Chapter 5: Where People Live: Person Environment Interactions

New directions for Nursing Homes

(Eden Alternative, the Green House Concept, and the Pioneer Network have a commitment to viewing older adultsas worthwhile members of society regardless of their physical limitations) + The Eden Alternative - Caring for frail older adults starting from the premise that skilled care environments are habitats for people rather than facilities for the frail - Protecting the dignity of each person, with 10 principles 1) The 3 plagues of loneliness, helplessness and boredom account for the bulk of suffering among older adults 2) Creating a habitat where live revolves around close and continuing contact with plants, animals and children 3) Easy access to human and animal companionship, as antidote to loneliness 4) Eldred-centered community creates opportunity to five as well as receive care, as the antidote to helplessness 5) Daily life with variety and spontaneity by creating environments with unexpected and unpredictable interactions, as antidote to boredom 6) Meaningful activities for the human spirit 7) Medical treatment should be the servant of genuine human caring, never its master 8) Honors elders by de-emphasising top-down bureaucratic authority, seeking instead to place maximum possible decision making into hands of elders 9) Create elder centered community with human growth 10) Wise leadership - Help launched culture change to improve residents quality of life - Blends person-centered care with relational care (care that takes unintended actions into account) - Main outcomes are resident-directed care and staff empowerment + The Green House Project - Grounded in the Eden Alternative - Radical departure from the concept that skilled nursing care is best provided in large residential facilities - Provide older adults who need skilled care a small, homelike environment that shifts the focus from a large facility to a more homelike setting - 6-10 residents, in a dwelling that blends architectural with houses in the neighborhood + Emphasizes the importance of encouraging residents to participate in their care, by helping with daily tasks - Personal dignity is maintained and quality of life improved + The Pioneer Network - Focuses on changing the culture of aging in America regardless of where older adults live - Focuses on respecting older adults and providing maximally supportive environments - Know each person - Relationship is building block of a transformed culture - Respond to spirit as well as mind and body - Risk taking is a normal part of life - Put the person before the task - All elders are entitled to seld-determination wherever they live - Community is the antidote to institutionalization - Promote growth and development of all - Shape and use the potential of the environment in all aspects; physical, organizational, psychological, and spiritual - Practice self-examination, searching for new creativity and opportunities to do better - Recognize that culture change and transformation are not destinations but a journey, always a work in progress + All have in common a commitment to viewing older adults as worthwhile members of society regardless of their physical limitations

How Should People Communicate with Nursing Home Residents?

+ Inappropriate speech to older adults is based on stereotypes of dependence and lack of abilities + patronizing and infantilizing speech are examples of demeaning speech, that are rated negatively by older adults + the communication enhancement model has been proposed as a framework for appropriate exchange + this model is based on a health promotion model that seeks opportunities for health care providers to optimize outcomes for older adults through more appropriate effective commmunication

Common Theoretical Themes and Everyday Competence

+ All 3 theories focus on the interaction between person and environment, and no single environment meets everyone's needs + Everyday Competence: persons potential ability to perform a wide range of activities considered essential for independent living; it is not the persons actual ability to perform the tasks + An older persons competence in the psychological domain includes cognitive problem solving abilities, beliefs about personal control and self efficacy and styles of coping + Must identify cultural and contextual differences in everyday competence + Willis developed a model of everyday competence incorporating all key ideas discussed earlier + He distinguishes between antecedents, components, mechanisms and outcomes of everyday competence - Antecedents include both individual and sociocultural factors (e.g. health, cognition and stereotypes, social policy) - These influence the intraindividual and contextual components, the particular domains and context of competence - Which components are most important or exert the most influence depends on the overall conditions under which the person lives - These elements of the model reflect the basic ideas in both the competence and environmental press model and the person environment model - The mechanisms involve factors that moderate the way competence is expressed - The model proposes the primary outcomes of everyday competence are psychological and physiological well being + Understanding this is important for considering if people are capable of mankind decisions for themselves + Model also points out that health outcomes of one episode of everyday competence are the antecedents of the next - Means future competence is related to current competence + Older adults can age in place to the extent their everyday competence permits

Living In a Nursing Home

+ At any given time, only about 5% of older adults are in nursing homes. Such Facilities are excellent examples of the importance of person-environment fit + The percentage of older adults enrolled in Medicare who live in a long-term care facility at any given point in time increases from 2% in those aged 65-74 to abou 14% of adults over age 85 + over their lifetime, over 50% of older women and about 30% of older men will spend at least some time in a long-term care facility + the gender difference is because older women take care of their husbands at home, but in turn need to relocate to a long-term care facility for their own care because their husbands are, on average, deceased

Adult Day Care

+ Designed to provide support, companionship, and certain services during the day + Arises most often when the primary care giver is employed or has other obligations during the day + Primary goal is to delay placement into a more formal care setting + Provides alternative care that enhances self-esteem and encourages socialization + 3 general types available 1) Provides only social activities, meals and recreation, with minimal health services 2) Provides more intensive health and therapy intervention and social services for people with more serious medical problems or conditions 3) Provides specialized care to particular populations, like those with dementia or Alzheimer's + Can be independent or sponsored by a profit (22%) or non-profit (78%) organizations + May provide transportation to and from + Insurance may cover some expenses + about 35% of adult day care clients, live with an adult child and 20% with a spouse or partner + Average age of clients is over 70; about two-thirds (2/3) are women + For people with cognitive impairment, changes in routine can result in confusion or disruptive behavior, so it is important to inform them of the decision, and engage in trial runs + Compared with keeping relatives with cognitive impairments at home, the program can reduce problematic behaviors and lower the need for psychotropic medication in clients, and result in lower reports of care giving burden + Key factor in success is having appropriate programs in interventions

What factors did Langer identify as being detrimental to the well-being of nursing home residents?

+ Detrimental Factors: (1) Resident not included in decision making process. (2) Labels (e.g. "nursing home resident"; might mention priming age study here). (3) Reinforced dependence. (4) Physical qualities of Nursing Home. (5) Predictability of the environment (need to change the routine). + So, don't treat them like babies, it could kill them

The Ecology of Aging: Community Options

+ Ecology of Aging: field of environmental psychology, which seeks to understand the dynamic relations between older adults and the environments they inhabit + Small changes in environments can result in major changes in behavior

What is elderspeak? How should we communicate with older adults and nursing home residents?

+ Elderspeak is speaking to OA like they are babies. + Talk to them like they are adults...and don't yell. Basically, make them feel useful and competent, and minimize aspects of a conversation that emphasize one's limitations.

Preventive and Corrective Proactivity (PCP) Model

+ Explains how life stressors and lack of good congruence in person environment interactions (component b), especially when the person has nothing to help protect against these things, results in poor life outcomes (component F) + The helpful buffers include external resources (component E), or internal resources or dispositions (component C), and specific proactive behaviors (component D) + The model proposes proactive adaptations and helpful external resources reduce the effect of life stressors on quality of live outcomes + Two types of proactive adaptations 1) Preventive Adaptations: actions that avoid stressors and increase or build social resources (ex: increasing social network by making friends) 2) Corrective Adaptations: actions taken in response to stressors and can be facilitated by internal and external resources (e.g. changing diet after heart attack) + Older adults tend to engage in more corrective adaptations than preventive + But many actions that start as corrective turn into preventive (Ex: exercise) + Proactive adaptations significantly reduce the negative impact of stressors

Deciding on the Best Option (how do people decide on the best option?)

+ Finding the optimal fit where individuals competence and the environmental press are in the nest balance + It must be determined whether the individual has significant cognitive or physical impairment requiring intervention or support + An assessment of the ability of family members to provide support of care + Then the next decision is whether there is an option for providing intervention in the current home situation or if other options are needed + The individual in question needs to be an intefral part of decision making

Langer and Colleagues Studies: What do they say about the importance of congruence for older adults?

+ Group 1: Residents told staff were there to do everything the resident needed or wanted done. Group 2: Residents told staff were simply there to assist. - Group 2 residents showed greater well-being later, and even a lower mortality rate.

Competence and Environmental Press (C/EP)

+ How a theory incorporates elements of the biopsychosocial model into the person environment relation + Competence: the upper limit of a persons ability to function in five domains; the maximum capability a person has for functioning in the domains of physical health, sensory perceptual skills, motor skills, cognitive skills, and ego-strength (self-efficacy) + Environmental Press: the physical, interpersonal or social demands that environments put on people + Lawton and Nahemow's model establishes poiints of balance between the two, called adaptation levels. One implication of the model is the less competent a person is, the more impact the environment has + people can show proactivity (doing something to exert control over their lives) or docility (letting the situation determine their lives) + Both competence and environmental press change as peoples move through the life span + The demands put on you by the environment changes as you age, + The competence environmental press framework reflects the lifecycle factor as well + Adaptation Level: - The area where press level is average for a particular level of competence - This is where behaviour and affect are normal + Zone of Maximum Performance Potential - Slight INCREASES in press tend to improve performance + Zone of Maximum Comfort - Slight decreases in press in which people are able to live happily without worry about environmental demands **People with little competence can withstand less of a change in press than someone with more competence + Combinations of competence and environmental press that fall within either of these two zones result in adaptive behaviour and positive emotion that translate into high quality of life + As a person moves away from these areas, behavior becomes increasingly maladaptive - These can result from several different combinations and for different reasons - Ex: too many environmental demands on a person with low competence + Each person has potential of being happily adapted to some living situations, but not all + Whether people function well depends on if what they are able to do fits what the environment forces them to do + People respond with changes in their combinations of environmental press and competence is two basic ways 1) Proactivity: people choose new behaviors to meet new desires or needs and exert control over their lives (change behaviors) 2) Docility: when people allow the situation to dictate the options they have and have little control (fail to exert contol over life) + Proactivity is more likely in people with HIGH competence and docility in people with LOW (people with more competence are likely to be more proactive) ** E.g. Response to INCREASE Environmental Press, like loss of a spouse. Learn what the spouse had been doing, like cooking, laundry, cleaning, finances, etc. + The model accounts for why people choose the activities they do, how well people adhere to medication regiments, and how they adapt to changing housing needs over time + The Less competence a person is the greater the impact of environmental factors + To the extent people experience declines in health, they are less able to cope with environmental demands - Important because many older adults choose to live at home + Personal competence predicts how well older adults adapt after being discharged from a hospital or when provided with assistance technology + The model has been the basis for evaluating and optimizing living situations with people that have severe cognitive impairments - Must identify the right level of environmental support based on level of competence

Who is Likely to Live in Nursing Homes?

+ Latineo American and Asian residents increased roughly 55% each between 1999 and 2008, and African American residents increased nearly 11% percent, meanwhile; European American residents declined to 10% + Average resident has significant mental and physical problems + Main reason for placing almost 80% of residents is significant health problems + 80% have mobility problems, and more than 1/3 have mobility, eating and incontinence issues + between 30 and 50% show signs of clinical depression + Often do not see it as an option until all other avenues have been explored, which may be why there is such high numbers of truly impaired people + Placement decisions are often made quickly in reaction to a crisis + Older White women over the Age of 75 + People with cognitive impairment, problems with mobility, and/or incontinence + no spouse, children, or siblings nearby + recently discharged from a hospital

Stress and Coping Framework

+ Lazarus and Folkmans cognitive theory of stress in coping (chapter 4) to understand older persons interaction with environment + People evaluate situations to assess their potential threat value, and establish a range of coping responses they have at their disposal for avoiding harmful situations + Outcomes of coping are positive or negative depending on many contextual factors + Schooled showed the presence of social support systems affect the likelihood that situations would be defined as threatening - Applied to certified nurse aides (CNA)

Special Care Units

+ Most residents have cognitive impairment, with the majority having dementia + Providing a supportive environment for people with moderate to severe dementia requires certain specialized design and intervention features - This need has resulted in development of special care units in many nursing homes + Provide a supportive and therapeutic set of programs that help the person function at the highest level possible + Staff receive specific training to work with persons with dementia + Best units have physical designed elements that take functional limitations into account + Most residents with cognitive impairments wear wrist or ankle bands that trigger alarms if they wander beyond a certain point + Also provide private dining area to minimize possible negative interactions between residents with dementia and those without + Must have the right level of environmental support at the time of placement, as well as the availability of additional levels of support when the persons competence declines + Memory aids should be built into the unit + Staff training includes aspects such as - Appropriate and effective communication techniques - Behavioural management techniques to address aggressive/aggregated behaviour - Appropriate techniques for assisting with personal health and hygiene that protect residents dignity - Methods for dealing with incontinence - Techniques for handling sexuality in persons with dementia - Controlling wandering - Supervising and assisting with eating - Interventions to address memory failure and disorientation - Assisting with mobility + Residents of special care units are younger, more behaviorally impaired, and less likely to be minority than general nursing home residents when both exist in the same facility + Residents tend to have lower hospitalization rates, were less likely to have serious other health issues, and family members who were satisfied with quality of care, compared to residence of non-special care units - The increased quality of care is more the result of a difference in philosophy of care

Characteristics of Nursing Homes

+ One way of evaluating them is applying the competence-environmental press model + The goal is to find the optimal level of environmental support for people who have relatively low levels of competence + Most important things to consider when selection are: - Quality of life for residents (e.g. well groomed, food is tasty, rooms are comfortable) - Quality of care (e.g. if staff respond quickly, if family is involved in decisions) - Safety (e.g. enough staff, hallways are open) + Skilled nursing care is usually available only for short time following hospitalization, whereas custodial care may be an option for a much longer period + Nursing homes that only take Medicaid residents may offer longer term but less intensive care levels + Nursing homes without Medicaid might force residents out when funds run out + Ensure the facility and administrator are fully licensed, and a full array of staff training on topics like neglect, how to deal with difficult residents, and how to report complaints + Ensure the residents care plan is put together by a team of professionals, and residents have choices and can exert some control over routines and care + The best nursing homes use "person-centered care" approach to policies, especially when working with people with cognitive impairments - Based on promoting residents well being though increasing their perceived level of personal control and treating them with respect - Focus on on the individual, and does not use one size fits all approach - Involves a team who knows and cares about the individual - Method has shown major decreases in the need for certain medications, soft restraints, and number of residents who are incontinent + Residents who have higher perceived personal control show significant improvement in well being and activity level, and actually live longer + Feelings of self-efficacy are crucial to doing well and adjusting to life in a long-term care facility + Many nursing homes still use the traditional approach of rules, routines, and requirements person-centered care is considered a best practice in nursing homes

Decision-Making Capacity and Individual Choices

+ Patient Self Determination Act (PSDA): a law that mandates that all facilities receiving Medicare and Medicaid funds comply with 5 requirements regarding advance care kenning, referred to as advance directives 1) Provide written information to people at time of admission about their right to make medical treatment decisions and to formulate advance directives (i.e. decisions about life-sustaining treatments and who makes decisions if they are incapacitated) 2) Maintain written policies and procures regarding advanced directives 3) Documenting the completion of them in persons medical chart 4) Complying with state law regarding the implementation of advance directives 5) Providing staff and community education about advanced directives + Assessing a persons capacity to make medical decisions is a challenge for medical ethics - Many studies show the theory does not hold up well in practice - Most people see such planning as a family process - They engage in informal advance care planning, preferring to allow family members to make decisions for them when the need arises and to give them leeway in interpreting advance directives even when they exist - Thus it is unlikely a person being admitted will have a complete formal advance directive + New resident is unlikely to understand the information presented as mandated by the PSDA + If they are cognitively impaired, they may be thought to be unable to act on their own behalf in communication treatment preferences and end of life wished + No uniform approach to determining residents cognitive competence exists + Lack of agreement between residents and families also caries with ethnicity + Resolving the problem involves using the various approaches considered for determining person-environment interactions, combined with clinical assessment

Congruence Model

+ People look for environments that fit their abilities and needs: The better the congruence, the better the well-being. - e.g. An OA might move into an assisted living facility after the loss of a spouse, or illness.

Assisted Living

+ Provides assistance with some ADL's and IADL's but person is still fairly independent + Are housing options for older adults that provide a supportive living arrangement for people needing assistance with personal care (such as bathing or raking medications) but who are not so impaired physically or cognitively that they need 24 hour care + Ideal assisted living situation has 3 essential attributes 1) The physical environment where a person lives is designed to be as much like a single family house as possible - That way, the setting has a residential appearance, a small scale, and personal privacy that includes at a minimum a private room and a full bath that is not shared with other residents - Indoor and outdoor access 2) The philosophy of care at an ideal assisted living facility emphasises personal control, choice, dignity and autonomy, and promotes a preferred lifestyle residents and their families consider to be abnormal quality of life - Residents exert control over lives, schedules, and dwellings 3) Should meet residents routine services and special needs - Levels of support are not meant to deal with high level, intensive nursing or other complex needs - Transportation, socialization, and daily checks + There are serious gaps in service and regulation among assisted living facilities + A more cost effective approach than long term care facilities for those older adults who cannot live independently + Residents are independent apartments or similar units + Usually include monitoring and management of health care, assistance with activities of daily living, housekeeping, reminders for medication, recreation and entertainment, transportation and security + Ranges between $25000-50000 + Medicare does not pay for either living costs or any of the services provided, but sometimes they may pay for services under certain circumstances + Residents well being is related to whether the decision to live there was under their control and to the quality of relationships formed with co-residence + One of the main future challenges will be the blurring of congregate (independent) living, assisted living, and long term care facilities into hybrids of these + The cost of assisted living, is another challenge, that is already out of reach for many +Different Housing Options that exist for older adults who experience change in competence: - Modify the home (e.g. build a ramp.) - Adult Day Care: 1. Social activities, meals, recreation 2. Health care and Therapy 3. Special Care (Dementia). Most are non-profit

How is Decision making Capacity Assesed?

+ The Patient Self-Determination Act (PSDA) requires people to complete advance directives when admitted to a health care facility + A major ethical issue concerns how to communicate this information to people with cognitive impairment in nursing homes

Home Modification

+ The competence environmental press model provides two options for people who experience difficulties dealing with everyday tasks - People can increase their competency and develop better or new skills - People can lower the environmental press by modifying the environment to make the task easier + The most frequent solution involves modifying ones home (i.e. changing the environment) in order to create a new optimal balance or better fit between competence and environmental press + Many strategies, from minor structural changes like assistive devices, to more extensive modifications like making home fully accessible by wheelchair + Some options may be unaffordable + Home modifications done to address difficulties with accomplishing ADLs typically reduce disability related outcomes + Auxiliary dwelling unit ( ADU ) is a portable hospital room that is a separate dwelling place next to a family's main dwelling to give an older relative privacy and proximity to family - Colloquially known as granny pods, the dwelling contains a number of devices; can have a number of "smart" devices that do everything from serving as a virtual companion - They can be as temporary or permanent as needed - Provide independence and support for aging in place

Consider the implications of cognitive impairment with respect to involving older adults in decisions about the care they receive.

+ Those with cognitive impairment will likely have difficulty making decisions about their care. ** It can be difficult to tell when they become incapable of making informed decisions.

Communicating with Residents

+ Uneasiness of communication often results in people relying on stereotypes of older adults, and results in inappropriate communication styles + Patronizing Speech: inappropriate speech to older adults that is based on stereotyped of incompetence and dependence - Described as a general 'communication predicament' of older adults - Conveys a sense of declining abilities, loss of control and self esteem, and withdrawal - Increased volume, higher pitch, repetitions, simple words + Infantilization/ elderspeak: secondary baby talk, also involves the unwarranted use of a persons first name, terms of endearment, simplified expressions, short imperatives, and assumption that the recipient has no memory, and cajoling as a way to demand compliance - Community dwelling older adults Viewed extremely negatively by some older adults and were resentful of its intonation aspects as indicative of lack of respect - Nursing home residents were less harsh, giving support to the idea that being exposed to it lowers ones awareness of its demeaning qualities + Residents with dementia tend to be more resistive to care when they are targets of elderspeak + More experience in interacting with older adults is related to lower use of patronizing speech + There may be different types of elderspeak with different effects on the targets of the communications - Two types: right and wrong - Used towards women most often + Ryan et al. proposed the communication enhancement model as a framework for appropriate exchange - Based on a health promotion model that seeks opportunities for health care providers to optimize outcomes for older adults through more appropriate forms of communication - Communication must be based on recognizing individualized cues - Modifying communication to fit individual needs and situations - Appropriately assessing health and social problems + Combining communication enhancing model with person-centered care model provides we way for paraprofessional staff in facilities to communicate more effectively + Less positive perceptions of conversations in some casesin Korea, Japan, China, Philippians, than in some Western countries + Few suggestions for visiting with older adults (page 150)

Who pays for nursing home care?

+ We do. + $80, 000 per year and rising beyond inflation rate. + Medicare only pays for a few months. - 100 days (20 fully covered; 80 - copay $152/day). - Clock resets after 60 days of non-use. + Insurance doesn't pay much, and is prohibitively expensive anyway. + People must "spend down" until they are poor, so that Medicaid will pay. + Is this fair or moral?

Can a Nursing Home be a Home?

+ Yes + The circumstances fostering this feeling include - Having time to thing about and participate in the placement decision - Having prior knowledge and positive experience with a specific facility - Defining home in terms of family and social relationships rather than in terms of place, objects or total autonomy - Being able to establish a kind of continuity between home and nursing home through activities or similarities in living arrangements + Residents pull from their repertoire of coping stratifies to help them come to terms + Getting residents to reminisce about home actually facilitates adjustment + Residents satisfaction related to; facility, staff, residential factors (figure 5.5) - Staff satisfaction plays a crucial role

Aging in Place

+ You grow old and die where you have lived most of your life + As the environment in which one lives becomes more restrictive, many older adults engage in selection and compensation to cope + May select a different place to live or adapt behavior in order to compensate for their limitations + The idea of aging in place reflects a balance of environmental press and competence through selection and compensation + Being able to remain independent in community is important for people, especially in terms of their self esteem + Older adults who age in place form strong emotional and cognitive bonds with their residences that help transform a house into a home - Having a home provides a strong source of self identity + Making a change in where people live, and having to psychologically disconnect with a place where they may have lived for many decades, can be difficult and traumatic + Feeling one is at home is a major aspect of aging in place + Providing older adults a place to call their own that supports the development of the psychological attachments necessary to convert a place to a home is key for successful aging in place + Cluster housing is an alternative that combines the aging in place philosophy with supportive services - Key feature is that services are provided to the residents by staff hired by the owner or provider under contract - Emphasizes individual choice on the part of the residents in terms of what services to use - Low cost alternative to nursing home, but not covered by insurance

Types of Nursing Homes

+ little to no independence, high degree of medical care required + House the largest number of older residents of long-term care facilities + They are governed by the state and federal regulations that establish a minimum standards of care + Two levels of care are defined - Skilled nursing homes: consist of 24 hour care; covered by Medicare Part A (Inpatient Care) for 100 days; Patients need continous care - Intermediate care is also 24 hour, but at a less intense level; covered by Medicare Part B (Outpatient Care) - The difference is the type and numbers of health care workers on the staff + The cost is high + Will be an increasingly important political issue in coming decades because of baby boomers

Congregate Housing

+Kind of like living in campus dorm; cafeteria, some health services, but not extensisve + Includes a range of living options from those providing only housing to those providing some level of medical services + Most common form is an apartment complex of older faults that provides a level of support such as shared meals + Often the least expensive form of supported living for older adults, because the cost is typically subsidized by various government agencies and non-profit organizations + Especially important option for low income, who need support to remains out of a nursing home + There is a shortage of them though + Level of medical assistance is lower than in assisted living + Do not provide 24 hour medical services on site + Service coordination accomplished several things: interface with housing officials, individual service plans for residents, coordination of shared activities and mediation of resident conflicts + Most require residents to be capable of independent living and not require continual medical care, be medically stable, know where they are and oriented in time, show no evidence of disrupted behaviour, and be about to follow any specific service plan developed for them + Typically move in, in response to a significant decline in functioning or health related problem + Good for those seeking specific types of social engagement

Person-Environment Interaction

- means behavior (B) is a function of both the person (P) and the environment (E) + Most models emphasize the importance of peoples perceptions of their environments + Kurt Lewin's Equation: - B=F(P,E): Behavior is a function of both the person and the environment; so is well being and health