413 exam 3

depression

"Everyone feels sad or blue sometimes. It is a natural part of life. But when the sadness persists and interferes with everyday life, it may be depression. Depression is not a part of growing older. It is a treatable medical illness, much like heart disease or diabetes." -Geriatric Mental Health Foundation

importance of person-environment fit

-"No environment is inherently good or bad. What matters is the extent that the environment fits with their physical, cognitive, and emotional needs and allows them to maintain a degree of control over their surroundings." -not too easy or too hard for older adult -"The 'place' of aging impacts how we age." (Hooyman & Kiyak, 2018)

"the village movement"

-"a virtual approach to aging in place in which residents pay an annual fee and receive services and supports, often provided by neighbor volunteers, that allow them to remain in their homes.: Not necessarily a physical space, but a place where community members come together benefits for older adults in the village approach: can stay at home but receive services like grocery shopping, provided transportation, social life (having neighbors who you see- often/sometimes/regularly)...

other losses and stressors

-"bereavement overload" - stress of widowhood experiences in conjunction with other stressors, such as... -financial strain -loss of work and community roles -compromised mobility -health declines -loss of sensory functions -loss of daily routines -getting up in morning- having coffee/making coffee with/for spouse

late stage

-1-3 years -requires around-the-clock assistance -unable to respond to environment or hold a conversation -changes in physical abilities -unaware of recent experiences SEE SHEET FOR MORE

financial strain and work impacts

-17% report financial strain due to caregiving -60% say they have experienced at least one impact or change to their work situation due to caregiving -near-term consequences: reduced wages and reduced job security (due to missed days or reduced hours)--> Boomer caregivers report spending 13% of income on caregiving (Gen X 24%) -long-term consequences: low lifetime earnings has negative impact on retirement funds; health implications -17% = nearly 1 in 5... ? -maybe got passed over by promotion (didn't get it purposely or like you know you can't devote your time to/in a new position - was not offered it, did not take it if offered, or did not apply/make themself in the running/show interest in (wanting) a promotion

middle stage

-2-10 years -confusion with words -personality and behavioral changes -forgetfulness of events or personal history -changes in sleep patterns SEE SHEET FOR MORE

early stage

-2-4 years leading up to diagnosis -functions independently, but has memory lapses -problems with concentration -challenges performing tasks -trouble remembering new information SEE SHEET FOR MORE

emotional stress of caregiving

-38% say their caregiving situation is highly stressful -26% find it moderately stressful -emotional stress increased for: -those caring for a spouse -those caring for someone with Alzheimer's or dementia or long-term condition -Caregivers in role for a year + and high burden White vs. African American or Hispanic -White- higher burden than African American -African America- spread out of caregivers, White- most likely one caregiver doing it by themself- don't expect it (that role)

burden of care (level of care index*) *level of care index is based on #hours of care given, # ADLs and #IADLs performed

-40% of caregivers for someone 50+ are in high burden situations -high burden = -50.9 hours/week -3.1 ADLs -5.2 IADLs -example = help getting into bathtub, help with transferring (more of an always thing) -low burden= help occasionally with getting into bath/shower, transportation (low burden = 42%

caregiver health and health changes

-48% of caregivers say their health is excellent or very good -17% say their health is fair or poor -73% say providing care has not affected their health -21% say caregiving has made their health worse -health suffered more for... -those who felt they had no choice in taking on caregiver role -those caring for someone with Alzheimer's or dementia -higher-hour, high burden caregivers -caregivers in role for a year or more -White and Asian vs. African American and Hispanic for second part -Alzheimer's or dementia- cognitive issues as well as physical- comorbidities -White and Asian (Americans ? ) said their health was affected (negatively) more so than African Americans and Hispanics -really when the burden of care is significant

where do most older adults live? (pie chart of older adult (65+ years) living arrangements, U.S., 2011-2015)

-78% independent -15% caretaker (household in which older adult is caretaker for non-elderly person) -7% caregiver (household in which older adult lives with non-elderly caregiver) -2% institutionalized -most older adults live independently -majority live in single detached housing, more likely to have that house paid off (compared to younger people) -caretaker role: young adult child with disability, grandchild

DSM-V (Diagnostic and Statistical Manual) Diagnostic criteria for major depressive disorder

-A. at least 5 form list; of those #1 or #2 required (one of the first two has to be experienced/included) -B. same 2-week period or more (has to be at least 2 weeks); AND -C. represent change from previous function 1.depressed mood most of day, nearly every day 2.markedly diminished interest or pleasure in activities, apathy 3.significant weight loss or weight gain, or appetite change 4.sleep disturbance (insomnia or hypersomnia) nearly every day 5.agitation or lack of activity nearly every day 6.low energy level or fatigue nearly every day 7.self-blame, guilt, worthlessness 8.poor concentration, indecisiveness 9.recurrent thoughts of death (not just fear of dying), suicide -symptoms may be going on longer but treatment is not sought out or noticed perhaps -combinations could be either of 1 or 2 then 4 more or it could be 1 and 2 and then 3 more

who takes care of older adults (age 50+)?

-According to National Alliance for Caregiving & AARP (2015), Caregiving in the U.S.: -average caregiver age: 50.3 years -over half (55%) are caring for someone 75+ years -60% are female (*signs of younger men taking on a larger role though) -relationships to care recipient: -47% care for a parent (34% mother, 13% father) -11% care caring for a spouse

Alzheimer's disease (and causes)

-Alzheimer's is a progressive brain disease that causes problems with memory -specific changes in the brain, the formation of plaques and tangles -Alzheimer's causes nerve cells to die which leads to shrinkage in the brain -the brain changes result in changes in memory, thinking, and behavior -results in severe cognitive decline *accurate diagnosis is important to understand where in the brain something is occurring

differentiating Alzheimer's from normal aging

-Alzheimer's is not a normal part of the aging process -normal aging vs. Alzheimer's: -you forget where you parked your care but not that you drive a care -you forget where you put your keys, but not what the keys are fore -you go into a room and forget why you're there, but not where you are -you forget people's names, but not their faces -you sometimes can't find the right word, but don't forget what the word means -driving to your friend's house, you inadvertently turn into the shopping, but you don't lose your way ***!!-Alzheimer's is secondary aging- the bodily deterioration/disablement is not inevitable with age; instead it is induced by disease (i.e., Alzheimer's) -all humans don't experience these changes--> Alzheimer's (it is not universal)

factors that affect the widowhood experience

-Carr & Jeffreys (2011) examined 4 influences that are particularly important and modifiable: -nature of the marital relationship -conditions surrounding the death -social support and integration -other co-occurring losses and stressors

grief vs. a major depressive episode in DSM-V (chart)

-GRIEF: -dominant affect is feelings of emptiness and loss: --dysphoria occurs in waves, vacillates with exposure to reminders and decreases with time --capacity for positive emotional experiences --self-esteem preserved --feeling thoughts of joining deceased -MAJOR DEPRESSION: -dominant affect is depressed mood: --persistent dysphoria that is accompanied by self-critical preoccupation and negative thoughts about the future --limited capacity to experience happiness or pleasure --worthlessness clouds esteem --suicidal ideas about escaping life versus joining a loved one -grief more or less comes in waves -depression= low self-esteem and lack of capacity to experience happiness -depression= thoughts of suicide

advance directives

-Patient Self-Determination Act (PSDA) of 1990 guarantees right of all competent adults to have active role in decisions about their care --> advance directive or living will stipulate end-of-life treatment --> durable power of attorney for health care appoints a health care proxy --> do not resuscitate order directs health care workers not to use resuscitation --> request for palliative care provides relief from symptoms (e.g., pain) and some services but does not hasten or postpone end of life

the law and active euthanasia

-Supreme Court Ruling of 1997 --no constitutional or fundamental "right to die" --did not preclude statement of passing laws allowing physician assisted suicide --prescribing drugs with the intent to relieve suffering is legal even though drugs may have the foreseeable side effect of hastening death --> explicitly endorsed "terminal sedation" -six states currently have "Death with Dignity" laws: California, Colorado, Montana, Oregon, Vermont, and Washington -under the legislation, patient must be... --competent --request aid in dying at least twice --have a prognosis of 6 months or less to live --be able to take the prescribed medication themselves

dementia

-a general term for a collection of symptoms that are severe enough to interfere with daily life -dementia is an umbrella term- under the umbrella falls: Alzheimer's which is the most common cause of dementia (60-80% of all cases of dementia are Alzheimer's), vascular dementia, dementia with Lewy bodies, and frontotemporal dementia

long-term services and supports (LTSS)

-a range of types of personal assistance to individuals of all ages who, as a result of chronic illness or disability, are limited in their functional ability -need determined by assessing limitations in capacity to perform ADLs and IADLs -older people primary users of LTSS; need increases with age --half will need it at some point --average duration of need is ~2 years --women more likely to need it (and for longer) --14% of people expected to need LTSS for 5+ years -women have more chronic conditions and lack partner to take care of them (women take care of men...)

who needs care?

-according to National Alliance for Caregiving & AARP (2015), Caregiving in the U.S.: -average care recipient age: 69.4 years -47% of all care recipients are 75+ years old -among care recipients age 50+: -67% are female -63% have a long-term health condition -most common problems/illness (as reported by caregivers): "old age" (16%); Alzheimer's/dementia (9%); mobility issues (85).

assessing LTSS system performance (AARP, 2017)- where does the state of Arizona rank?

-affordability and access= bottom quartile (46th) -choice of setting and provider= second quartile (24th) -quality of life and quality of care= third quartile (33rd) -support for family caregivers= second quartile (23rd) -effective transitions= top quartile (8th) -communicating across services- Banner... and other hospitals (services) as well as between social services

strategies for aging in place

-age-friendly/livable communities -flexible housing -universal design: accessible and usable by broad range of individuals -other innovations, e.g., intentional (or niche) communities; Elder cottages/mother-in-law units -structures put into place in the community -islands in between two sides of the street- older adult may not be able to cross all 4 lanes in 20 or 30 seconds -ramps -rails -wider doors -having other communities (for elders to choose (to live in)

advance care planning: advance directives

-all 50 states have laws authorizing the use of advance directives to avoid artificially prolonging death -thoughts and questions should be written down before making one -having a health care proxy- give someone the authority to make decisions for you

bereavement from a biopsychosocial perspective

-all corresponding to response to bereavement --biological: stress on body --psychological: range of negative emotions; impaired attention and memory --sociocultural: altered position in family and community; financial burden; change in support network -support network- maybe a caregiver whose spouse died has more time for social life now to go hang out with friends...

assessing LTSS system performance (AARP, 2017)

-all types of services not just nursing facilities -support for family caregivers: respite care- integration between hospital and working with long term support... GRAPHIC -top bubble= high-performance LTSS system is composed of five characteristics: --affordability and access --choice of setting and provider --quality of life and quality of care --support for family caregivers --effective transitions (integration of health, LTSS, & social services) -these 5 characteristics are approximated in the Scorecard, where data available, by dimensions along which LTSS performance can be measured, each of which is constructed from --> individual indicators that are interpretable and show variation across states ***A HIGH PERFORMANCE LTSS SYSTEM DOES HAS/INCLUDES ALL CHARACTERISTICS (GOOD COMPONENTS OF THEM)

why focus on depression in older adults?

-although depression is not a normal part of aging, older adults are at increased risk for experiencing depression -depression is the most prevalent mental health problem among older adults -1-5% of community dwelling elders have some type of depressive disorder --> rates are higher among those in hospitals and skilled nursing facilities

treatment: evidence-based community programs (continued)

-an example: IMPACT (Improving Mood- Promoting Access to Collaborative Treatment): --a collaborative, clinic-based program for older adults with major depression, combining primary care and mental health services --depression screening plus follow-up mental health questionnaire (where indicated) during primary care intake visit --treatment: combined problem-solving therapy + antidepressants -trying to figure out best combination can take some time

consequences of spousal loss in later life

-compared to married counterparts, widowed persons show... -more health problems, depressive symptoms, lower life satisfaction -reduced social networks and contacts -feelings of loneliness -shifts in daily routines (single greatest difficulty) -possible relocation -increased mortality risk- "widowhood effect" -increased use of alcohol and tobacco -"bereavement overload" FIRST SET -is widowhood bringing on the loneliness or was this going on before? -for many, these things were happening before the spouse died (reduced social networks because of caretaking role for spouse taking up all your time) SECOND SET -increased mortality in those who have just lost their spouse or partner -bereavement overload: lots of multiple stressors going on that compound it- lost spouse and you have all these other stressors going on

greif process

-complex emotional response to bereavement -can encompass a wide and changing response to bereavement -loneliness, anger, and depression, but also laughter and reminiscence of individuals- not only negative but also resilience

hospice costs

-costs associated with hospice care are covered by Medicare Part A (Medicare Hospice Benefit) --> over 90% of hospices in U.S. are certified by Medicare -->80% of people who use hospice are 65+ and entitled to medicare Hospice Benefit -also covered by Medicaid and most other health insurance -little or no cost to the patient

mourning

-culturally patterned expectations about the expression of grief

treatment: evidence-based community programs

-depression can be effectively addressed through evidence-based, community programs -home- or clinic-based Depression Care Management (DCM: -such programs follow a team approach in which "...a trained social worker, nurse, or other practitioner oversees patient education, outcomes tracking, and support/delivery of evidence-based treatments prescribed by a primary care provider in consultation with a psychiatrist..." -treatment typically involves psychotherapy interventions and antidepressant medications, individually or in combination -treatments that appear most effective- team approach, psychiatrist, nurses... working together (identify issue- how to best tackle it)

good death

-dignity and reasonable control over what happens -understanding of what to expect -control of pain and other symptoms -choice about where death occurs -access to information and expertise and to palliative care/hospice at any location -supports to minimize spiritual and emotional suffering -ability to maintain religious/spiritual/cultural beliefs -sufficient time to say goodbye (often fear comes from the unknown) -->understanding of what to expect

bereavement and the grief process

-earlier westerns views of death and the grieving process shaped by work of Kubler-Ross (1969) viewed as fixed sequence of orderly stages -denial -anger -bargaining -depression -acceptance -in fact, grieving process is more like a roller coaster- with wide variation among people -no two people grieve the same way -it highly varies- not necessary for people to have bargaining- they may go straight to depression and not have anger or denial...

stages of Alzheimer's

-early (mild) stage -middle (moderate) stage -late (severe) stage -no two individuals experience the symptoms and progression of Alzheimer's disease in the same way -while symptoms worsen over time, people progress through stages at different rates as their abilities change -(some fast, some slow... - it is fluid) -behavioral problems= personality changes, loss of impulse control... -communication problems= minimal or no speech, difficulty thinking logically, shorter attention span -person in early stage might have symptoms of middle stage -2 sides: cognition and physical function -stages are important- they help family get ahead of each step, avoid crisis, help person with Alzheimer's be as independent as possible

hospice care

-end-of-life care that includes palliative care *focus on care rather than cure

person-environment fit model of adaptation

-environmental press (top left): -social-emotional demands -cognitive demands -physical demands -individual competence (top right) -social-emotional abilities -cognitive abilities -physical abilities -adaptation below the two columns BALANCE SCENARIO -balance between individual competence and environmental press -residents are maximally adapted when there is a balance (or fit) between environmental press and individual competence

caregivers and their impact

-estimated 804,000 family caregivers in Arizona (32nd in the nation)--> economic value of those caregivers: more than $9 billion -caregiver support (45-64 year old person per person 80+) -currently: 6.2 adult to older adult (42nd lowest rate in country) -projected: 2.2 adult to older adult (50th in the country) (Arizona for both?) -26,000 personal care aids 912th most in the country ) (Arizona?) -6,500 home health aids--> earnings for both (personal care and home health aids ? ) about $11 (in 2016) (Arizona?) -considering the older adult population we have this is kind of low (but other states have higher general populations- so that must be taken into account

euthanasia and physician aid in dying

-euthanasia: painless or peaceful death -active euthanasia: deliberate steps to end a patient's life, usually with the use of drugs -passive euthanasia: withdrawal of life-sustaining treatments or failure to treat life-threatening conditions --> objective handle pain, not stop the death from happening -physician assistance in dying (aka physician assisted suicide) --physician actively aids a patient who is dying, usually through lethal injection --a form of active euthanasia; also referred to as "hastened death"

nature of the death

-expected vs. unexpected death -whether unexpected deaths are more difficult is unclear -allows for "anticipatory grief" (grieving the loss even prior to the death) (expected death ?) -seems to have beneficial effects overall (anticipatory grief ?) -intentional time spent together beforehand is helpful -positive- you have time to say goodbye but host of negative factors too...

consequences of spousal loss in later life (continued)

-explanations of the "widowhood effect" -for older adults... -stress due to bereavement + weakened immune system= increased vulnerability to infection -health declines prior to widowhood -they had other health complications and stressors before spouse's death- it wasn't like they just all of a sudden had health issues after spouse died

who takes care of older adults? -circle chart

-family caregivers = 65% -combination: family/paid = 26% -paid care only = 9% -often combination- lady from video falls into this --> she takes care of home activities, getting her up, dressed... then taker her to daycare (paid care) -misconception because if people do go to nursing home it's not for very long and they usually go after they have already been taken care of by family (they aren't sent to nursing home until the dam breaks...)

elderly suicide completion

-fewer warnings of intent -are more likely to use lethal methods (firearm/gun) --> firearms most common means (72.1%) for suicide in elderly (especially men) -are more likely to be socially isolated and therefore not noticed missing and not found in time for rescue -have less recuperative capacity, so cannot easily bounce back from the wound, drugs, etc. -also, more likely to have suffered from a depressive diagnosis prior to their suicide

women and men social support

-for both women and men... -social isolation and limited contact impedes adjustment to loss -isolation can be due to... -lack of transportation -physical limitations on mobility -physical distance from loved ones -perceived inadequate support -death of siblings and friends -men more likely to have ADL and IADL issues -older adults are likely to move in with children- move closer to children -isolation because of other deaths- oldest olds are the most likely to have the most difficulty (outlived friends and siblings- or friends and siblings have health complications making it harder to see them and have close relationships with them

poor fit: environment press is too low

-for example: -an older person, Sophie, living in a nursing home is capable of buttoning her clothes, but the caregiver at the nursing home quickly buttons them just to keep things moving along -implications: -environmental press should be challenging, but not overwhelming -issue of "over-care" and relocation stress -->can be offset when older adult has control over and involvement in relocation decision

poor fit: environmental press is too high

-for example: -stairs in the home demand that older person be able to walk up and down stairs -the individual is cognitively healthy, but unable to walk and balance themselves without a walker

why discuss suicide along with depression?

-fortunately, only a small of those treated for depression attempt suicide -but depression is a risk factor for suicide --> one of the leading causes of suicide among the elderly -other risk factors: -other mood disorders -serious physical illness with severe pain -recent death of a loved one -social isolation and decreased social support -major loss of independence (i.e., ability to do ADLs) -major changes in social roles -older people are less likely to attempt suicide -social isolation... goes back to the point where older adults are most likely to die from suicide attempt... ? (unsure if correct statement ? ) (true I think)

why high suicide rates among older white males?

-greatest incongruence between ideal self-image and actual aging self -more likely to be socially isolated -thus, who's at highest risk? --> older men who are: --white --widowed --isolated --ill, with chronic pain --history of major depression --firearm available -firearm is a key risk factor -a lot of these things go together: could be having depression, have a firearm available, be widowed... (all together, all happened to you...) -lack of social support--> isolation -men are more likely to have a firearm available, especially white men

hours dedicated to caregiving (bar graph)

-hours increase as person's (older adult's) age increases -sometimes caregiving is a full time job on top of a full time job the caregiver already has (child (or spouse)) -this is typically because older people are needing more help with their ADLs and IADLs -older age group 65 to 75 + dedicate more than 30 hours of care per week and 15-64 dedicate from 14.8 to 25.3 hours of care per week *dedicate= hours of care provided each week

what do caregivers do for older adults?

-hours of care provided: -on average: 24.4 hours/week -22% provide care for 41+ hours/week -activities of daily living (ADLs): -60% help with at least one ADL (average = 1.7) -22% find it difficult to help with ADLs (increases with # of ADLs) -six days per month doing these tasks -22% is the spouse who lives with the older adult- and this care is usually provided to the oldest-old population and frail (oldest old are typically frail)- need the most care -ADL= bathing, toileting...

does someone you care about need help with one + of the following, and YOU provide that help?

-housekeeping or home maintenance -grocery shopping -transportation -bill-paying or personal finance -preparing or eating meals -managing their medications -dressing or bathing -remembering things -hiring or supervising help -if you provide one of these things you are experiencing caregiving- you as the caregiver -Caregiver Self Assessment provided by Jan Sturges, M.Ed.

"anticipated deaths"

-however, "anticipated" death may be accompanied by other stressor that take a toll -for example, partners' long-term illness and suffering; intensive caregiving, and neglect of one's own health issues -anticipatory grief can leave the individual more depressed -caregivers may show improved psychological health following loss of a spouse -quality of end-of-life care and place of death (these are in addition to expected vs. unexpected death in nature of the death category) -this person was probably sick for a long time -declining health of caregivers- giving time to help their spouse... (not paying attention to their OWN health and health needs) -could be associated with depression- knowing your spouse or partner is going to die -identity is tied up in spouse- yeah they gave up a lot of things but they had purpose and identity now they have to change this (caregiver to something else...) -most people would prefer to die in home, when it's in the hospital- usually perceived as worse by family and friends- when quality of care is not good- negative adjustment; most people don't like to die in hospital with a bunch of tubes around them but that is what happens in American for a majority of people

grief vs. a major depressive episode in DSM-V

-important note: clinicians must be careful about diagnosing major depression following a significant loss, because normal grief "may resemble a depressive episode." --> new guidelines and criteria under DSM-V (published in May 2013)

benefits of aging in place (book)

-improved health -greater life satisfaction -increased self-esteem -ability to avoid or delay relocation to a long-term care facility

social and health services to promote aging in place (for an older adult at home)

-in home: -home care -home health services -home-delivered meals -home repairs -technology -in community: -social services -adult day care/day health... (care?) -transportation -shopping

types of caregivers

-informal caregivers -formal caregivers

long-term services and supports: types of care

-institutional care -residential care

what do caregivers do for older adults? (continued)

-instrumental activities of daily living (IADLs): -99% help with at least one IADL (average= 4.2) -13 days a month doing these tasks -58% help with medical/nursing -other key activities: -monitoring recipient's health (68%) -communicating with healthcare professionals (66%) -advocating with providers, services, agencies (51%) -grocery shopping, doctor's appointments, making phone calls for appointments= IADLs

why, then, do we most often link young people and suicide?

-it seems much more tragic when a young person loses their life -also, young people attempt suicide at higher rates (100-200 attempts for 1 completed suicide) as compared to older adults -however, older adults have a higher suicide completion rate (4 attempts for 1 completed suicide) -attempts: completed ratio--> -young= 100-200: 1 -old= 4: 1 HOW CAN WE EXPLAIN THIS DIFFERENCE? -why might an older adult be more likely to pass away with the attempt? --body more resilient in young adulthood --someone less likely to walk in on the adult doing it- whereas youth maybe a parent or sibling could find them

LGBT partner loss and bereavement

-level of "outness"- undisclosed identity- can make bereavement difficult -"disenfranchised grief"- involves a loss that one is not able to publicly acknowledge or mourn -might have family, friends, coworkers who may not know they even had a significant other- they have to grieve in private so they don't have that social support of friends and family- comforting them, asking if they are okay, OR they might have known of significant other but didn't feel comfortable with them or comfortable talking about them

"oxygen masks" for the caregiver: how caregivers can take care of themselves

-like in a plane, be sure to care for yourself in order to provide quality care for your relative -taking time for pleasurable activities, self-care -ask for help (and use local resources) -support groups -respite: a relative or a professional gives you a few hours or days off from caregiving; treat yourself -council on aging in each county or area (here it is Pima Council on Aging)

attachment view

-maintaining continuing bond with deceased can be beneficial -holding on to thoughts/memories and keeping possessions is not abnormal -thoughts about the deceased (arrow pointing to this in center of slide) -for some people it can be healthy to maintain one's emotional bonds

choosing long-term care

-make a list of needs of the person -decide where care should be (home, community center, residential setting, etc.) -figure out how it will be paid -visit possible locations -what are the needs of the person? does not just have to be physical but also socioemotionally -could happen that you place older adult somewhere based on physical needs but it's not a good place for them socioemotionally

nature of marriage/romantic relationship

-marital relationship quality: -is a happy marriage linked to better adjustment? --> no in the short term, but yes in the long run -partner from an abusive or burdensome relationship may show improved adjustment following death -free for the first time, flexibility to do what they want -even just being with a husband who didn't give wife access to finances or things they could do... -even women who married young, had kids, took care of them and husband in old age- now they are free for the first time- adjustment is usually positive in the end (above one too (?) )-not saying it's not difficult but usually positive adjustment in the end

hospice services: family-focused interdisciplinary approach

-medical services: physician, nurse case manager (RN), certified nursing assistant (CNA) --> assessment of medical needs --> pain and symptom management -social services: social worker --> assessment of psychological and family needs -pastoral care services: to address spiritual needs -family services: bereavement specialist; volunteers --> bereavement counseling with family for 13 months --> respite caregivers -spiritual needs are being sought after- if they have a place they normally go to but cannot (church maybe) - they have someone come to them (a priest maybe)...

gender differences: who suffers more?

-men tend to do worse than women following bereavement: -higher levels of depression -more physical limitations (require more help with ADLs and IADLs) -mortality rates somewhat higher--> period of mortality risk may be longer -about 2.5 to 3 times higher for men to experience mortality after bereavement

men's social support

-men... -seek social support in new romantic relationships -is re-marriage adaptive or maladaptive? -some evidence suggests that a new relationship may be healthy and adaptive BUT studies have been retrospective and can't determine direction of effects. -within the first two years about 1/4 of men got into a new relationship and remarried--> men reported this was positive for them (unsure of situation, can't just solely believe this) -about 5% for women (lower) (because less than 25%)

aging in place

-most older adults prefer to age in place -aging in place = "...continuing to live with social supports and services in a private home or apartment in one's own neighborhood" (book) -we know that most individuals would like to age in place -majority of adults want to live in their residence when they age -61% of adults age 65 and older say they would [stay in home, but have someone there care for them] if they could no longer live on their own -...17% move into an assisted living facility... -8% move in with a family member -4% move into a nursing home -"home is where the heart is"

non-pharmacological treatment approaches (continued)

-non-pharmacological therapies that have shown promising results with dementia patients: 1.massage/touch therapy (e.g., hand massage), physical activity/exercise 2.music/music therapy -music therapy is one of the more well-documented effective therapies for treating a range of psychological, psychiatric, and physical conditions, including Alzheimer's/dementia

philosophy of hospice care

-not a place, but a philosophy -end of life is not a medical event, but a natural part of life -concerned with palliation of patient's pain and suffering -focus on comfort, self-respect, and quality of life in final days and months -physical, emotional, and spiritual care for patient and their family -should be culturally appropriate -hospice is not a place- it provides quality care and comfort... -24/7 care

costs of care: Arizona & U.S. (bar graph and table)

-nursing facility $90,000 a year (pays for meal, room, board, rent...) (for a private room) (similar number for shared room- about $80-90K) -from 2017 -source= AARP -adult day services cheapest (about $20,000 or a little under)

institutional care

-nursing homes: medical institutions that provide room, meals, skilled care, medical services, and protective supervision (nursing home at top- like family tree- branching off below it are...) -skilled nursing facility: provides the most intensive nursing care available outside a hospital AND -intermediate care facility: health-related services for people who don't need hospital or skilled nursing facility -skilled nursing: people need most intense help, have the most issues with everyday ADL, IADL

relocation

-older adults are less likely to relocate than other age groups -relocation rates decline with age -older adults are more likely to move to a different type of housing nearby -one of the first moves for older adults is moving to some other type of living situation in the same community -move out of two story house with basement to a single story apartment in a continuing care (facility) community bar graph in slide (relocation rates 2014-15) -4% of adults 65 and older moved in one year vs. 13% adults under age 65 moved in one year

how to help grieving older adults

-older adults experiencing "normal" and relatively short-term sadness over loss may not require professional treatment/intervention (professional treatment may be required for not normal long-term sadness over loss ? (perhaps) ) -however, both professionals and non-professional caregivers can help to support the grieving older adult -services, support groups available are all really important (one resource center can target one aspect older adults are having- finances or loneliness, depression)

challenges of diagnosing and treating depression in the elderly

-older adults often don't report mood changes (stigma) -older adults may have health conditions that can cause depressive symptoms -symptoms that seem to indicate depression can actually be induced by medications -implications: --clinicians must first rule out other health conditions and medication-related problems --diagnosis and treatment approaches must take into account the interconnection between physical and mental health in the elderly first part -maybe men who fought in the war- saw really sad things- depressing things, now dealing with it still (thinking about it...) can't unsee it -not talking about things second part -shortage of mental health providers -a lot of older adults are not getting the treatment they deserve *older adults are often misdiagnosed and undertreated

why do older adults relocate?

-older people generally relocate in response to "push factors" --> major life changes (e.g., retirement, poor health, loss of partner) -there may also be "pull factors" -->chance to live closer to children; availability of more desirable living situation -more desirable: moving to active aging community, move to a place they would prefer to live in (kids are gone, don't need to live in house they did when they had their kids...)...

hospice use

-only about 25% of those who could benefit from hospice are referred -why isn't hospice used more? --physicians trained to cure --referred too late (31% of hospice patients die within a week) --lack of knowledge, fears about hospice --racial disparities -with racial disparities- physicians less likely to refer or talk about hospice care as an option for elders of color...

formal caregivers

-paid care providers who provide care in a person's home or in a care setting (e.g., day care, residential facility, long-term care facility) -also called direct care workers

end-of-life care

-palliative care -hospice care

person-environment (P-E) theories of aging

-posit that the individual is likely to experience active aging and quality of life in an environment that is congruent with-or fits- his or her physical, cognitive, and emotional needs and level of competence -environment press and the competence model --environment press: the demands that the social and physical environment (e.g., the home, neighborhood, society) make on the individual to adapt, respond, or change --individual competence: the individual's capabilities (physical, cognitive, emotional) to function in the environment -what are the demands- socioemotionally, relational, cognitive... -if you have someone living in their own home who is physically and cognitively capable but socially they are not around people- this may be an issue...

evidence of music therapy effectiveness

-recent meta-analytic reviews of randomized and clinical controlled trials of music therapy interventions for those with dementia: -moderate to large effects on disruptive behavior -moderate effects on anxiety levels and depression -small to moderate effects on cognitive functioning -may also promote positive social interaction -helps with a lot of frustrations individuals are feeling -more beneficial when it has been sustained (continuing for an extended period of time) -more beneficial when it is more than a one time thing

contemporary perspectives

-recognition of diversity of healthy ways grief is expressed -high amount of variability - some people may not even grieve at all or they may show it differently

advantages of music therapy as a therapeutic approach AND best practices

-relatively low cost -can be implemented by informal caregivers in the home setting as well as in clinic settings (individually and in a group) -has no known side effects -can be safely prescribed in both late and early stages of dementia and when diagnosis is pending or uncertain -can enhance effectiveness of other non-drug treatments (e.g., massage therapy, physical exercise) SOME GUIDELINES FOR CAREGIVERS (Alzheimer's Association): -identify music that's familiar and enjoyable to the person (a song they know) -choose a source of music that isn't interrupted by commercials (can cause confusion) -use music to create the mood you want -encourage movement (clapping, dancing) to add to the enjoyment -avoid sensory overload (background noise, high volume) -songs that would be relaxing to the person

residential care

-residential care facilities: 24-hour supportive care services and supervision to individuals who don't need skilled nursing or health-related care: --board and care home --assisted living facility --group home --adult foster home -what are the physical, cognitive, socioemotional abilities of the person and how can we best match that with the care they need?

why does music therapy work?

-rhythmic and well-rehearsed responses require little cognitive processing --influenced by motor center of brain that responds directly to auditory rhythmic cues -ability to engage in music remains intact late into the disease process

barriers to healthy caregiving

-some caregivers believe: -I should do it all myself -I don't want to accept outside help -home is always the best option -no one will do as good a job as I do -healthier view: you are a good caregiver when you make sure your loved one receives good care; you don't have to do it all by yourself; ask for help as (or before) the health of the caregiving recipient declines -you can't and shouldn't do it yourself -identify ways to reach out/ask for help

model with environmental press too high

-sometimes environmental press is too high -environmental press exceeds individual's competence -the scale is tilted to the right with environmental press higher than individual competence (toppled too high...) & unbalanced! -dementia... -forgetting

model with environmental press too low

-sometimes environmental press is too low -competence exceeds environmental demands -the scale is tilted to the left with individual competence higher than environmental press (toppled too high...) & unbalanced! -environmental press is not demanding enough: i.e., caregiver or other person doing things for an individual that that individual is capable of doing (themselves)

3-stage model of migration among older adults

-stage 1= amenity or life-style moves -->usually among young-old and recent retirees; often to retirement communities in Sunbelt -stage 2= assistance moves precipitated by chronic illness or disability that limit elders' ability to perform their daily tasks (move to nearby facilities or move closer to family members) -stage 3= assistance move when severe or sudden disability, chronic illness, or loss of partner makes it impossible to live even semi-independently for stage 1 -Arizona= Sunbelt state; most people are staying in their states because they can't afford a second home (now) for stage 2 -closer to family, can hire aide help to come to the household; people can either go into house or residents can go out; technology- life alert, controlling heat and air conditioning from mobile device so immobile person can manage it while not having to go to thermostat (can't move...)

traditional view

-survivor must "work through" their grief and break emotional bonds with deceased -grief that lasts for more than one year is abnormal -thought about the deceased (arrow pointing to this in center of slide) -people had to work through their grief

risk factors of Alzheimer's

-the greatest known risk factor for Alzheimer's disease is age (after age 65, 1 in 9 people will have Alzheimer's) (an individual's risk for developing the disease increases at age 65) -family history: those who have a parent or sibling with Alzheimer's increases an individual's risk (are more likely to get it) -risk genes and deterministic genes are the two types of genes associated with Alzheimer's Populations at higher risk: -Hispanics, African Americans and women are at an increased risk for Alzheimer's -Hispanics are about 1.5 times as likely as whites to develop Alzheimer's and other dementias -African Americans are about twice as likely to develop the disease as whites -Almost two-thirds of Americans with Alzheimer's are women (women live longer, age is a risk --> therefore the higher risk they are at/in for the disease)

non-pharmacological treatment approaches

-therapies that employ approaches other than medication -goals of non-pharmacological therapies: 1.maintain or improve cognitive function, ability to perform activities of daily living, or overall quality of life 2.reduce behavioral symptoms such as depression, apathy, wandering, sleep disturbances, agitation, and aggression -like drug therapies, have not been shown to alter the course of Alzheimer's disease -idea is not to cure Alzheimer's but dealing with the symptoms and goals people have in life

risk groups for depression among older adults

-those with major physical conditions (especially if the condition involves chronic pain, loss of independence/autonomy) -those with sleep issues -those who are alone and with no social support network -those who have a combination of losses -nursing home residents -caregivers (if stressed and watching loved one deteriorate) -women (more than men), but caution: could be because women are more likely to seek help --> higher rate of alcoholism in men (in some cases could be depression, with alcohol used as a coping device) -relocation to nursing home or other place can be difficult too -women may be better about talking about it (depression) or more likely to seek out help from medical professionals... -alcohol may make men feel better- do not think they are depressed (when they are drunk and happy or unaware (numb) so do not seek help, people may not know they are depressed, do not show it when sober or drunk...)

theories of bereavement

-traditional view -contemporary perspectives -attachment view

palliative care

-treatment for pain and symptoms due to serious illness at any stage -umbrella type of care: still may be receiving life supporting treatment like chemo- care focused on dealing with any pain or illness that might come with that *focus on care rather than cure

who do older adults turn to for care?

-two ways of understanding how older adults get help (Gillen et al., 2012) 1. principle of substitution: order in which older adults choose their care provider: spouse or partner, children and other relatives, friends and neighbors, professionals 2. task-specific model: different tasks require the help of different people: -spouse/partner and close family members = tasks that require time and energy; personal tasks (e.g., bathing- ADLs) -friends and neighbors= errands, transportation, leisure activities -professionals= tasks that are too time-consuming, technical, or difficult for others for number 1. -how caregivers get selected: spouse or partner first to do the caregiving, then other relatives- if you are the spouse or child- you can ask neighbor to help out with the grass or getting groceries for who you are caregiving for -when caregiving happens it falls on 1 or 2 to do most of the work- but ideal is when the care is spread out -professional- when ADL issues are uncomfortable (feeding, dressing, toileting) when things are getting time consuming and extensive -mail man with newspaper not getting to door- neighbor can help move it

informal caregivers

-unpaid individuals (e.g., spouse, partner, family member, friend, neighbor) who provides assistance with activities of daily living and/or medical costs -also called family caregivers

music therapy

-use of musical elements (sound, rhythm, melody, and harmony) by a qualified music therapist... to facilitate and promote therapeutic objectives related to psychosocial, cognitive, and sensorimotor behavior... -can also involve informal music activities delivered by non-therapists -widely used both as an alternative to and in combination with pharmacological treatments -from documentary: Henry, Gil, Denise (got up from walker- did not need it to move around- first time they saw her do that (not rely on walker) in a long time/forever...

U.S. suicide rates per 100,000 by age 2016 (CDC) -table! and words

-we usually think about youth and suicide, but older adults die as the result of suicide at a much higher rate -among the older adults, the oldest old (85+) die as the result of suicide at a higher rate -the oldest old has the highest suicide rates among all age groups (19) except for middle adulthood age (45-64) 19.3; 15-24 is 12.9 (lowest out of all age groups) -suicide at any age is often underreported -an older adult who starves themselves or if they have an accident like drive their care off the road it may be classified as car accident and not suicide...

nursing home trends (continued)

-what is the average length of stay in a nursing home? --was 2.2 years (30 years ago) --now ~1 year... why the change? BECAUSE -residential care is now an option for many older adults who are still fairly healthy, and who in years past, might have gone to a nursing home and lived quite a number of years -because of all the housing and residential care out there (adult day care, modifications to house...) this is why there is a change...

nursing home trends

-who is most likely to live in nursing homes today? --85+ (oldest-old) --female --caucasian --no spouse (major predictor) --multiple chronic conditions and multiple ADL needs --> the frailest elders often in last months of life -older females who are widowed, have several chronic conditions, typically white...

why do men suffer more?

-wife was confidante -men are less likely to seek out social supports -a wife's death tends to be more unanticipated -husbands are typically less experienced with daily household tasks -loss of spousal caregiving support may be a factor in men's pos-loss mortality -women are more likely to have more close friends but men just rely on wife for everything- so when they're gone they have no one -most men do not expect to outlive spouse or partner- they are not as prepared for widowhood as much as women are -amongst the older generation of men they are less likely to have experience with household tasks- laundry, cooking (where are you gonna get food? - packaged food- saltier, won't help their health) -social networks in general may decline

plan ahead, plan ahead, plan ahead

-without future planning critical decisions are often made in a time of crises: -importance of advanced directives -importance of discussing "what if's" before they become an issue -barriers to planning ahead: -fear -denial -as a culture, we value self-reliance, individualism, independence, not interdependence -need to plan because crises do happen and if you're not prepared you have to handle things on the fly or figure out in the ICU room not like over the course of a month or something -culture- we don't talk about these issues... (our (American ? ) culture)

percentages of older adults who are widowed by sex and age group, 2015 -bar graph

-women are much more likely to experience widowhood than men -why are widowhood rates dropping? - remarriage (or never got married in the first place), divorce -differences between men and women at all the age brackets - women= more -highest percentage for men and women at oldest age group 85+ then 75-84 then 65-74

reasons for gender differences in prevalence of widowhood

-women as compared to men... -have longer life expectancy (~6 (more) years) -tend to marry someone who is older -are less likely to remarry -also experience longer time as widows (often 15+ years) -second on: say spouse is 2 years older than woman, women live 6 years longer- 8 year time span difference (??) -because of the decreased life expectancy of Latino (men?) and men of color, women of color's widowhood is a lot longer

Women

-women, though, face special challenges: -financial-related, especially if: -depleted savings to care for chronically ill husband -however, this may be changing in more recent cohorts of older adults -if you think of lack of savings older adults have- you lose chunk for caregiving for your spouse's illness- you won't have as many savings (hopefully you have SS and pensions to rely on) -now where will you go for long term care now because of that- Medicaid is what you may use

social support and integration

-women... -long-standing intimate social relationships (children, friends, siblings) are resource in adjusting to spousal loss --receive more instrumental and emotional support from children --have larger and more varied supportive friendship networks -women are more likely to maintain their friendship- from locations they are at- they keep in contact with people from jobs then they move, cities, then they move -women also get more help from their children as well as their friends! --instrumental from sons --emotional from daughters -have varied supports- quality relationship with siblings...

choosing a nursing home (gathering information)

1. contact: -local ombudsman (at local area agency on aging; e.g., Pima Council on Aging) -Better Business Bureau 2. narrow options: -locale, affordability, services offered 3. bring a checklist: -AARP nursing home checklist -Medicare.gov- Nursing home checklist 4. plan a 1-2 hour visit: -over mealtime; unexpected visit 5. speak with: -admin (e.g., admission director), staff members, residents, families or residents 6. ask to see copy of annual state inspection: -regulated by State Dept. of Health Services Online -important factors in choosing a nursing home: -meeting needs of older adult -spaces for people to sit that are comfortable- bars to hold on to to get to one place to another -friendly staff (understanding safety, licensing, what have they done to improve, inspection reports...) -close to family perhaps? -if you're not from the area- place (local area agency on aging) can help you identify a best place... in the area (Medicare nursing home compare)

criteria for hospice admission

1.physician prognosis of 6 months or less to live 2.can be any age (although 80% of hospice patients are 65+) --> anyone with a life-limiting condition 3.agree that no more aggressive treatment is given 4.hospice can be anywhere you call home: house, assisted living, car, motel, hospice facility

suicide rate ages 65+ by race and sex (bar graph)

2015, United States, suicide injury deaths and rates per 100,000, all races, both sexes, ages 65 to 85+ -highest rates are for White males age 85+ --> 52.5 (per 100,000) (85+ not grouped in 65+ group) -age 65+ it is 35.4 per 100,000

advance care planning: benefits and challenges

BENEFITS: -less likely to die in a hospital -more likely to receive hospice care and for longer periods of time -increased quality of life at the end of life HOWEVER, the majority of the general population does not have such documentation, and less than 50% of terminally ill patients have advance directives (race and SES differences) -hospice care is beneficial when they are on it for more than a few days

REVIEW

What part of Medicare covers hospice care? -Part A Hospice care means you can still receive life sustaining treatment (T/F?) -false, palliative care allows this (hospice care- focusing on managing symptoms but not tackling what is actively killing the person) What are the criteria needed to be admitted into hospice care? -less than 6 months to live (physician prognosis or 6 months or less to live) -any age (can be any age (although...)) -take place wherever you call home -agree that no more aggressive treatment is given

right-to-die

belief that person has... -right to take their own life if experiencing untreatable pain -right to physician assistance in the dying process doctrine of informed consent -patient right to accept or refuse treatment based on understanding of harm/benefit

grief vs. a major depressive episode in DSM-V (table)

clinical indications of typical GRIEF: -may have tendency to isolate but generally maintains emotional connection with others -hope and belief that the grief will end (or get better) someday -maintains overall feelings of self-worth -experiences positive feelings and memories along with painful ones -guilt, if present, is focused on "letting down" the deceased person in some way -loss of pleasure is related to longing for the deceased loved one -suicidal feelings are more related to longing for reunion with the deceased -may be capable of being consoled by friends, family, music, literature, etc. clinical indicators of MAJOR DEPRESSION -extremely "self-focused"; feels like an outcast or alienated from friends and loved ones -sense of hopelessness, believes that the depression will never end -experiences low self-esteem and self-loathing -experiences few if any positive feelings or memories -guilt surrounds feelings of being worthless or useless to others (not related to the loss) -pervasive anhedonia (inability to feel pleasure) -chronic thoughts of not deserving, or wanting to live -often inconsolable

widow/widower

person whose spouse has died -widow= woman -widower= man

reversible and irreversible causes of dementia

reversible: -some dementias are reversible and can be "cured" -they are caused by reactions to medication, alcohol, hormonal or nutritional problems, infections, thyroid problems, depression, diabetes, or other diseases irreversible: -Alzheimer's or vascular dementia -have no discernible environmental cause and cannot yet be cured

widowhood

state of being a widow/widower

bereavement

state of being deprived of a loved one by death -"spousal bereavement" = death of a spouse

REVIEW

what is a difference between grief and major depression? -anything from table (clinical) e.g., someone experiencing grief may be capable of being consoled by friends, family, music, literature, etc. BUT someone experiencing major depression is often inconsolable what is a challenge with correctly diagnosing major depression amongst the older population? -older adults often don't report mood changes (stigma) -older adults may have health conditions that can cause depressive symptoms -symptoms that seem to indicate depression can actually be induced by medications

REVIEW

what is the widowhood effect? -"excess mortality among widows compared with those who remain married" 6-18 month window usually- men longer than women what is anticipatory grief? -grieving the loss even prior to the death (positive because you are able to have meaningful end to relationship- time and space to say goodbye ? ; negative- caregiving, older adult is experiencing a lot of pain ? where are men likely to seek support following the loss of a spouse or partner? -romantic relationships (women- children, friends)

REVIEW

what type of caregiver are these people? Adult day care worker, nursing home staff, in-home nurse support, and Council of Aging van driver -formal caregivers when are older adults likely to turn to direct care workers for support? -when tasks are too time-consuming for their family and friends (i.e. informal caregivers), or they are too technical or difficult to do the majority of caregivers of older adults report caregiving has affected their health -false (almost 3 in 4 said it has not affected their health)