuse Lewy Body Disease ´Pick's Disease ´Multiple Sclerosis ´Fronto-temporal *Vascular Dementia *Alzheimer's Disease ´Others... ´Imaging techniques aid differential diagnosis: *=highest chance with cardiovascular disease

Alzheimer's Dementia (AD)

´Plaques-get in the way so for neurons to transmit one to the next ´Tangles-block the neuron's transport system ´Neuronal loss ´Annual costs of caring for patients with AD is >$200 billion in the US

Diagnosis

´Sadness is a universal emotion, not depressed ´Depression is not a normal part of aging Diagnostic Criteria (DSM-5): 5 or more, incl 1 or 1st 2, 2-week period. Has to have 5 symtoms on their list and include at least one of the first two mentioned ´Depressed mood ´Markedly diminished interest or pleasure ´Significant weight gain/loss or reduced appetite ´Insomnia or hypersomnia ´Psychomotor agitation or retardation ´Fatigue or loss of energy ´Feeling worthless or excessive guilt ´Diminished concentration, indecisiveness ´Recurrent thoughts of death, suicidal ideation, plan, or attempt

AD (discovered in 1901, every 4 seconds someone is diagnosed) vs. Vascular Dementia (having a series of TIAs which are mini strokes)

´Usually history of vascular disorder such as hypertension (high BP), diabetes, cardiovascular disease, puts them at increased risk. ´Often has a step-wise pattern of deficits ´Cognitive deficits often associated with known vascular lesions ´Rarely has the same distinct pattern in Neuropsychological testing

Continuum of Care

• Good business ideas adapt to the realities of the present, anticipate the future...and let go of the ways of the past. Historical Business Model repositioned business went from independent, assistantm nursing being the biggest, now reversed: nursing, memory support, assisted, independent, and community based services being the biggest.

Person-directed care

•"Culture Change": Places for living and growing vs. declining and dying -Eden Alternative www.edenalt.com -Pioneer Network www.pioneernetwork.net -Wellspring www.wellspringis.org •A new model of living and providing care, changing institutions into personal communities •Where caregivers pay attention to individual wants and desires and how they can help people find meaning value and joy in life. Leads to: -improved health outcomes, satisfaction and quality of life among residents -improved employee satisfaction, performance and retention -reduced health care costs *old school: provide only one meal choice for meal, eat or don't eat. Now leaning to more option

Economic well-being

•"Double Jeopardy"/"Multiple Jeopardy" •Poverty rate higher for older adults •Consider differences in economic well-being

Questions to consider while viewing Almost Home:

•1) The administrators of the nursing home have asked the staff to create a "homelike" atmosphere. What do you think they mean by that? Does everyone share the same vision of what a home is like? --John George Admin. He wants to create a homelike atmosphere by doing a social model. We let your rise naturally, have choices, staff doesn't wear uniforms, looks medical, no shower area, you decided if you want a tub bath or shower and what time spa area. Every Monday at 4 o'clock cocktail hour. Having people valued the moment you walk in, to the moment you die. Delivering meds in room, have medications in bathroom.no one jumbo med cart. Engaging residents in activities. -Staff/family views: family members didn't like the rise naturally because they could sleep for 24 hours. Residents are never in their rooms, less convenient for staff. Years ago, everyone got up around the same time and everyone got their meds at the same time (traditional model), a staff member argues it's still a nursing home. Give them a piece of bacon and that residents chokes. Policy, is they don't wear bibs. Bothers some family members •2) Administrators acknowledge that most of the people who work at St. John's could never afford to be residents there. What kinds of difficulties do you think that situation creates? »-Stereotypes, racism, creates a dynamic that needs to be paid attention to. On average cna gets paid 18,000-21,000 a year, housekeepers make less. Not a job you just do for the money, something that your heart has to be in, not just their cna we are their family. Assuming this is their only source of income. •3) What extra challenges are added to the mix when residents (who at St. John's are all white) and CNAs (who at St. John's are predominantly black) come from different ethnic and racial backgrounds and neighborhoods? »-Some whites residents are still stuck in the past and call people of colored slang names to describe them or do not want came done on them if they are that color because they are still stuck in the racism. •4) There is no doubt that staff members care about (not just for) the residents of St. John's. So what is the source of the resistance to some of the suggestions and policy changes made by administrators? If you were running the facility, what would you do to overcome that resistance? --raise in pay -make a sheet on ways to get involved with residents, activities should take around 30 mins, staff doesn't know where those hours are going to come from because they are too busy. His man concern is residents are with staff and staff are only talking to each other and not involving residents in conversations

The aging market

•45+ is "the new custim marjarity" •50+: -Controls 3/4 total net worth and financial assets - more than $7 trillion -Responsible for > 50% discretionary income (a lot of power and wealth) •How can the mature consumer market be segmented?-Think what kind of things 50+ might be willing to purchase

Who are the Baby boomers?

•77 million born in the U.S. between 1946 - 1964 -Began 65 in 2011 -58-76 Today •Generation: specific cohort born in a specific time •Age-Period-Cohort model:physical changes and how others react to those changes everyone at same time - more specific groups of people •Social Construction:manmade facts about human existance in the world

Hispanics

•8% of 65+ 20% (2050) •Overwhelmingly Catholic, great diversity on other dimensions -"Hispanic Paradox": folks who have longer longevity have less education, income, and acess to healthcare. • LE 65, ¯ lifetime earnings, SS years, education •Face significant disability challenges •living conditions and health care disparities • poverty, ¯ health status, cognitive impairment in later life •COVID - 2X (2yr) worse life expectancy *hit harder on covid •More likely to rely on informal supports than on formally organized services

African Americans

•9% of 65+ > 13% (2060) •Lower life expectancy at birth and in most decades of life -COVID lost us 1 year, 3X worse in AA community *lost 3 years of life expectancy due to covid and already have a lower life expectancy. If you are african american and can make it to 70, you havea higher chance to make it to old age. •Experience impairment, but ¯ NH admittance, tend to rely more on family members for caregivers. -Cross over Phenomenon or caregiving patterns? *African African woman make it to old age. •Informal support networks •AA face many disadvantages, not all to same degree 1.African-Americans constitute the largest minority group among the aged, currently comprising 9% of all Americans over age 65. 2.By 2060, it is estimated that 13% of the older population will be African-American. 3.In comparison with Whites, African-Americans generally face a lower life expectancy at birth and in most decades of life. 4.Older African Americans also tend to experience more functional impairment from chronic illness, yet they are far less likely than Whites to be admitted to nursing homes. 5.Is this disparity attributable to the crossover phenomenon-after AGE 75 black LE exceeds white LE, to discrimination in long-term care facilities, or to some other factor, such as family caregiving patterns? 6.This last possibility points to a source of strength among many Black families, namely, extensive informal support networks. 7.Although African-Americans face many disadvantages, all are not disadvantaged to the same degree. 8.For instance, some are quite well off at retirement, especially those who have had college educations and professional careers, another example of how important it is to look at where an individual is positioned across multiple characteristics such as education level, social class, ethnicity and race, sexuality, and gender.

"Pay-as-you-go" Financing

•A "pay-as-you-go" system •Could begin paying benefits quickly - System started in 1935, first benefits paid in 1940 -Regressive: advantage the wealthy, collection of ss -Progressive: Advantages the poor, payout of ss -Income system is progressive, higher tax bracket -The poor is getting a bigger % from what they paid into vs wealthy. The poor earner have small amount vs the wealthy have a bigger amount.

A culture of collaboratioin

•ALL stakeholders working together •Shared vision of the future •There is a place for innovation in a person-directed approach •The well being of each person should serve as our common denominator!

The aging Network

•Aging Interest Groups: -AARP (1958) - American association of retired people (not called that anymore) The voices of the older adults. Also sell memberships www.aarp.org -Others... •National Council on Aging •Gerontological Society of America •American Society on Aging •National Committee to Preserve Social Security and Medicare The "gray lobby": older adults vote more than any other demographic •The Older Americans Act -Nutrition Programs -Senior Citizen Centers -Ombudsman Program:An advocate for anymore living in a care community -Caregiver Support -Information and Referral Services •U.S. Administration on Aging-coordinate, advocacy •State Agency on Aging-disperse federal $ •Area Agencies on Aging-local (city/county) -responsible for planning and organizing services to older people in that region •Some estimate only serve 5-10%

Changing trends

•Consumers - better educated and greater access to information •Higher consumer expectations - will want their individual needs/wants met •Increased demand for Home and Community Based Services Medical research - greater disease prevention and delay onset of chronic illness Demand for preventive and predictive healthcare will increase The role of technology is exploding •Role of "Nursing home" - Transitional care and Highest acuity LTC •Government policies may affect SS, Medicare, and Medicaid (primary LTC payer) •Access to quality care will be far from universal *literacy went down

Sources of Retirement income

•Economic circumstances vary sharply, but much wider range •Income vs. Wealth-all assets you have commulative over a life time for ex biggest one may be house •"Three-legged Stool" 1) social security (vast majority of people who have worked or are married) 2) private pensions (worked for a corportaion used to have this) 3) individual savings and assets •Older people have not shared equally in the increase in retirement income *less likely to get inheritiance than they were

silver industries

•Financial services •Health care •Travel and hospitality •Retirement housing •Others? -What do older consumers want? -How are they distinct from other consumer groups? Similar? -If you were an older consumer, how would you want products and services to be marketed to you? -best buy

Different Generations

•GI Generation/ast •Silent Generation: WWI, educate gender roles, not very demanding *These two above are most of our customers. •Baby Boomers -Selfish/negative or idealistic/positive? -4/5 plan to work in retirement •Really? -Health Status •Gen X: both parents worked, "latched key. Cold war, seeing divorced families for the first time. Golden hand cuffs- saw dad work for the same company for many years. Theme: work, life, balance. •Millennials: 2nd BB, more power than BB did. Least loyal to jobs, grew up with cps •Generation Z: post economic recession •How will society, government, boomers respond to changing circumstances? *older BB: did have hospitals, school, so build more, got new stuff, fresh stuff *Young BB: influences by different format things like gen z (fight for civil rights)

Exercise

•Getting into 2-person breakout rooms •Tell them 2-3 things you like about your wallet or purse, and 1 or 2 things you dislike •Reverse roles •3 minutes > Return to Main •Discussion

Pioneer Network's Values and Principles

•Know each person •Each person can and does make a difference •Relationship is the fundamental building block of a transformed culture •Respond to spirit, as well as mind and body •Risk taking is a normal part of life •Put person before task •All elders are entitled to self-determination wherever they live •Community is the antidote to institutionalization• **Do unto others as you would have them do unto you -- yes, the Golden Rule •Promote the growth and development of all •Shape and use the potential of the environment in all its aspects: physical, organizational, psycho/social/spiritual •Practice self-examination, searching for new creativity and opportunities for doing better •Recognize that culture change and transformation are not destinations but a journey, always a work in progress

Changing Financial Outlook

•Life cycle model of savings •Inflation impact: hitting people on a fixed income payment pretty hard. •On average, improvements over past two decades, but still significant poverty

Race and Ethnicity

•Majority 65+ White, but minorities increasing- a lag time •African American •Hispanic/Latino •Asian •Native American •Heterogeneity & many, many other ethnic groups

Asian Americans

•Many countries of origin, differences in languages and customs 4% (2017) > Fastest growing, highest income and education -Within remains diversity •Indian (18.4%), Chinese (23.2%), Japanese (7.5%), Filipino (19%), Vietnamese (10%), and Korean (9.9%) origins. •Discrimination (all) Older Asian Am immigrants - difficulties reconciling cultural heritage with American values •Honor one's parents & filial piety -Coping with erosion of status/traditional roles of older adults *one of the fastest growing groups, higher immigration, education, socioeconomics status. -greater honor for caring for one's parent and eachother, stuggling with this balance of traditional races

What is Medicare?

•Medicare: Federal program "entitlement program" you pay in to it now and benefit from it later. If you had a job, you have paid into medicare -People 65 and older -Some with disabilities under age 65 -People with End-Stage Renal Disease •Overview: •Costs-Handout •Having "insurance" does not mean 100% coverage! Plan A,B,C,D Medicare donut hole=Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs; you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again. Covid relief bills helped fixed this and now its gone now. Was a good deductable of $25,000 and then pay $3,000 *Each of the 60 reserve days may be used only once during an individual's life time.

End-of-Life Issues

►Competency & Decision-Making (legal issue) -Competent: (people over the age of 18 unless proven otherwise)The capacity to understand and the judgement to make a decision. Doesn't have to be good ones, just need to understand the consequences. As long as you are this, you can make any decisions you want. vs. Rational: is the idea of mind/sanenss, of the sound of mind and patient seems quite rational. ►Advance Directives-in anticipation of losing competency -Living Wills: Here is what I would like to happen and here is what I don't want to happen when I can no longer make decisions for myself. This is valid in any state and can be changed whenever. -DPA (Durable power of attorney)- can be for financial, more talking about end-of-life. You sign over the ability for another person to make decisions on my behalf. *other names fo this include HC agent, HC proxy. ►Patient Self-Determination Act (1991): They ask you this question now when you are at the clinic which is, Do you have a advance directive and if not, would you like a pamphlet about it. ►Legally & Ethically: "Obligation to treat unless told otherwise"-obligation to treat if have no knowledge of what they wanted. If you had knowledge of what they wawnted and do otherwise=can take legal action. ►Right to die?-In a lot of places people don't have the right to die. In the states that allow the right to die, only half of the people got the meds to end their life. This more about the feeling of control even if the person never uses the medication. *POLST (Physician order for life sustaing treatment): This the only time a physician would have to write an order for what you want and its in your healthcare records. Similar to Will. Will or DPA do not need a physician or any type of doctor to sign their forms.

In Closing

•On average, "not too bad?" "could be worse?" •Impact of economic downturn is enhanced for Seniors •Has improved over time, but... -Enormous variation -The "near-poor" -Once "old & poor" nearly impossible to reverse

Life:Dignity

►Dignity & Choice are important: -Personal privacy-bathroom, money/mail *Easy access of bathroom. For example, one LTC had a bathroom in the middle of two bathrooms, so it was shared between the two rooms. Anothe example, is not having shower/tubs built into their room, and having to go down the hallway with a sheet draped over you to do so. -Want to be viewed a certain way-"Personal Identity" *Does not want to be identified by their disease. -How is dignity lost? *Sharing a room with a roomate *Bath scenario *Having slow responses to call lights *incontinence and waiting to change *Having someone calling them honey/sweetie/pet name ►Clients are dependent: -Reliance on help creates a paradox *The more dependent on others for care, the more you have to relie on them to exercise your autonomy

American Indians and Alaska Natives

•Only 0.5% (2017) & understudied (smallest group) •Origins in more than 500 distinct tribes in North America •Common (esp on isolated reservations) > major economic disadvantages/barriers to receiving needed services -May be partially offset by family support/social integration -Tribal elders > cultural conservators, gaining respect for memories of old ways -Enhances prestige & helps the next generation *limited services available due to distrust of services

Life:decisions

►Informed Consent-what will be done, by whom, and what are the side effects -Providing them with the info to make informed choices ►Decision-making processes are flawed: especially in moving a resident into a LTC. Get person to buy into it themselves and explain it. Make sure you speak to patient first even if they can't respond. -Less attention paid to informed consent -Multiple family members -"Discharge" Planners' 1° goal: Social worker usually moving people out of hospital and helps find a place to send this person. ►Often automatic rules for referrals

The Baylor Elder HouseCall Program

►Initial Assessment: -Patients receive home-based "Comprehensive Geriatric Assessment" followed by longitudinal primary care through house calls. Instead of going to the clinic, a doctor would come to your own home. ►Patient Care Coordinator (RN) ►Geriatrician ►Advance Practice Nurses (APNs) ►Dietitian ►Social Worker ►Medical Psychologist ►Home Care Nurses ►Subsequent Care: -Triaged by RN, primary care provided by GNPs and Geriatrician

Least-Advantaged Older Adults

•Poverty Among the Old -Large reduction over past 30 years •Biggest gains in income for were in 60's & 70's (because of medicare and medicaid) -Supplemental Security Income (SSI) •Means-tested •Cash benefit program -elderly poor, blind, and disabled *Helps them pull above poverty line. These are people who retire and depend on social security check. » -Cummulative disadvantage-lower SES over the life course tends to produce cumulative disadvantage, which is perpetuated in old age

Residents' Perspectives

►Kane, et al. (1990) ® 270 cognitively intact residents & staff ® 10 everyday activities -Both felt control & choice over everyday matters ►Impt to residents: leaving, phone *ability to leave facility and make a private phone call ►Impt to staff: activities *Have to talk to your customers ►>1/3 dissatisfied with amount of control & choice over all activities -staff pessimistic over how to increase this ►Irony ® Lose ability to privately confer with MD *It gets harder and harder to have a private phone call with doctor .

Choices

►Let me make... -Communicate my options. -Honor my decisions. -Offer me guidance and support. -Include me in discussions. -Collaborate my health care. -Exercise my basic human rights. -See me as an individual.

Ethics in Home Care

►Likely to: retain more autonomy than in Nursing Home. That's why people want to stay in home as long as possible, to have more choices. ►Fierce desire to retain privacy ® no professional help. They don't like strangers in house, feel the needs to ger dress/look nice, have house already cleaned up before the help comes. They are afraid the outsiders will come in and convince them to change living and go to a AL or SNF. ►Role of family members? Depends on support structure how long you can stay at home ►Still important to balance risk : safety. In home care setting, could have a fall and it may be awhile for someone to find you. Getting rid of throw rugs different square shaped rugs covering your hard wood floor. ►Important to work with interdisciplinary teams

Life:LTC

►Need to encompass ways to respect: -Choice -Dignity -Privacy ►"Prescriptions for LTC are prescriptions for life" - little room for autonomy (guiding principle of U.S. bioethics)

Life: Role of LTC Provider

►Providers are gatekeepers to ordinary life: -Alcohol, smoking, eating, sleep and TV habits, leaving a facility *Having headsets available for shared bedrooms if the other roomate does not want to watch tv. ►Important to: ► Max autonomy, choice, pleasure *For example, dinner, having 3 meal choices. ► Question the appropriateness of this authority *Job into max quality of life/autonomy, choice, pleasure

Life: Balance safety

►Subject to Intense Protection: -Increased risk of falls & difficulty summoning help -LTC programs designed with most attention to protection ►Protect at expense of privacy & autonomy -How do we balance risk : safety ? *Balance between safety and quality of life is a tough one *For example: alarm in facilities, more startle them and they tend to fall because they forgot it's under them, not quality of life, alarm free facilities. -Ombudsman: to protects residents right.

What is Social Security

•Social Security Act passed in 1935 •First benefits paid in 1940 •A contributory Social Insurance Program: everyone pays in and everyone receives benefits -an "Entitlement". Not a welfare program. Not an investment program. •Financed by a 12.4% tax on wages up to $142,800(2021) •Half paid by worker, half by employer (6.2% out of your pocket and your employers=12.4%) • Provides retirement, survivors and disability benefits to eligible workers and their families •The largest government program in the world; takes up almost one-quarter of the total federal budget (24%), not an investment program. *1 trillion dollars that we out spend that we outs spend our income every year.

Social Security and the Modern Family

•Social Security's benefit structure is stuck in the past •Dual entitlement role: A spouse is entitled to her own benefits or benefits equal to one-half of the higher earning spouse - but not both. •63 percent of working women receive no additional benefits for the taxes they pay. •The dual entitlement rule is one of the most regressive aspects of Social Security *Never worked at all SS=0. But if married, you half of your spouses SS if you didn'r work.

Ethnic Disparities and Social Security

•Some Shorter Life Expectancies (Men before females) •Lower Incomes •Disability •Marriage

varieties of aging experiences

•Stereotypes: assuming every member of this group must be like this vs. Generalizations: not a memeber of a specific group and understand some information of that people from that specific group. •Ageism -"ill-derly" (lower socioeconomics) -"well-derly" (higher socioeconomics) • Age, gender, race, and social class -Interact in complex ways to define individual experiences •Adaptive strength of many disadvantaged older people •Increasing ethnic diversity-a lag time

But won't the trust fund help pay benefits?

•Technically, the government bonds in Social Security's trust fund will help pay full benefits until 2035 •NOTE: 5 years ago this projection was 2037, and 10 years ago this projection was 2041 •But the Social Security trust fund is largely a debt the government owes to itself •Only way to turn those IOUs into cash is to raise taxes, cut spending, or borrow

Social security and divorce

•To qualify for spousal and survivor benefits a marriage must last 10 years. •George and Rita Ball are divorced after 10 years and 1 day of marriage. Rita is entitled to full spousal and survivors benefits based on her ex-husband's earnings. •John and Judy Hill end their marriage after 9 years and 11 months. Judy is entitled to no benefits based on her husband's earnings. If she did not work outside the home, she may have no entitlement to any benefits or protections.

Ethical Dilemmas

►What would you want? ►Are your wishes documented?-https://www.dhs.wisconsin.gov/forms/advdirectives/adformspoa.htm ►Suppose you were with your 75-year old Grandpa and he told you he wanted to end his life. -What would you do? -What should you do? ►Terry Schiavo Case: A 30 year old women that was married and it was believed she had an eating disorder and one day collapse at her home and was never the same again. Her husband took care of her for 8 years, she was on a feeding tube and after 8 years, the hubsand wanted to remove the feeding tube because he said she wouldn't want to live like this. The parents wanted it kept in. So this went through multiple court trials whether or not to keep the feeding tube in. In the end it was uncontinstutional and they took the feeding tube out and she lasted for another 10 days. ►HC Cost Implications?

Social Class

•Unequal shares of wealth, status, and power - - •Four elements influence class position: 1) Occupation 2) Income 3) Property 4) Education •Downward mobility: Once people leave the workforce, expenses goes up while income goes down. •Old age not equal to poverty and economic vulnerability *Education can influence your income and occupation and what kind of property you own. The best way to grow your assets (property)

Gender and Aging

•Worldwide, women comprise the majority » •"Feminization of Poverty": woman tend to have lower retirement funds. If not in the workforce, collects some % of husbands social security. -Lower retirement incomes-55% of men's •Median income: older women $19,180 older men $32,654 -For below poverty line, 75% are females -Caregiving -Widowhood •70% 65+ men live with spouse, only 48% women *young-old 60-75 80% of men living with a spouse, 52% women 75+ women only 24% living with a spouse.

Life: Autonomy conflicts

►Autonomy-ability to make meaningful decisions, and in doing so, direct the course of one's care. -can get more challenging whem your dependency relies on other's to help do ADLs ►Reconciling limitations/needs of institution -Staff may not feel choices are appropriate/safe -Balance needs of individuals and groups *Like what you want to wear and when you want to go to bed

Wear and Tear

"Chance": Years of damage to cells, tissues and organs eventually wears them out, killing them and then the body DNA: sustains repeated damage from toxins, radiation and ultraviolet light -Less effective at repairing damage over time *e.g. brittle bones and joints

Aging Clock/Pacemaker Theory

"Fate": Biological clock -Neuroendocrine *connections between the brain - nervous system - endocrine glands -Pituitary Gland: Master gland *high BP, impaired sugar metabolism, and sleep abnormalities *In a study, mice lived longer without their pituitary gland *Puberty: menopause (big hormonal shift) -Decline in immune function= "immune clock" *In cancers that occur with age

Biological theory of Aging

"Normal Aging" vs Signs of potential disease No single theory of aging explains it all -Chance: the result of external events -Fate: the result of an internal necessity Can we prevent modify or reverse aging? -Multifactor contributing factors: * Genes * Environment * Behaviors

Obesity Trend Among U.S Adults 1990, 2000, and 2010

*BMI>30, or about 30 lbs. overweight for 5'4" person) *obesity only getting worse

Racial differences in documentation of advance directives (ad) after enrollment in the housecall programs

*Significant culture differences. Non-white used AD at a lower rate. *Eliminate culture differences by making more aware of the information out there.

The maximum human life span is approximately _______ years. The body defends itself from free radicals by producing substances called antitoxins T/F

-120 -F

People who need long term care

-2018-numbers are as high as ¼ -42% are age 65 and above -45.6 million people do not need another person's help with ADLs -8.8 million people who recieve LTC services in a home or community setting -3.5 million residents of a nursing home or other institution

Living Arrangements

-4.5% of 65+ live in a nursing home -1.1% of 65-74 -4.7% of 74-85 -15% of 85+

Aging and Senescence

-A process of gradual change, resulting in maturation through childhood, puberty, and young adulthood and then decline through middle and late age -The process by which the capacity for cell division, growth, and function is lost over time, ultimately leading to an incompatibility with life; i.e. the process of senescence terminates in death

Epidemiology of Aging

-Aging is not a disease, but it does increase susceptibility to disease -3/4 > 65 die from: heart disease, cancer, and stroke -Chronic conditions - persist for a long period, regardless of whether they cause death. Treatments but not cures. Don't necessarily get worse overtime but some can (progressive) *Examples:Arthritis, Osteoporosis, Parkinson's Disease, Cancer, Cardiovascular Disease, Dementia and Alzheimer's Disease, etc.

Aging

-Aging is not same as disease -Aging with vitality = balancing the damage with repair mechanisms - Aging is about the big picture - 3 "Major Agers": 1. short telomeres (tips and ends of chromosomes), prevent this from more exercise and less stress 2. Inefficient Mitochondria, eat more omega 3 fatty acids 3. No nitric oxide, deep breathing, using diaphragm. This will increase blood flow *Vegas nerve meditation: These studies show that meditation can increase energy, reduce stress, slow breathing, decrease anxiety, reduce pain, increase blood flow and provide a sense of peace to name a few. When the Vagus Nerve receives the signals from these meditation effects it sends a message to the brain that all is well, there is no danger and there is no need to be in fight or flight.. Extending your exhale * "Doing nothing does everything"

Some conditions more common in aging may foster creativity

-Alone -Inactivity -Reminscing -Gullibility -Discipline

Vision

-Begin mid-life (30-40) stabilize at 70-80 -Then further changes increase by 95% when you are 70 years or older. Like cataracts (The lens of the eye get cloudy and less curved) or other vision problems -To compensate: -Increase illumination -Reduce glare -Use large, clear visual images (increase font) -Increase contrast

Hearing

-Begin midlife, mild 60-70 -Reduced ability to hear low intensity and high frequency sounds -"That's the wrong way" vs "That's the long way" -To improve communication -Raising voice may not be enough -Lower you pitch and speak slowly -Rephrase your sentence -Avoid background noise -Face-to-Face (Facilitates lip reading)

How does religion help older adults cope in a variety of ways?

-By reducing the impact of stress in late-life illness -By providing a sense of order and meaning in life -By offering social networks tied to religious groups -By strengthening inner psychological resources, such as self-esteem

Use it or lose it

-Cognitive decline is less in those who engage more frequently in Cognitively stimulating activities (games and puzzles etc) -Cognitive traing programs can reverse cognitive impairment in many cases -What's good for the heart is good for the brain! -Results from a study among community dwelling senior *66% increased their cogitive functioning *40% increased their predeclined level and retained at least 7 years

Resulting in health problems

-Cognitive dysfunction -Depressed immune function -Anemia -Fatigue -Orthostatic hypotension -Increased risk of hip fracture -Decreased muscle strength -Pressure sores -Swelling of the feet and ankles -Depressed thyroid function -Increased risk of detrimental drug interactions

Mobility

-Combined functions of cardiovascular respiratory, and musculoskeletal systems -Common threats: arthritis, strokes, pulmonary disease -Interventions to cope with impairments: -Identify alternative or adaptive ways of accomplishing Activities of Daily Living (ADLs)

Does living in a LTC facility mean my sex life is over? no. What should caregivers consider? What if one or both residents were married?

-Consent ability/consent -Autonomy/residents rights -physical space -staff attitudes -safety risks, including stds -others -Their families disapproved? -Staff disaproved? -One or more residents? -Are significantly coginitively impaired? -this were a same sexed couple?

Obesity

-Covid-19 deaths were correlated with obesity. *vaccinations correlated with covid-19 -51+ obesity: 1 in 4 -"Younger Old" more likely to be obese *Obesity is greater because people who make it to old-old were living a healthier lifestyle while others who have dealt with obesity do not make to the old-old stage -Rates likely increasing -10% overweight as an older adult is protective. Why? *helps protects from fall and extra fuel storage -Men have higher obesity rates than females

Demographic trends

-Currently (2019) 16% or 54.1 mil Americans are 65+ -Projected to increase to 21.6% and 80.8 mil by 2040 -Starting in 2011, 10,000 people turn 65 everyday through 2030 -only 5,664 65+ die each day -In 2019 100,322 > 100 years (0.2% of seniors)

Social security and the budget

-Defense: 15% -Social security:24% -Medicare: 14% -Medicaid: 10% -Interest:10% -All other activities: 30% *SS is the larget single item in the budget.

Signs of caregiver stress

-Denial -Anger -Social Withdrawal -Anxiety -Depression -Exhaustion -Sleeplessness -Irritability -Lack of Concentration -Health Problems

Economics of Health Care

-Didn't know people would live this long! *Government Programs *Medicare-largest HC insurance for 65+ (old people) 65% *Medicaid-like financial aid, for poor people (adults/children) *Family Care (duable eligilbility for Medicare and Medicaid) -Health care is Reimbursement driven (The way we pay for HC is policey driven)

Assessment of Customer Care Needs

-Differ by setting and payor-type -Home Care - OASIS -Assisted Living - Up to provider, if receiving Medicaid funds, State may dictate -Skilled Nursing Facilities - MDS -MDs: minimum data set on every person who is recieving care using systematic data

Research on age and cognitive function has found that the personality changes through adulthood, particularly in response to health problems, economic hardships, and bereavement. Wisdom is most like crystallized intelligence and not fluid intelligence. The Seattle Longitudinal Study and other research on cognitive function found that the largest average declines in intelligence come after age 60, but that intellectual decline in later life may be reversed.

-False -True -True

Motor and sensory changes

-Impairments tend to increase with age

What health conditions affect sex?

-Medications: that affect libido, erectile dysfunction -Surgeries: can impact desire and self image -Traumas -Illnesses *cancers *vascular system *neurological sys -Chronic pain -Incontinence -Others

What is MDS?

-Minimum Data Set -Core set of clinical and functional status items -Standardizes communication -Purpose/useful for: *Care Planning-CAAs *Reimbursement-RUGs *Quality -Quality Indicators *Research/Quality Terms/Acronyms: RAI-Resident Assessment Instrument -MDS-Minimum Data Set *CAA-Care Assessment Area *RUG-Resource Utilization Group

life expectancy

-Overall life expectancy today is 77, was 78.9 in 2019; lost 2 whole years due to covid -Those reaching 65 today (2017) have average life expectancy of additional 19.4 years -If you make it to 75 years, you have an additional 12.3 years -There has been increase in diversity and education and divorce in the population of seniors

Remediation of Cognitive Impairment

-Pychoeducational include info to modify people's expectancies and beliefs about how the mind works + specific strageties +explanations about why they work -Arousal/Mental fatigue *build in rest breaks, increase nightime sleep *stimulants *Aerobic Re-Conditionig

Acurary is critical

-Regulatory Requirements like assessments *MC/MA Certified *OBRA 1987 (Omnibus Budget Reconciliation Act): improved the quality of care in nursing homes -Appropriate care -Adequate reimbursement -Public data on Quality -Documentation! -Strong training of all staff is critical! -It's common for people to underdocument

Home and Community Based Services (2007-2008) Biggest Umbrella

-Rehabilitation/Skilled Care -Home health=more people will want to do this in the future -Homemaking, personal care, & attendant services -Emergency systems -Home delivered meals=meals on wheels -Home modification -Transportation -Day Programs -Respite care=caring for their loved one at home but with you during the day at a care facility and takes them back home at night -Independent Senior Housing -Case management=someone who can coordinates appointments -Family support services -Equipment -Hospice Skilled Nursing Facilities/Nursing Homes Residential Care/Assisted Living Home & Community Based Services

How does our sexuality change as we age?

-Relationships aspects of sexuality become more important -A second "peak" once "empty nest" *empty nest: -an extended post parental period of life that occurs after children have grown up and left home -Women: *menopause: Libido decreases, hot flashes, sleep disturbances, mood changes, vaginal dryness, weight gain, -Men: *increased time to arousal, shorter duration *erects dysfunctional *ways to compensate *shifts more gradually vs females more constant

Am I too old to worry about safe sex?

-STDs are a real problem *older generation not as educated *females are not worried about getting prego so they don't care if its unsafe anymore *not worrying about STDs *menopause *Leisure activity *The provider not asking if they are still engaging in sexual activity *Access/mobility to drive *immune sys decreases *multiple partners -50+ has the fastest growing HIV rate -gender ratios: more females than males -dating later in life -cohort differences

Downsides of Pay-as-you-go

-Sensitive to the ratio of workers to retirees. Cont to get worse -Demography is turning these ratios against Social Security •People are having smaller families→fewer new workers paying in •Seniors are living longer, and collecting for more years •And the Baby Boom generation has started retiring...

Analyzing the Effects of Percieved Quality of Life on Nursing Homes Ratings

-Shows no one is exactly on the same page.

Tabacco

-Single most preventable cause of death: obesity, close contender if not surpassed -Decreases your lifespan -Affects your health and those around you -Responsible for 1 in 3 cancer deaths, and 83% of lung cancers.

The Challenge of Longevity

-There are many questions about modern societies' values towards old age *Are the old less valued than the young? *Where will we find the resources to take care of the frail elderly? *Could medical breakthroughs have unforeseen consequences for society, either for good or ill? -There are also many challenges that people face as they grow older, including: 1.Coping with an aging body 2.Maintaining a value place in society while aging 3.Individuals grow older in the wider context of an entire society that is undergoing a transition to population aging

In Summary

-There are normal cognitive declines associated with aging, but don't have to interfere with functioning lSome crystallized intelligence, creativity, and wisdom continue to develop with age -We can take control by: *Changing our own perceptions/attitudes to facilitate better adaptation-find new roles *Engage in cognitively stimulating activities *Find ways to draw on strengths and compensate/cognitive training

Nursing homes

-Touchstone for LTC *Misnomer because it's not long term care but a touchstone -Dual constituencies *PAC *LTC -Average age = 79 -Acuity levels are higher than ever before. Primarily because people have other choices. Most expensive care MN: 416 NH with 40,999 beds WI: 411 NH with 44,319 beds

Basic Stimulation Impairments

-Vision -Hearing -Mobility

Method of Loci sample items

-You can write a 10 item list forward/backward by memorizing a base -The method of loci is a strategy for memory enhancement, which uses visualizations of familiar spatial environments in order to enhance the recall of information. The method of loci is also known as the memory journey, memory palace, or mind palace technique

Empty nest syndrome

-an extended post parental period of life that occurs after children have grown up and left home -In the 1930s 90% of women's years after marriage were spent raising independent children. By the 1950s that proportion had dropped by 40%. This gave a rise to Empty nest syndrome

Conscious aging Habituation

-an idea based on an assumption that late life can be a period for positive spiritual growth. A central practice of this is meditation -the essence of aging is a process of becoming gradually deadened or more mechanical in our response to life because of the power of habits

Social clock

-concerning the appropriate age for certain life events -Life events vary based on ethnicity, wealth, occupation etc -Today, a person will spend on average, at least ¼ or even ⅓ of adulthood in retirement -Young-old- 65-74 -Old-old- 75-84 -Oldest-oldest- 85 and over

What accounts for the shift in population?

-decreased birth rates -increased life expectancy -graying of the baby boomer

Life review Reminiscence

-defines a natural even universal process stimulated by awareness of approaching death -about the good old days= suffer less depression reflecting on past

"Tonight's the night"

-documentary from Canada with different types of couples and their sexual activeness -First couple active -Second couple living across the hall but together and intimate -Third couple living apart but see each other, more hold hands/kiss *Overall point of video: perspective on the importance of society accepting sexuality in seniors.

Locus of control

-in which they lose the ability to control such basic matters as bedtime and meal choices -When residents feel manipulated by forces beyond their personal control, they may become more withdrawn, fail to comply with medical treatment, and become fatalistic and depressed. -They may also experience "excess disability"- or more disability than necessary because the environment in which they live is either too challenging or not challenging enough in response to their needs and abilities. -Increase locus of control- allowing residents to choose their activities or giving them responsibilities for taking care of plants. This is shown to decline mortality rates.

Which of the following factors is responsible for rising health care costs? Daniel Callahan argues that people should live out their "natural" life spans of approximately 80 years, and then they should be allowed to die. "Managed care" refers to which of the following? Medical costs in the last year of life amount to about 30 percent of the entire Medicare budget. Healthcare expenditures for the older population have outpaced general economic growth in recent years.

-increasing longevity,increasing intensity of services, fraud, waste, and abuse -True -combining insurance with health care providers and facilities in a unified network to control costs -True -True

Fluid intelligence refers to Which part of the WAIS focuses on comprehension, arithmetic, and vocabulary?

-is intelligence applied to new tasks or the ability to come up with novel or creative solutions unforeseen problems -Verbal

Disengagement theory of aging

-looks at old age as a time when both the older person and society engage in mutual separation, as in case of retirement from work -The process of disengagement is understood to be a natural and normal tendency reflecting a basic biological rhythm of life. In other words, the process of disengagement is assumed to be functional, serving both society and that individual. -The status of older adults must decline as society becomes more modern and efficient, so it's natural for older adults to disengage. -Related to modernization theory

Continuity theory of aging

-makes a similar point, that as people grow older they are inclined to maintain as much as they can the same habits, personality, and style of life they developed in early years

Rites of Passage

-special events that mark the transition from one role to another such as a bar mitzvah, confirmation, grad ceremony, or a wedding etc. -Life transitions characteristically associated with ages such as 30,40, and 50.

Modernization theory of aging

-the status of older adults declines as societies become more modern. The status of old age was low in hunting and gathering societies, but rose dramatically in stable agricultural societies, where older people controlled the land -Modern societies have tended to devalue older people -The modernization theory suggests that the role and status of older adults are inversely related to technological progress.

Phenomenological approach

-to the interpretation of aging, foregrounding and appreciating individuals' lived experiences as legitimate sources of knowledge

Moral Economy

-we can speak about these life expectations. The moral economy embodies expectations of what is fair and right -Ex- stay in school and you'll get a good job.

Activity theory of aging

-which argues that the more active people are, the more likely they are to be satisfied with life. -Activity theory assumes that how we think of ourselves is based on the roles or activities in which we engage. Most will continue the roles and activities established earlier because they continue to have the same needs and values.

Longitudinal Research

-which follows an individual over a long periods of time, is a key to methodological design to reinforce the life course perspective because such an approach allows researchers to view developmental changes as they unfold over time within the same people -The meaning and experience of aging vary significantly by culture and are influenced by the powerful factors such as gender, socioeconomics status, and ethnicity.

Sleep

1 of 3 age 65+ complain of insomnia -Too little sleep leads to: * Poor work performance * Diminished mood * Reduced energy level * Impaired concentration * Decrease memory * Irritated mood * Strained relationships * Jeopardized safety Impacts on health: -Obesity, Chronic illnesses There's a difference between insomnia can't sleep/insomnia won't sleep -Keep tossing and turning and keep looking at the clock, increased anxiety because the clock keeps sticking and you haven't got sleep vs -Binging Netflix doing things that are keeping you awake

Why are there more heart attacks in November

1) First snowfall, shoveling 2) Hunting, dragging the deer out of the woods

How can SS be made solvent

1)Reduce Social Security benefits 2)Increase payroll tax on high earners (threshold and/or rate) 3)Raise the age of entitlement further 4)Increased 'means-testing' •Only available to low incomes •"Affluence test" -benefits eliminated above some threshold (for ex if you have below this income you qualify) 5)Privatization - 2 biggest possible problems: •Borrow money to finance privatization •Large national influence over the stock market

Trends in Public Policy and Aging

1)Social Security and Medicare have grown rapidly 2)Federal programs for older adults continue to enjoy broad political support 3)Programs for older adults have developed incrementally 4)Growth of benefit programs for the aged reflects growth in size of the aging population itself Until recently, the general shape of federal aging programs was unlikely to change dramatically

1. Which of the following is the most prevalent chronic disease of old age? 2 .______ is the chief, primary government program that pays for health care for elderly Americans. 3. In 1983, Congress responded to the high costs of hospital care under Medicare Part A by introducing ______. 4. Once someone is admitted to a nursing home, they are likely to remain there for the rest of their lives. 5. A multidimensional functional assessment is best described as involving which of the following?

1. Arthritis 2. Medicare 3. The prospective payment system 4. False 5.a full examination of physical, mental, and social conditions

The major public payer of care in nursing homes is ______. The vast majority of care for aged relatives is provided by women, typically wives, daughters, or daughters-in-law. Which of the following theories of aging is best applied to patterns of caregiving over the life span? In order to allow caregivers some time off, ______ may be provided, which constitutes temporary care of dependent elders. Public opinion poll data show that a majority of adults in the U.S. support increased taxes to help pay for a long-term care program. Filial responsibility is

1. Medicaid 2. True 3. Exchange Theory 4. Respite care 5. True 6. The responsibility for the care of older adults by their adult children