HST308 Final Exam Notecards

Rehabilitaton

any service or activity that addresses or prevents body impairments, activity limitations, and social participation restrictions experienced by an individual.

Federal Food, Drug, and Cosmetic Act

defines a drug as being an article "intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals" or an article "(other than food) intended to affect the structure or any function of the body of man or other animals."

Social Health in Canada

examine the relationship between frequent social participation & self-perceived health, loneliness and life dissatisfaction in a sample of 16,369 people aged 65 or older

Population aging is

unprecedented pervasive enduring has profound implications for all facets of human life

Social Engagement

one's degree of participation in a community or society • Social engagement is different from the concept of a social network, as social network focuses on a group, rather than the activity. (Prohaska et al. 2012) • Key elements of social engagement include activity (doing something), interaction (at least two people need to be involved in this activity), social exchange (the activity involves giving or receiving something from others), and lack of compulsion (there is no outside force forcing an individual to engage in the activity).

Facts about caregiving

over a quarter of caregivers provided care for age-related needs providing transportation is the most common caregiving task median weekly caregiving hours is the longest when caring for a spouse (and then child) SK has more canadians providing care Women spend more hours caregiving compared to men Women more likely to help with personal care, men with house maintenance The more hours of care they provide, the higher levels of stress and worse health caregivers report Caregiving duties caused more than half of caregivers to feel tired, worried, or anxious. Developmental disabilities or disorders require the most hours of care from family and friends

Do-Not-Resuscitate Orders

"A Do-Not-Resuscitate order, or DNR, is a medical order written by a physician. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating; A DNR order is created, or set up, before an emergency occurs. A DNR order allows you to choose whether or not you want CPR in an emergency. It is specific about CPR. It does not have instructions for other treatments, such as pain medicine, other medicines, or nutrition."

Marriage

***Compared with older people who live alone or in other living arrangements, older married people report higher life satisfaction, greater well-being, and greater happiness Married people tend to adjust better to aging than non-married people.A good marriage gives the couple intimacy, mutual support & high life satisfaction (Proulx et al. 2007) • Married partners monitor each other's health.

Frontotemporal Dementia

**□ Frontotemporal dementia is an umbrella term for a group of rare disorders that primarily affect the frontal and temporal lobes of the brain (FTD) **□ These are areas generally associated with personality and behaviour

C. Stephens & J. Noone (2014). Upstream and Downstream Correlates of Older People's Engagement in Social Networks: What are their effects on Health Over time? Int'l. J. Aging & Human Development, Vol. 78(2) 149-169.

***In this article we examine the relationships between social context, social network engagement, and social support on health across time as suggested by the model.*** A prospective survey of a New Zealand population sample aged 54-70 at baseline was used to assess the effects on mental and physical health across time. 1. There is strong support from decades of research for the effects of perceived social support and engagement with social networks on both physical and mental health 2. socioeconomic status, ethnicity, age, and gender contribute to social network type, which affects perceived social support and loneliness, and mental and physical health 3. Social networks are understood in the Berkman et al. (2000) model as the social structures that potentially provide support to individuals. - include a complex of structural characteristics such as size, composition, and distance, and relational characteristics such as frequency and intimacy of contact. D 4. Social engagement in networks (participating in social activities) is understood as a particularly promising focus for intervention and support of the wellbeing of older adults 5. The Berkman et al. (2000) model - suggests that the relationship B/W social engagement and health is mediated by social support which is described as the "downstream" effect of social network engagement 6. Perception of support is an important pathway factor, since not all social networks provide positive support; there are 6 categories - attachment (emotional closeness and security) - social integration (belonging to a group of people who share common interests and recreational activities) - reassurance of worth (acknowledgment of competence and skill) - reliable alliance (depending on others for assistance) - guidance (advice and information) - opportunity for nurturance (responsibility for the wellbeing of another). 7. The positive relationship between social engagement and physical and mental health will be mediated by perceived social support. - Within countries, social differences such as gender, age, religion, educational level, ethnicity, and socioeconomic status (SES) have been found to influence the personal networks of older people - The change in social status from worker to retiree is also associated with a change in social networks due to the loss of work-based relationships - predicted that differences in SES, age, retirement status, ethnicity, education level, and gender would affect network engagement in older people. 8. study provides the following insight: - the prediction that social network engagement has an effect on health through pathways such as social support - partial support that social context factors will have a direct effect on network engagement. While higher socioeconomic status, female gender, and Maori ethnicity predicted higher levels of engagement, age and retirement status showed no such effect. Social engagement was positively correlated with physical health and mental health network engagement had a significant indirect positive effect on mental and physical health via social support. & ethnicity had significant indirect effects on T2 mental and physical health via network engagement and social support Social engagement was predicted by gender, but not age or retirement status. Women, non-Maori, and those with better a better standard of living reported higher levels of network engagement socioeconomic inequalities and ethnicity which both directly affect social network engagement those with lower economic living standards report less social engagement and lower perceptions of social support 9. Indigenous people, in this study the Maori of Aotearoa/New Zealand, reported higher social engagement - Older Maori who are strongly connected in these ways can count on the wider whanau for assistance, including financial aid, transport, and support for disability and sickness - great deal of support given by kaumatua (older Maori) to whanau (wider family), this support includes cultural assistance, accommodation, support during illness, encouragement with education, and strong leadership in learning and speaking the Maori language 10. mediation analysis indicates that network engagement may indirectly influence health outcomes through the provision of social support, but the strength of these differs according to mode of health under study - For example, the confidence intervals for the indirect effects of social engagement on mental health were further from zero compared to the indirect effects on physical health - Moreover, there was almost no overlap in the confidence intervals for mental health and physical health, indicating that differences in the indirect effect are unlikely to be a chance event o This indicates that engagement has a stronger influence on mental rather than physical health, when considering the intervening effects of social support.

Income distribution

* Equal income distribution has proven to be one of the best predictors of better overall health in a society*

Social Capital

- using personal social networks to strengthen social support, social influence, social engagement, attachment (e.g., interpersonal bonding), and access to scarce resources Higher levels of social capital have been found to be associated with better mental well-being in older adults

5 categories of Secondary health conditions (SHC) **ON EXAM**

-physical toll -psychosocial toll -pain -functional impairments -chronic medical conditions

Illness beliefs

Beliefs about illness are closely tied to beliefs about medicines Example: -Movement away from vaccinations Europe -More than 53% of older patients with moderate to severe asthma believed that they did not have asthma when they did not experience any symptoms.

Activity theory of aging/dying

people want to stay active throughout their lives and substitute new roles and activities for ones that they lose as they age.

Biological Death

termination of all biological functions that sustain an organism."

Bereavement

the state of having recently experienced the death of a loved one

Drugs for symptom management

tylenol antihistamines (so many of these: going to keep taking them)

Plasticity

describes the brain's ability to change and adapt over time

Public Health Agency of Canada (2014). Seniors' Falls in Canada, Second Report. Ottawa.

Executive Summary • Fall: sudden and unintentional change in position resulting in an individuals landing at a lower level such as on an object, the floor, or the ground, with or without injury. o leading cause of injury related hospitalizations among Canadian seniors o affect the individual, their family, friends, care providers and the health care system o lead to negative mental health outcomes such as fear of falling, loss of autonomy and greater isolation, confusion, immobilization and depression o significant associated financial costs ~ 2 billion annually o majority resulted in broken or fractured bones • 20% of the cases lead to death • cause 95% of all hip fractures o induced physical limitations intensify the need for support and increases pressure on Canadian health care systems o number of deaths due to falls increased by 65% from 2003 to 2008 o 50% of falls that result in hospitalization occur in the home and the same percentage of seniors are discharged to a home setting The Scope of the Problem What seniors report about falls and related injuries • The Canadian Community Health Survey (CCHS) • self-reported fall-related injuries: o rates increased significantly from 2003-2009/2010 o rates were higher in older age groups (aged 85+) o majority resulted in broken or fractured bones • majority of injuries are to the shoulder and upper arm, knee or lower leg and then the ankle and foot. • highlights the importance of bone health o respondents were: • more likely to be female • Females are at a greater rate of osteoporosis. • Proportion of females in the population increases with age • more likely to be older (85+) • less likely to be married • likely tied to differences in age→ older individuals are more likely to be widowed • 46% with an injury due to the fall reported that they were walking when the injury occurred • 67% of respondents sought treatment at an emergency room → impact of falls on the health care system What hospitalization data tell us about seniors' falls • 2006/2007 through 2010/2011: 15% increase in the number of individuals who were hospitalized as a result of falls o increased due to increased numbers of older adults in the Canadian population o Fall related hospitalizations account for about 85% of injury hospitalizations for seniors • length of hospital stay related to a fall related injury increased with age o Average stay after a fall is 3 weeks→ 9 days longer than the among seniors admitted for any cause. o Disproportionate health care costs of fall-related injuries in comparison to other causes of hospitalization among seniors • over one third of fall related hospitalizations among seniors were associated with a hip fracture o Hip-fractures due to falls account for 95% of all hip fractures among seniors 65+ • 50% of falls occur at home, 17% in residential institutions What hospitalization data tell us about falls among seniors in residential care • those living in residential institutions tend to have more complex health challenges, such as advanced dementia, multiple chronic health conditions and limited mobility. o Puts this population at greater risk of falling and sustaining a fall-related injury. • Fall-related hospitalizations among seniors living in residential care o 2006 to 2010: 19% increase o average length of stay in the hospital remained relatively constant with age but longer than community dwelling seniors o associated with more hip fractures possibly due to the increased number of comorbidities • Fall-related hospitalizations among community-dwelling seniors o 2006 to 2010: 15% increase o average length of stay in the hospital increased with age • may reflect the delays in arranging community or other support services for home-based seniors after discharge What mortality data tell us about deaths dues to falls • mortality data from statistics Canada were analyzed for all direct deaths due to falls among those age 65+ for 2003-2008 o steady rise in both the number of deaths due to falls and the age standardized mortality rate o number of deaths due to falls was higher among females, the age- and sex- standardized mortality rates were significantly higher among males Risk Factors For Falls and Fall-Related Injuries Among Seniors Risk factors- Complex and interactive • most falls occur because of compounding factors which combine and make it difficult for the older person to maintain or regain balance • Risk factors: compounding factors which represent an interplay of biological, behavioural, environmental and socio-economic conditions. Varies for each individual Biological or intrinsic risk factors: factors pertaining to the human body and are related to the natural aging process as well as the effects of chronic or acute health conditions • Acute illness o symptoms such as weakness, pain, fever, nausea and dizziness can increase the risk of falling. o Effects of medications taken to treat the conditions or symptoms can also increase risk of falling • Balance and gait deficits o Result when there are changes to the normal functioning of the systems underlying postural control. • Chronic conditions and disabilities o Chronic conditions can result in physical limitations that affect one's mobility, gait and balance o Bowel or bladder incontinence and urgency • Leads to rushing to the bathroom o Osteoporosis • Characterized by low bone mass and the deterioration of bone tissue increasing the risk of fractures from a fall • Older women are at more risk than men • Cognitive impairment o Affect one's ability to anticipate and adapt to environmental stimuli to maintain or restore balance o Symptoms may be further intensified by side effects of medication taken o Normal age-related cognitive changes can also affect balance • Low Vision o Decreases visual field sensitivity, acuity, contrast sensitivity and stereopsis o Indirectly linked to decreased physical activity as it impedes one's ability to walk safely because one cannot detect hazards in the environment o Can also affect the ability to maintain balance • Muscle weakness and reduced physical fitness o Leaves one unable to prevent a slip, trip or stumble from becoming a fall o Most important risk factor as it increases the risk of fall by 4 to 5 times o Weakness in the lower extremities was found to be a risk factor for fall-related hip fractures Behavioural risk factors: include actions, emotions or choices of the individual • Assistive devices o If properly used and maintained they can promote independence and prevent falls o Lack of maintenance, malfunction, inappropriate fit or overreliance on the device can turn an assistive device into a fall hazard • Excessive alcohol • Fear of falling o May lead to decrease in physical activity leading to muscle weakness and poor balance o May be reduced through home-based exercise and multifactorial fall prevention programs as well as through community-based tai chi offered in a group format • Footwear and clothing • History of previous falls o One of the strongest predictors of future falls o Considered a behavioural risk when one chooses not to seek information on ways to reduce risk or chooses not to take action to reduce the risk even when safeguards proven to be effective are known • Inadequate diet o Lead to physical weakness, fatigue and frailty • Medications o Psychotropic (alter mood), sedative (induce calm) and hypnotic (induce sleep) medications o Medications causing drowsiness, dizziness, hypotension, parkinsonian effects, gait disturbance or visual disturbances increase an older person's risk of falling. o Any drug that decreases bone density or increases the risk of bleeding can increase the risk and severity of injury from a fall • Risk-taking behaviours o A behavior is considered risk-taking when a discrepancy exists between the risk associated with the activity and the abilities of the individual engaging in that activity • Vitamin D o Linked to bone and muscle strength o Vitamin D supplements combined with calcium may reduce the risk of falls Social and economic risk factors • Social networks o Linked to feelings of isolation o Being married, living in current residence for 5+ years, using proactive coping strategies in response to stress, having a higher level of life satisfaction, and engagement in social activities in older age all have protective effect on preventing hip fractures due to falls • Socio-economic status o Association of low-economic status with poor environment, poor diet and barriers in accessing health care services o Low education and low health literacy prevent individuals from benefitting from resources on strategies for preventing falls Environmental Risk Factors: factors associated with the physical environment • Risk of falls result from an interaction between an older person's mobility, physical abilities or risk-taking behaviour and their exposure to physical environmental hazards • Work together to create risk conditions that increase the likelihood of falls among seniors • Factors in the community o Related to design standards and building codes • ex. poor stair design, inadequate lighting, etc. • Factors in the living environment o Environmental hazards in the home are the most common • Ex. throw rugs, electric cords in walkways, raised door sills, etc. o Moving to a new environment may also pose a risk because of unfamiliarity of a new environment • Weather and climate Best Practices for the Prevention of Falls Initial risk assessment • Recommended that primary health care providers ask all older adults at least once a year about falls, the frequency of falling and any difficulties in gait and balance • Components of a comprehensive clinical assessment o can determine the risk of falls, identify the risk factors and assist in identifying the most appropriate tailored interventions o involves history of falls, use of multiple medications, problems with gait, balance and mobility, impaired vision, other neurological impairments, reduced muscle strength problems with heat rate and rhythm, postural hypotension, foot problems and incorrect footwear, environmental hazards Multifactorial interventions: focused interventions targeting multiple risk factors identified during a comprehensive risk assessment • Assistive devices and other protective equipment o Clinical expertise sought for the appropriate assessment of equipment needs o Devices which prevent injury not the fall • Clinical disease management, including chronic and acute illness o Appropriate treatment of medical conditions reduces falls • Education o Important for the implementation and sustained use of fall prevention strategies o Education of long term care staff has mixed results, it can help and prevent falls but it can also not have significant impact o Canadian Falls Prevention Curriculum for health care professionals and community leaders has been shown to have a positive impact on practice and to enhance implementation of evidence based fall prevention • Environmental modification o Occupational therapists may play a role here o Environmental assessment for required modifications • Exercise programs o Target balance, gait and strength training o Can reduce the impact of muscle loss associated with the natural aging process and increase mobility, physical function, bone density and balance o Ex. Tai Chi o In residential care setting these should be carefully constructed based on individual abilities • Medication review and modifications o Targeting inappropriate drug use may be effective in reducing falls. • Nutrition and supplements o Sufficient protein to maintain muscle strength and adequate hydration o Vitamin D combined with calcium • Vision referral and correction • Other interventions o Residential care setting: • Safer transferring techniques • Creating multidisciplinary teams and promoting commitment among staff to fall prevention Stepping Up Fall Prevention in Canada Managing the risk factors • Age friendly communities (AFC) o Healthy and supportive environments for older Canadians which have a strong influence on personal mobility and safety from injury

Clinician and patient differ on these things which might influence prescription

Personal Values Medication Experience Relationships SES Acute vs chronic illness Religion Health literacy Education

Caregivers need a break

Take care of yourself first Everything will not be perfect Making a choice is better than staying still. Ask for help Explore options

Homelessness

Two types - early vs. late life homelessness. • Compared to women, older men became homeless earlier in life & so spend more years living in the street. (McDonald et al., 2007) • Recent recession & loss of jobs forced some older adults into homelessness; People near the poverty line & on a fixed income may also fall into homelessness if rent increases. • Group lacks street smarts of long-term homeless people & exposes them to greater danger from other shelter residents & on the streets. McDonald et al. (2007) examined homelessness in older adults. • Eviction, loss of income due to retirement, and widowhood were found to be the main causes of recent homelessness in older adults. • 55% of the recent older homeless population was born outside of Canada. They were more likely to be widowed or divorced than long term older homeless people who tended to remain single throughout their lives. • Recent older homeless people struggled with a lack of information about the homeless service system.

Income maintenance

CPP and QPP

Why are older adults using more medications? (ON THE EXAM)

Combination of prescribing and demand? -Availability of new medications? -New diseases/ illnesses? Marketing?

The Initiation of Help-Seeking for Medication

Stages: -Loss of Control -Information seeking -Uncertainty -Problem recognition -diagnoses

Older people vs younger people for depression

More occurrences of depression without sadness (more anhedonia) More unexplained somatic complaints Longer hospitalization Excessive use of health care services

Polypharmacy

"the use of multiple medications, typically five or more" -Multiple medications: not necessarily the appropriate medications, more medications than clinically indicated -Prevalence of inappropriate medication use:***** 11.5%- 62.5% (KNOW THIS NUMBER) -27% of seniors: iatrogenic effects--> illness resulting from treatment -Dangers of multiple medications ("polypharmacy") •Adverse effects •Drug-drug interactions •Duplication of drug therapy

WHO Definition of Palliative Care

"Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." IMPROVE THE QUALITY OF LIFE

Total costs of palliative care/hospitalizatons

$1,625,658.07. Most money spent on community care, and then hospitalizations (31 percent)

Non-compliance

"a person's informed decision not to adhere to a therapeutic regimen" and "the failure of a patient to follow precisely the recommendations of the physician or other health care professional" (Morris, 1992)

-Drug Therapy Self-Management **ON EXAM

"conducting one's own drug therapy, through the activities of planning, organizing, coordinating, directing and controlling, with responsibility for therapeutic outcomes" (Carter et al., 2003) Drug therapy self-management sometimes involves taking no medications at all

Concordance

"prescribing appropriate therapy with and not for the individual"; a mutual, shared decision-making process

Medicine

"something that treats or prevents or alleviates the symptoms of disease and/ or illness" Subjective highlights the difficulty in translating clinical meanings and purpose of medications to the lived world of older patients For example, dandelion tea could be medicine to someone.

Discussion Point: In general, should we be worried about the fact that older adults are using more medications now than 20 years ago?

"studies have failed to support that the use of newer drugs has led to fewer hospitalizations, lower health care costs, better quality of life, work productivity and reduced mortality"

Adherence

"the patient's use of the right drug in the correct dose at the right interval"

Other Alternative Therapies for Dementia

Art therapy Music therapy Snoezelan Light therapy Montessori Philosophy

Injury and Older Adults ** ON EXAM

Chronic illnesses put seniors at risk for falls Injury: serious public health issue--> older adults have a slower recovery from falls, broken bones--> limits ability to age in place Can exacerbate existing issues, including chronic illness, disability and lead to death Intervention: surgery, hospitalization, institutionalization Many types of injury: suicide classified as such

What makes a chronic illness different from a terminal illness or acute illness?

Chronic: lasting 3 months or longer Terminal illness: end of life Acute illness: more short term

Canada's pension policies

Income security (OAS: old age security) Guaranteed Income Supplement (GIS) Income maintenance systems (CPP/QPP) Up to 6 percent of income is going towards CPP (you can redeem for disability or for old age). You can take CPP at the age of 60. A lot of older adults take it early because you start to get money before you really need it. You get a penalty for taking it early. If you take it at 60, you get less, but you get it earlier. If you take it later, you can get a huge bonus to take it later (like at 75). It's a strategic decision based on financial situation. QPP: 11 Percent

Nutrition and Aging: Physiological

Increased body fat, decreased muscle mass • Low fat diet for those with a chronic illness - Unable to hold a spoon-> Parkinsons • digestion/ absorption--> declining • Proteins-> enzymes, hormones • Sensory changes->taste, thirst, hearing vision • Changes in dentition-> salivation, chewing • Polypharmacy->vitamins, minerals + meds - Unable to consume certain foods due to medications 16

Mortality by Major Cause

Injury As you get older, circulatory disease and cancer

Litzelman, K. et al., (2014). Association Between Informal Caregiving and Cellular Aging in the Survey of the Health of Wisconsin: The Role of Caregiving Characteristics, Stress, and Strain. American Journal of Epidemiology, 179(11):1340-1352.

Informal caregiving: unpaid care to a family member/friend with an illness or disability o Crucial for the care of the aging and disabled in the United States - Caregivers themselves are at increased health risks - Telomere length: DNA protein complexes found at the ends of chromosomes protecting them from degradation during cell division o A biological marker of cellular aging o We can potentially use this to gain an understanding of the pathophysiological consequences of caregiving o Typically shorten then age—short telomere length has been linked with many health conditions and earlier mortality o Short telomere length potentially suggestive of poor biological state or higher disease risk - Stress theory and recent research suggests that the environment plays an important role in explaining why some caregivers but not all experience elevated stress and/or negative health outcomes - This is the first study to investigate the association among caregiver characteristics, caregiver strain and telomere length o Clarifying these relationships will improve our understanding of the physiological effects of caregiving and assist in identifying caregivers at risk - Purpose of the study is to determine whether and to what extent o Caregivers had shorter telomeres than on caregivers o Global perceived stress in the past year was associated with telomere length o Caregiving characteristics and caregiver strain were associated with telomere length - Methods: o Data source: participants selected from a random sample of Wisconsin households; participants complete face-to-face interviews, self-administered questionnaires, and a physical examination with blood or saliva samples o Independent variables: Identification of caregivers—did you provide care or assistance to a family member or friend within the last 12 months? Global stress: Global Perceived Stress Scale from Jackson Heart Study Caregiving characteristics: duration of caregiving o Dependent variable: telomere length o Covariates: Sociodemographic characteristics: race, age, sex, education, etc Lifestyle factors: smoking patterns, alcohol consumption, diet, etc Health factors: health conditions - Results (adjusted): o Shorter telomeres found in the following groups: Those providing more hours of care per week Caring for individuals 25 years of age and younger With greater caregiver strain o BUT, overall interaction between global perceived stress, caregiver strain and telomere length did not reach statistical significance (P = 0.13) - Discussion: o Subgroups of caregivers who have shorter telomeres (i.e. those providing more hours of care, caring for a child or young adult, or reporting greater strain) may be at high risk of poor health outcomes o Association between cellular aging and stress and caregiver strain requires further examination o Interesting relationship between degree of stress and telomere length Individuals experiencing moderate-to-high levels of stress = longer telomeres Low levels of stress = shorter telomeres • Small amounts of stress might improve fitness = ? - Implications of this study: o Telomere length difference were in accordance with the magnitude seen in relation to chronic disease burden and myocardial infarction proving clinical significance o Assessing and monitoring hours per week of caregiving, age of care recipient, and level of caregiver strain helps clinicians identify high risk caregivers o Interventions that reduce psychological distress shown to increase telomere length; same might be said for self-care behaviors (i.e. exercise) o There is a need for more research to better understand the role of caregiving and stress in telomere dynamics - Limitations: o Telomere length as a biomarker = controversial Does not meet all the criteria for a biomarker of aging

Self-Ageism

Negative attitude: "I'm too old for this" or "it's too late for me now" -Age-grading oneself Self-fulfilling prophecy Ageist attitudes are often reflected back at oneself at a certain age Social clock: rites of passage Self-ageism: a factor in the underreporting of abuse

Decisions to Institutionalize

Three conditions influenced family members' decisionsto institutionalize an olderadult: 1) the amount of care needed older relative 2) the caregiver's ability to provide that amount of care 3) the formal supports available Usually a difficult decision to institutionalize someone

Preventative Drugs

Vitamin C Flu Vaccine

Chronic Health condition and gender

WOMEN GET SICKER, MEN DIE QUICKER

Medication Cascade

You take advil that gives you high blood pressure which causes you to take ..... Cascade Numbers are explained things like this.

Grief

a sense of profound loss and the experience of deep sorrow

Functional specificity of relationships model:

about your relationships impt.

Family members as caregivers

change work schedule take time off work leaves of absence lost income and benefits home modifcations medications out of pocket care expenses change social schedule

Disenfranchised Grief

grief defined by society as illegitimate and therefore unacknowledged because society defines the relationship between the grieving person and the deceased as insignificant.

Anticipatory grief

grief experienced prior to and in anticipation of the death of a loved one

Sensory memory

information perceived through the senses and stored as memory

Ageism

more broadly defined as any prejudice or discrimination against or in favor of an age group

Cost drivers

population aging and chronic illness

Clinical death

stoppage of heart beat, pulse and breathing."

Disease

very objective. Some pathological marker in your body that's changed

David Armstrong (2014) Chronic illness: a revisionist account January, Sociology of Health & Illness, Vol. 36 No. 1,pp. 15-27

• Omran 1971 - Epidemiological Transition • Relying on the epidemiological transition to explain the emergence of chronic illness is based on its fundamental assumption: "that the diagnostic labels of any period reflect an underlying biological reality and that data in the historical record result from a medical perception largely uncontaminated by contemporary world-views or theoretical frameworks." → Exploration of whether chronic illness has increased so dramatically at the end of the 20th and beginning of the 21st century, or if diagnostic criteria, medical practice and societal norms can partly account for this change. • Historically, the duration of a disease was the only differentiating factor between chronic and acute disease. The new meaning of chronic disease came about in the 20th c • Then the result of the symptom, i.e. if it were disabling, began to be analyzed • Illness summarized patient-experienced symptoms, and Disease described the underlying pathology, however both were often used interchangeably • Disability as a factor chronic illness or disease became implicit Spatializing Illness across the population • Chronic disease/illnesses of the 20th c began to present by their disabling qualities, rather than their observable pathologies, making them more difficult to classify with existing medical technology → this led to the evolution of population-based approaches of public health and epidemiology to focus on these disabling diseases • Observation of these illnesses became epidemiological rather than clinical • More focus was placed on the patient's capacity to function → Chronic disease "may be defined as any deviation from health that affects a person's total life pattern in a significant way because of either duration or prolonged after-effects" (JAMA 1950: 466) • A condition could be called chronic illness to represent the ways in which collections of symptoms impacted patients' lives, or it could be called chronic disease to capture the pathological forms which had these effects. • "Health" was no longer classified the absence of pathological disease The Pathology of Ageing • Pathological processes that led to chronic disease degeneration and aging became blurred • Degenerative disease increased, but so did population's life expectancy → discussion about whether this increase was relative to the populations aging or absolute The Causes of Disease • Many diseases were thought to be degenerative and a natural and inevitable part of human aging. The fact that these appeared differently in different people however, and could be affected by lifestyle and other factors undermined this • Use of the term degenerative in JAMA declined by mid 20th c as understanding that many conditions deemed "degenerative" were preventable and treatable and therefore conflicted with their degenerative classification The age of chronic illness • Chronic disease decentered illness from the hospital, took a more population-based approach and understood that multiple external causes led to chronic disease, rather than one single internal pathology • Rise in popularity of surveying, primary and secondary prevention, screening, long term surveillance of illness, etc. • While previously separate explanatory frameworks, aging and pathology/disease were discussed as related to one another. Ageing was now viewed as risk factor for chronic disease • Shift to a more population-centered view of health • Main causes of death shifted from infectious in 1900 to chronic, non-communicable in 1951 • Some of the change in causes of death can be attributed to a change in labelling, rather than an actual change in the diseases present in the population • Natural ageing was medicalized

Plaques and Tangles in Alzheimer's Disease

□ Plaques and tangles tend to spread through the cortex in a predictable pattern as Alzheimer's disease progresses □ People with Alzheimer's live an average of eight years, but some people may survive up to 20 years □ The course of the disease depends in part on age at diagnosis and whether a person has other health conditions

The End of Caregiving

Few studies look at "quasi-death" (dementia), "quasi-widowhood", "social death", "ambiguous loss" You know this person is going to die so you start to live life without them Death at Home: thats not the reality, but 85% of people want to die at home. When someone dies at home, the meaning changes (it's the place where your loved one dies). Caregiving doesn't end when someone is institutionalized or passes away.

Theories of Aging/Dying

Activity theory Disengagement theory Ego development theory

Transportation types

Most common for seniors over 65: Driving a motor vehicle

Grey Divorce

older men more likely to be married, divorce is growing even with older adults

Delirium

A reversible condition Usually precipitated by - Physical illness - Drugs - Individuals with dementias are at higher risk

Behaviours Associated with Dementia

Agitation delusions Aggression Catastrophic thoughts Wandering combative Inappropriate sexual behaviour euphoria Sundowning elation Hallucinations Loss of motor control Restlessness Low mood Repetition Quick mood swings Screaming irritable Cursing crying

Issues with depression in older adults

Higher rates world wide for women and the unmarried Depression increases the risk of mortality from physical illness and suicide Contributes to cognitive decline Is an early manifestation of dementia

Hospitalizations related to mental health

In 2013-2014, seniors' top 3 mental health diagnoses were mood disorders, dementia/other cognitive disorders and schizophrenia/other psychotic disorders. In addition to mental health diagnoses, 27.8% of seniors had 3 or more medical diagnoses (compared with 6.9% of non-seniors). Also, on average, seniors stayed in inpatient mental health beds nearly twice as long as non-seniors (47.0 days versus 26.2 days).v

Chronic Illness and Mental Health

Many of the common chronic illnesses in later life have known correlations with mental illness. For example, major depression occurs in about 40% of patients who have experienced an acute stroke (Robinson & Spalletta, 2010). Co-morbidities make accurate diagnosis of mental illnesses much more challenging: untangling symptoms of physical illnesses from somatic presentations of mental illnesses. BUT Estimates suggest that, in any given year, about one in every five people living in Canada will experience diagnosable mental health problems or illnesses.

Mental Health Trends

Mental health is a continuum ranging from well-being to distress About 80 percent of people at any age report that they are happy, while 20 percent have some type of medical diagnosis indicating mental distress Mental well-being does not vary with age in survey research, with no difference between gender on life satisfaction Young, Non aboriginal have highest self rating of mental health

HIV-Associated Neurocognitive Disorder (HAND)

Usually mild Some people describe issues with: Concentration/attention Information processing speed Learning Recall memory Prospective memory (the ability to execute a future intention) Word-finding Executive functioning challenges (multi-tasking, etc.) May interfere with taking medication on time/regularly Similar symptoms can be caused by depression

Social death

"... refers to the perception or behavior of others that indicates that they perceive or treat a person as physically dead when in fact the physical body has not yet died."

Compliance

'the extent to which the patient's behavior coincides with the clinical prescription (medical or health advice) regardless of how the latter was generated' (Vermiere, 2001)

Dementia with Lewy Bodies

(Named after Frederick H. Lewy, M.D., the neurologist who discovered them while working in Dr. Alois Alzheimer's laboratory) Alpha-synuclein protein, the chief component of Lewy bodies, is found widely in the brain, but its normal function isn't yet known □ Changes in thinking and reasoning □ Confusion and alertness that varies significantly from one time of day to another or from one day to the next □ Parkinson's symptoms, such as a hunched posture, balance problems and rigid muscles □ Visual hallucinations □ Delusions □ Trouble interpreting visual information □ Acting out dreams, sometimes violently, a problem known as rapid eye movement (REM) sleep disorder □ Malfunctions of the "automatic" (autonomic) nervous system □ Memory loss that may be significant but less prominent than in Alzheimer's

Drugs on the Market

*Patented Medicines: patents cover new medicines, giving the manufacturer the exclusive right to make and sell the "invention" for a limited time (currently in Canada, patents cover 20 years); *patents may cover Rx and OTC drugs; most patented drugs require a prescription Some medicines (ie. Cold FX) have a patent over a propietary ingredient Evergreen or Me too drug- when the patent starts to run out, they add one ingredient and then they get to modify the patent and have the drug for another 20 years. National health products have started to be regulation. DIN: drug identification number on things like monster drinks. *in 2016, 47,290 drug products on Health Canada's list of drugs approved for human use. (22,000 in 2008) *about 16,130 were prescription drugs (excluding biologic drug products such as viral and bacterial vaccines, and controlled substances such as heroin) (5,200 in 2008) *there are an estimated 50,000 NHPs currently available in Canada (now regulated under the Natural Health Products Directorate of Health Canada), but only 5500 registered *Non-patented medicines: drugs not covered by patent protection or no longer under patent (i.e. Dichloroacetate DCA) *Generic Medicines: refer to products that are copies of drugs for which original patents have expired--> bioequivalent Can over-the-counter medications be returned to Rx status? Yes. Medications are returned to Rx status when: -new ADRs discovered -to protect the public (ie: drug-resistant bacteria) -Rx status may vary from country to country, and over time.

Fahim, M., McDonald, L., Smirle, C., Lau, K., Mirza, RM., and Hitzig, SL. (2016). Social Isolation and Loneliness in Chinese Older Adults: A Scoping Review for Age-Friendly Community Planning. Canadian Journal on Aging (Under Review, February 2016)

- A scoping review looking at the experiences of social isolation and loneliness in Chinese older adults in Western countries. Examines how the World Health Organizations Age Friendly Community initiative, which has been adopted in Canada, is experienced by this population who experience a higher level of barriers in aging than other populations might. - Because of the high level of risk factors that lead to social isolation and loneliness in seniors, the Age Friendly Initiative (AFI) has been integrated as a multi-sectoral policy in Canada. - Specifically in an urban setting, there are many barriers to social participation for Chinese older adults, such as integration tension, living alone, and lack of knowledge of official languages. - There is a poor self-perceived health, poor social integration apart from families, and a health care barrier with a lack of Chinese speaking medical professionals. - There is a lack of knowledge about available supports and community events, again related to the language barrier. - Overarching finding: older Chinese women are more likely to experience social isolation and loneliness in Western urban settings. - Implications of this research include: o Policies focused on long term sustainability of Chinese communities, such as outdoor spaces in Chinatown. o To continually include changing demographic in policy discussions. o To ensure front line health care professionals are screening for social isolation, also that they can speak Chinese dialects. - Social isolation is multidimensional and may be triggered by many factors that are not addressed in the AFI guidelines and policies. - Need to adopt multi-sectoral intervention, involve multiple stakeholders, and address both physical and social challenges that inhibit social participation and active aging.

Anxiety and older adults

- A significant proportion of seniors with anxiety disorders have been treated with benzodiazepines (tranquilizers) over long periods of time - As they age, are at increasing risk for cognitive and physical complications (such as memory loss, poor balance, accidents and falls) from these medications. - Mental health services often need to assist in the transition to less harmful treatment options for those who have severe and persistent anxiety disorders.

The Recovery Philosophy in Seniors' Mental Health

- A transformed mental health system will be guided by the philosophy of recovery. -The seniors' care community is uncomfortable with the terminology recovery philosophy. - The word recovery is often associated with 'cure'. -The philosophy of recovery and well-being focuses instead on the journey of health. - The symmetry between the recovery philosophy and personcentred philosophies, which are central to dementia care (Hill, Roberts, Wildgoose, & Hahn, 2010).

Medical Model of Disability *ON EXAM

- Disability results from an individual person's physical or mental limitation -Disability is biological, not social or geographical - Source of the problem is within the individual - Responses focus on the individual - Disabled person seen as a 'victim'

Deliriums- Diagnostic Criteria

- Disturbance of consciousness - Change in condition (memory deficit) or the development of a perceptual disturbance not accounted for by a dementia; - Disturbance develops over a short period of time; - Evidence of direct physiological medial condition

Making reference to at least 3 course readings or textbook chapters, please discuss the following: "to sustain and eventually improve canada's healthcare system we must shift spending towards models of care that will improve the health of canadians aged 15-64

-Education of healthy lifestyle -Subsidising caregivers: caregiver burnout puts people into long term care -Put money into transportation.

Molton et al. (2014). Modeling Secondary Health Conditions in Adults Aging with Physical Disability. Journal of Aging and Health. Vol. 26(3) 335-359.

- Primary disabilities feature functional limitations whereas secondary health conditions are those indirectly caused by the primary disability (an example would be chronic pain, fatigue, balance problems, immunosuppression, UTI, ect.) - The results proves the bio-psychosocial model of SHC with physical disability severity - Conceptual models of SHC hypothesized that primary disability is "bi-driectionally associated" therefore causing aging to have a direct developmental effect on SHC. - Increasing incidence of chronic health problems with older age associated with SHC - Five categories in which SHC can impact one through physical toll, psychosocial toll, pain, functional impairments, and chronic medical conditions (CMC). - Physical symptoms/presence of CMC as well as systemic health problems increased linearly with age for those with disabilities, referred to as the accelerated aging hypothesis - Psychosocial SHC presented no linear relation with age therefore psychosocial effects take place at any time in ones life, in particular around the middle of ones life - Psychosocial distress, and somatic symptoms take the biggest peak during ones mid-life rather than towards the end of life for those with disabilities as it is the "highest environmental demand colliding (i.e. taking care of children as well as aging parents at the same time) with emerging physical health problems." - Support is therefore needed in self-management to manage impact of SHC in the workplace to prevent involuntary retirement, which could cause added stressors impacting ones psychosocial health in turn. - By measuring and treating SHC, one can maximize independence which contributes to ones perceived sense of well-being.

Vahid Ravaghi, (2014). Comparing Inequalities in Oral and General Health: Findings of the Canadian Health Measures Survey. Canadian Journal of Public Health. Vol. 104, No. 7.

- The aim of this study was to measure and compare the magnitude of income-related inequalities for oral and general health outcomes in Canada. - The most socially and economically vulnerable people usually have the greatest level of oral problems but also the most difficulty accessing oral health care, in Canada the inequality in oral health care was the largest when compared to other parts of the health sector including physicians and hospital care - Authors examined two health outcomes, number of decayed and missing teeth and general health outcomes: Obesity and high blood pressure - used total annual household income as a measure of socioeconomic status - results: o higher socio-economic status has a lower prevalence of obesity high BP and lower mea numbers of decayed and missing teeth o the CI for all general health and oral outcomes were negative: means that there is a higher concentration of general health outcomes and oral health outcomes among the poor the CI shows it that the oral health outcomes are statistically significant from equality while the general health outcomes did not - magnitude of inequalities was greater for oral health outcomes compared to general health outcomes - oral health care is almost wholly privately financed with approx.. 60% of dental care through job-insurance and 35% from out of pocket - links strongly to the utilization of and access to dental care with ability to pay

Spouses as Caregivers

-60% of older caregivers: older women -40% of older caregivers: older men -Older men receive care from older women-->report spouse as confidante; cross "gender boundaries" -Older women receive care from children, spouses, friends. Women don't find male spouses to be their confident. They use their friends in time of stress. Women are more likely to share concerns and stresses with their friends and men do this with their spouses -more likely to share concerns and personal problems with friends -Older spouses suffer greater burden then do adult children; Spouses -->health problems themselves -Older spouses have fewer informal resources to draw on

Adverse Drug Events

-Adverse symptoms -Adverse clinical outcomes -Increased doctor visits or hospitalizations -Falls -Functional decline -Changes in cognition (delirium) -poor quality of life -Increased cost

Who is eligible for public drug programs in Canada

-All residents in manitoba -All residents in BC -SK: all residents with no other coverage -QB: All residents without access to a group drug plan or other public plan

Importance of Social Health

-Along the life course, and especially in later life, people need to adapt to changes - life transitions, formative events. • Examples of major life events: divorce/retirement/grandparenting/moving into a retirement home/widowhood/etc. • People who remain actively engaged in the society and those who maintain and develop significant connections with others around them, are known to adapt better to changes, which results in better health and well-being.

3 Types of Frontotemporal Dementia

-Behavioral variant frontotemporal dementia (bvFTD) -Primary progressive aphasia (PPA): affects language skills in early stages, but often also affects behavior as it advances. -FTD movement disorders affect certain involuntary, automatic muscle functions.

Health care costs and populations aging

-Canadians age 65 and older consumed an estimated 44% of provincial health care spending in 2011, about the same proportion they had been consuming yearly since 1998. -population aging adds up to 1% a year to provincial and territorial government health care spending between 2002 and 2026. -Taking inflation into account, the pure aging effect "can be expected to increase provincial and territorial governments' real per capita spending from $2,321 in 2002 to $2,940 by 2026

Determining between aging or medication use?

Guessing game Try to figure out why you're having an issue Long term care- when do doctors come?

Purpose of a Retirement Income System ** ON EXAM

-Functions of Retirement Income -The elimination or alleviation of poverty -Post-retirement income maintenance and security GOALS: To assure fair opportunities for canadians to provide for their retirement To enable canadians to avoid serious disruption in their standard of living upon retirement -Pensions tied to earnings To ensure a basic income for those without resources of their own

Nutrition and Aging: Implications

-High prevalence of malnutrition in hospital (35-50%) and institutional patients (5-85%) ...but also high rates of obesity in older men and women (almost 20 percent)

Future health care

-In absolute terms, the projected increase to healthcare and long-term care is not insignificant. - In dollar terms, 1.9% of GDP would equate to about $30.9 billion in 2010, or $905 per Canadian. - This amount would translate approximately to a 1.5% average annual increase in public health expenditure.

Caregiving and child living

-Intimacy at a distance: seniors prefer not to live with their children Majority of seniors: -At least one child living with -At least one child living within a 30 minute drive Decision to insitutionalize: done with reluctance -"only after all other avenues have been exhausted"

Informal vs Formal Support

-Life course capital and Social capital -the resources available to older adults -Social policies: promotion of a mix of formal and informal support -Turn to formal support after informal support -Formal care increases with age -Informal caregivers: 67% of care provision -Research often does not look at how informal and formal support connect -Support networks: greater subjective well-being

Risk Factors for Adverse Drug Events

-Managing ≥6 chronic diseases -Administering >12 doses/day -Using ≥9 medications -Low BMI -Age is 85 years+ -History of prior adverse drug event

What is the impact of chronic illness on an older adult? ** ON EXAM

-Mental health issues: "give up attitude" -Reckless behaviour: "life is short, let me eat what I want" -Withdrawal from social roles -Start to 'feel old': sickness associated with being old --> have to adjust to a new normal -People compare themselves to others: - "I'm not as sick as my friend, they have 3 diseases and take 15 medications"

Challenges of Prescribing in Geriatric Populations

-Multiple medical conditions -Multiple medications -Multiple prescribers -Different metabolisms and responses -Lack of evidence for use in elderly -Adherence and cost -Supplements, herbals, and over-the-counter drugs

The increase in chronic illness

-Now younger adults have increased in chronic illness -Aboriginal has high rate of chronic illness. JAILS have high rates of chronic illness, homeless population has high rates of chronic illness. • An aging population: older adults are at a higher risk to develop a chronic illness • Rates of chronic illness are increasing in younger adults-> growing older with chronic illnesses • Various populations have higher rates of chronic illness (i.e. aboriginal population)

What is the role of the older patient's 'medication experience'? ** KNOW FOR EXAM

-Older patient's medication experience is defined as the "sum of all the events a patient has in his/her lifetime that involve drug therapy" -Older patient's develop decision-making strategies reflective of their experiences and age -Try to balance their 'needs' and 'wants' with regard to medication use in relation to drug therapy self-management

Ontario Mental Health Act (1990)

-Ontario's Mental Health Act is a relatively brief document -It defines categories of psychiatric institution (Sections 1 and 2), -It covers the legal rights of patients and outlines who is to ensure these (Section 14), - It covers procedures for obtaining consent for treatment by patients deemed unable to consent for themselves (Section 15).

What does it mean to be a caregiver?

-Overwhelming physical demands -Emotional burden -Married older men's exclusive reliance on their wives -Financial support -Decision support -Sense of pride and accomplishment -Important partners for seniors and healthcare professionals -Transition into the role-->"one day I was the son/daughter to an older adult, the next day I was their caregiver"

Physiological Changes and Medications

-Physiologic changes due to aging -Physiologic changes due to disease states -Physiologic changes due to medication use -'Aging bodies' respond to and process medications differently than those of younger adults -Changes to heart, kidney, liver, central nervous system and excretory system play a role in drug delivery, absorption, excretion and effectiveness -Food drug interactions (You can't take lipitor and citrus. They didn't test for this in the trials but after many people come to the emergency room they attach this.) -oftentimes older adults don't take medications (If you don't like your medications, you may not take them. People make a calculation about needs and wants. If this starts to affect people's quality of life, they will probably not take the drug.)

Advance Care planning

-Power-of-Attorney -Substitute Decision Maker -Do-Not-Resuscitate Orders -End-of-Life Care Conversations

How do older patients respond to symptoms of illness, disease or poor health?

-Self-Managment -Seeking "Medical" Advice--> not necessarily from a healthcare professional --Or a combination

Stages of chronic illness

-Similar to the stages of grieving process Diagnosis Denial Anger Grief Acceptance NOT all adults go through these stages in this order!

Advice given to caregivers

-Take care of yourself first -Everything will not be perfect -Making a choice is better than staying still. -Ask for help -Explore options

Why do older adults take medications?

-To restore health -To assert and regain control over condition -Because it "makes sense" --> the use of medications fits into the context of therapeutic procedures -Doctor's recommendations (or others!) -From lecture on Chronic Illness--> the idea of decision support--> to 'get better' or 'not get worse'

How do older adults 'get medicines' or drugs?

-Various "gateways" See a allied health practitioner See general physician See a physician in the emergency department Refills for long-term medications by pharmacist See a nurse practitioner Emergency room visit/ Hospital Setting Long-term care How else? -From their friends and family

Caregiving as social support

-Various dimensions to support *Emotional *Feelings of esteem and belonging *Assistance with activities -Grandparents raising grandchildren- increased divorce Social support important in times of: Meeting needs on a daily basis Stressful events Crisis Retirement Widowhoodis social support necessarily a positive thing?

Social Model of Disability

-Views disability as a consequence of environmental, social and attitudinal barriers that prevent people with an impairment from maximum participation in society -Source of the problem is society -Responses focus on social change Ageism as a social barrier

What are the 3 health care system cost drivers discussed in class

-drugs, hospitals, doctors

Neurocognitive change

...but dementia and mental health issues are not a 'normal' part of aging ...dementia is now referred to as a "Major Neurocognitive Disorder"

Leisure and Health

1 in 5 seniors report pain and discomfort as reason for limiting participation in activities (women reporting at higher numbers than men)

CIHI (2013). National Health Expenditure Trends, 1975 to 2013. Canadian Institute for Health Information, Spending and Health Workforce

1) Health spending in Canada is projected to reach $211 billion this year, or $5, 988 per person. This represents 11.2 per cent of Canada's gross domestic product (GDP), a share that has fallen gradually in the past few years. 2) Rate of growth in health spending (2.6%) is less than inflation and population growth. After adjusting these factors, health spending decreases by an average 0.2% per year in the last three years. 3) 60% of total health spending is directed to hospitals, drugs, and physicians. Hospitals account for 30% of total health spending. Drugs represent 16.3% of total health spending. Physicians represent approximately 15% of all heath spending, up from 13% in the early 2000s. 4) The public share of total health spending has remained relatively stable at around 70% since the late 1990s. 65 per cent comes from provincial/territorial governments and 5% from federal/municipal governments and social security funds. 5) 30% of total health spending financed privately, 15% directly comes out of pocket, 12% through private health insurance, and 3 per cent from other private sources. Majority of private-sector funding is spent on drugs and dental care, while hospitals and physicians are financed primarily by the public sector. 6) According to the OECD (Organization for Economic Co-operation and Development countries, Canada is slightly below average in the share of health spending funded by the public sector. In the Netherlands, Norway, and Denmark of health expenditures are funded by the public sector. 7) The following map illustrates the variation in per person heath spending across the country and the percentage spent on health by government in each province and territory, relative to the size of its budget. The amount spent per person reflects the population of each province and territory and its health care needs, as well as how health services are organized, health personnel compensation and the sharing of costs between public and private sectors. Spending on health per person is higher in territories due to their small, dispersed population. 8) Average per person health spending in Canada is $5, 988 and takes 38% of the budget. 9) Canada's remains among the five countries with the highest proportion of GDP spending on health care and among the top quartile of 30 comparator countries in terms of health spending per person. 10) The annual repot National Health Expenditure Trends, 1975 to 2013 provides an overview of how much is spent on health care every year; what the money is used for; and where that money comes from.

M. Sinha (2013). Portrait of Caregivers 2012. Analytic Paper. Statistics Canada, Catalogue No. 89-652.

1) Nearly half (46%) of Canadians aged 15 and older, or 13 million Canadians, have provided care to a family member or friend with long-term health condition or aging needs. Over 8 million Canadians provide care to a chronically ill or disable friend or loved one in the 12 months preceding the survey. Providing care included, among other activities, driving someone to an appointment, preparing meals, helping with bathing and dressing, or administering medical treatments. 2) Caregivers providing end-of-life care were caring for their terminally ill parents (41%). 3) Age-related needs were identified as the single most common problem requiring help from caregivers (28%) This was followed by cancer (11%), cardio-vascular disease (9%), mental illness (7%) and Alzheimer's disease and dementia (6%). 4) Most often, parents were the recipients of caregiving activities. About half (48%) of caregivers reported caring for their own parents or parent in-law over the past year. Adult children were almost 4x more likely to report caring for a parent than parent-in-law, and 2.5x more likely to report caring for their own mother than father. Other recipients of care included friends or neighbours (16%), grandparents (13%), siblings and extended family members (10%), spouses (8%) and sons or daughters (5%) 5) Women represented the slight majority of caregivers at 54%. They were also more likely to spend more time per week on caregiving activities than did male caregivers. 6) Cancer was the leading reason behind spousal caregiving (17%), while problems with mental health, such as depression, bipolar disorder and schizophrenia, were the more reasons for a sick child (23%). 7) Caregivers perform a range of tasks in caring for their family member or freind, with providing transportation being the most commonly reported (73%). Other tasks included housework (51%), house maintenance and outdoor work (45%), scheduling and coordinating appointments (31%), managing finances (27%), helping with medical treatments (23%) and providing personal care (22%). 8) Based on stats, in 2012, 60% of caregivers were working at a paid job or business and 28% had children under the age of 18. And 73% of employed caregivers were satisfied with their current balance between work and home life. 1 in 10 saying they were dissatisfied. 9) Most caregivers spend under 10 hours a week on caregiving activities. 26% caregivers reported spending 1 hour or less per week caring for family member or friend. Another 32% reported spending an average of 2 to 4 hours per week and 16% spent 5 to 9 hours per week on caregiving activities. 10) 1 in 10 caregivers spend 30 or more of care a week providing some form of assistance to their ill family member or friend - most likely caring for an ill spouse (31%) or child (29%) 11) Caring for those with developmental disabilities takes most times.

C. Estabrooks et al. (2013). A Profile of Residents in Prairie Nursing Homes. Canadian Journal on Aging / La Revue canadienne du vieillissement 32 (3): 223 - 231

1. Domestic, national, and international reports describe indicators of suboptimal quality of nursing home care with less than clear evidence as to why such poor-quality conditions exist. o Quality of care differs between and within provinces 2. In response to this, the implementation of the resident Assessment Instrument which is designed to assess resident's needs, strengths, and potential risks to inform individualized care planning and monitoring. 3. Hirdes et al (2011) found that the majority of nursing home residents in these Canadian samples were females o Comprised of approx. ⅔ of the long-term care population o Residents averaged 85 years of age 4. Dementia common diagnosis o Affecting 40.9%-70.8% of nursing home residents 5. Translating research in elder care program (TREC) o Purpose is to identify modifiable characteristics of organizational context (ie. the work environment) in nursing homes that are associated with the use of best practices by care providers and the subsequent impact of organizational context and the use of best practices on resident and staff outcomes 6. The TREC study consisted of 30 urban prairie province facilities, stratified by size and randomly selected o Not explicitly designed to be representative of homes with different number of units, but to provide a sample representative of the prairie region 7. Average facility size among the 30 homes studied was 133 beds 8. The differences in facilities according to unit count were often minor with each of the groups counting both best and worst rates for the selected quality indicators. 9. Findings: The provincial differences suggest that each province has developed a residential care system distinctive of the needs and values of each 10. Limitation: analyses did not use TREC data to compare the intra-facility variation in quality care by these functional units.

Pamela L. Ramage-Morin et al. (2010). Health-promoting factors and good health among Canadians in mid- to late life. Statistics Canada, Catalogue no. 82-003-XPE, Health Reports, Vol. 21, no. 3, September

1. Health is defined by a composite measure that includes self-perceived general and mental health, functional abilities and independence in activities of daily living. 2. Eight modifiable factors were associated with good health: smoking status, body mass index, physical activity, diet, sleep, oral health, stress, and social participation 3. Degenerative diseases develop over a lifetime of behaviours, lifestyle factors and environmental influences, and so are more evident at older ages. 4. Results of the 2009 CCHS - Healthy Aging showed that seniors (65+) were more likely than people aged 45 to 64 to experience a number of specific chronic conditions. 5. People with dementia and stroke have a higher odds of living in long-term health care facilities. 6. Incontinence is a predictor of moving to a health care institution and has a severe impact on health-related quality of life. More than one in ten seniors in the household population reported urinary incontinence. 7. As people age, they are more likely to have multiple chronic conditions. 25% of seniors reported at least four chronic conditions, compared with 6% of 45-64 year olds. Creates a burden on family and peers if the conditions result in greater dependency, hospitalizations and further complications. The more chronic conditions one has, the less likely they were to have good health. 8. The prevalence of good health declines with age, but even up to age 85, at least half the population were in good health in 2009. 9. Among seniors, men were more likely than women to have good health. 10. Higher levels of education were positively associated with good health. 11. The prevalence of good health rose significantly in almost every age group from 2000/2001 to 2009. This was not evident in seniors 85+. 12. Percentage of individuals who were independent in activities of daily living (ADL/IADL) decreased slightly. This decrease was used to suggest why prevalence of good health was not evident in seniors 85+ over the nine-year period. 13. Factors within individuals' control can prevent the development of chronic conditions or limit their severity. 14. People who refrained from smoking walked frequently and were not obese were more likely to be in good health than were those who did not have these characteristics. 15. A senior with positive tendencies on five or more factors was more likely to be in good health than was a 45-64 year old with positive tendencies on two or fewer factors. 16. Even in the presence of some chronic conditions, 76% of people aged 45 to 64 and 566% of seniors living in private households had good health, based on their perceptions of general and mental health, functional abilities, and independence in activities of daily living. 17. Canadians in mid- to late life were slightly more likely to be in good health in 2009 than they had been almost a decade earlier.

CIHI (2011). Seniors and the Health Care System: What Is the Impact of Multiple Chronic Conditions? Analysis in Brief.

1. Key findings a. Healthy seniors need less health care - these services are largely dependent on the # of chronic conditions one has; not age b. The more prescription medications a senior takes → greater risk of experiencing side effects that requires medical attention c. There are gaps in preventative and collaborative care for seniors Summary of Results 2. Prevalence and impact of chronic conditions a. Prevalence and comorbidity in Canada i. Chronic conditions account for 89% of deaths in Canada and increases with age 1. Comorbidity = multiple chronic conditions ii. Frequently reported chronic conditions = high blood pressure, arthritis, etc. These typically exist in various combinations iii. Seniors = 4x more likely to report having a chronic condition vs. adults b. Self-reported health status is poorer as comorbidity increases - indication of negating effects from chronic conditions i. % of seniors who reported they had "good" health ↓ as # of chronic conditions ↑ c. ↑ comorbidity = ↑ health care use: seniors with 3+ chronic conditions used more health care resources not just singular to physicians/nurses i. # of chronic conditions = determinant of health care use vs. age d. ↑ medication use closely related to ↑ comorbidity - seniors with one and two chronic conditions took at least three prescription medications i. Polypharmacy = taking five or more medications e. Economic impact of chronic conditions - substantial effect on health care costs and productivity i. Seniors account for 44% of publically funded health care, where 70% of health care costs provided by public sector 3. Self-management and collaborative care in the treatment of chronic conditions a. Seniors report confidence in self-management i. Chronic conditions = persistent, require treatment through a patient's lifetime, managing perspective vs. curative, success depends on patient ii. Barriers of self-management = comorbidity, lack of understanding of conditions iii. Greatest improvements of health outcomes = better patient education/support, planned/team-based care delivery, improved provider expertise, improved use of registry based information systems iv. Main finding: no difference between self-managing between seniors describing health status as good or poor b. Gaps in preventative care - using prevention to reduce economic/health burden of chronic conditions i. Main finding: lack of discussion RE: improvement of health/preventing illness between patients and physicians ii. Solution: regular engagement in preventative care from early in life c. Collaborative care gaps - patient-provider collaborative care where patients actively participate in treatment plans and decisions i. Includes setting goals for and preparing treatment, being aware of the various options available, patient education, and potential role of electronic systems 1. Research suggests that electronic systems can lead to improvements in patient care; strengthens collaboration among providers 4. Medication management among seniors with chronic conditions a. Medication use introduces risk of side effects and adverse reactions = # of medications consumed correlated with adverse drug reactions (ADRs) i. ADRs = result of dosage, toxicity ii. Polypharmacy → lack of compliance with medication regimens, drug-drug interaction problems, and ADRs b. Patient safety gaps in medication management - consider inappropriate prescribing i. Potential strategies 1. ↓ # of medications (if possible) = ↓ # of side effects 2. Undergoing medication reviews - drug pharmacokinetics can change with age

Advance care planning

1. What do I value most in terms of my mental and physical health? 2. What would make prolonging life unacceptable for me? 3. When I think about death, I worry about certain things happening: 4. If I were nearing death, what would I want to make the end more peaceful for me? 5. Do I have any spiritual or religious beliefs that would affect my care at the end of life? 6. Other wishes and thoughts:

10 Warning signs of AD (know these!!)

1. Memory loss that disrupts daily life 2. Challenges in planning or solving problems 3. Difficulty completing familiar tasks 4. Confusion with time or place 5. Trouble understanding visual images and spatial relationships 6. New problems with words in speaking or writing 7. Misplacing things and losing the ability to retrace steps 8. Decreased or poor judgement 9. Withdrawal from work or social activities 10. Changes in mood and personality.

M. Sinha & A. Bleakney (2014). Receiving Care at Home. Analytic Paper. Statistics Canada, Catalogue no. 89‑652‑X —No. 002.

1. Most care receivers are women (56 percent) which reflects their longer life expectancies and greater representation as seniors 2. Mental illness was the single most common health condition identified by older patients 3. Men and women report similar conditions as reasons for care. Notably, they were equally as likely to be receiving care for the two most common health conditions: mental illness and accident related.Women were more likely than men to be receiving care for aging needs and arthritis, both related to the greater share of women as seniors.Other gender differences in reasons for care may be explained by differences in risk of health conditions. For instance, fibromyalgia, a condition typically affecting women, was almost exclusively a reason for care among women while cardiovascular disease was more common among men 4. Most care receivers (82%) were satisfied with the balance of help from family, friends and professionals. Those who were dissatisfied generally wanted more professional help. 5. Nearly 9 in 10 Canadians receiving care at home relied on help from family and friends, with about half of these also getting help from professionals. A small minority of care receivers (12%) had only professional help. 6. Three quarters of care receivers indicated that they received emotional support from family and friends. Emotional support was significantly lower for those relying exclusively on professional help, with 54 % reporting no emotional support from family and friends. 7. While seniors were the most common group of care receivers, just under one third of care receivers (29) percent were under the age of 45 8. Receiving care at home was a reality for 2.2 million Canadians or 8% of the Canadian population aged 15 years and over. Senior care receivers represented the largest segment of care receivers. Unlike their younger counterparts who were most often coping with mental illness, senior care recipients often received help to deal with age related needs. 9. Most felt that they received the care or help they needed in the past 12 months and did not prefer other sources of care. 10. There was an emphasis on greater need for professional services for those who were dissatisfied with the balance of help from family, friends and professionals.

Williams, AM., Crooks, VA., (2010). Tracking the Evolution of Hospice Palliative Care in Canada: A Comparative Case Study Analysis of Seven Provinces. BMC Health Services Research. 10: 14, 2-15.

1. Purpose of this study: analyze the evolution of hospice palliative care (HPC) in 7 provinces so as to inform such planning and provision elsewhere 2. In order to undertake enhance HPC, it is essential to understand how HPC in Canada has evolved o Difficult task because HPC in Canada is considered to be a patchwork-quilt of services and programs that is provided inconsistently across both place and time 3. The trend towards growth in the aging population and the rise in chronic illness amplifies the demand for HPC services o Additionally, more Canadians are voicing that they would prefer to die in their homes which leads to a shift of end of life care from hospitals and acute care facilities to the community instead 4. Argues that there are structural inheritances in place that have both facilitated and slowed the advancement of HPC in Canada o Inheritance, service structures and planning, health system decisions 5. Inheritance: Canadians inherited a culture of health care delivery characterized as both highly curative and biomedical which focus on healing the bio-physical body rather than attending the psycho-social elements of the dying being o National and provincial policies and practices is an important founding inheritances for the development of HPC especially because they existed before HPc was formally introduced and have consequently shaped the development of this form of care 6. Service structures and planning: deficiencies in health service structures and planning have negatively impacted the delivery and overall advancement of Canadian HPC o Limited progress of developing hpc services to meet community needs underline the slow pace at which health service progresses 7. Health system decisions: various of intentional health systems design decisions (often at the provincial level) have affected the availability of HPC o Regonalization: in regionalized models of healthcare each decision making body is autonomous therefore HPC services and modes of delivery are not homogenous across regions even within the same province or territory • Lack of shared understanding of what constitutes HPC across regions leads to discrepancies in funding allocations and services delivered o Identification of core services: when health services are formally identified as "core services" there is more accountability involved with the allocation and spending of funding 8. Circumventions (ways to bypass or overcome pre-existing organizational structures ) (type of action undertaken to overcome the limits of inherited systems or structures o 3 forms: • interventions and initiatives to shift the system • Service innovations • New alternative structures o Research confirms that in order to overcome obstacles arising from inherited health systems and structures, circumventions are essential for the progression of HPC 9. Advocacy will continue to advance HPC across the country o May also shift the mentality away from a "curative mindset* to a 'caring mindset' where a person as a whole being is considered rather than just the bio physical body 10. HPC progression and activity at the provincial and regional levels demonstrates that while evolution has been slow it has been continuous in responding and adapting to the changing needs and expectations of Canadians o To progress, focus on entrenching some of the circumventions into inheritance in order to have them be sustainable in the long term

Tochukwu C. Iloabuchi (2014). Risk Factors for Early Hospital Readmission in Low-Income Elderly Adults. J Am Geriatr Soc 62:489-494.

1. This cohort study identified the risk factors for early hospital readmission in community-dwelling low-income older adults using secondary analysis of the data set from the Geriatric Resources for Assessment and Care for Elders (GRACE) randomized controlled trial for 24 months. 2. Of 457 index admissions in 328 participants, 19% were followed by an early readmission. Early readmission was defined as a repeat hospitalization occurring within 30 days of a prior hospital discharge. 3. Five significant risk factors for early readmission are as follows: living alone, poor or fair satisfaction with primary care physician (PCP), not having Medicaid coverage, receiving a new assistive device in the past 6 months, and staying in a nursing home in the past 6 months. 4. Three of the five were social rather than medical, which reveals the role of social factors in early hospital readmission in this population of low-income older adults. 5. Early readmission was more than 10 times as likely when three or more risk factors were present as with no risk factors, suggesting a cumulative effect of multiple risk factors. 6. Assistive devices usually issued because of decline in function may represent a cumulative effect of multiple comorbid medical conditions. 7. Association between satisfaction with one's physician and early readmission is not limited to an inpatient setting; rather, prompt primary care follow-up seems to be important in preventing hospital readmission. 8. Having Medicaid can be protective against early hospital readmission with better access to home and community-based long-term services. An intervention that facilitates Medicaid enrollment of eligible low-income elderly adults may help them in accessing long-term services and supports that may improve their health outcomes. 9. Because each of the five risk factors can be assessed easily at hospital admission, individuals at risk for early readmission can be targeted for interventions delivered during the hospital stay to prevent early readmissions. 10. Early identification of individuals at risk of readmission and implementation of targeted interventions can positively affect transitional care outcomes.

Pettigrew et al. (2014). Older people's perceived causes of and strategies for dealing with social isolation. Aging & Mental Health, Vol. 18, No. 7, 914-920

1. Twelve focus groups and 20 individual interviews were conducted with Australians aged 40 years and older. Data were collected in metropolitan and regional areas. The age threshold was based on the need to generate formative research to inform interventions to encourage people to engage in preventive behaviours prior to reaching older age when they become more susceptible to social isolation. 2. Lay theories, are the theories people use in their everyday lives. Lay theories about health, for example, are comprised of beliefs about symptoms, the diagnosis process, appropriate remedies, and the efficacy of treatment. 3. There are two primary components of social isolation - objective isolation (determined by the size of an individual's social network, also known as structural isolation) and subjective isolation (individuals' perceptions of the quality of their relationships with other people, also known as functional isolation or loneliness). 4. There is increasing recognition of the importance of preventing and treating social isolation because of its association with a range of adverse health conditions. These include mental health problems, such as depression and cognitive decline, and physical health problems, such as increased risk of falls, heavy drinking, poor nutrition, re-hospitalization/ institutionalization, and all-cause mortality. 5. The overall aim of the study was thus to identify potential interventions that could assist people avoid or ameliorate physical and mental health problems in later life. The specific objectives of the present study were to explicate lay theories relating to social isolation and to identify instances of positive deviance to inform future efforts to encourage older people to participate in protective behaviours. 6. The minimum age of 40 years allowed inclusion of the views of different mature cohorts in various stages of life. The life course perspective suggests that it is important to ensure people understand and are favourably predisposed to the behaviours that can optimize their quality of life in later years, prior to them reaching this stage of life. 7. Across the sample, being socially active was viewed as a form of mental stimulation that can be protective of decline in terms of both mood and cognitive functioning. References to a lack of interaction causing people to feel 'down' and 'lonely' were made frequently, along with the occasional mention of more serious conditions 8. Two primary lay theories were identified in the data; Importance of social interaction, developing relationships is harder later in life. 9. Strategies that were reported as being effective in increasing social interaction included the positive deviance of data recorded, three positive deviances identified in this study; Incremental advancement (positive interactions with others by making a conscious effort in their casual contacts), offering personal assistance (proactive inviters, reluctant invitees, starting with impersonal contacts), focusing on empathizing with others (prioritizing the needs of others was described as a means of simultaneously distracting people from their own concerns and facilitating social interaction) 10. The participants' view that the solution to social isolation is for people to actively establish and maintain relationships and to make the effort to join groups is consistent with the recommendations in the literature. This provides support for an intervention focus on ensuring that a broad range of group activities is readily available for seniors with varying backgrounds and interests. The instances of positive deviance reported by some of the participants provide insight into how increased social interaction may be encouraged through appropriate interventions.

Shaw et al., (2014). Socioeconomic inequalities in Health after 50: are health risk behaviours to blame. Soc Sci Med. 2014 Jan;101:52-60.

1. Using data from the Health and Retirement Study (N =19,245), this study examined the degree to which four behavioral risk factors: smoking, obesity, physical inactivity, and heavy drinking - are associated with socioeconomic position among adults aged 51 and older, and whether these behaviors mediate socioeconomic differences in mortality, and the onset of disability among those who were disability-free at baseline, over a 10-year period from 1998 to 2008. 2. Results indicate that the odds of both smoking and physical inactivity are higher among persons with lower wealth, with similar stratification in obesity, but primarily among women. 3. Significant socioeconomic inequalities in mortality and disability onset are apparent among older men and women; however, the role that health behaviors play in accounting for these inequalities differs by age and gender 4. Findings suggest that within the U.S. elderly population, behavioral risks such as smoking and physical inactivity contribute moderately to maintaining socioeconomic inequalities in health. 5. Promoting healthier lifestyles among the socioeconomically disadvantaged older adults should help to reduce later life health inequalities. 6. Analyses focusing on disability included only those respondents who had zero disabilities at baseline, and valid interviews in both 1998 and 2008. 7. Three sets of analyses were conducted, each stratified by gender and age. Age was stratified into two groups: baseline ages 51-65 to represent late middle-aged adults, and ages 66 and older to represent older adults 8. The primary aim of this study was to examine the role of health risk behaviors in accounting for these disparities in risk observed after age 50, and persisting beyond age 65 9. It is important to consider that the impact of health risk behaviors in accounting for socioeconomic inequalities in late life health varies across age and gender subgroups of the population. 10. Findings indicate that prevalence rates of key behavioral risks are relatively high among the most socioeconomically disadvantaged adults over age 50, and this stratification remains even after age 65

Dixonbarra, A., and Horner-Johnson, W. (2012). Disability Status as an Antecedent to Chronic Conditions: National Health Interview Survey, 2006- 2012. Centers for Disease Control and Prevention.

10 Main Points: 1. Disability and chronic conditions are strongly related, and this relationship may be in either causal direction (disability causing chronic conditions, or chronic conditions causing disability). 2. The causal direction of this relationship is significant to determine because deciding if disability is a result of or risk factor for chronic conditions affects the approach of health promotion and disease prevention efforts. 3. The purpose of the study is to use NHIS data to determine whether chronic conditions are more prevalent in people with lifelong disability, compared to healthy controls. 4. The NHIS is a cross-sectional survey that collects health and health service utilization information in the US. 5. In studying the chronic conditions from NHIS data, the authors chose coronary heart disease, cancer, diabetes, hypertension, and obesity, because the former 3 are among the most common, costly, and preventable health problems in the US, and hypertension and obesity are often comorbid and contribute to the onset of 1+ of the other conditions. 6. Lifelong disability was operationalized as self-identified limitation (physical, mental, intellectual and developmental, and/or sensory) with onset before age 6 affecting ADLs or IADLs. This did not include limitations due to drug and alcohol problems, surgical after-effects, and other factors. 7. Results showed that people with lifelong disabilities were at a significantly higher risk of developing all chronic conditions compared to people without limitations, with the strongest effect seen for coronary heart disease. 8. People with lifelong disabilities differ significantly from the comparison group on all sociodemographic variables and a greater proportion of people with disabilities report having each of the chronic condition. 9. Findings suggest that activity limitation is a potential risk factor for initially developing chronic conditions, suggesting that health promotion efforts should target the population with disabilities across the lifespan. 10. Limitations of the study include (1) excluding people who do not identify their disability status as a limiting factor in their lives, (2) a small sample size of people with lifelong disabilities, as is common in disability epidemiology, and (3) NHIS data does not include data on income and education, so it was not possible to investigate the relationship between chronic conditions in people with lifelong disability and socioeconomic status.

Dementia numbers in Canada

15 billion dollar economic burden in 2008, 153 billion dollar in 2038. Increase to 872 billion dollars over the next 30 years 1.5% of canadians in 2008 had dementia. 2.8% of canadians in 2038 with dementia

Profile of Medication Use for older adults

1997- 2016: Population of 65+ increased by 18% in Ontario claims to drug benefit programs increased by 235% Atlantic Provinces: population older Canadian National Population Health Survey: 53% of institutionalized seniors use 5+ medications 13% in community

Canadian seniors and chronic illnesses

2008 Canadian Survey of Experiences With Primary Health Care, three out of every four Canadian seniors (76%) reported having at least 1 of 11 chronic conditions Compare this with one in every two adults age 45 to 64 (48%) About one-quarter (24%) of seniors reported being diagnosed with three or more of these conditions (known as multi-morbidity). Chronic disease rates increasing (14%) annually Based on biology, based on lifestyle, chronic illness more prevalent in older adults

Disability in Canada

3.8 Million Canadians with Disabilities (most are older adults- 42.5 percent)

Older Siblings as caregivers

70%of older adults report being somewhat,very, or --extremely close to at least one sibling Sibling relationships -Longest lasting tie -Reactivated by declining health and shrinking social circles -80-85% of seniors (65+) have one living sibling -Siblings provide little support for divorced and married men Sibling relationships become stronger as you grow older

Health System Quality Indicators ** on exam

72% percentage of palliative care patients with paliative home care/any home care Percentage of palliative care patients who had at least 1 home visits from doctor Percentage of palliative care patients who had unplanned visit to emergency department Percentage of palliative care patients who died in hospital

Blue Zones

8 zones across the world where older adults live to be 100 years old Lifestyle habits in these zones Diet: mediterranean diet, Social: socialization in environment, new jobs, volunteering. A lot of things in these zones that allow people to live a long time. Low levels of plaques in these individuals Healthy way of living No cars No such thing as retirement They only eat 80% of what is on their plate These are all social, psychological!!

Driving

A large majority of seniors drive cars; In 2009, 3.25 million people aged 65 yrs + had a driver's license; Of that number, 200,000 were aged 85 years+ (Turcotte, 2012). • Current generation of seniors comprises a large number of women who had never driven - substantial gender gap in the 85 year+ group

The Symptom Iceberg ** ON EXAM

A pathology may present without symptoms, or signs The symptom iceberg represents those aspects of the illness that are not discussed, shared or presented to a healthcare professional Response of older adults to ailments over a 2-week period • Saw a doctor or dentist - 10% • Saw a pharmacist - 1%

Social Isolation

A state in which the individual lacks a sense of belonging, lacks engagement with others, has a minimal number of social contacts and they • An objective lack of relationships. "at risk phenomenon"

Gay & Lesbian Older Adults

About 2% of Canadians (346,000) adults between ages of 18-59 selfidentify as gay, lesbian or bisexual (Stats Canada, 2011) - with close to 91,000 living in same sex unions (about ¼ of all LGBT adults). • Seniors (65+) make up about 4% of same-sex couples. • Men who had past partners (wife, lovers or combination of both) reported high life satisfaction even if they now lived alone.(Lee, 1987) • Many people who are gay or lesbian have strong, committed relationships and active social networks. • Significant lack of research on this topic

L. Hurd Clark (2014). Negotiating Vulnerabilities: How Older Adults with Multiple Chronic Conditions Interact with Physicians. Canadian Journal on Aging / La Revue canadienne du vieillissement / Volume 33 / Issue 01 / March, pp 26 - 37. **USE THIS FOR THE QUESTION ON EXAM

Abstract/Overview - Patient-physical interactions have ignored the perspectives of older adults with multiple morbidities - Study focuses on how participants perceived and experienced the care provided by primary care physicians - Study has 16 men and 19 women with an average of 6 chronic conditions Introductions - Living with a chronic condition is increasing within Canada for the elderly - The purpose of the study was to consider perceived sources of, and explanations for satisfaction with primary care physician and the strategies that older adults with multiple chronic conditions employ to maximize the care they receive - The study was analyzed by using qualitative data from in-depth interviews with 35 men and women aged 73 and over who had an average of six chronic conditions Literature Review - Research suggests that most elderly individuals are satisfied with the care they receive - Older adults' contentment with their general practitioners has been found to be related to positive perceptions of physicians' expertise ad technical competence, the physician demonstrating a caring attitude and friendliness, and collaborative decision making. - Recent studies have examined that older adults prefer the changing models of health as oppose to the traditional approach to care. - Some research has shown that the definition of egalitarianism and involvement in medical encounters may differ for older adults, who tend to privilege effective, open, patient-centered communication and a trusting, supportive, and caring relationship with their doctors over active participation in the decision-making process - Methods - To satisfy the purpose of the study, they investigated a broad range of topics, including the participants' interactions and relationships with their primary care physicians - In-depth interviews were conducted with 35 urban, community-dwelling older individuals (16 men and 19 women), all of whom were interviewed twice either by the first author, the third author, or another graduate student research assistant - Interviews were semi-structured, and although participants were encouraged to speak freely, the study used a topic guide to ensure that there was consistency across all the interviews. Findings - 57 per cent of participants (eight men and 12 women) stressed the importance of thoroughness on the part of their general practitioners - 23 per cent of the participants (four men and four women) commended their doctors for being thorough as they made comments similar to those of a 75-year-old man who had five chronic conditions - Many participants stressed that they wanted primary care physicians who had specific c personal qualities, including being friendly, open, and trustworthy - Not all of the participants felt that their physicians were open, supportive, and responsive to all of their health care needs • some female participants felt uncomfortable with their physician when it came to discussing sexuality or mental health issues - Notable gender differences between men and women Discussion/Conclusion - Participants emphasized the importance of thoroughness during medical consultations, effective gatekeeping, interpersonal skills, and decision-making approaches - The findings are consistent with the research which has found that older adults' satisfaction with their primary care physicians is related to their perceptions of their doctors' technical competence, trustworthiness, and caring attitude - Findings build on existing research which has identified health care system constraints such as lack of time during appointments to be a source of discontent among older patients - Findings suggest that the presence of multiple morbidities exacerbates concerns about the amount and usage of time during medical appointments - Female participants often reported having to choose between their numerous chronic health issues for which they obtained medical assessments and advice during appointments, leading to the sense that they were receiving inadequate care. - Affording opportunities for older patients to voice their concerns and complaints, attending to men's and women's differing preferences for decision making, providing continuity of care and a comprehensive care plan, and maintaining a caring relationship may do much to address older adults' dissatisfaction with their medical treatment and promote greater trust within the doctor-patient relationship.

Parson's sick role

Acute illnesses Sick role Responsibility to get better • Sickness could lead to societal breakdown resulting from the inability of the sick to fulfill their necessary social roles • 'Sick role' concept: way for society to manage sickness • Healthcare professionals legitimize 'sick role'

Acute vs. Chronic Illness?

Acute: Single, Accurate Chronic: Uncertain, no cure, pervasive, complementary

Who are the caregivers in canada

Adult children Spouses give less care in hispanic and black communities

Ethics of End-of-Life Care

Advance Care Planning Hospice Palliative Care

Paganini-Hill (2013).J Aging in Place in a Retirement Community: 90+ Year Olds. Journal of Housing for the Elderly, 27:191-205.

Aging in place is desired by most older adults 2. The paper examined the association between living situation of a population based cohort of 90+ year olds with health and life style variables 3. 53% of 1485 participants in the study still lived in their homes at a retirement community designed to foster wellness 4. Dementia was the chronic disease most significantly related to living situation 5. With the help of family and friends and a medical and social support system, many 90+ year olds can age in place, because they have a caregiving spouse or paid caregiver 6. The study was a population based longitudinal study of aging and dementia among people aged 90 years and older 7. Participants were asked to undergo an in-person evaluation, including a neurological examination and a neuropsychological test battery, and information was obtained by telephone or from informants 8. Only 18% of participants could perform normally on all ADLs and only 14% on all IADLs 9. Difficulty in mobility was the most frequent problem for these individuals 10. For the majority of older people, the home is the preferred residence in which to grow old. The study showed that despite ill-health and increased functional disability but in an elder-friendly community with the help of family, friends, and paid caregivers and with a medical and social support system, many 90+ year olds can continue to live independent lives at home.

Super Agers

Aging-->not necessarily about decline • Start healthy habits and maintain them throughout life--> fit and active; healthy aging starts at any age • Strong mind body connection--> socialize • Low amounts of age-related plaque • More energy, positive outlook on life • Health protective 'weight'

Cancer Patients

All Cancer Patients: $ 114.73 Long-term care facility: $ 124.55/day; US Medicare Hospice Benefits: $ 125.71/day; Residential hospice: $ 200.00/day; Alternate Level of Care: $ 445.00/day; Hospital ward: $ 1,000.00/day

Dementia History

Alois Alzheimer: examines brain of 46 year old female patient and finds lesions, tangles and plaques

The Impact of Population Aging on Rates of Disability in Canada

Although not inevitable, aging is often accompanied by declines in physical, cognitive, and sensory capacity, which may lead to limitations in daily life-- Freedman 2014 In Canada, aging of the population is one of the factors contributing to the increase in the disability rate from 2001-2006. Aging explains about 40% of the rate increase The percentage of Canadians with disabilities increases with age; nearly half of people in their 80s report experiencing activity limitations

Caregiving

An adjective and a noun As an adjective: characterized by attention to the needs of others, especially those unable to look after themselves adequately; professionally involved in the provision of health or social care; As a noun: characterized by attention to the needs of a child, elderly person, invalid, etc.

The Dementias

An umbrella term used to describe a range of symptoms associated with cognitive impairment -Alzheimer's: 50-75% -Vascular: 20-30% -Lewy Body: 10-25% -Frontotemperal: 10-15% "A chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning"

Drugs that cure

Antibiotics

Case Study: Cancer Medication, Avastin

Avastin: $4555 per treatment/ 2 x a month: funded in some provinces rejected in others -Provincial drug plans review same clinical and economic data BUT not necessarily at the same time!! -Came to different decisions/ interpretations of benefits/ affordability Western Provinces: All residents covered for cancer medications New Brunswick and PEI: residents not covered for cancer medications Urgently needed medications can be reviewed by provinces prior to Health Canada approval: -Current example: BC and Alberta approved the medication for lung cancer, breast cancer, or colon cancer BUT not for brain cancer 64

Drugs

Any biological substance, synthetic or non-synthetic, that is taken primarily for non-dietary needs.

Disability Definitions of Human Rights

Any degree of physical disability, infirmity, malformation or disfigurement that is caused by bodily injury, birth defect or illness and, without limiting the generality of the foregoing, includes diabetes mellitus, epilepsy, a brain injury, any degree of paralysis, amputation, lack of physical coordination, blindness or visual impediment, deafness or hearing impediment, muteness or speech impediment , or physical reliance on a guide dog or other animal or on a wheelchair or other remedial appliance or device • A condition of mental impairment or a developmental disability • A learning disability, or a dysfunction in one or more of the processes involved in understanding or using symbols or spoken language • A mental disorder • An injury or disability for which benefits were claimed or received under the insurance plan established under the Workplace Safety and Insurance Act, 1997

Prescribing Culture **ON EXAM**

Assumption: medical advances are more influential on health than environmental changes -Environmental and social changes are slow Prescribing and medication culture ignores a complex set of factors at work. For instance: -cultural attitudes toward drugs -toward health issues of seniors, women, and ethnic minorities -a medical system where hospital stays are shrinking Collaborative care, concordance, patient centred care, pharmaceutical care--> have these models of patient inclusivity led to more pressure to prescribe Opposing viewpoints: patients being proactive and treating conditions early or assuming that every problem can be and should be addressed with medications **88% of patients who requested a specific medication DID NOT have the condition the medication treated Ethical Prescribing: Drug marketing directly to consumers: empowering patients or creating demand? -Things to consider: *informed and demanding consumer (ie. refuse to accept generic substitutes) -Drug formularies: *restrict what can be prescribed--> make it more difficult to meet physician and patient demand

Shifts in delivery of healthcare ** ON EXAM

At home: 85-90% of care provided to older adults--Relatives •View: LTC is Abandonment of older adults •Family councils in LTC •Tensions between parents and children Shift in terminology:"carepartners" 2:1 ratio of older adults institutionalized: at home --Why might these numbers be higher? The number of older adults living in institutional settings has gone down in the last 30 years

Social Health ** KNOW DEFINITON

At the individual level - involves the ability to form satisfying interpersonal relationships with others. It also relates to one's ability to adapt comfortably to different social situations and act appropriately in a variety of settings. A socially 'healthy' person can (KNOW FOR EXAM): • Form secure/meaningful/close relationships, • Socialize/make friends/get along easily with others, • Work well within a group of people, • Mobilize his/her network, • Give and receive support, • Engage in the community

Temel et al., (2010). Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. N Engl J Med. 363: 733-42.

Background - Metastatic non-small-cell lung cancer is the leading cause of death from cancer worldwide - Results in high burden of symptoms and poor quality of life - Patients w/ metastatic non-small-cell lung cancer have substantial symptom burden & may receive aggressive end of life care - This study: examined the effects of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients w/ newly diagnosed disease Methods - Randomly assigned patients w/ newly diagnosed metastatic non-small cell lung cancer, received either: o Early palliative care integrated with standard oncology o Standard oncologic care alone - Assessed quality of life and mood at baseline and 12 weeks using the FACT-L scale and Hospital Anxiety and Depression Scale. - Primary outcome: change in quality of life at 12 weeks - Data from end-of-life care were collected fro electronic medical records Results - Of 151 patients: 27 had died by 12 weeks, and 86% remaining completed assessments - Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care - Fewer patients in the palliative care group than in the standard group had depressive symptoms - Despite fact that fewer patients in early palliative care group than standard care received aggressive end of life care → Median survival was longer among patients receiving early palliative care Conclusions - Among patients w/ metastatic non-small-cell lung cancer: early palliative care→ significant improvements in both quality of life and mood - As compared to patients who received standard care: palliative care patients had less aggressive treatment at end of life, but higher survival

Individual Level Impact of Disability

But.... Physical functioning does not define successful aging! A study by Romo et al. (2012) found that: • A majority of older adults with late-life disability felt they had aged successfully by adapting to their new circumstances or focussing on positive aspects of their lives • Successful aging is a subjective concept "It's very depressing at times ... Because you know you sit there and you think, 'Okay I want to do this, this and this today.' Intellectually I can do those things, physically no ... One of thehardest things about being disabled is that you can't do as much for other people as you've always done. You become dependent on other people instead of helping other people and it's an awful hard blow to take. It's really hard."

Patterns of Drug Use

Canada spending: $24, 800, 000, 000 dollars on prescription medications Biggest: Cardiovascular, and then psychotheraputics Psychotheraputics: -Sleep -Depression -Anxiety

Case Study: Retirement Income

Canadian pension plan: everyone is contributing Canada pension plan is not specifically for retirement- related to disability and social security. Problem: not much money.

Alzheimer's disease

Characterized by irreversible brain damage in which cell to cell connections in the brain are lost and die Alzheimers disease leads to nerve cell death and tissue loss throughout the brain. Over time, the brain shrinks dramatically, affecting nearly all its funtions

Housing Preferences

Clarity (2007) found that among 402 community-dwelling seniors, 26% feared loss of independence & entering a nursing home (13%) more than they feared death (3%).

Hospice Palliative Care Service Delivery

Community-based hospice palliative care teams [such as a Regional Palliative Care Team] partnerwith primary care providers, taking on mutual responsibility for the patient (shared care); Shared Care: -Sharing knowledge and -Skills Such integrated care has been shown to be: -Widely adopted (Australia, Italy, United Kingdom, Spain, etc.) -Effective.

Poverty for Seniors

Compared to most advanced industrialized countries, Canada has a relatively small number of low-income seniors. ****Only 5.2 per cent of individuals 65 years of age & older were below Statistics Canada's Low Income Cut-Off (LICO) line in 2010. In 2015: LICO= $15,982 for a single person and $22,374.00 for a couple What the govt. will pay you = $24,346.44 (max) if you have no other sources of income and only $16,684.92 if you have other sources of income. Approximately 10% of seniors lives below income rates Aggregate statistics mask a deep problem: the disproportionate vulnerability of single elderly who live alone; 70% who are women. The single elderly living under the LICO is twice that for the Canadian population & 4 times that for the older aged population. Almost 10% of seniors are living under low income status 5.2 per cent of individuals 65 years of age and older were below stats canada's low income cut off (LICO) line in 2010 The people are doing really well are doing better as they go on, the people doing badly are doing worse

Quasi-Widowhood

Conceptualized as a life course transition Really hard "... conceptualized as a life course transition, a term intended to capture the situation of living alone without one's former mate yet still married and still involved in many ways in the spousal role."

Power of Attorney

Continuing Power of Attorney for Property: -"A Continuing Power of Attorney for Property is a legal document in which a person gives someone else the legal authority to make decisions about their finances... It is called "continuing" because it can be used after the person who gave it is no longer mentally capable to make the financial decisions themselves." Power of Attorney for Personal Care: -"A Power of Attorney for Personal Care is a legal document in which one person gives another person the authority to make personal care decisions on their behalf if they become mentally incapable."

The Impact of Depression for aging adults with HIV

Contributes to neurocognitive symptoms - memory, language, motor, problem-solving Independent predictor of heart failure among PLWHIV Lower quality of life -physical, mental, role functioning, pain, social, energy, disability days Poorer cART adherence and persistence

Pharmacological Treatment Options for dementia

Currently no cure for Alzheimer's disease and no treatment that will stop its progression. Several drugs are available that can help with some symptoms Aricept, Exelon, reminyl □ Ebixa: is a memantine hyrochloride inhibitor prevents the reabsorption of the leaking neurotransmitter glutamate which istoxic to the cell □ Using the cholinesterase inhibitor and memantine hydrochloride together may produce a greater benefit.

Adult Children as Caregivers

Daughters:greater feelings of stress Marital status->Married children? Less likely to provide support Filial Piety: eases caregiver burden? -Actually may prevent caregivers from asking for help due -Asking for help=failure Divorced fathers: receive the least support Older parents: -Greater stake in relationship with children? -Who has more to lose?

What are the Societal Impacts of Chronic Illness?

Declining population health Increase in income/ economic inequity Increased system wide healthcare spending Focus will have to shift from prevention to treatment Direct healthcare costs and increase in hospitalizations, ER visits

Use of antipsychotics on seniors

Dementia -Antipsychotics will typically numb and sedate you -users are at increased risk of cardiovascular disease, diabetes, weight gain, falls and fractures -use of anti-psychotics in the elderly with dementia almost doubles the risk of mortality

Stages of Dying

Denial, Anger, Bargaining, Depression, Acceptance

HIV Stigma Experienced by Older adults

Depression among older people living with HIV is largely related to HIV stigma and isolation (Grov et al, 2010) Older people living with HIV report feeling that others don't want to be around them due to their HIV status (Emlet 2006). One strategy they use to deal with this is selective disclosure. This can decrease access to social support. Intersectionality -Higher HIV-related stigma scores for women; highest among Black women -Older heterosexual men and women may be more likely to experience depression than older gay men (Brennan et al 2013)

Depression **ON EXAM

Depression is the most common mental health problem for older adults (CCSMH, 2006a), substantial depressive symptoms affect an estimated 15% of those living in the community (CCSMH, 2006a). Rates of depression are higher in long term care homes with up to 44% of residents having an established diagnosis of depression or significant (3 or more) depressive symptoms (CIHI, 2010b). Usually this is not too difficult to reverse if diagnosed because it is the environment. Community affective disorders are more likely to be related to personality and genetic dispositions.

Grandparents as Caregivers

Dramatic increase in grandparent headed households Child welfare agencies are turning to grandparents to provide kinship care Since 2001, the number of children being raised by grandparents has increased by 15-32% •Accurate data no longer exists Grandparents willing to take in their grandchildren and raise them 33 percent of grandparent caregivers had a disability 45 percent of children in care are younger than 14 75 percent of participants: income range 15k-50k

Ageism and HIV in older adults

Enacted and/or internalized ideas about the 'legitimate patient' Discomfort discussing sexual health Assumptions and stereotypes about older adults

Good death vs bad death

Each culture defines a "good" and a "bad" death. Western culture: Good Death: -Heart attack, "natural death" -quick, painless -at home, in bed -with loved ones -during old age, timely, prepared -meaningful, expected, accepted Bad death: -Cancer, AIDS, Alzheimer's disease, ALS -slow, agonizing, without dignity -in hospital, in intensive care unit (ICU) -alone or with strangers -in very old age, untimely, unprepared -meaningless, sensless

Endocrine and Immunological Theory

Endocrine system controls growth, metabolism, reproduction and stress response; -estrogen and testosterone decrease with age alongside the timing of hormonal release and the responsiveness of tissue -immune system 'ages' as especially T-cells, that must replicate to respond to pathogen attack, come up against the Hayflick Limit

Pseudodementias

Elderly people may become forgetful, disoriented, or confused because they have developed a quickly reversible condition that is totally unrelated to dementia. For example, drug interactions or overdoses, poor diet and other physical or mental problems cause symptoms that mimic dementia. Depression often resembles dementia in that its victims withdraw, cannot concentrate and appear confused.

Disability & Functioning in Seniors

Eliminating arthritis would result in the greatest reduction in ADL disability, IADL disability and social participation restriction among older adults Other significant drivers of disability included diabetes, eye disease, heart disease, respiratory disease and depression. Little relationship detected between cognitive impairment and functional limitations

Substitute Decision Maker

Every Patient in Ontario AUTOMATICALLY has a person who will have legal authority to act as his/her SDM if he/she becomes incapable; To appoint someone as an Attorney, the Patient must sign a Power of Attorney for Personal Care document that meets the legal requirements. Hierarchy of Substitute Decision Makers: 1. Guardian of the Person with authority for Health Decisions; 2. Attorney for Personal Care with authority for Health Decisions; 3. Representative appointed by the Consent and Capacity Board; 4. Spouse or partner; 5. Child or Parent or CAS (person with right of custody); 6. Parent with right of access; 7. Brother or sister; 8. Any other relative; 9. Office of the Public Guardian and Trustee.

How do patients take medicines?

Exactly as prescribed: "full compliance" -Time of intake -Dosage frequency -Recommended Dosage etc. Full compliance was reported in some cases to be influenced by: -a desire to achieve therapeutic goals -fear of health related repercussions due to non-compliance -a desire to maintain a favourable relationship with their practitioner -Some fill the medication and not use it -Some discontinue using the medication early

Fast, J. et al. (2013). The economic Costs of Care to Family friend Caregivers: A Synthesis. University of Alberta: Edmonton

Families -> central feature of how societies will face population aging • Families responsible for care and support of members w/ chronic illness/disability • Escalating economic and time constraints for family/friend caregivers, spillover of costs onto employers since most employers employed full time • Need to understand economic costs of care both to caregivers and to their employers to support and sustain family/friend care 1 in 4 Canadians is a family/friend caregivers • More than 1 in 4 Canadians/3.8 million people 45 or over provide assistance to an adult w/ a long term health condition or p\physical limitation (2007) • 76% relatives, 24% for friends/neighbours • From 2002-2007: numbers increased by 65%, proportion increased by 10% Caregivers across the life course is a normal experience: people often have caring careers • Increasingly normal experience • >1/2 of all women 45 and over have provided care to at least one family member or friend w/ a long term health problem or disability at some point since they were 15 • Women spend more of their lifetime providing care than men (5.8 years vs. 3.4 years) Family/friend care has short and long term economic costs • Three domains of economic cost for caregivers: o Employment consequence o Out-of-pocket expenses o Caregiver labour • Each has subcategories • Each also leads to a different set of immediate and longer term economic outcomes o Reduced/foregone income o Lost benefits o Reduced pension o Reduced savings/investments o Increased healthcare costs

Family conflict, caregiving and elder abuse

Family, social support and multigenerational living -The myth of the harmonious unit Elder mistreatment -Neglect -Physical abuse -Psychological abuse -Financial abuse Older female victims of abuse outnumber male victims

The Health Promotion Model

Focuses on prevention and self care It claims to prevent disease through life-style change, increased knowledge about health behaviour, and environmental improvement -seat belt legislation, weight control, pollution, smoking, etc. are these applicable to an older population? -Examples of health promotion activities specific to an older population??

Serial Caregiving

For married, working women, sandwich generation has to care for children, then care for parents and then care for husband

Generations and ageism

Gen Z most ageist (1996-->), Gen Y (1977-1995) and Gen X (1965- 1976) are more likely to hold negative perceptions

GIS: Guaranteed Income Supplement

Guaranteed income supplement is NOT taxable because you are considered in a low income bracket •Because the C/QPP did not help those already retired, the GIS was introduced at the same time (1967) which was income tested & a form of social assistance and income security. •It was an interim measure until the C/QPP matured in 1976. •65+ to receive must reside in Canada. •Must receive full or partial OAS and have little or no other income. •Must apply annually. •Payment based on year's previous income tax (income tested). •Not subject to income tax.

What is the impact of non-compliance

Health/ Social: -Poor health outcomes, disease control and long-term consequences (e.g., hypertension; diabetes) -Antibiotic resistance --> 'superbugs' -Greater dependence on others-->caregivers Economics -Emergency room visits on average 4.2 days due to non-compliance (Patel & Zed, 2002) -Approximately 70% of hospitalizations may be preventable -$30 Billion in "wasted" health care expenditures in North America

Canada Food Guide and Older Adults

Healthy fats Wider range of foods Fluids Softer proteins MIND: high berries. Meant to offset neurodegenerative disease DASH: low sodium Mediterranean: plants, olive oil, fish, wine.

Hospice Palliative Care

Hospice Palliative Care is INTERDISCIPLINARY -Physicians, nurses, social workers, allied health professionals [family caregivers, volunteers...]; Teamwork approach; Provided in a multitude of settings: -Community -Hospital -Long-Term Care Facilities -Residential Hospices ... Specialist teams can enhance primary care hospice palliative care capacity.

Costs

Hospitals: #1 Medications: #2 Physicians: #3

Older adults and financial literacy

How money works, how to manage your money, how to invest your money -Making financial decisions in uncertain times -i.e. should I take my CPP early or should I wait? Financial Literacy on Canada's National Agenda: older adults may not benefit from typical literacy programs, as their needs are unique Subgroups of older adults face great economic challenges in later life Hard for older adult to become financially literate -You have to start much younger Similar to health promotion: have to start early

Other Medical Services

In addition to using more hospital care than other segments of the population, seniors are high users of several other sectors of Canada's health care system: - Continuing care: In 2009-2010, 95% of people in residential care and 85% of people in hospital-based continuing care were age 65 and older; - Home care: In 2009-2010, 82% of home care clients were age 65 and older; -Prescription drugs: In 2009, provincial and territorial governments spent an average of $1,311 per senior compared with $170 per adult age 20 to 64 for prescription drugs Family physicians: In 2009, the share of seniors who frequently (10 times a year or more) visited their family physician was almost double the share of frequent visitors among non-seniors (9.7% versus 5.5%); Seniors are also more dependent on income and social support provided by governments at all levels. According to Statistics Canada, in 2008, senior families reported median government transfers of $24,100, compared with $2,900 for all other families

What do caregivers do?

IADLs, ADL

Life expectancy of Males and Females by income Quintile of Neighbourhood

If you're in the poorest poor Women do okay in this graph

Collectivist Approach

Illness behaviour: culturally learned response - No conceptualization of "depression" in certain cultures - Different ways of looking at body systems and associated health and healing strategies Socioeconomic differences: perception of health Gender differences: reporting illness (Kroenke & Spitzer, 1998) Cultural differences: management of illness (Morgan & Watkins, 1988)

Caregivers in the clinical context **ON EXAM

Implications for health communication not uncommon for older adults to be accompanied by a caregiver to see a health care professional Needs, values and beliefs of older adults and caregivers are different

Widowhood

In 2006, there were almost 1.3 million widowed Canadians aged 65+. • This came to 30% of all older Canadians - 14% men & 43% women. • Among seniors, there are more than 4x as many widowed women as widowed men (Statistics Canada, 2006). • Most men, particularly those younger than age 85, can expect to end their lives with a spouse while older women (particularly 75+) are more likely to live their final years in widowhood. Widowhood is now an 'expectable' life event - one that creates a great deal of stress. • Many widows reported widowhood stripped them of their identity (end of being a wife).

Housing Preferences for Rural considerations

In comparison to urban dwelling seniors, rural older adults are often disadvantaged in terms of: • Having lower incomes, less education & lack of adequate housing. (Elnitsky &Alexy, 1998; Sylvestre et al. 2006) ; Poorer mental & physical health (Crowther et al., 2001) ; High prevalence of functional disability, increased sedentary lifestyle & less use of preventative care(Kumar et al., 2001) ; More chronic illness (Ortega et al., 1993). • Bascu, et al. (2012) examined key determinants for supporting healthy aging in rural communities (Saskatchewan) & found that housing is a major concern - perceived lack of affordable housing across different levels of care; • Housing needs to incorporate a common space for social interaction. • Compared to urban settings, rural seniors' housing often requires more costly repair & maintenance b/c of age of housing.(

Tangles

In healthy areas: □ The transport system is organized in orderly parallel strands □ Food molecules, cell parts and other materials travel along the tracks □ A protein called tau helps the tracks stay straight In areas where tangles are forming: Tau collapses into twisted strands called tangles The tracks can no longer stay straight. They falll apart and disintegrate □Nutrients and other essential supplies can no longer move through the cells, which eventually die

Studies looking at the ethics of prescribing

In one study, physicians accepted all-expense trips to sponsored events: -Assumption: these activities would not affect prescribing of certain medications -***Result: 3-fold increase in prescribing of promoted drugs over two year period Industry detailing: pharm sales rep teaches the doctors about the drug. Reciprocity rule: you feel like you have to give something back because you got something

Gov Support for Caregivers

Indirect payment -Federal tax deductions Employment insurance benefits -Compassionate car benefits Caregivers wage -Financial payment for their work --to reward caregivers --to help with cost of caregiving --to delay with instituionalism

Larson et al. (2013). New Insights into the Dementia Epidemic. New England Journal of Medicine Perspectives Dec. 12th.

It has been expected that since the aging population is increasing and account for the largest proportion of dementia cases, the dementia epidemic will grow. However, population-based community studies have found that dementia rates have declined for those born later in the first half of the 20th century. • A US longitudinal study using long-term care surveys from 1982-1999 found that the prevalence of dementia decreased from 5.7% to 2.9%. Potential reasons for this finding include higher levels of education and decrease in stroke rates. • The U.S health and retirement study found that in 1993, 12.2% of adults 70 and older had cognitive impairments, and in 2002, this decreased to 8.7%. It was found that education protected against cognitive impairment, as well as medical, lifestyle, demographic, and social factors. • The Rotterdam Study used a sub-cohort in 1990 and in 2000 and found that there was a low incidence of dementia in the 2000 sub-cohort group. MRI shows that individuals who were born later had large brain volume and less cerebral small-vessel disease. • A Swedish study had two-cross sectional surveys of people 75 and older from 1987-89 and 2001-04. The prevalence in dementia was similar in these two groups, however since the hazard ratio for death was lower in the later group with dementia, incidence rates may have decreased. This was attributed to favorable changes in multiple risk and protective factors. • The CFAS study contained two groups surveyed at different times (CFAS I- between 1989-1994, and CFAS II 2008-2011) the prevalence rate for CFAS I was 8.3% in comparison to the CFAS II group with a prevalence rate of 6.5%. Those born later in life had lower risk of dementia, most likely due to differences in education level and better prevention of vascular diseases. • From these study we find the better education, greater economic well-being increases life expectancy and reduce rates of late-life dementia. Controlling vascular and other risk factors during mid-life may lead to lower rates of dementia. • These findings also are a benefit for life-style interventions and improving educational opportunities in early and late life as well as promote physical activity and reduce vascular risk factors. It also shows dementia is a syndrome that has complex symptoms and multiple causes. • Dementia cases that occur later on in life involved a mixture of Alzheimer's disease, vascular disease, as well as other degenerative factors. • Future research in the prevention of late-life dementia should look at reducing societal and personal level risk factors to reduce the rates of dementia among the older population.

Responding to Requests for Medical Assistance in Dying

Joint Centre for Bioethics (UofT): -Have all care options that might be applicable to the person be considered? -Are the perspectives of all appropriate people (e.g., family members, etc.) known? -Has there been meaningful involvement from palliative care and/or other specialist services (e.g., psychosocial services including spiritual counseling) that might contribute toward alleviation of suffering?

Rosso et al. (2013). Mobility, Disability and Social Engagement in Older adults. Journal of Aging and Health. 25(4) 617-637.

Key Words: - Mobility: ability for individual to purposefully/purposively move around their own environment - Disability: difficulties with ADLs, IADLs ⇒ Limitations which affect individual's health and well-being Main Points: - Individuals with single IADL dependency are more likely to be obese ⇒ Difficulty may due to body size ⇒ Not a functional limitation - Individuals with high mobility and a disability are less likely to be in poverty ⇒ Mobility limitations are overcome with a vehicle - ADL dependencies are less common with low mobility and disability than IADL dependencies ⇒ IADL dependent individual more likely to have multiple dependencies - Lower life-space mobility and disability are each associated with lower levels of social engagement - Social engagement ⇒ Maintenance of social engagement important for quality of life, prevention of further decline in mobility and development of disability ⇒ Social media is a means to counteract any effects of mobility limitations • Provides accessible activities

Chronic Illness

Lasted 3 months or longer

Loneliness

Loneliness is a complex and usually unpleasant emotional response to isolation or lack of companionship LONLINESS IS SUBJECTIVE

Quality Indicators

Lowered caregiver and patient distress within 14 days of program enrollment (distress thermometer); Continuing mild to moderate symptom severity on Edmonton Symptom Assessment System (ESAS); 63% overall place of death concordance.

Income security

OAS and GIS

End-Of-Life- Care Coversations

More than half of people don't have access to palliative care "To cure sometimes, to relieve often, to comfort always." -Hippocrates "Doctors should be obliged to go into hospital once a year, so that they remember what it feels like." -Therese Vanier

Pharmaceutical 'Personhood'

Medication as a means to return us to our 'authentic self'-->using medicines to resist aging New medications and the desire to be 'well'--> new demands on the older adult Link to 'successful aging' Ethnopharmacology-->using one's own 'aging' body as a mini clinical-trial to assess what works

Is Rx Status Arbitrary?

Medication is given Rx status when: -restrictive legislation applies (ie Narcotic Control Act re: use of morphine & other narcotics) -considered unsafe for self administration -known or risk of ADRs -narrow margin of safety

What is medicalization?

Medicine as an institution of social control - Older adults often 'medicalize' their own issues - Munchausen's Syndrome: when people pretend to be sick - Medicalization of death and dying • Chronic Illness as deviance, building on Parsons' idea of the Sick Role • Medicalization leads to medical surveillance • Demedicalization also occurs--> challenges to medical definition

Definition of Mental Health

Mental health is a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his own community.

Mental Health Commission of Canada

Mission is to promote mental health in Canada, and work with stakeholders to change the attitudes of Canadians toward mental health problems, and to improve services and support. The Vision is a society that values and promotes mental health and helps people who live with mental health problems and mental illness lead meaningful and productive lives. This was founded by the Harper Government in 2007 where he allocated funding for the next five years of over 50 million dollars.

Disability Type and Age

Most commonly reported types of disability among older adults are: #1:•Mobility •Flexibility •Pain More than a quarter of people age 75+ report experiencing each of these types! The prevalence of hearing disabilities was also high among older persons • 7.3% for age 65-74 • 14.6% for age 75+

Myths Related To Medication Use and Costs in Canada

Myth: Older Canadians in all parts of Canada have equal access to prescription drugs under provincial government Pharmacare plans. Reality: There are significant regional variations in who is eligible for coverage and the reimbursement levels under government drug insurance plans. Residents of Atlantic Canada do not fare as well as residents in other parts of Canada. (Newfoundland, Labrador, Nova Scotia, and New brunswick have high out of pocket costs. Quebec has high funding from provincial governement)

Health Care Services

Of all the components of Canada's health care system, hospitals receive the greatest share (37.3%) of public-sector health care dollars. Compared with other age groups, seniors use a disproportionate amount of hospital services. For example, although 14% of the population: in 2009-2010, 40% of acute hospital stays were for patients age 65 and older. Seniors use hospital services not only more often than other age groups but also in different ways.

Living Arrangements

Oftentimes, sandwich generation (taking care of parents and taking care of children) Considerable diversity in livingarrangements: -One spouse in an institution, one at home -Both at home -Multigenerational homes -Sandwich generation -Lifelong singles Older women more likely to experience changes inliving arrangements-->sometimes dependent on care responsibilities

Health, Loneliness & Life Satisfaction

On the whole, Canadian seniors tended to report positive health and well-being— Self report: 76.5 percent. Younger seniors (65 to 74) were more likely than older seniors to have positive selfperceived health, and less likely to be lonely or to report life dissatisfaction • Women were more likely than men to be frequent participants in family and friend, church, educational and "other" activities, while men were more likely to be frequent participants in sports. *****With the exception of church and "other" activities, participation in most types of social activities was lower at older ages.

National Study of Chronic Disease Self-Management

Ory et al., reading; evaluation of chronic disease self management program to older adults • Self-management an important aspect of chronic illness care for older adults-->goal: allow older adults to take care of their health • Results: improved health outcomes, reduced healthcare utilization, reduced depression symptomology, improved communication • Note: suggests physicians may not be prepared for geriatric patients • Significant decrease in ER visits: more efficient healthcare system

Decline in per capita spending

Overall, the ratio of per capita health spending on seniors to younger adults decreased between 1998 and 2009. The decline was most noticeable between 2004 and 2009.

Transition model vs trajectories

Palliative care -More holistic -Not only focus on patient, but on the family. Terminal sedation -The intent: to keep the person out of pain -Giving doses that are no longer able to sustain a body -Overdose of an opioid. The outcome will be death. The intent is to reduce pain. -This has been in place for a long time. Medical assistance in dying -No one can say that it's a completely new thing because of Terminal Sedation.

What is covered in private and public Rx drug programs in Canada?

Provinces/territories develop lists of drugs, known as formularies, that their plans cover. Some drugs are covered in all jurisdictions; others vary. In some cases, drugs may have "restricted status", limiting coverage to particular types of patients or situations--> for limited use (LU)

Heathcare vision

Policy-makers must treat aging as a lens through which all policy decisions are assessed, and not as an isolated policy issue Ensure older Canadians have access to person-centred, highquality, integrated care as close to home as possible, provided by those who have the knowledge and skills to care for them Ensure that the family members and friends of older Canadians who provide unpaid care for their loved ones are acknowledged and supported

** ON EXAM: Polypharmacy in LTC and outpatient

Polypharmacy Living in a long term care center, more likely to be using multiple medications Extreme polypharmacy-- LTC Age is not a predictor of the number of medications that you will be using. It is actually the number of chronic conditions.

Determinants of Mental Health

Poverty limits older people's opportunities to join in social activities, follow a healthy diet, to have adequate housing, to meet uninsured health care costs and maintain self-esteem. Physical environments that are physically, economically or psychologically inaccessible interfere with older adults' ability to engage in civic and social activities. The physical or social environments do not accommodate the challenges of aging or when they devalue seniors. Transportation has an impact on the social participation, security, independence and overall health and well-being of older adults (WHO, 2002b). It is key to access their community and its health, social, recreational and civic resources. Housing location, including perceived safety and proximity to family, services and transportation, is a significant determinant of social interaction, which is key to quality of life among seniors (WHO, 2002b; Migita, Yanagi, & Tomura, 2005).

What is the difference between prevalence of chronic illness vs. incidence of chronic illness?

Prevalence: Amount of cases exist Incidence: Amount of new cases

Costs by age

Provincial and territorial governments spent more health care dollars per capita on infants and seniors than on any other age group in 2015 Spending on infants,0-11 months: $7400 Spending on Canadians, 1-64: $1700 - In 2010, the per person spending for seniors ($9500) increased with age: $6,223 for those age 65 to 69, $8,721 for those 70 to 74, $12,050 for those 75 to 79 and $20,113 for those 80 and older.

Nutrition and Aging: Psychological/Social

Psychological Changes - Depression - Cognitive issues Social Changes - Eating Alone/ Isolated/ lack of support system - Lack of routine--> retirement - Transportation - Institutional setting - Lack of culturally appropriate food

Sources of Senior's Income

Public: 20 percent Public OAS: 23 percent

De-prescribing medications older adults

Push towards deprescribing Prescription drugs are cost driver

Individual Level Impact of Disability *for short answer*

Quality of Life Dominick et al. (2004) found that osteoarthritis and rheumatoid arthritis in older adults was associated with poorer self-rated physical and mental health, more activity limitations, more pain, worse sleep Social Disengagement: Rosso et al. (2012) found that lower life-space mobility & disability were each associated with lower levels of social engagement, indicating that mobility limitations even in the absence of disability are associated with reduced social engagement • Intersection of ageism and ableism Poverty Wilkinson-Meyers et al (2014) found that the tangible resources and time required for people with disabilities to achieve an adequate standard of living was significant

Importance of Health Literacy?

Questions older patients have asked their doctors are sometimes sounding ridiculous. Health literacy is important so medications can be taken correctly

Registered Savings Plan/ Registered Retirement Savings Plan

RPP: employee retirement benefit programs provided voluntarily by employers or by unions in both public & private sectors of the economy. RRSP: a personal retirement savings program that allows individuals to make deposits into personal savings plans for future retirement income. Defined Contribution (DC)- pension benefits vary depending on contributions accumulated by each individual & the return on these monies. Defined Benefit (DB)- pension benefits are fixed based on a variety of formulas, including such things as the number of years of service. Registered with Canada Revenue Agency: tax shelter RPP: not real money, just take a deduction during paycheck --Can't withdraw until 65

Rehabilitation Strategies for Coping with Disability

Rehab services: physiotherapy, occupational therapy, mental health counseling, speech language pathology.

Public Transportation

Relatively few seniors use public transit; The proportion of older adults who used transit at least once in the previous month decline with increasing age.

The Niagara West End-of-Life Care Project

Resource utilization and cost analysis

4 components of the sick role **probably on exam**

Rights: -The sick person is exempt from 'normal' social roles -The sick person is not responsible for his condition Duties: -The sick person should try to get well -The sick person should seek technically competent help and cooperate with the healthcare professional.

Criticisms of the sick role

Rigidity of rights and duties: • Extent to which a person is allowed exemption depends on the nature of the condition • Sick person may be held responsible for certain types of conditions • There are illnesses from which a person cannot recover • Alternative forms of treatment Not necessarily applicable to chronic illness or older adults

Assessing Nutrition Issues/Factors

Self report! This is an issue

Strategies and Programs to Promote Active Lifestyle

Senior Centres • Senior centres across Canada provide a range of services including arts, social activities, physical activities, legal advice, counselling, meal and nutrition programs, and drop-in services. Education • Courses or programs tailored to older adults' needs can promote lifelong learning. Technology: • Promoting learning of technology to reduce divide between young vs. older individuals' use. Civic Engagement/Volunteering: • Can promote good mental health, stronger social networks, high life satisfaction. ***• Seniors who volunteer give more time to volunteering than any other age group

Medications

Seniors who reported one and two chronic condition(s) were taking an average of 3 and 4 prescription medications, respectively. Seniors who reported three or more chronic conditions were taking an average of 6 prescription medications. Among seniors, the number of prescription medications was more closely related to number of chronic conditions than to age

Medicalization of sleep in older adults

Sleep disturbances-->emotional and physiological Review: Medicalizing problems which were once not seen as medical issues. Ease of access and a "quick fix": medication -doesn't get at what's causing the sleeplessness Dealing with the underlying reasons for someone's anxiety or depression--. takes time, so "easier to write the script Some examples? Is sleeplessness a local issue or international? (HUGE north american issue)

Social Support overview

Social support is the perception and actuality that one is cared for, has assistance available from other people, and that one is part of a supportive social network. • Can be measured as the perception that one has assistance available, the actual received assistance, or the degree to which a person is integrated in a social network Informal and formal caregivers distinction important for exam Formal: community services provided Informal: family, friends, neighbors, colleagues

Modifiable Risk Factors for Dementia

Socialize Eat Well Read Write Sleep

Loneliness & Social Isolation on Health **ON EXAM

Socially isolated older adults have a range of health risks: (Hawkley et al., 2010) • Increased systolic blood pressure •Infection(Pressman et al, 2005) (Wilson et al., 2007) • Impaired cognitive function Loneliness associated with • Progressive Alzheimer's Disease (Wilson et al., 2007) •Depressive symptoms (Cacioppo et al., 2006) • Sleep Issues

Driving & Disease/Disability

Some provinces monitor the ability of older drivers - Ontario requires persons 80 years+ to take written and road tests each year; Alberta requires a medical report clearing driving for persons 75 years+ & then renew it at age 80 and every 2 years after that.

Cultural Dimensions of Caregiving

Spotlight: Caregiving for Elderly in ChineseFamilies Only 10% of Chinese seniors live alone-->67%with extended families Familism and provision of care -->embeded in Culture -Stigmatized disease states -Filial guilt-->higher rates of depression and guilt -expectations for role in protection and advocacy -Emphasis on the cultural element of the experience -Gendered roles -Cultural expectations -->"forced upon"some

Medical assistance in Dying ** DEFINITELY ON EXAM

Supreme Court of Canada (2015): -Allowed for "a competent adult person who: -clearly consents to the termination of life; and -has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition."

How does one become a caregiver?

Task specificity model Hierarchical compensatory model Functional specificity of relationships model Convoy model of support

Murray, S., Kendall, M., Kirsty, B., and Sheikh, A. (2005). Illness Trajectories and Palliative Care. BMJ 330; 1007-1011.

Ten Main Points: 1. If patients and their carers gain a better understanding by considering illness trajectories this may help them feel in greater control of their situation and empower them to cope with its demands. 2. Three illness trajectories for people with progressive chronic illnesses: (1) A trajectory with steady progression and usually a clear terminal phase, mostly cancer (2) A trajectory (e.g. respiratory and heart failure) with gradual decline, punctuated by episodes of acute deterioration and some recovery, with more sudden seemingly unexpected death (3) A trajectory with prolonged gradual decline (typical of frail elderly people or people with dementia) 3. Trajectory 1: short period of evident decline, typically cancer - Entails a reasonably predictable decline in physical health over a period of weeks, months, or in some cases, years. - Weight loss, reduction in performance status, impaired ability for self-care occurs in patients' last few months - Earlier diagnosis & greater openness about discussing prognosis allows time to anticipate palliative needs and plan for end of life care - Fits well with traditional specialist palliative care services (hospices and their associated community palliative care programs) 4. Trajectory 2: long term limitations with intermittent serious episodes - Usually in patients with heart failure conditions and chronic obstructive pulmonary disease - Patients are usually ill for many months or years with occasional acute, often severe exacerbations. - Deteriorations are generally associated with admission to hospital and intensive treatment - Each exacerbation may result in death. More exacerbations and survival of such episodes leads to a gradual deterioration in health and functional status - Timing of death remains uncertain 5. Trajectory 3: prolonged dwindling - People who previously survived cancer and organ system failure are likely to die at an older age of either brain failure such as Alzheimer's or other dementia or the weakening and frailty of multiple body systems - Patients may lose weight and functional capacity and then engage in little daily chores or events that may be physical. If both occur at the same time it can prove fatal. - This trajectory may be cut short by death after an acute event such as a fractured neck of femur or pneumonia. 6. Optimising quality of life before a timely, dignified, and peaceful death are the primary aims of palliative care 7. An outlook on death and expectations that are much more easier to grasp and accept in reality may moderate the "technological imperative," preventing unnecessary admissions to hospital or aggressive treatments. 8. These trajectories provide an option of supportive care, focusing on quality of life and symptom control to be grasped earlier and more frequently 9. Trajectories allow practical planning for a "good death" - 65% of individuals at the end stage of cancer and organ failure wish to die at home - Determining the "preferred place of care" is now a standard in some palliative care frameworks and helps general practitioners plan for terminal care where the patient and family wish. - Advanced planning is sensible in Trajectory 2 type patients - Living wills (advanced directives) such as resuscitation status may be becoming more popular with patients and is needed for patients of all three trajectories → such planning may be particularly relevant to people in the 3rd trajectory, when progressive cognitive decline is common. 10. Limitations of the trajectory approach - Individual patients will die at different stages along each trajectory, and the rate of progression may vary - Other diseases or social and family circumstances may intervene - Some people may make it harder to work in open communication at earlier stages - Some illnesses might follow none, any, or all of the trajectories - Renal failure might represent a fourth trajectory consisting of steady decline, with rate of decline dependent on the underlying pathology and other patient related factors - Patients with multiple disorders may have two trajectories running concurrently 11. Implications for service planning and development - Uncertainty about prognosis may result in patients and their families to be neglected by health and social services. → a strategic overview of the needs of and services available to people on the main trajectories may help in the formation of better policies and services that considers all people with serious chronic illnesses - The use of end of life care pathways in nursing homes has shown to be effective and prevent admission to hospitals where they end up dying. - Models of care for one trajectory may inform another. (e.g. patients with organ failure could benefit from ideas developed in cancer care, such as advance care planning frameworks and end of life pathways).

Alzheimer's Society (2010). The Rising Tide: The Impact of Dementia on Canadian Society. Canadian Alzheimer's Society.

Ten Main Points: 1. purpose: review burden of disease (prevalence and economic burden), review actions taken to date AND propose & evaluate future interventions 2. Alzheimer's disease: 1. most common dementia 2. progressive, degenerative and ultimately fatal 3. not a normal part of aging 3. core risk factors: aging, genetic predisposition, numerous chronic diseases/health indicators (diabetes, chol, CVD, etc.) 4. prevention = lifestyle changes: diet, exercise, socializing & protecting against head injury 5. predictions: 1. steady increase in incidence over next 20 years AND roughly doubled prevalence 2. largest increase in burden of care to fall on informal caregivers in community 3. total economic cost to increase tenfold over next 20 years, including lost caregiver wages 1. transfer into LTC significantly increases cost per individual with dementia 6. future intervention models: 1. preventative: physical activity: LEAST effective 2. preventative: push diet & lifestyle change to delay onset by 2 years: MOST effective 3. caregiver skill-building and support program: MODERATELY effective 4. case manager program: guidance for diagnosed individuals: MODERATELY effective 7. action taken to date: 1. international policies: prioritize early diagnosis & intervention, investing in formal & informal caregivers AND investing in research 2. Ontario leads in CAN context with only comprehensive healthcare & research strategy in place to date 8. call to action: CAN needs national action plan to combat dementia, including: 1. investment in research & integrated healthcare system (chronic and acute care) 2. priority on prevention, and early diagnosis & intervention 3. supporting formal (gerontologists across allied health professions) & informal caregivers

Y. Tieu & K. Konnert (2014). Mental health help-seeking attitudes, utilization, and intentions among older Chinese immigrants in Canada. Aging & Mental Health, 2014, Vol. 18, No. 2, 140-14.

Ten Main Points: Three goals of study: 1) Asses how much "demographic factors, perceived social support and Chinese cultural beliefs predict attitudes toward mental health help seeking" (p. 140) 2) Appraise use of mental health services 3) Evaluate intentions of 55+ Chinese adult immigrants in Canada to use mental health services -Insufficient use of mental health services is linked to culture: beliefs, values (eg filial piety) and cultural factors -However, based on depression rates and self-reported health, mental health services are needed for immigrant Chinese adults - The degree of impact "help-seeking attitudes" have on Chinese adults not getting help is important since they have been found to be a barrier to access in mental health; this study examines the attitudes of Chinese older adults (p.141) -Method: 149 participants partook in a semi-structured interview (conducted in Cantonese or Mandarin), measures were of : "perceived social support", "help seeking attitudes", "mental health utilization", "intentions to seek help", "Chinese cultural beliefs" (p.142) Results: Predictors of help seeking attitudes: 21.8% of variance in attitudes attributable to perceived social support, health scores, and belief in Chinese culture, greater support of Chinese cultural beliefs linked to "less positive attitudes" (p. 143) Mental health utilization: help seeking attitudes were not prognostic Help seeking intentions: Self-care and general practitioner > close friends and psychologist Close family members > psychologist Discussion: Significant link between upholding Chinese values and demonstrating not as favorable "attitudes toward seeking mental health services" (p. 144). Probably associated with stigma Self-evaluated social support positively connected to outlook on getting help Conclusions: -Education with the purpose of information gain on illness and services, and reducing stigma may be beneficial, as well as mental health services partnering with community organizations -Stigma important to consider in clinical practice and future research

E. L. Mortensen et al. (2014). Personality in Late Midlife: Associations With Demographic Factors and Cognitive Ability. Journal of Aging and Health. Vol. 26(1) 21-36.

Ten Main Points: • study is based on the Cophenhagen Ageing and Midlife Biobank (CAMB) and participants were from Danish cohorts with the goal of the study being "...(a) to analyze associations in late midlife between sex, age, education and social class, and the Big Five personality traits; (b) to analyze associations between these personality traits and cognitive ability in late midlife; (c) and to evaluate how these associations are influenced by demographic factors" (p. 23) • personality variable was measured using an inventory that assessed the Big Five personality traits (Neuroticism, Extraversion, Openness, Agreeableness & Conscientiousness), cognitive ability variable was measured using three subtests from the German Intelligenz-Struktur-Test 2000, demographic factors included: age, sex, school education, vocational training, and occupational social class • "late midlife" was defined by the participant pool as between 49-63 years old Results/Dsicussion • associations between demographic factors and personality: "...younger age group had significantly higher scores on Extraversion" (p.30) • "...women scored significantly higher than men on Neuroticism, Openness, and Agreeableness. These sex differences are in accordance with other studies (Costa et al., 2001), and notably, our results suggest that they are independent of education and social class and that sex differences in personality may contribute to explaining sex differences in health and aging processes" (p.32) • "...with regard to both school education and vocational training, the only significant adjusted association was found for Openness" (p.32) - combined measures of length of education should be used in analysis • "... a characteristic pattern of associations between occupational social class and personality was observed: Neuroticism increased, whereas Extraversion and Conscientiousness decreased with lower social class" - this relationship is complex because of the direction of association, social class may influence personality and personality may influence social class • "... cognitive ability and personality, all unadjusted correlations between cognitive ability and the NEO-FFI personality traits were significant" (p.33) • some of the personality differences among cohorts can be attributed to selection factors in the establishment of the cohorts • ***BIG POINT**: "sex, years of education, social class, and cognitive ability were associated with Big Five personality traits in late midlife" - which may influence health and early aging

The Mental Health Program

The program and services that are available to those with mental illness and their families; Mental health reform in Ontario - including Brian's Law (Bill 68), "Making It Happen", and the Mental Health Implementation Task Forces; The Consent and Capacity Board, an independent body created by the provincial government that conducts hearings under the Mental Health Act, the Health Care Consent Act, the Substitute Decisions Act and the Long Term Care Act.

Balancing Public and Private Interests for medications in older adults

The Older Patient as A Burden To the Health Care System and Society The older patient as an asset to the Pharmaceutical Industry Marijuana: you can't patent marijuana, but you can patent the combinations

Intelligence

The ability to negotiate environmental demands successfully or: That which intelligence tests measure. (fluid and crystallized)

Alzheimer's brain

The brain physically shrinks Brain develops holes in the brain Usually you can't identify in the MRI imaging. Nerve cells that change the signals. In the cell, the

Cost of Chronic Disease

The financial impact of chronic conditions is substantial, and both the direct impact on health care costs and the indirect effects (such as loss of productivity) a study by PHAC found that the total burden of cardiovascular disease in Canada in 2000 was $22.2 billion, including $7.6 billion in direct costs (33% of costs). 2000 study showed that the total economic impact of arthritis was $6.4 billion, with seniors accounting for $1.7 billion (27% of costs)

Canada Health Transfer

The health transfer currently represents about 10 per cent of all federal spending. For the sake of comparison, health-care costs make up 42 per cent of the Ontario government's total program spending.

K. Jacklin et al., (2014). The Emergence of Dementia as a Health Concern Among First Nations Populations in Alberta, Canada. Can J Public Health, 104(1):e39-e44.

The number of people who have dementia and Alzheimer's disease is expected to double in the next 30 years - In the past, there haven't been many studies conducted on dementia in the First nations population - This paper discusses dementia as a health concern among the First Nation Population in Alberta using population-level data - Methods used to examine this ussie included analyzing Aggregate data from Alberta health and Wellness, checking physician treated prevalence rates of dementia for First nations and not first Nations who have taken treatment and who have not taken treatment - Effects of sex and age were examined - dementia disproportionately affects males who are in the younger age group examined in this report in First Nation populations - Dementia is an increasing health concern in the First nation population for reasons such as the impacts of social determinants of health, aging population, and a higher rates of risk factors - There is not much access to dementia health services in remote reserve locations where most Frist Nations people live - Due to the effects of residential schools on the First Nations population, the PTSD from this historical trauma can have an impact on the prevalence of dementia - Program planning, policies and having dementia care services are necessary for this population

Age-Friendly Communiites

The physical and social environment is designed to promote "active and healthy aging"

Aging in Place

The situation of older people living into late old age in the same place they lived in their middle years Policy attempts to provide older people with environmental, social & economic supports so they can stay in their own homes as they age. • Corresponds to the desire to stay out of a nursing home. • Salomon (2010) found that 89% of people wanted to say in their homes "indefinitely"; If not possible, then to say as long as possible in their local community

Key finding o social isolation studies

The strong associations between social participation and health and well-being emphasize the importance of addressing the barriers faced by the nearly one-quarter of seniors who reported a desire to participate in more social activities.

Dr. Samir K. Sinha (2013). Living Longer, Living Well. Highlights and Key Recommendations From the Report Submitted to the Minister of Health and Long Term Care and the Ministry responsible for Strategy for Ontario

There is a greater number of Ontarians living longer and living well into their later years - Older Ontarians helped build our country and remain an integral part of society (i.e. through sharing of experiences, knowledge, wisdom, etc.) - In Ontario, older adults drive health care costs because they tend to use more expensive and intensive types of services - If this is not addressed, this demographic challenge could bankrupt the province but this is also an opportunity to better understand and meet the needs of our aging population - In 2012, Ontario set out a new vision to make the province the healthiest place in North America to grow up and old—development of a Seniors Strategy to work towards identifying and addressing ways we can improve as the needs of older Ontarians change in the future - Ontario's Action Plan for Health Care: Ontarians receive the right care, in the right place, at the right time - Seniors Strategy required the review of a number of strategies, approaches and practice as well as the involvement of many stakeholders - 5 principles for a Seniors Strategy: help build a province that values, encourages and promotes the wellness and independence of older Ontarians o Access—accessing appropriate services and supports in a timely and efficient way o Equity—ensure that ALL older Ontarians have their unique needs met o Choice—need to ensure that older Ontarians, their families and caregivers have as many choices as possible and provide them with the best information so they can make informed decisions o Value— efficiently and effectively spend our tax dollars to ensure the sustainability of our system, programs and services o Quality—constantly ask ourselves whether we are focusing on quality and need to ensure we are not sacrificing quality for the sake of costs - Summary of overall findings and key recommendations o (1) Promoting health and wellness: improving access to information and services (i.e. physical activity, volunteer work, continuous learning) that allows older adults to stay healthy and at home longer o (2) Strengthening primary care for older Ontarians: provide high quality care and ensure every older Ontarian who wants a primary care provider can get one o (3) Enhancing the provision of home and community care o (4) Improving acute care for adults: every hospital needs to be a senior friendly hospital o (5) Enhancing Ontario's Long-term care home environments o (6) Addressing the specialized care needs of older Ontarians: importance of specialists in geriatric medicine, psychiatry and palliative medicine in supporting older Ontarians, their families and caregivers o (7) Medications and older Ontarians: need to improve the knowledge of older Ontarians taking medication, to support safer prescribing practices, and the administration and review an individual's medication o (8) Caring for caregivers o (9) Addressing ageism and elder abuse: educating Ontarians on elder abuse (what, how to prevent and how to support victims) o (10) Addressing the unique needs of older Aboriginal People's in Ontario: providing culturally appropriate care and services o (11) Supporting the development of elder-friendly communities - Adequate funding is critical to support the successful implementation and sustainability of recommendations and goals listed in the report

E. Raymond & Amanda Grenier (2013). Participation in Policy Discourse: New Form of Exclusion for Seniors with Disabilities?. Canadian Journal on Aging / La Revue canadienne du vieillissement, 32, pp 117-129.

This article is a discussion about 'participation' of adults as they age. The current definition of what it means to participate does not match up with the actual ability and reality of older citizens to be able to participate. Often times due to disabilities they cannot end up participating and the current policy excludes these individuals in their definition of participation. It argues that we need to examine the definition of participation that current policies reflect and how that affects the number and ability for older individuals to participate in society. The current view of aging individuals has changed from policies that viewed them as needing to be protected and weak to the current policies that emphasize the important societal rolls they fulfill. This results in exclusionary attitudes towards many older individuals. They examined policies enforced by the Quebec government to frame their arguments. Policy 1) participation was employed to define the roles and contributions of older people in society Policy 2) participation focused on the individual's rights and desires to access diversified and meaningful projects in retirement. Policy 3) shifted further Participation was no longer an array of practices articulated according to seniors' preferences and situations, but implied that aging took place within an active and contributory framework. Their two main arguments against these policies are 1) People who are aging that have disabilities aren't included in policies as they refer to older people living independently as adults and making it seem as though participation is primarily a matter of choice. (bench mark of social death) 2) These frameworks don't' capture the extent to which individuals are living with disabilities The argument and overall conclusion of the paper based upon these studies and their findings is that policies need to be more inclusive and not structured so much in a way to push others to the outside. Individuals who are older or disabled and cannot participate in such activities as they said according to the "defined standards would be left out". They concluded policies need to be more inclusive to get more people involved, both within Quebec where these policies are as well as outside this jurisdiction. A major component to achieving this is understanding the various perspectives and experiences of older aging individuals and understanding how intersectionality (mainly regarding disability) plays a role. When we understand the experiences of those individuals when it comes to social activity and participation in their daily lives we can have more reflective representative definitions of participation and supporting policies

M. G. Ory et al., (2013). National Study of Chronic Disease Self-Management: Six-Month Outcome Findings. Journal of Aging and Health. 25(7) 1258-1274.

This study investigated how the Chronic Disease Self-Management Program (CDSMP) changes health outcomes, lifestyle behaviours, and healthcare service utilization over a 6-month period. 2. With the increasing prevalence of multiple chronic conditions in our society, self-management strategies are essential to avoid the onset of chronic conditions and help those with diseases manage their conditions more effectively in terms of slowing disease progression, reducing complications, and lowering costs. 3. CDSMP is designed to address the complex array of health issues and self-management behaviours that cut across different chronic illnesses. This program was delivered in a small-group workshop format and stresses concepts, including goal setting, problem solving, and action planning. 4. Outcome measures were collected at baseline and 6-month follow-up in terms of improvement in primary outcomes (social/role activities limitations, depression, and communication with physicians) and secondary outcomes (healthcare utilization, and lifestyle behaviors such as prescription medication adherence and physical activities). 5. All three primary outcomes (role, emotional, and medical management) improved significantly. The adjusted analysis also revealed significant changes for most of the secondary outcomes, with the exception of stress symptomatology, medication adherence, and number of doctor visits. 6. Better patient-physician communication can positively influence self-efficacy and behavioral outcomes among patients with chronic conditions. 7. The continued widespread dissemination of CDSMP should be complemented by geriatric education programs that assist physicians in not only being prepared but also for initiating more meaningful communication with their patients. 8. Study participants reported significant improvements in more physical activity and less emergency room (ER) visits and hospitalization. 9. These findings stress the importance of encouraging increased patient referrals to such evidence-based CDSMP. 10. Decrease in ER visits and hospitalization is indicative of the potential saving in healthcare costs. Considering the fact that economic burden of chronic diseases has increased, CDSMP has potential to contain health care costs.

Health care costs

Total health care use increased with the number of reported chronic conditions across all senior age groups. Older seniors did not report a higher rate of health care use than younger seniors; therefore, the number of reported chronic conditions was more important than age as a determinant of health care use by seniors. Overall, adults age 45 to 64 and seniors accounted for 14% and 44% of all reported health care visits, respectively

Saunders, C. (2001). The Evolution of Palliative Care. Journal of the Royal Society of Medicine. 94; 430-432.

Total pain: o Defined in 1964 o Included physical symptoms, mental distress and social and spiritual problems • In 1950s 3 surveys were undertaken that demonstrated inadequate conditions of those in the end stages of life in nursing homes and at home, as well as that much suffering remained untreated in London hospitals and that patients near end of life were aware of their prognosis despite the lack of information often given at that time. • Patients and doctors widely held the beliefs that drug dependence and tolerance would be developed out of drug use for pain management • 1950's oral administration of morphine and detailed recording regimen. This reduced pain immensely • 1959 began a project on how to improve the gap in National Health Service provision was launched as a new charity St. Christopher's Hospice • By 1967, 184 references from the library of the Royal Society of Medicine had been assembled, despite anecdotal evidence far outweighing officially documented evidence • Poorer Londoners joined the medical students for their rounds and new practices in pain management and evidence of a positive response became the basis of lectures and articles • Widely transferable methods were developed to be used in the new hospice upon its completion • Challenges included accommodating for the spiritual and grief needs of their patients, especially in an increasingly secular society and institution. The building had a chapel for Christian worship but was not officially affiliated with any faith • Another challenge was training staff in an innovative way to deal with pain and bereavement • A tour of the United States and visits to the UK allowed for connections to be made, knowledge to be acquired and similar projects to be developed elsewhere • St. Christopher's Hospice became a model for similar homes for the aged globally their methods of pain and bereavement management were especially innovative

Aging with HIV Impacts on Mental Health

Uncertainty • Unexpected survival • Symptom interpretation • Medical uncertainty Stigma • In healthcare • Misinformation • Physical appearance • Compounded stigma • Anticipated stigma

ON EXAM: Conceptualizing Chronic Illness

Underlying drivers: social determinants of health, globalization, urbanization, population aging Behavioral risk factors: tobacco use, unhealthy diet, physical inactivity, harmful use of alcohol Metabolic/physiological risk factors: raised blood pressure, overweight, raised blood glucose, raised lipids.

Vascular Dementia

Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrients. □ Vascular dementia symptoms may be most obvious when they happen soon after a major stroke. Sudden post-stroke changes in thinking and perception may include: □ Confusion □ Disorientation □ Trouble speaking or understanding speech □ Vision loss □ Common early signs of widespread small vessel disease include: □ impaired planning and judgment; □ uncontrolled laughing and crying; □ declining ability to pay attention; □ impaired function in social situations; and □ difficulty finding the right words.

Stereotypes about Disability

Victim: •People with disabilities can't lead a full life • People with disabilities are sick, in pain • People with disabilities should be the object of sympathy, pity • People with disabilities are dependent, need help Hero: • People with disabilities prove their worth by overcoming disability to become more 'normal' • Promotes individualistic view of disability; society doesn't have to accommodate • Burden of being 'brave' and 'inspiring' Villan: • Resentment fuels anger among people living with disability • People living with mental illness are especially vulnerable to this stereotype

Death trajectories

We know a lot about the first trajectory which is basically the cancer trajectory. (usually the 1st 2nd and 3rd line of treatment, and then quality of life goes down. Really difficult to predict in medicine Chronic disease trajectory is more and more prevalent Last trajectory is for alzheimers is steep decline in quality of life, but trajectory towards death is long (could be 10, 15 years)

The Discourse of Aging and Medication use

We think about aging as a disease or that is working against you. Your body is something you can fix with medicine Drugs ascure/can't cure •The deficit lens vs. hope •Aging as disease •Body as object to be 'fixed' •External authority •Shackled to medication regimen/ non-compliance •Normality/ Seen as different •Drugs as cure/ Can't cure

What do people do when they feel sick or feel that 'something is not right'?

When you haven't had before Interfering with school, work, or daily life Cyberchondriac: diagnose yourself online. In older adults, does this same process apply? Older adults have experienced a lot of the pain.

Increase of Poverty in older adults

While the seniors below the LICO threshold have declined sharply since the mid-1970s, Canada has witnessed a recent increase from 4.8 to 5.2 per cent between 2007 and 2010.

Gendered differences in sources of income

Women make a lot less than men do: differences in workplace pension Note: the income GIS OAS is higher for women (which show that you are low income)

Chronic illness in older adults: globally

Worldwide: Chronic Illness accounts for 63% of all deaths; and premature deaths in those 60 years of age and under 13% in High Income Countries vs. 29% in Low/Middle Income Countries African countries will see a rise in deaths from chronic illness by the year 2020

Ambiguous loss

a loss that occurs without closure or understanding. This kind of loss leaves a person searching for answers, and thus complicates and delays the process of grieving, and often results in unresolved grief."

Parkinson's Disease Dementia

a decline in thinking and reasoning develops in someone diagnosed with Parkinson's disease at least a year earlier. □ Changes in memory, concentration and judgement □ Trouble interpreting visual information □ Muffled speech □ Visual hallucinations □ Delusions, especially paranoid ideas □ Depression □ Irritability and anxiety □ Sleep disturbances

Disengagement theory of aging/dying

awareness of impending death starts the process of disengagement. People know that they will die soon, so they ease their way out of social life

Leisure and Health: Activity Leisure Lifestyle

beneficial because: • Aerobic capacity and peak performance declines with age • BUT! There is a lack of research consensus about role of age vs. past health issues, underuse of body, past habits and lifestyle on this decline. • Exercise can slow or reverse this decline. • Leisure can help cope with stress. Exercise helps with memory, cognitive speed and intelligence.

chronic illness and disability

chronic illness and disability are not always the same thing nor always occur together • A chronic illness is a specific health condition (e.g., diabetes, HIV, dementia) "of long duration and generally slow progression" (WHO) • Disability occurs when there is a complex interaction between a person's body and their environment

Alzheimer's Tissue

has fewer nerve cells and synapses than a healthy brain. □ Plaques, abnormal clusters of protein fragments, build up between nerve cells. □ Dead and dying nerve cells contain neurofibrillary tangles, which are made up of twisted strands of another protein.

The components of mental health recovery

hope, self direction, individualized & person-centered, empowerment, holistic, non-linear, strengths-based, peer support, respect, responsibility

Unique factors for mental health in older adults

i) those growing older with a recurrent, persistent or chronic mental illness; ii) those experiencing late onset mental illnesses; iii) those living with behavioural and psychological symptoms associated with Alzheimer's disease and related dementias; and iv) those living with chronic medical problems with known correlations with mental illness (for example, Parkinson disease, cerebral vascular disease, chronic obstructive lung disease).

Drugs to maintain/restore health

inhaler antidepressant

Illness

more subjective

Age Stratification

patterns of the unequal distribution of wealth, power and privilege among people at different ages in the life course, still persist into old age. Pension system is based on what you contributed: based on how much money you are making. Inequality persists! YES: 1. Accumulation of advantage/disadvantage hypothesis 2. Ageism ingrained in social structures 3. Triple jeopardy hypothesis: Older woman who has dementia who is a widow (triple jeopardy) Absolute vs relative socioeconomic inequality: -Older adults doing better, but when you are looking at some populations, they are doing better -Relative equality: relative to people around you

Social Support

refers to help and support we give to and receive from others Social support for older adults-->coping with aging, quality of life and well-being Informal support: refers to unpaid help given by friends, neighbours and family Formal support: help given by professional caregivers such as doctors, nurses, social workers... paid homemakers, and healthcare services Informal Caregiving: unpaid care provision with a tie of kinship affection toward the care recipient -accounts for 70% of care of older adults

Ego development theory of aging/dying

the last stage of life leads to a life review. A person looks over his or her life, achieves acceptance of the life lived, and prepares for death... People in this stage often feel a deep concern for others and for the culture they will leave when they die." Gerotranscendence

Long-term memory

the storehouse of knowledge that also includes the rules for applying knowledge

Hierarchical compensatory model

theres a hierarchy of people helping based on your relationship with the person

Task specificity model

when you need something you have certain people who will provide specific support for you.

Immigrant older adults and finance

women immigrants more likely on GIS (double jeopardy)

Exam question: What are the implications of living longer:

women- living on low income, living alone, may have to go back to work

Convoy model of support

you will move through these events with people, as you start to loose people along the way, you will recreate those functions and roles in life

Lifelong Singlehood

• A small proportion of older Canadians have never been married (5.3% of older men & 5.5% of older women) - down from just over 8% in 1981 (Turcotte & Schellenberg, 2007) • Little research on the lives and social relationships of lifelong single older adults (Carr & Moorman, 2011) • Older singles face stereotypes of aging • Live lonely, socially isolated lives, disconnected from family. • Most older singles, particularly single women, develop strong and diverse social networks & have active ties with siblings, friends & other family members

Health and Social Isolation

• Berkman and Syme (1979): Very famous study found that people without community or social ties were more likely to have died at follow-up. • Mendes de Leon, et al. (2003): More socially engaged older adults reported less disability. • Healthy Aging in Canada (2006): • Social support is a critical component of mental health promotion. • Distress, isolation and social exclusion increase substantially the risk for poor health and loneliness and act as a predictor to death. • Canadian seniors who reported a strong sense of community belonging were more likely to be in good health compared to seniors who felt less connected

Later Life Event

• Changes in marital status (divorce, widowhood) often lead to change in a person's social status and a change in that individual's network. • In 2011, 72.1% of senior men and 43.8% of senior women lived as a couple. • Men are more likely than women to be married in later life (Milan et al., 2007; Turcotte & Schellenberg, 2007) • Among the oldest seniors (85 years+), 46.2% of men and only 10.4% of women lived with a spouse or in a common-law relationship. ***• Older women are more likely to be widowed.

Old Age Security

•A taxable federal income security payment to older adults 65+, who make less than $115,000 •Residency requirement (10 year minimum). Funding: •OAS now financed out of government's consolidated revenue fund. Administration: •Through the Income Security Programs Branch of ESDC now through regional offices. THIS IS A TAXABLE INCOME

C. M. Ogle et al., (2014) Cumulative exposure to traumatic events in older adults. Aging & Mental Health, Vol. 18, No. 3, 316-325.

• Exposure to multiple traumatic events exerts a greater negative impact on how severe post traumatic outcomes are in comparison to singular trauma. • Older adults may experience certain types of trauma such as loss of a spouse or social networks. • Retirement can also be associated with triggering PTSD symptoms. • Cumulative exposure to self oriented (trauma directed at the self) events are associated with more depression and loss of wellbeing • Early life other oriented traumas (not directed at the self) are associated with lower depression and higher well being • This article focuses on 60+ baby boomers because they are ideal to examine the effects of cumulative trauma since they have lived "long enough" to be exposed to many different types of trauma • Also they have experienced significant historical events at points in development ex: Vietnam war. • PTSD is classified by an event or events that involved actual or threatened death or injury and those perceived to be life threatening are associated with more severe symptoms than those that are non life threatening. • According to the big five personality traits, neuroticism is associated with high negative affect meaning the likelihood of encountering a negative situation is higher and the tendency to interpret neutral or ambiguous situations as threatening are increased. Therefore, ptsd symptoms may be increased • Participants included themselves and their spouses and were from the North Carolina Alumni Heart Study. n=3682. • All participants were born in 1940 and onward • Results showed that cumulative exposure significantly increased PTSD symptom severity • PCL severity scores the greatest cumulative exposure was childhood violence. • Even in community dwelling baby boomers who have greater access to resources that can protect against PTSD (due to education/cohort membership), PTSD from these cumulative exposures still affect them. • Single traumas did not account for variance in symptoms • The more older adults construed their distressing trauma as central to their identity the more variance there was in PTSD symptoms - This could be possibly because they see the trauma as apart of who they are it informs daily actions/decisions • They also found a relation to the life course perspective in the sense that cumulative disadvantages negatively impact developmental trajectories • Individuals who experience "other oriented" traumas may feel a social responsibility to care for individuals impacted by the event. Therefore, this responsibility to care for others may alleviate PTSD symptoms - Perhaps helping is a means of distraction from the traumatic event or the social aspect of being with another person helps. Does this mean that increasing social opportunities has a role in helping PTSD? • The sample all attended college so they are considered "advanced" in terms of socio economic status which may play into the trauma they experienced in comparison to someone of a lower SES • As well SES may have increased the amount of resources they had available to them to help cope with the trauma

Best Social Network

• Family-dependent or private-restricted networks are most at risk for depression, loneliness, and other mental illness, whereas those in locally integrated networks are at the least risk. • Wenger et al. (1996) report that those with private or self-contained networks are more likely to be isolated than those with locally integrated or community-focused network types.

Types of Older Adult Social Networks (ON THE EXAM)

• Family-dependent: Focused on close family ties with few neighborhood and friend links. • Locally-integrated: Including close relationships with local family, friends, and neighbors. • Local self-contained: Primary reliance on neighbors. • Wider community-focused: A high salience of friends. • Private restricted: Has no relatives, few nearby friends, and low levels of community involvement.

Quick Stats: Fall Related Injuries

• Focus: Falls, leading cause of injury related hospitalizations and death in Canada for 65+ • Older women (74+) more likely to fall and be injured then men • Interesting? 56% of fall victims: married • More likely to fall if you are widowed? - Why? by themselves Fall related injuries are increasing Time measurement effects: people are using their cell phones more! 74% of falls related injury is from walking 32% of fall related injury to knee, lower leg, hip Importance of calcium: Calcium: bone strength Body's ability to handle acid: calcium carbonate. Fall related injury includes mostly broken or fractured bones: have to do with calcium Treatment Sought: Emergency room is 67% (high cost place)

Case Study: Urinary Incontinence (UI)

• For many community living and institutionalized older adults, urinary incontinence is a major issue • Urinary incontinence: symbolizes loss of control-->view is incompatible with idea of successful aging and self-reliance • Moral consequences: incontinence seen as the starting point of incompetence • The condition is aggressively treated in younger adults, those with spinal cord injuries and disabilities--> but not in older adults • Therapeutic aim: removing stigma and keeping younger person connected to society • Urinary incontinence is treated with "adult diapers"--> can be treated, reversed with medication • Views of health professionals: UI is inevitable for older adults Urinary incontinence is an illness. For younger adults, it is treated in a completely different way than in older adults. --In younger adults, it is aggressively treated • Many older adults with UI never report having this issue • Report: Fear of becoming dependent or being thought of as "losing it"--> loss of personhood • Medicalization and De-medicalization of issues: try to fit older adults into a stereotypical view of aging • Bladder control: central to the maintenance of sense of self

Research Dilemma

• If you were investigating social variables on health in older adults, and could only include two constructs (e.g., social engagement + loneliness, OR social networks + social support, etc.), which two would you pick + why? • Would it depend on who you were doing the research for (e.g., inform government policy; inform health professionals?)

Impact of Rehabilitation in Chronic illness

• Improved quality of life • Decreased impact of the primary illness and/or secondary health issues • Enhanced functioning and coping • Supports therapeutic adherence • Enables preparedness to cope with episodes of illness • Increased number of symptom-free days • Decreased need for pharmaceutical management of mental health issues and pain. • Increased satisfaction with primary care

K. Kobayashi et al. (2009). Making meaningful Connections: A Profile of Social isolation and Health among Older Adults in Small Town and City B.C. J Aging Health 21: 374

• In 2003, the Federal-Provincial-Territorial Ministers responsible for Seniors in Canada identified social isolation as a priority issue, emphasizing it's potential impact on the health status and health care utilization rates of older adults. - The reason for this interest was that socially isolated older adults (whether physically isolated geographically or by circumstances) may have poorer health and a higher than average need for care and might consequently use the health care system in inadequate ways (under-utilize services resulting in unmet need or over-utilize services resulting in a burden on the system) - Social isolation is a complex concept o Has been constructed as an "at risk" phenomenon o A negative consequence of the representation of social relationships and health - Studies show that older adults (age 65 and older) highly and consistently rank the importance of relationships with friends and family as the second most important value, after health. o Among older adults, social integration and participation in society are regarded as important indicators of productive and healthy aging and according to the World Health Organization; social support has a strong protective effect on health. - Physical environment factors such as place of residence, geographic distance from family and friends. Problems negotiating transportation and weather, inadequate housing or homelessness, and living alone have all been found to contribute to social isolation in later life populations. o In addition to mental health, a range of risk factors for social isolation such as depression, introversion, coping with loss, and lack of self-esteem, emerges. o Social factors also contribute to social isolation such as being female, having low income status, coming from certain ethnicities, being widowed or divorced, experiencing family conflict, and experiencing ageism. - The unanswered question: Social isolation has a negative impact on health or declining health status results in increased social isolation among older adults?

Health Equity, Intersectionality, Aging & Disability

• In almost every age group, more women experience disability • Older Indigenous women are 1.5x as likely to live with disability than nonIndigenous older women • Prevalence of disability among older immigrant women is higher than for non-immigrant women, and all men

Older Adult Social Networks

• Large networks most common among those who were still married & single people more likely than others to have small social networks.

C. Gibbons et al., (2014). The Psychological and Health Consequences of Caring for a Spouse With Dementia: A Critical Comparison of Husbands and Wives, Journal of Women & Aging, 26:3-21, 2014

• Main goal of this study was to clarify differences in the experience of caregivers who were husbands and wives with respect to burden, health, healthy behaviors, presence of difficult care recipient behaviors, social supports, and the quality of the premorbid relationship • Most caregivers had a medical condition themselves with a greater proportion of women compared to men. - Conditions include: arthritis, back problems, diabetes, heart conditions, high cholesterol, hypertension, anxiety, and osteoporosis • Majority of care recipients were male being cared for by their partners of the opposite sex • Overall female care recipients demonstrated fewer problem behaviors than men. - No differences on both the nonphysical and physically aggressive behavior - Men demonstrated a greater frequency of both verbally and nonverbally aggressive behaviors • Women experienced higher strain in the caregiving role, personal life, physical component, mental component, had higher rates of depression and healthy behaviors. • Results of this study support research demonstrating a difference between the caregiving experiences of women and men - Female caregivers experienced more burden, had poorer mental and physical health, increased depressive symptomatology, and took part in fewer health-promoting activities • Several wife caregivers were physically and sexually attacked by their husbands • It is possible that women also experience a higher risk of morbidity

Housing and Transportation older adults

• More than one senior household in four (28.4%) lived in "below standard' housing - housing that lacked adequate physical conditions, suitable size, and affordability. (Canada Mortgage & Housing Corporation, 2010) • 14.4% had core housing need - lived in unaffordable & crowded housing. • One quarter of senior women living alone reported a core housing need. • Quality of housing largely dependent on a person's income.

Barriers to Social Participation

• Nearly one in four seniors (24%) reported that they would have liked to have participated in more social, recreational or group activities in the past year. Younger seniors and women were more likely to have felt this way. • Most commonly mentioned obstacle to participating in more activities was a health limitation (33% of men, 35% of women). • Social participation may not be entirely dependent upon personal choice—external factors can play a role. • For example, the cost and the availability of activities in the area or at a suitable time or location can influence participation. Such barriers were reported by 4% to 9% of Canadian seniors.

Changes in Social Networks

• Older people's networks have also been shown to change across time (Antonucci, 2001; Carstensen, 1992) • Whereas some older people may retain a broad range of contacts, others reduce their connections for practical or emotional reasons, and for some, these changes mean that social contacts become limited to family or carers.

HIV and Aging: income issues

• Pension insufficiency • Workplace/private pension plans • Savings • CPP • The combination of age-based eligibility and the potential for functional decline at a younger age • Changes in total income and cash flow when transitioning between benefit programs

episodic disability

• Periods of good health may be interrupted by periods of illness or disability. • Often it is difficult to predict when these "episodes" of disability will occur or how long they will last. • Other episodic disabilities include multiple sclerosis, lupus, arthritis, cancer, diabetes and mental health conditions, amongst others. Challenges: Many of the same challenges associated with other forms of disability (e.g., stigma) PLUS • Definitions of disability • Care, treatment and support issues • Workplace accommodation / employment issues • Income support and security • Legislation and policy • Education

Contributing factors to poor social health ** ON EXAM

• Personality (e.g., low self-confidence or self-esteem) • Being a caregiver (no time and energy) or having other personal/ family responsibilities • Physical/functioning limitations (e.g., disability, mobility restrictions) • Mental changes (e.g., depression after the loss of a partner) • Environmental problems (e.g., poor accessibility - transportation, location of residence) • Abuse (e.g., neglect, financial, physical) • Poverty (e.g., cost of activities, barriers for reciprocity - inviting people over, buying presents, etc.)

Older Adults' Use of Time

• Post-retirement, older adults may engage in a variety of activities including housework, shopping, leisure, recreation and civic and social engagement (Stobert, Dosman & Keating, 2006). • Two common forms of leisure for older adults--passive leisure (e.g. watching TV or listening to radio) and active leisure (e.g. reading, socializing with friends). • Men, and people with a university degree tend to show the greatest tendency to engage in active leisure

Rehabilitation Services Access Barriers

• Rehabilitation services not publically funded outside the hospital setting • Some people may have coverage through employee benefits plans, but this is not universal and may not be adequate Barriers to access include: • cost of private provision • availability of services which differs by geographical region, health and social status • strict eligibility criteria both for insurance coverage and participation in services (including age-related criteria) • wait lists for publically‐funded care • lack of awareness of the full potential of rehabilitation services among health practitioners and individuals experiencing disability • a health system‐wide orientation toward acute, reactive care rather than prevention and the proactive development of self‐management strategies

Remarriage

• Remarriage late in life is relatively uncommon. • More likely to occur for men than women and for divorced older adults than widowed. *** Motivations to remarry later include loneliness (especially for men) and financial security (particularly for women)

Housing for Homelessness

• Shelters do not meet the needs of older homeless people • Cannot help with ADLs or address mobility issues. • Supportive housing & assisted living sometimes serve homeless seniors - do not provide 24-hr nursing care but provide a room, meal services, recreation & healthcare programs. • Greater awareness of senior homelessness may lead to more support for poor older people; supports should include: quality low-cost housing, healthcare services, food services (e.g., Meals on Wheels) where needed.

Role of Gender

• Small networks were most common among single men, followed by widowed men, while married men were the least likely to have small networks, • Among women, social network size was unrelated to marital status while men's networks appeared to shrink on widowhood, while women's networks remained stable, • Provided some indications of variation in networks.

Components of Social Health

• Social Networks • Social Capital • Social Support • Social Engagement • Social Isolation/Loneliness

Social Networks

• Social structures that potentially provide support to (Berkman et al., individuals 2000) • Defined as the web of relationships surrounding the individual, they include a complex of structural characteristics: • Size: Number of network members (reported subjectively by the core member in a total number or by names of people from different circles) • Composition: Who is in the network? (in terms of gender, relations to the focal person, age, etc.) • Distance: The direct connections from one actor to the next • Density:Extent to which members of the network know each other • Also have relational characteristics: • Frequency: The number of times actors interact with one another • Intimacy: The focal members' subjective perception of the strength of ties

M. J. McGregor, et al. (2014). Nursing Home Characteristics Associated with Resident Transfers to Emergency Department. Canadian Journal on Aging / La Revue canadienne du vieillissement, 33, pp 38-48.

• Study examines how nursing home facility ownership and organizational characteristics relate to emergency departments transfer rates - When nursing home residents are ill or injured (experience complex medical and functional trajectories), they are typically transferred to the nearest hospital emergency department (ED) for additional care and/or evaluation • Facility ownership is one factor found to influence variation in nursing home performance - Non-profit facilities: facilities owned and operated by non-profit community and religious organizations - For-profit facilities: facilities registered as corporations that may or may not be part of a larger corporate chain o A significantly higher proportion of for profit facilities had contracted out the long-term hiring, management, and remuneration of nursing staff to an outside company - Publicly owned facilities: facilities owned and/or operated by hospitals or health authorities o Publicly owned facilities were somewhat larger compared to for-profit (difference in mean number of beds: 22) and non-profit facilities (difference in mean number of beds: 60). o A significantly greater proportion of publicly owned facilities employed a clinical nurse specialist and other allied health staff (physiotherapist, social worker, and occupational therapist). o Publicly owned facilities also had a significantly higher mean number of total direct-care nursing (registered nurse [RN], licensed practical nurse [LPN], and care aide) hours per resident day • Facility characteristics associated with significantly lower rates of ED transfers in univariate cross-sectional analysis were : - (a) larger facility size; - (b) facility employment of a care coordinator, clinical nurse specialist, a physiotherapist, a social worker, an occupational therapist, or an activity aide; - (c) higher mean registered nurse hours per resident day; - (d) higher mean total direct-care nursing (RN, LPN, and care aide) hours per resident day; - (e) fewer number of physicians per 10 residents; - (f) timely attendance by physician or nurse practitioner described as "easy"; and - (g) facility reporting a majority of residents' usual physicians attend annual care conferences • Facility characteristics associated with significantly higher rates of ED transfers were - (a) facility employment of a clinical resource nurse or recreation therapist; - (b) participation of care aides in annual resident care conferences; - (c) reported attendance of medical director of care at the residents' annual care conference "most of the time"; and - (d) presence of standing orders in palliative care • How do population ED transfer rates in one large British Columbia health region differ by facility ownership? - The study found a significantly lower rate of ED transfers among residents of publicly owned facilities compared to both for-profit and non-profit facilities. • Other factors that influence lower ED transfer rates - Timely attendance by a physician or nurse practioners was associated with a lower ED transfer rate o Having timely medical assessment of an ill resident may enable an early clinical diagnosis and the initiation of treatment at the facility - Facility employment of an activity aide was associated with lower ED transfer rates

International Classification of Functioning, Disability and Health **(ICF) BIOPSYCHOSOCIAL on exam

• The International Classification of Functioning, Disability and Health, known more commonly as ICF, provides a standard language and framework for the description of health and health-related states. • A biopsychosocial model • A classification of health and health-related domains -- domains that help us to describe changes in body function and structure, what a person with a health condition can do in a standard environment (their level of capacity), as well as what they actually do in their usual environment (their level of performance).

Coyle, K. & Dugan, E. (2012). J Social Isolation, Loneliness and Health Among Older Adults, Journal of Aging and Health 24(8) 1346-1363.

• The differences between social isolation and loneliness. Social isolation is the lack of relationships and interactions, while loneliness is a subjective feeling, both contribute to poor health. The level of social connection can affect one's psychological and behavioral processes. • HPA (Hypothalamic-pituitary-adrenal): an axis in the neuroendocrine system that's responsible for stress in the body. The feeling of loneliness can trigger HPA and result in negative health outcomes. • The reading focuses on the connections between social isolation and loneliness, as well as their individual affect on the health of older adults. • Data is derived from the Health and Retirement study (HRS), a cohort panel that started in 1992 and interviewed samples of adults aged over 50 in the United States. Samples of participants must complete the Leave Behind Questionnaire (LBQ), which is a self-report questionnaire. Nursing home residents were excluded due to their unique social resources. • Mental health was determined by one question: "Has your doctor ever told you that you have an emotional or psychiatric problem? This is an universal indicator of recognizing mental health issues. • Factors such as the frequency of contact with family members and friends are measured. To test for loneliness, the questions such as "How often do you feel that you lack companionship?" "How often do you feel left out?" and "How often do you feel isolated from others?" Most replied with often to almost never. This was also used to measure depression. • Other behavioral factors such as smoking and drinking habits were also taken into account, to show that high consumption in alcohol and smoking result in worse health conditions. • Approximately 16.6% of the sample reported having a mental health problem. 25% of the sample reported their health as being fair/poor. Depressive symptoms for this sample averaged at about 1.5 symptoms. • It was found that loneliness and social isolation are not highly correlated, since loneliness is more subjective and social isolation is more objective. Social isolation is not always accompanied with the feeling of loneliness. • The findings from this study find that loneliness is most strongly related to mental health and social isolation with self-reported health.

Volunteering

• The health benefits for older adult volunteers include a decreased incidence of heart disease and improved mental health **** About a quarter of Canadian seniors actively participate in volunteer activities. However, literature shows that most of them volunteer as a result of being approached rather than initiating involvement (Chappel, 1999). themselves Thus, personal request from someone you know was given as the best communication approach to recruiting volunteers

Social Isolation Intervention

• There are different types of interventions for social isolation, which can be delivered by health or social care professionals, instructors, volunteers, students, counsellors, and other professionals. • Group services: seniors are engaged in groups which fills a (social) need (widening their social circles, discussing important issues like loses, friendship and health promotion). • Support groups (bereavement, caregiving). • Educational groups (e.g., internet and social media training, art lessons, therapeutic writing, social skills training, etc.). • Sports and activities (e.g., group exercises in day centers).

Ballantyne, P J, Mirza, RM., Austin, Z, Boon, H., Fisher, J., Cohen-Kohler, JC. (2011). "Becoming Old as a "Pharmaceutical Person': Negotiation of Health and Medicines Among Ethno-Culturally Diverse Older Adults". Canadian Journal on Aging 30 (2):169- 184.

• This article argues biomedicine's increasing reliance on medicines for the treatment of the elderly has placed new kinds of demands on persons navigating later life and old age than experienced by earlier, less medicated generations. • The study used in depth interviews for 2 samples (Canadian subsets) 1 purposive sample of older adults (65 +) with Little English Proficiency. Secondly, a convenience sample of English proficient older adults (65+) • In most interviews, we found that health was framed in terms of social connectedness, being functional and able to engage in desired activities. • Participants from all groups had established lay strategies for health & health care: - self-monitoring, modifications to diet, physical and social activity, and the vetting of medical explanations and recommendations. • Medical consultations were given high priority, but participants described a broad range of other informal and "alternative" health care options. Alternative health care methods were discussed relative to Western medicine, indicating a shared view that biomedicine is the dominant form of health care. • About half reported regularly using Chinese herbs or other therapies (i.e. acupuncture) and prioritized these for particular types of health problems. Portuguese participants described traditional remedies (medicinal diets, or herbal remedies) for health that were based on knowledge and practice passed down through generations. • It is notable that some participants indicated they did not expect their relationship with the medical doctor to include discussion and debate, the physician was professionally trained, and not accountable to them. • Additionally, participants emphasized their respect for the physician, and thought that withholding opinions & actions that were contrary to their physician's advice reflected that respect. • Given the predominance of medicine reliant health care for the elderly and the sub-optimal "adherence" to medicines (non-adherence to prescription meds, inappropriate use of meds, overprescribed): - older patients need to be re-conceptualized as a "pharmaceutical person" - where they negotiate the benefits and costs of medication use in their aging body and recognize it as important to the life of the older patient and prioritize patient-professional communication & interaction for optimal medication use outcomes. • The data demonstrated the patient- professional communication was extremely limited - One step toward addressing the communication gap might be to conduct follow-up research of findings such as ours, take the excerpts from participants interviews to health care professionals for their responses to and reflections on patients' actions and adaptations of medical advice and prescriptions.

Votova, K. et al., (2013). Polypharmacy Meets Polyherbacy: Pharmaceutical, Over-the-counter,and Natural Health Product Use Among Canadian Adults. Can J Public Health 2013;104(3):e222-e228.

• This study looked at prescription medication (PM), over-the-counter (OTC), and natural health product (NHP) used by Canadian adults • NHP used to supplement prescription medications and over-the-counter products • Polypharmacy: individual's use of multiple medications (5+ medications) • Excessive Polypharmacy: more than 10 prescription medications • Polypharmacy more to older adults • Polyherbacy: use of multiple NHPs (dietary supplements, vitamins, minerals, herbals) • Some studies show dietary supplements may be detrimental to health • Higher all-cause mortality risk in older women (65+) with regular supplements compared to women who were not • NHP in North America regulated as food products & not subjected to the same patient safety regulations as pharmaceutical products so consumers may think NHP use is safe i. Some practitioners recommend NHP use and are increasing the risk of adverse drug effects • Subjects in group 1 (high PM & NHP, low OTC) and group 2 (low PM, NHP & OTC) significantly predicted by being older, male, Canadian immigrants • Subjects in group 3 (high PM & OTC, low NHP) predicted by being younger and female • Canadian-born subjects had greater use of OTC than immigrants • Group 1 & 3 more likely to have a regular doctor, less likely for group 2 • Group 3 associated with smaller household size -> more likely to live alone or with 1 other person • Comorbidity significantly associated with group 1 & 3 • Fair/poor health significantly associated with group 1, while good overall health was group 3, and very good/excellent health for group 2 i. Therefore, poor health indicators were associated with a greater propensity to use PM & NHP, but not OTCs • 1 in 5 adults during the study consumed at least 1 of all 3 types of health products i. for these Canadians, potential for drug-herb contraindications was high

Transportation

• Transportation gives older people a sense of independence & sense of control over their lives - visit friends, attend cultural events, go shopping, receive healthcare, etc. • A lack of transportation can lead to isolation, poor health & decreased well-being. • Women aged 85 years+ listed transportation problems as the second most common reason after health for NOT participating in more social, recreational or group activities

Older Adults' Leisure Activities

• Two theories can help explain leisure in later-life: • Research on aging and leisure supports continuity theory of aging: - Activities from mid-life will likely continue post-retirement - e.g., athletics, socializing and travelling. • Older adults may also add on new activities in later-life (life-span perspective of aging).

Divorce

•Divorce rates have increased significantly since the early 1970s. • Liberalization to the DivorceAct • 38% of married couples can expect to divorce before celebrating their 30th Anniversary (Lambert, 2009; Statistics Canada, 2008) • 7% of men & 7% of women aged 65 years + reported they were divorced, and (Statistics Canada, 2006) that rates increased from 2 to 7% between 2001 and 2006 . • Divorce in later life often means economic insecurity, particularly for women ***High rates of poverty among older unmarried women

CPP / QPC: Canada / Quebec Pension Plan

•Income maintenance program-> replaces up to 25 percent of income in retirement. •Compulsory contributory plans with benefits linked to contributions based on a person's earnings--> Quebec opted out of the plan (1965). •Equal contributions required from the employee and employer and were set at 3.6 of earning in 1966 (each paid 1.88 percent of the contribution). •Today (2017) the contribution by each is 6.0% by-2016). •Take your pension early: a penalty of 0.6% per month. •Take your pension later: a "bonus" of up to 30%. •May be compensated for years caring for a child over the age of 7. •What about caregivers? i.e. grandparents raising grandchildren.

RRSPs

•RRSPS account for 12% of Canadians assets. •Allow tax payers to save for older ages by allowing tax breaks •The limit is based on 18% of the previous tax year's earned income, to a fixed maximum, less any pension adjustments, plus any unused room carried forward. •The fixed maximum RRSP contribution in 2011 was $22,450, up from $22,000 in 2010. •Nationally, the median contribution was $2,830, a 1.4% increase from 2010. •RRSP's - a personal retirement savings program that allows individuals to make deposits into personal savings plans for future retirement income. •These have been increasing while RRPs have been declining. - You can get it any time, but you have to pay tax rate: forcing you to save so that you will save it until a later time. The expectation is that at that time it's at a lower rate because you will have a lower income. At 70, they force you to take it out - People are forced to put the money into this

Clinician's Perspective of Dementia

□ Difficult to provide person centred care --> personhood dynamic due to disease and therefore care is compromised □ Communication challenges □ Caregiver plays a greater role in provision of care and in continuity of care --> second patient □ Capacity to consent has to be monitored

Patient's Perspective of Dementia

□ Fear due to uncertainty related to diagnosis □ Depression and life changes (i.e., intimacy) □ Challenges related to maintaining independence □ Housing modifications □ Financial considerations, employment changes □ Stigma

Caregiver's Perspective of Dementia

□ Managing emotions is difficult □ Frustration, anger, guilt, fatigue □ Depression and physical illness □ Decision to institutionalize □ Quasi-death and end-of-life of loved one

Framingham Heart Study Incidence of Dementia over Three Decades in the Framingham Heart Study 2016 NJM

□ The 5-year age- and sex-adjusted cumulative hazard rates for dementia were 3.6 per 100 persons during the first epoch (late 1970s and early 1980s), □ 2.8 per 100 persons during the second epoch (late 1980s and early 1990s), □ 2.2 per 100 persons during the third epoch (late 1990s and early 2000s), and □ 2.0 per 100 persons during the fourth epoch (late 2000s and early 2010s). □ Relative to the incidence during the first epoch, the incidence declined by 22%, 38%, and 44% during the second, third, and fourth epochs, respectively. This risk reduction was observed only among persons who had at least a high school diploma (hazard ratio, 0.77; 95% confidence interval, 0.67 to 0.88).

CIHI (2013). Adverse Drug Reaction-Related Hospitalizations Among Seniors, 2006 to 2011.

● Adverse Drug Reactions (ADR): adverse effects of a drug that was properly administered in the correct dose. Many Emergency Department visits are attributed to ADRs. Seniors are at a much higher risk for ADRs, due to polypharmacy, and age related issues. ● This paper was an analysis of the data-- collected from Discharge Abstract Database, Hospital Morbidity Database, National Prescription Drug Utilization Information System Database. ● Largest ADR related hospitalization for seniors was for Anticoagulants (which accounts for 12.6% of ADR-related hospitalizations for seniors). This is followed by Antineoplastic drugs (used for cancer), and followed by opioids (used for pain management) . ● Hemorrhagic disorders due to anticoagulants are the largest percentage of ADRs for hospitalizations in seniors. ● ADRs are underreported in hospitalization administration data, but the rate is reported at around 3 percent of hospitalizations of seniors. This can be compared to non-senior hospitalization for ADRs which is at 1 %. ● Risk factors for ADR include How long the patient has taken the medication (tolerance development) for ADRs that may be dose related, as this is especially true for hospitalization for ADRs linked to anticoagulants. ● Number of drugs taken by seniors is also a risk factor for ADRs, as seniors who take more drugs are higher risk for hospitalization for ADRs. ● Males were slightly more likely to be admitted for hospitalization of ADRs, as well as older seniors (over 85 years old) ● Another risk factor for ADR hospitalization for seniors include being prescribed by multiple physicians and multiple prescribers. ● Seniors who were hospitalized for ADR are more likely to be hospitalized again for ADRs ● Medication reconciliation may help reduce risk of ADRs (this is when a patient's medications are reviewed together) ● Anticoagulant and Opioid user hospitalization for ADR was examined. Changes in the dosage of anticoagulants and opioids were much more likely to occur after a hospitalization related to ADR (opioid users after ADR hospitalization are often put on a lower dosage).

Harassment of Older Adults in Workplace

-Being left out of decisions that affect your work 23.0%

Unitnentional ageism

-refers to ideas, rules, attitudes or practices that are carried out without the perpetrators awareness. example: the Toronto Airport (lack of a built environment), subways,national parks, office on 6th floor with no elevator (Discrimination based on exclusion)

sex ratio

2011 in canada Age 65: there were about 125 women for 100 men Age 80: 170 women per 100 men For age 100 and over: there are over 6000 centenarians in Canada and 80 percent are women

Ageist behaviors in medical settings: Case 1: Organ Transplants

Growing older on a waiting list: not always first come first served Goal of transplant: maximize the number of year provided by a donated organ Organs "rationed" and "allocated" based on best chance of living the longest Dilemma: give "younger organs" to older patients or give "older organs" to older patients

Wisdom, and the 5 criteria

Highly valued and outstanding expert knowledge. 5 criteria: 1) A store of factual information about human nature; 2) Rich procedural knowledge about handling life's problems; 3) An awareness of life's contexts and how they change over the lifespan; 4) Understanding the relativism of values and tolerance for others; and 5) Understanding of how to deal with uncertainty.

Personal ageism

Ideas, attitudes, beliefs and practices on the part of individuals who are biased against persons or groups who are older

Maximum Life Span vs. Life Expectancy

Maximum life span: Maximum number of years a member of a species can live (between 110 and 125 years) Life expectancy: the number of years at birth an average member of a population can expect to live (75 to 80)

Foreign born Population

Very big foreign population in canada is huge (20.6) and is growing!!

Old population

an informal rule used by demographers is that any population with more than 10 per cent of the population over age 65 is an old population

Brain games: training and physical activity

can improve mental process (in the specific skills trained), for example one specific funciton multiple training strategies have the best chance of skill transfer physical activity can forestall mental decline and help to maintain good mental function

Extrinsic aging

changes due to external circumstances -including effects of smoking, sunlight, pollution, noise, etc. -->determinants of health

Intrinsic aging

changes within the body due to normal wear and tear, genetic mutation and other internal sources of change including decrease in lung capacity, hardening of arteries and arthritis senescence: normal decline that takes place in the body over time

The Medical Care Act (1966) and the Canada Health Act (1984)

express "...universality, comprehensiveness, accessibility, portability and publicly administered physician and hospital services"

The Oldest Old

older population is itself aging globally, the percentage of older persons aged 80 years or over, the "oldest old" was 14% in 2013 -this group will grow to 19% in 2050 There will be 392 million people aged 80 years or over by 2050

Population aging

populations of people can grow older or younger as measured by indicators used to describe the age structure of a population. Two indicators of age structure of a population are the proportion of persons aged 65 years and over and the proportion of children aged less than 15 years

Life Course Perspective

takes a grand view of the life cycle . It includes growth through social roles and stages of life, it takes into account social institutions and it places all of this into a historical context. People develop multidemensional: biologically, physically, psychologically and socially. They develop multidirectional and change throughout the life course. And: Development takes place from birth to death within a historical context Older people give meaning to the events that shape their lives

Ageist behaviors in medical settings: Case 3: Capacity and Consent

Definition for capacity does not make exceptions for age or physical/mental disability Ageism--> circumvent the process Paternalism, convenience and efficiency-->assumed consent Advance care planning used in lieu of consent Screened for abuse-->without consent and without consequences discussed --Often with no social support

Devaluation of the Aging Experience

Denial of one's status as an elderly person can also have negative consequences - e.g., the attempt to "pass" for a member of the dominant, younger group by -undergoing cosmetic surgery -using advertised anti-aging products -the quest for eternal youth can become inappropriate and, ultimately, self-defeating for those who attempt to stop the natural aging process

Developed vs Developing countries

Developing countries have lower life expectancy than developed countries.

The medical model

-The medical model focuses on the treatment of diseases; -Treatment usually occurs in medical facilities -Drug therapy, surgery, rehabilitation (OT and PT) -Medical history, physical exam, diagnostic tests and treatment of a single disease; -A focus on the physical, biological and genetic\ - Physicians control the entire system including other health professions; -Health care insurance supports this system through funding of docs and hospital

Martin, P. et al., (2014). Defining Successful Aging: A Tangible or Elusive Concept? The Gerontologist, 2014, Vol. 00, No. 00, 1-12.

-Throughout history, there have been various religious and cultural views on ageing. Hinduism, the ancient Greeks, the Romans, etc. all have points of view on ageing the role age has in the development of the mind and spirit of an individual -One of the earliest definitions of successful ageing was introduced by Robert Havighurst; prior to Havighurst there were two existing theories of ageing; activity theory and disengagement theory -Activity theory stated that aging successfully meant maintaining middle-aged activities and attitudes into later adulthood; gerontologists generally preferred this theory because it was assumed to capture the desire of aging individuals. -Disengagement theory, on the other hand, meant that a person aging successfully would want, over time, to disengage from an active life -Havighurst believed that a theory should describe conditions promoting a maximum of satisfaction and happiness and that an operational definition of successful ageing should measure how well an individual fit into these two theories -Neugarten introduced the idea that coping style, prior ability to adapt, and expectations of life, as well as income, health, social interactions, freedoms, and constraints played an important role in the theory of successful aging. -In 1984, the MacArthur Network on Successful Ageing was launched, led by led by Jack Rowe, a physician, and Robert Kahn, a psychologist. The MacArthur study operationalized three criteria of successful aging: freedom from disease and disability, high cognitive and physical functioning, as well as active engagement with life. -Rowe & Kahn also coined important demographic terms now used: low probability of disease and disease-related disability, high cognitive and physical functional capacity, and active engagement with life. A combination of all three, according to Rowe and Kahn, meant successful ageing. -According to Baltes and Baltes, successful aging consists of optimizing life expectancy while at the same time minimizing physical, psychological, and social morbidity in the final years of life -Kahana and Kahana believed that older adults are likely to face normative stressors of chronic illness, social losses, and lack of people around them, however things such as health promotion, helping others, and planning ahead (preventive adaptations), along with marshaling support, role substitution, and environmental modifications can improve the conditions for older adults. -Depp and Jeste sought to find a universal definition for successful ageing, noting that the ideal definition of successful aging should be acceptable to clinicians, researchers, and older adults alike. They also noted that the physical definition of successful ageing was often used in literature, and many older adults may not meet that definition, even if they believe they are ageing successfully (in terms of their cognitive and emotional capacity) -Phelan and Larson identified seven major elements in defining successful ageing: life satisfaction, longevity, freedom from disability, mastery/growth, active engagement with life, high/independent functioning, and positive adaptation. They also noted that there has never been a universal definition of successful ageing, and that in the future, that this definition should be considered from an individual's perspective. -Some have also done research into longevity and its relation with successful ageing. Studies have been done for those living over 100 to analyze how they have lived a long and healthy life (mostly focusing on the physical aspect)

Intentional Ageism

-refers to ideas, attitudes, rules, or practices that are carried out with the knowledge that they are biased against older groups and individuals. example:marketing, media that use stereotypes, denial of job training, firing older adults just prior to retirement, older drivers' snitch line

Error Theories

-somatic mutation theory -cross-linking theory -free radicals theory

George, D. R. & Peter J. Whitehouse (2011). Marketplace of Memory: What the Brain Fitness Technology Industry Says About Us and How We Can Do Better. The Gerontologist . Vol. 51, No. 5, 590-596.

- Alzheimer's drugs are failing, there has been no breakthroughs so the industry has turned to technology to help enhance memory, concentration, and visual and special skills. - This industry has quickly garnered interest and has become a highly financially supported industry, yet it lacks the scientific back-up in research. The data supporting this improvement is generally insufficient. - They portray the brain as more than just another organ, it is venerated almost as its own entity. This leaves out that the health of other organs, which is directly connected to cognitive health. - A movement that aligns with out neoliberalist society, a focus on self-sufficiency within the market place. - The research is not generalizable. Though people can show improvement in the games, can this improvement be transferred to activities of daily living? There is no data suggesting that they can or cannot. - These apps and games fail to frame brain aging as a public health and broader social issue, focusing instead on behavioural level interventions. Could look to social interactions and proximate relationships instead. - People residing in communities that have a high level of centurions have strong family and community affiliations, high sense of purpose, emphasize natural movement and have low levels of smoking. - Look at brain fitness alone with partnerships, especially intergenerational partnerships. Maybe a social digital environment or intergenerational participation in technologies. - Reinforce broader, multifactorial notion of brain health by combining these 'brain games' with broader, community level changes. - Look to enrich one's community and creating relationships while also enriching brain health.

Common forms of ageis

- Being ignored or treated as though they are invisible (41%) - Being treated like they have nothing to contribute (38%) - Assumption of incompetence (27%)

H. Skirbekk & Nortvedt, P. (2014). Inadequate Treatment for Elderly Patients: Professional Norms and Tight Budgets Could Cause ''Ageism'' in Hospitals. Health Care Anal 22:192-201

- Doctors & nurses admit to treating elderly patients different from younger patients - Elderly given lower priorities -> increase suffering/decrease wellbeing - Little or too much treatment -> too much drugs + little care - Acute disease (severe/sudden disease) is higher priority than chronic illness (disease longer than 3 months - cancer, diabetes, Alzheimer's/dementia) - Care, communication, & rehab given at low priority - Interviewees say that older people have more complex illness than young so brings issues because treatment could deteriorate their quality of life and not give much benefit too ➢ View older as having less to grain from treatment than younger patients - Patients that complain a lot are branded as difficult and professional avoid her - Some treatment given to younger won't be given to older because it will make them ill or death ➢ Doctor argued this is not ageism because they are treated based on their biological age not chronological age - Professionals defend their differential treatment was sensible because older people less likely to recover than young - Emphasis is on invasive medical care with no positive effect on patient's wellbeing and health -> not in best interest of the patient

Life expectancy

-78 years in developed countries -68 years in developing countries in 2010-2015 -By 2045-2050, newborns can expect to live to 83 years in developed regions -74 years in developing regions

Ageism is a societal problem

-80% of Canadians: Seniors 75 and older are viewed as less important than younger generations -21% of Canadians: Older adults are a burden on society

What is aging?

-Ageing represents the accumulation of changes in a human being over time, encompassing physical, psychological and social changes (Merriam-Webster); -The process of becoming older(→ maturing), a process that is genetically determined and environmentally modulated (medicinenet.com); -The process of growing old, especially by failure of replacement of cells in sufficient numberto maintain full functional capacity; particularly affects cells (neurons) incapable of mitotic division(mediLexicon).

Programmed Senescence

-Hayflick Limit: Number of divisions a cell can undergo in an organism before it dies; vaires by organism (humans: 40-60 times) telomere shortening seen as the primary factor for the Hayflick Limit: when cells divide, some of the telomere gets removed and the protective effect is lost. -Phase III phenomenon: over time, cells take longer to double in number, debris accumulates, they gradually stop dividing and die -Apoptosis: cells ability to divide is switched off; leads to sarcopenia (muscle loss--> frailty; heart muscle loss) -Pleiotropic genes: genes that serve a positive function early in life but damage the system later (-->e.g., calcium production for bone density turns to calcium deposits in arteries..Calcium is really good when you're growing- but at a certain time its too much.)

Polarized Ageism

-In a study of polarized ageism, representations of older adults in a national newspaper in Canada, the Globe and Mail (Rozanova et al., 2006) were those of 'successful' aging often seen as a positive view -Namely, those of 'successful' aging often seen as a positive view - "a lifelong process optimizing opportunities for improving and preserving ... independence; quality of life; and enhancing successful life-course transitions." -Although optimistic, assumptions based on positive ageism may lead to responses that are just as biased as negative ageism and can do as much harm (Binstock, 2010, Townsend 2006). -Thus, those who don't 'age successfully' are likely aging failures, notwithstanding their genetic make-up, accidents and poor health.

Very old countries

-Japan is the only country in the world with more than 30 percent of its population aged 60 or over -by 2050 there will be 64 countries where older people make up more than 30 percent of their population -for every 100 women aged 60+ worldwide, there are 84 men -for every 100 women aged 80 or over, there are 61 men.

Ageism and Healthcare

-Perpetuation of myth of physical and cognitive decline -Disease management vs. prevention -Cognitive and mental deficits: expected--> debilitating to older patients self-esteem and performance -Older patients less likely to be referred for psych evaluations

Programmed Theories

-Programmed Senescence -Endocrine and immunological theory

Looking at Canada

-women live longer than men -older adults accounted for a record high of 15.7% of the population in Canada in 2014, up from 13,7% of seven years earlier -according to the medium-growth scenario of statistics canada's most recent population projections, by 2016, the number of older adults will exceed the number of children, a first in the country. life expectancy in canada: 80 Fastest growing group: older adults

Reading: Evidence of accelerated aging among African Americans and its implications for mortality

1) Background: race and health are associated in the US • Blacks experience age-related disease and death earlier in life than whites o Life expectancy for blacks is 5 years less than for whites • Weathering Hypothesis the accumulated effects of SDoH (SES, access to healthcare, stress, etc.) over a lifespan negatively impact the health of disadvantaged minorities 2) Authors' Hypothesis: blacks age faster than whites; this explains the racial health disparities • Biological age a measure of how well your body still functions o If you're 50 years old, does your heart, lungs, kidney, liver, immune system, etc. work as well as those of the average 50 year-old in the population? o Measured by biomarkers (blood concentrations of certain proteins, blood pressure, and maximum eye and lung function) • Chronological age:how old you are in years since birth • Accelerated aging:your body has deteriorated faster than it should have • Biomarkers show that at age 50, blacks on average have a biological age of 53; whites have a biological age of slightly less than 50 • The measured differences in biological age largely account for the observed health differences between black and white Americans 4) Discussion & Conclusion • Accelerated aging is a mechanism for explaining how SDoH impact health • Racial differences decline past age 70 because of selection o The most disadvantaged people have died off

Robin T. Higashi et al., (2012). Elder care as "frustrating" and "boring": Understanding the persistence of negative attitudes toward older patients among physicians-in-training. Journal of Aging Studies. 26: 476-483.

1. The purpose of the study was to determine why medical students studying geriatrics have negative attitudes towards caring about senior patients 2. Medical students studying geriatrics were the participants and they were asked whether older patients, as a group, were more likely to receive lesser care or be less enjoyable for staff to treat medically. 3. Participants described patients with drug addictions, non-adherent patients, the homeless as having strong feelings of frustration, anger, or resentment, 4. However, older patients, by comparison, were described as mildly frustrating, or simply less interesting. 5. A few participants went so far as to distinguish that it wasn't older patients that were frustrating, per se, but rather the characteristics that are assumed to accompany old age, e.g. dementia, fragility, multiple chronic illnesses, and lack of social support. Here we describe how physicians-in-training 6. In Situations where an older patient was indeed in the terminal stage of an illness, several participants seemed surprised, and sometimes frustrated, when an older patient wished to continue pursuing all possible treatment avenues, instead of being transitioned to palliative care. "People assume that they would not want to be full code or they assume that 7. Other participants had similar feelings about elder patients saying that they already have lived a full life and should spend the rest of their time with family 8. When comparing an 84 year old to a 42 year old patient which both have stage 4 cancer, the doctors in training seemed to have sympathy for the younger patient, using words like tragic, and how his children will miss him, and some even raised their eyebrows when discussing the younger patient but none of participants mentioned the word tragic when discussing the older patient or mentioned his/her children 9. Older patients were also viewed as having a lot more medical problems because of their age which will not get resolved no matter how much medical treatment they get 10. Therefore, as the medical education system continues to try and prepare physicians-in-training to meet the needs of an expanding population of older patients, it is important to acknowledge that curricular changes must go beyond simply adding lectures on geriatric topics or encouraging physicians in- training to develop new skills. As these narratives of physicians-in-training show, efforts to change behaviors or attitudes must, as Thomas et al. point out, be achievable in clinical practice (2003).

Sources of Ageism

1. Younger people 2. Employers 3. Government 4. older adults themselves 5. Healthcare professionals

C. Hwang (2013). Undergraduate Students' Knowledge about Aging and Attitudes toward Older Adults in East and West: A socio-economic and cultural exploration. Int'l. J. Aging & Human Development, Vol. 77(1) 59-76.

1. knowledge about aging and their attitudes toward older people 2. Undergraduate students from 6 countries: - 4 countries in eastern culture: Japanese, Vietnamese, Chinese, Taiwan - 2 countries in western cultures: US & United Kingdom 3. All subjects completed two questionnaires in their own language (involved 5 languages) - 1 questionnaire about Knowledge about Aging - 2nd questionnaire about attitudes towards older adults 4. Translation process had 3 stages and 3 research teams to ensure translation quality - translate english questionnaire into target language - target language back to english - compare translated english to original english questionnaire, if not identical, the process was repeated. 5. Results: • Knowledge about Aging - US and United Kingdom > (highest level of knowledge) compared to low average of China, Taiwan, Vietnam, and Japan - Therefore, the West > significantly higher than East • Attitudes about older adults: - US students have the most positive attitudes about older adults - Japanese students have the most negative attitudes about older adults - East vs West grouping; attitudes in West more positive than the East 6. 2 Major findings: A. Eastern countries have lesser knowledge about aging and more negative attitudes towards older adults compared to Western countries. This doesn't support traditional Eastern culture of reverence (Confucianism) for elders. B. Two Industrialized Western countries (UK & US) have more knowledge about aging and positive attitudes towards elders compared to Eastern countries. This doesn't support assumption of modernization theory: - marks the end of traditional values of reverence for older adults - older adults are living longer than before, low status as they aged, less important position in society - Additionally, modern and industrial societies now deal with 3rd ism ageism (subsequent to racism & sexism) 7. However, Modernization theory supported when comparing Eastern countries but not the Western countries. 8. As modernization theory predicts, the tradition of respecting older adults in eastern culture declines under the influence of a quicker rate of population aging and late timing of industrial modernization. 9. The rate of population aging in Eastern countries is quicker, and continued once modernization began. 10. The timing of industrial modernization in Eastern countries began later, some still undergoing modernization, hence, the negative results.

Reading: Flatt (2013) Are "anti-aging medicine" and "successful aging" two sides of the same coin? Views of anti-aging practitioners

1. purpose: to compare discourse and objectives of 'anti-aging' community VS. gerontological theory of 'successful aging' 2. main result: GOALS of anti-aging practitioners match with those in successful aging theory but METHODS and MESSAGES of anti-aging practitioners are different - both share similar goal of maintaining functional ability throughout life course 3. anti-agers: -reject idea of inevitable decline with age, re-frame functional losses as the result of lifestyle choice -use controversial hormone replacement therapies -consider social connection/social supports as an outcome of good health, NOT as preventative factors to support aging 'well' 4. gerontologists: -tend to be more socio-culturally aware: consider external hardships borne by marginalized groups 5.conclusion: similar goals; different methods; generally critical of each other -authors suggest market basis of anti-aging 'industry' is the biggest obstacle undermining acceptance by gerontological community

Ageism and Elder Abuse

2.2%- 14% prevalence of five types of abuse: emotional, physical, psychological, sexual, financial (McDonald, 2016) 27.5%- 55% prevalence of abuse and neglect in older adults with dementia--> likely underestimated, as cognitively impaired older adults may not be able to report mistreatment or are excluded from research Health implications: 3X mortality risk increase over 5-year period vs. those not abused $5,300,000,000 in medical costs in the United States Elder abuse->predicated on age; difficult to operationalize concept in research, policy, practice settings Terror Management Theory: older adults de-personified--> a defensive, ego-protective mechanism to manage aging and death anxiety Identity Theory: 'out-group' seen in less favorable terms Perpetrators of ageism and abuse distance themselves from older adults-> prejudices and discrimination --Younger family members

Chronic Disease

2008 Canadian Survey of Experiences With Primary Health Care, three out of every four Canadian seniors (75%) reported having at least 1 of 11 chronic conditions Compare this with one in every two adults age 45 to 64 (48%). About one-quarter (25%) of seniors reported being diagnosed with three or more of these conditions (known as multimorbidity).

What causes population structures to change?

3 factors: -birth rates (low birth rates is a canadian factor for aging pop) -death rates -immigration rates

Older Adult Immigrants

3.4% of immigrants that came to Canada in the last 5 years were aged 65 and over In contrast, 14.8 percent of Canadians born were this age

Aboriginal Peoples

5.9 percent of the aboriginal population is 65 and older -reason for this is that aboriginals have higher fertility rates and a much shorter life expectancy Projected life expectancy at birth by sex for aboriginal identity: men and women not much different, but women higher by a little

Ageist behaviors in medical settings: Case 4: Radiation and Chemotherapy

50% of breast cancer cases = women over 65 Patients in their 50s four times more likely to received radiation and chemotherapy vs. 70+ year old women Healthcare providers decide on 'benefits'-->subjective? How are choices in cancer therapy decided? -Compassion or freedom of choice?

Reading: health, lifestyle, and gender influences on aging well: an australian longitudinal analysis to guide health promotion

A 12-year longitudinal study on healthy aging was conduced in Australia, which used a population group approach to health promotion rather than disease or risk factors approach. • In baseline, quantitative analysis, it was found that "successful aging" was a multi-dimensional concept with three components (being free of disease, engagement in life, and having high cognitive/physical function). Furthermore, loss of independence and having to enter residential care were the biggest fears for elder individuals. • Predictors for aging well in previous literature review examined the relationships between "older peoples" characteristics (cognitive impairment, Disease burden, etc.) and health behaviours early in life (diet, exercise, social and work support) with their experiences regarding various measures of aging well. • Baseline findings regarding socio-economic threats to aging well found that being a windowed woman of European background were significant threats to aging well. • Baseline findings for health related threats to aging included high number of medical conditions and frequent pain. • At baseline, life-style factors for not aging well included low strain, restless sleep, low physical activity, inadequate social support, being a current smoker. • At the end of the longitudinal study, a number of life-style variables were identified as threats to aging well which included poor nutrition, being under-weight, and low levels of perceived social support. • Independent influences for not aging well at baseline regarding women included things such as urinary incontinence, being underweight, and low physical activity. • Independent influences for not aging well at baseline for men included low strain, low perceived social activity and being a current smoker. • Social determinants such as income and education were not found to be associated with aging well at baseline.

Successful Aging

A biological and intrinsic focus does not explain (nor does it try to explain) the differences in functioning of older people as it does not deal with the influences of the environment, lifestyles and habits on physical functioning. Rowe and Kahn developed a Model of Successful Aging: (1) Low chance of disease and disability; (2) High mental and physical functioning; (3) Active engagement in social relations and productive activity

Elderspeak

A specialized speech resembling baby talk assumes that older people have poor mental ability or an impairment. When used older people internalize the meaning to create low self-esteem, poor communication, and poor interaction.

Apocalyptic demography

All older people are pension‐rich, 'greedy geezers'. Older adults are responsible for the debt and the imminent collapse of the health‐care system. The older population constitutes a social problem that must be solved. Intergenerational conflict will occur as older adults get more than their fair share at the expense of younger generations. Population change and politics will combine when the aging of the population becomes a tool for social policy reform based on cuts to the welfare state. (Gee 2002; Robertson 1997)

Selective Optimization with Compensation Example

Arthur Rubinstein- pianist performed into his 80s, was able to maintain career by decreasing his repertoire, selecting pieces he felt most capable of performing, and optimizing his performance by practicing these fewer pieces. to compensate for neurological slowing with age that affected the speed with which he could play demanding pieces, he slowed down the passage just before one with a fast tempo to make it appear that he played it faster than he did.

Government and Health in Canada

Canada's constitution puts the authority for taxation largely in the federal domain but the management of health care systems under provincial jurisdiction

Physical changes to chemical pathways in brain

Chemical pathways getdisrupted: Attention deficits and decline in working memory are due to catecholamine-norepinephrine and dopamine blockages.

What are the consequences of ageism ** ON EXAM

Consequences of ageism are similar to those associated with all attempts to discriminate against other groups: persons subjected to prejudice and discrimination tend to adopt the dominant group's negative image and to behave in ways that conform to that negative image. Dominant group's negative image typically includes a set of behavioral expectations or prescriptions which define what a person is to do and not to do: - e.g., the elderly are expected to be asexual, intellectually rigid, unproductive, forgetful, unhappy, enjoy their retirement, and also be invisible, passive, and uncomplaining Palmore (1990) identifies four common responses of older adults to these prescriptions and expectations: acceptance, denial, avoidance, or reform All of these responses can have harmful effects on the individuals This internalization of a negative image can result in the elderly person becoming prejudiced against him/herself, resulting in loss of self-esteem, self-hatred, shame, depression, and/or suicide in extreme cases) Ultimately, stereotypes are dehumanizing and promote one-dimensional thinking about others. Older adults are not seen as human beings but as objects who, therefore, can be more easily denied opportunities and rights A final consequence of ageism is that by devaluing this segment of the population, a vital human resource is lost. This is contrary to western values which entail respect for human worth and dignity.

Reading: UN. World Population.

Decline in fertility is the main driving factor behind population aging Increase in life expectancy--projected to continue to rise Growth rate is higher in the less developed regions than in more developed ones Median age: the age that divides the younger from the other half of the population -Japan, Germany, and Italy have the highest median ages in the world -faster aging correlates to an increase in the median age Old age support ratio: # of people aged 15 to 64 years divided by number of persons aged 65 years or over

Error Theories: Free Radical Theory

Free radicals due to oxygen production can lead to tissue damage as they have an unpaired electron, a large amount of free energyand a tendency to bond with other molecules; -Mitochondrial DNA faces a high risk of damage that increases withage; -Free radical attack can damage proteins and repair systems in older cells become less efficient as they produce fewer antioxidants; (effects on eyes, skin, lungs, and brain) and -Free radicals lead to an accumulation of chemical by-products (lipofuscin) that interfere with the cell's ability to create enzymes and to reproduce. Antioxidants bind and neutralize free radicals; these include nutrients such as vitamins C and E and beta carotene Certain foods (such as broccoli and cauliflower) may have an antioxidant effect.

Functional Capacity

Functional capacity is an indicator of one's ability to carry out everyday tasks. Functional capacity takes into account both basic activities of daily living (ADLs) - walking, bathing, toileting, eating and dressing and instrumental activities of daily living (IADLs) -shopping, housekeeping, food preparation, -With age, losses of functional capacity become more common and more severe. The most common reported functional capacity limitation across all ages was an inability to perform housework without assistance: 14% of all seniors were unable to do so. one-quarter (25%) of all seniors 85 and older reported a moderate (15%), severe (5%) or total (5%) limitation in functional capacity.

Federal Role in Health

Setting and administering national principles for the health care system through the Canada Health Act; Assisting in the financing of provincial/territorial health care services through fiscal transfers; -Delivering health care services to specific groups (e.g. First Nations and Inuit and veterans), and - providing other health-related functions such as public health and health protection programs and health research Federal government has limited power to enforce legislation or regulation that control provincial health care services; the only recourse the government has is to withhold transfer payments

Gerotranscendence:

In later life, the self begins to expand its boundaries and to reflect on the meaning of human life. It also refers to a shift from materialism and a more practical view of life to a more contemplative, cosmic view and greater sense of intergenerational continuity The search for fulfillment in later life can take many forms, including religious faith, spirituality and nontraditional beliefs. It tries to bring meaning and values to life, affirms the person and connects to someone/something beyond the individual

Crystallized intelligence

Intelligence that depends on stored information, acculturation and learning (stable or even increases with age).

Other theories: molecular genetics and the life course

Interaction between the environment andgenetic processes: -Sensitive Period Model: Effect of the environment on the individual at critical points of development; e.g., poor nutrition in childhood can lead to poor bonedevelopment and frailty in oldage; -Accumulation Model: Deficits early in life can lead to cumulative disadvantage; there seems to be a link between the environment and genetic traits; -Pathway Model: "Biology is not destiny" as there are creative responses to stressful lifeevents

Error Theories: Cross-Linking Theory

Long-term exposure of proteins to glucose (sugar) leads to glycation (binding of sugar molecule to protein) which leads to cross-linking, i.e., proteins binding together; This results in the toughening of tissues, hardening of arteries and loss of nerve and kidney function; Which is intensified by pollutants such as lead and smoke. -While macrophages seek out glucose molecules, engulf them, destroy them and send them to the kidney for elimination, this defense declines as the kidney function declines and macrophages become less active.

Social Model

Medical care is viewed as only part of the system Personal and family counseling, homecare, adult day care, home visits Goal is to keep people at home Doctor is part of a team of many other experts - nursing, social work, religious, pt, ot, speech language pathologist As you would guess -->this is cheaper care Long term care houses people with chronic illness and functional disabilities -- includes medical, nursing, social and community services

Error Theories: Somatic Mutation Theory

Mistakes in the synthesis of proteins as damage to DNA can lead to mutations when the cell divides Radiation (xrays) and chemicals in the body can damage DNA

Population Aging

Older persons are projected to exceed the number of children for the first time in 2047. By 2050, nearly 8 in 10 of all older adults will live in developing countries.

Biological Theories of Aging

Programmed Theories Error Theories Other Theories

Fluid intelligence

Reasoning, abstracting, concept formation and problem solving. It makes little use of knowledge gained through school, reading orwork and relies on how well the physical and nervous systems function (declines with age);

Canada Immigration Policy ** On exam

Recent (2011-2014) drastic changes to immigration policy Given the "super visa" for older immigrant family members and a new point system for economic immigrants that gives no points after age 46 for age Result: poorer older immigrants will be less likely to come to canada because they will have to pay for their own health care and will have more trouble locating a job.

Is the concept of retirement based on ageism?

Researcher Alan Walker states that - "...retirement is both the leading form of age discrimination and the driving force behind the wider development of ageism in modern societies...retirement maybe seen as an age discriminatory social process designed to exclude older people en masse from the workforce'

Ageist behaviors in medical settings

Selection and retention of patients -"One problem per visit" Grignon, Spencer &Wang (2010): -Ageist behaviour can have life threatening effects, -Older persons were more likely to have only therapeutic treatment compared to younger men who received more invasive treatment for acute myocardial infarction Two possible reasons; -the older patient's wish -it is a tool to ration care (bedside ageism) and is used in Ontario

Selective Optimization with Compensation

Successful aging is a response to life's challenges People face losses and/or physical distress as they age; Those who aged 'successfully' selected activities and optimized their ability: -When they could no longer engage in an activity, they compensated for the 'loss' by setting new priorities - or they substituted one activity for another one. -The SOC model recognizes that aging brings change - but it indicates that older adults can adapt to change and improve their mental ability→ 'active life management'.

Ageist behaviors in medical settings: Case 2: Clinical Trials

Systematic exclusion of older adults from clinical trials Age limits-->arbitrary; based on assumption that all older adults are sick and or a risk Drug's efficacy may not be positive with an older patient Become lab rats in society-->no information on how drugs will work in older patients

Dragojlovic, N. (2013). Canadians' support for radical life extension resulting from advances in regenerative medicine. Journal of Aging Studies 27, 151-158.

Ten Main Points: 1. propose three complementary approaches to intervening in the process through which age-related damage and degeneration leads to specific diseases and loss of function. - The first two - improved public health policies and metabolic manipulation using pharmaceuticals - are aimed at postponing the onset of age-related decline, whereas the - - third - regenerative therapies - would aim to repair and reverse the damage caused by aging. 2. public opinion on the topic of a longer lifespan of up to 120 years by the year 2050 is still in its early stages, but there is substantial enthusiasm for life extension in a recent national survey of Canadian adults. - 59% of respondents expressed desire to life to 120 if medical advances made it possible and 47% found the possibility of increasing average Canadian life expectancy to 120 years by 2059 to be plausible. 3. research was done with a sample of 1231 Canadian adults through an online questionnaire (Opinion Search, Inc.) which is used to measure respondent attitudes towards regenerative medicines and stem cell policy b/w June 29th and July 17th 2012 - determined that oversampling university undergraduates would likely lead to underestimate the support for life extension among the Canadian population. 4. Canadians' average life expectancy increased from 50 years in 1900 to 81 years today. Some scientists think it is due to modern medical techniques like regenerative medicine. Therefore these same therapies will allow us to stay healthier and longer. • First group: three demographic variables (gender, age, and educational level attained) and a measure of respondents' knowledge of biological science • Second group: includes two variables that aim to measure respondents' health status, since find that opposition to life extension is linked to health problems - General Health Status - . Disease Index • Third group: includes two measures of respondent worldviews that should be strongly related to how they view technological progress - Science Negativity - Declinist Worldview (ex: "Modern civilization has reached its peak and is in decline." • Fourth group: dummy variables measures a set of specific beliefs that indicate a secular worldview - (lack of belief in any sort of afterlife, a belief that nature is important, but not sacred or spiritual, and a lack of belief in any divine entity) 5. males are more supportive than females, which accords with the large body of literature that finds males to be more risk-tolerant than females and therefore more supportive of new technologies (radical life extension) 6. individuals' faith in technological progress influences attitudes towards radical life extension primarily by shaping perceptions of its plausibility (the effect for Science Negativity, on the other hand, remains remarkably stable across the two models) 7. The results reported have two major implications for researchers and policymakers in this area 1. Science Negativity: focuses on peacemaking people's concerns about how extended lifespans might change existing ways of life. 2. Building public support for a "Longevity Dividend" policy agenda like that described by Olshansky et al. (2007), 8. Interestingly, the second most important variables were the health indicators, with both General Health Status and Disease Index showing a positive relationship with Possible 9. level of education and Bio-Literacy have opposite effects on Possible - more educated respondents were less likely to believe that life expectancy could increase to 120 years by 2050, - respondents who had greater familiarity with biomedical concepts were more likely to believe that a radical increase in life expectancy is possible, 10. results presented point to two major conclusions: - Canadians appear to be more supportive of the concept than the samples of Australians and Britons surveyed in previous research. - people's general orientations towards science and technology appear to be the major drivers of their attitudes towards radical life extension o generic bio-conservatism directly reducing support o and a declinist worldview reducing support indirectly by increasing skepticism about the plausibility of the anti-aging endeavor. o Specific religious beliefs, on the other hand, do not appear to impact Canadians' thinking about greatly extended lifespans 11. Limitations for the study - Opinion Search's panelists are not recruited using probability sampling, so the sample used in this study cannot be said to be statistically representative of the Canadian public. - life extension scenario presented in this study was somewhat ambiguous.

Ontario Seniors

The number of seniors aged 65 and over is projected to more than double from 14.6% in 2012, to almost 24.0%, by 2036. By 2016, for the first time, seniors will account for a larger share of population than children aged 0-14. The older age groups will experience the fastest growth. The number of people aged 75 and over is projected to rise from 910,000 in 2012 to over 2.2 million by 2036. The 90+ group will more than triple in size, from 96,000 to 291,000. The proportion of women among the oldest seniors is projected to remain higher than that of men but to decline slightly as male life expectancy is projected to increase faster than that of females. In 2012, there were 46 per cent more women than men in the 75+ age group. By 2036, the ratio is projected to have fallen to 22 per cent more women than men of that age.

How Can Ageism be Counteracted?

To counteract ageism, changes must be made in the systems which perpetuate it. A first step in this process is identifying personal attitudes which are ageist in nature. Another approach which can modify ageist attitudes is personal contact with older adults. Social action and reform is another approach to counteracting ageism.

Reducing Transfers

Transfers to provinces linked to economic performance - What's the problem with this?? 1977 liberal government devised a way to gradually extricate Ottawa from the 50-50 cost sharing arrangement with the provinces. Any tax room ceded to the provinces--> part of their health contribution. The only incentive for individual provinces to adhere to Canada Health Act is that doing so allows them to get cash from Ottawa.

Per Capita Health Care spending

We are spending more on the elder population and the babies. How do we shift this graph? Chronic illnesses are most expensive. If we can delay chronic illness as long as possible, we can continue with system. -Older population will double soon. They will require more services. Account for 60 percent of health care spending. How do we look at this differently? Patients have changed and the systems haven't. If they bankrupt the system, it is the system's fault. System wasn't designed for this demographic (designed when people didn't live as long as they do today). Acute Care for Elderly Strategy. It's about designing a smart system.

Dental Health

Who pays? Competing priorities in healthcare system -Not covered by Canada Health Act; similarities to eye care? Costs: $4000- $6000 for dentures - 1/3 of yearly pension income Access to care: reliance on caregivers, limited access in longterm care Retirement--> changes in dental coverage - Seek treatment only when necessary 1/3 of seniors have untreated tooth decay -tooth decay, loss of dentition connection to Alzheimer's? -Can be a result of medication use -Poor diet 1/2 of seniors have serious root decay Gum disease can increase risk of cardiovascular disease by 3x Oral disease increases chance of pneumonia by 3-6X - #1 cause of death in Long-Term Care

Cognitive decline

is lead to by physical changes in the brain. -Aging leads to losses of gray and white matter in the brain MRI is a method to see the physical changes in the brain Losses of prefrontal gray matter correlate with reduced performance on frontally-mediated executive tasks; Loss in white matter integrity in the brain leads to a decline in cognitive functioning and decreased speed of episodic memory retrieval; There might be a general reduction in the functional intactness of the central nervous system

Cognitive reserve

refers to excptional mental performance, particularly when a person has to work at maximum mental capacity; it was first observed in cognitively impaired people who performed better than expected in everyday life

Memory

the recall of information after learning has taken place → The study of memory dominates the study of psychological aging in an effort to look for differences between normal and pathological changes in the brain in laterlife.

Demography

the scientific study of human populations that documents their size, age-sex structure, and how they are distributed geographically. These features of populations and any changes in them are a result of fertility, mortality, and migration rates

Gerontology

the study of the aging process of individuals as they grow from middle age through life

Institutional ageism

usually refers to the "missions, rules and practices that discriminate against individuals and/or groups because of their older age"

short term memory

where information is stored temporarily while it is being processed (or for a short time afterwards)

José Marmeleira (2013). An examination of the mechanisms underlying the effects of physical activity on brain and cognition. Eur Rev Aging Phys Act, 10:83-94

• Definitions • Physical Activity: Body movement produced by contraction of skeletal muscles that results in energy expenditure above resting levels • Exercise: subset of physical activity that is planned, structured, and repetitive and has a final or an intermediate objective the improvement or maintenance of one or more components of physical fitness • Physical Fitness: set of attributes that are either health-related or skill-related • Physical activity positively influences brain health and cognitive functions in older adults • Cardiovascular Fitness Hypothesis— gains in cardiovascular fitness achieved through regular participation in physical activity mediates cognitive performance benefits • Cerebral Circulation Hypothesis— chronic exercise results in an enhancement of oxygen and glucose transportation to the brain, which results in better cognitive performances because of the increased resources available to the cerebral environment • Neurotrophic Stimulation Hypothesis — physical activity increases brain volume that improves learning and mental performance • Neurotransmitter Systems — exercise induces changes in brain concentration and reduces depressive symptoms • Declines in mental and physical health result from insufficient physical and mental challenge, keeping mentally active will prevent age-related mental decline • Different types of exercises improve motor sills • Mode of exercise along with its cognitive demands may influence learning and mental performance obtained

Reading: National Institute on Aging

• Having an aging population has many challenges which includes a strain on social insurance and pension plans • People are living a longer life now compared to the past and a few reasons for this include advancements in medical technology, and learning more about various diseases and how to prevent them. • There was a time when young people outnumbered older people, however this is soon going to change where older people especially those who are over the age of 65 are going to outnumber younger people • Life expectancies of countries have also been increasing especially during the 20th century, for example Japans life expectancy is the highest being 82 years old • Some implications of having an older population includes the fact that health costs will rise, pension plans/retirement income need to cover more years of life and there will be a greater need for caregivers • The oldest old of an aging population are usually those who are 85 and over • There is an increasing burden of chronic and non-communicable diseases • Nowadays people are having less children and living longer, this has implications on the family structure regarding the care provided to the older people in the family • Many countries are improving their social insurance systems because of escalating pension expenditures • Population aging will involve an increase in economic challenges. There will be significant effects on labor supply and financial expenditures

McCleary, L. et al., (2012) Pathways to Dementia diagnosis among South Asian Canadians. Dementia 12(6) 769-789.

• Paper describes the experience of South Asian Canadians and the pathway to diagnosis of dementia by family carers. Meant to explore and describe experience prior to diagnosis. • South Asian population very connected to family culturally, and this is important when discussing aging and caring for aging family members- as many elder parents live with adult children for caring purposes. This is largely cultural. • Previous research shows that ethnic minorities seek treatment and diagnosis resources for dementia less than non ethnic minorities. • Data collected through semi-structured interviews with 6 people dementia and with one or 2 of their family carers. • 3 codes were used in analysing the information collected from the interviews: "perception"- when participants perceived a problem, "action"- when participants took actions to cope, and "affect"- used to code emotions connected to the experience with dementia. • Findings found that early signs of dementia were mostly viewed as normal by the person with dementia and by the carers. • Perception: They found that there was "no single pathway to recognition of a problem". A. For two of the individuals with dementia, their family recognized a problem after a trauma like a fall (for example) B. The other 4 individuals with dementia stated that there was a longer time to diagnosis and recognizing that there was a problem • Action: 3 types of actions were described in research: A. Lay interventions: memory cues for example, taken before diagnosis. B. Preserving and seeking respite: carer took respite to relieve depression C. Seeking and receiving professional help: all participants eventually did this • Affect: emotions prior to help-seeking. A. Boredom, sadness, and hurt feelings. • "The literature suggests several potential explanations for this delay: attribution to causes other than dementia; lack of knowledge about dementia; inaccessibility of services; or stigma of mental illness".

K. Walhovd, et al., (2014) Cognitive decline and brain pathology in aging - need for a dimensional, lifespan and systems vulnerability view. Scandinavian Journal of Psychology, 2014, 55, 244-254

• This reading discusses the factors affecting cognitive health such as dementia in terms of quantitative differences. It also identifies the factors that affect brain health through impact accumulated in life-long events that may not specifically have to be related to aging. This includes environmental and genetic factors. Argues against age-related cognitive decline • Cognitive and brain features in aging can be predicted by early life events, charcteristics, and impact. For example, reduced brain mass is a common characteristic in cognitive decline in healthy aging. However, it was found that small brain volumes could be observed in adolescence, even during the embryonic stage. Shows that risks of cognitive impairment might be present at a young age. • apoE, a gene that is responsible for neuron maintenance and repairing. It was found that APOE e4 causes an increase in risk of developing AD (Alzheimer type), and that it's evident in people with memory deficits. The e4 allele has many different effects on fitness throughout one's lifespan. It was found that the presence of e4 is related to the reduction of grey matter.CLU, CR1, and PICALM: other genes that could be contributing the risks of AD. It was found that CLU carriers have a reduced brain mass, independent of the APOE genotype. • AD is not only polygenic (depended on genotypes) but the genes are also pleiotropic (genes of unrelated effects). Can be concluded that the strong predictors of AD are not age related, but are mostly impacted by environmental factors. • Normal aging: changes in the brain and cognitive functions characterize normal aging,but it's independent of AD. Areas in the brain such as the entorhinal cortex and the hippocampus are the most vulnerable regions in AD as well as normal aging due to the high degree of neuroplasticity. • Amyloid in aging: accumulation of amyloid in some cortical regions can result in higher cognitive activity. However it was found that accumulated mental activity have positive effects on cognition in elderly and have inverse relations to amyloid deposition. • Cognitive reduction in aging: there are overlapping causes and relationships between the major cognitive, genetic and biological events in aging and AD • Dimensional perspective: many brain and cognitive symptoms are not unique to dementia, the changes in the brain in healthy aging and in AD cannot be clearly distinct. • There are multiple etiologies in dementia and cognitive declination in aging, and risks of AD is contributed by various genetic and environmental factors that are accumulated through life long events and impacts.