Geriatric Nursing 36 (2015) 228e231
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Assisted Living Column
Richard G. Stefanacci
Daniel Haimowitz
More than little old women. Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD a, b, c, *, Daniel Haimowitz, MD, CMD, FACP d, e, f a
Thomas Jefferson University, School of Population Health, Philadelphia, PA, USA The Access Group, USA Mercy LIFE, Philadelphia, PA, USA d Private Practice, Levittown, PA, USA e Arden Courts of Yardley, PA, USA f Brunswick at Attleboro, Langhorne, PA, USA b c
Boy, have times changed e geriatric care is certainly not what it used to be! Today’s geriatrics care is very different than it was a few years ago when typically physicians treated elderly white women in nursing homes e today it is more common for care to be provided by nurse practitioners in alternative sites such as Assisted Living Communities (ALCs) while the resident is more likely to be of a wider age range from younger and very old, more frail, less Caucasian, heavier and more male. These changes require different skills sets for today’s NPs and nursing staff. Dealing with these new types of geriatric patients requires a major change in our thinking e it’s not just “little old white ladies” any more. Moving home Because of the high cost of facility-based care payers such as Medicare and Medicaid are using financial incentives and funding pressure to steer treatment towards less expensive options. This focus is resulting in care that had historically been provided in nursing homes being shifted to the home and community-based settings such as ALCs (Fig. 1). While Medicare had historically focused senior care with Medicare Part A on hospital care there was a shift for additional care prior to returning to home to the subacute unit within skilled nursing facilities. Because of increasing pressure on resources there is further pressure to move from the skilled nursing facility to the * Corresponding author. Thomas Jefferson University, School of Population Health, Philadelphia, PA, USA. E-mail address: [email protected] (R.G. Stefanacci). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.04.004
ALC and even home and community-based services rendered in those settings. Medicaid is also shifting from the primary payer for nursing home care, to providing coverage for older adults that qualify for nursing home level of care to receive these services in ALCs and even at home. These shifts in focus are resulting in care being providing outside the walls of the nursing home far from where these frail older adults typically received care in the past. To die for In dealing with older males outside of nursing homes in more independent and less structured environments an eye toward identification and prevention of suicide must be appreciated. According to 2010 statistics from the Centers for Disease Control and Prevention, elderly white men have a significant higher rate: 29 per 100,000 overall and even more significant for those over 85 years of age of some 47 per 100,000. This is contrasted with numbers of 12.4 per 100,000 for Americans of all ages.1 Why are suicide rates so high among seniors? It is known that while older people make fewer suicide attempts than the young, they are far more likely to die from them, in part because they rely primarily on guns. “Younger people have more physical resilience and use less lethal means,” said Dr. Yeates Conwell, a psychiatrist at the University of Rochester Medical Center who has studied latelife suicide.2 Beyond mental illness, researchers have identified a cluster of other risk factors in late-life suicide, including physical illness and pain, the inability to function in daily life, fear of becoming a burden and social disconnection. Many of these factors exist with ALC
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 36 (2015) 228e231
229
Fig. 1. Change from Downward Funding Pressure.
residents so ALC staffs need to be aware of the signs of potential suicide especially upon the male residents. Depression is a significant risk factor for suicide. Several diseases and physical problems common among ALC resident may cause symptoms of depression: -
thyroid disorders diabetes Parkinson’s disease multiple sclerosis strokes tumors some viral infections
In addition, the following medications frequently used may cause symptoms of depression: -
blood pressure medication arthritis medication hormones steroids
Once underlying conditions of depression and the depression itself have been treated some residents will require referral to specialized sites available including the Center for Elderly Suicide Prevention where staff and volunteers handle 3000 calls a month to the “friendship line” (a name deemed more acceptable to seniors than “suicide hotline”). They also place 3500 outgoing calls to people considered isolated or otherwise at risk. Another resource is the Veterans Affairs Department’s Veterans Crisis Line.
Weighty issues During the past 30 years, the proportion of older adults who are obese has doubled and by 2050, the number of U.S. older adults, defined as persons aged 65 and over, is expected to more than double, rising from 40.2 million to 88.5 million.3 Both aging and obesity contribute to increased health care service use. Consequently, an increase in the proportion of older adults who are obese may compound health care spending. Obesity causes serious medical complications and impairs quality of life. Moreover, in older persons, obesity can exacerbate
the age-related decline in physical function and lead to frailty. However, appropriate treatment for obesity in older persons is controversial because of the reduction in relative health risks associated with increasing body mass index and the concern that weight loss could have potential harmful effects in the older population. A joint position statement from the American Society for Nutrition and NAASO, The Obesity Society reviewed the clinical issues related to obesity in older persons and provides health professionals with appropriate weight-management guidelines for obese older patients. The current data show that weight-loss therapy improves physical function, quality of life, and the medical complications associated with obesity in older persons. Therefore, weight-loss therapy that minimizes muscle and bone losses is recommended for older persons who are obese and who have functional impairments or medical complications that can benefit from weight loss. All geriatric care providers can assist in promoting these types of weight reduction programs for their overweight older patients.4 While weight reduction is the foundation of optimizing health outcomes for overweight adults there is also the very practical need to know how to physically care for these patients from a mechanical stand point. To that end, all geriatric providers need to know the principles in lifting or moving obese patients. These principles include the following: - Maintain the proper alignment of your head and neck with your spine. - Maintain the natural curve of your spine; don’t bend at your waist. - Avoid twisting your body when carrying a person. - Always keep the person who is being moved close to your body. - Keep your feet shoulder-width apart to maintain your balance. - Use the muscles in your legs to lift and/or pull. - Be certain to get assistance from others when necessary. For those patients where additional assistance is needed a patient lift and sling can be used. These are assistive devices that can help a caregiver transfer a patient, with limited mobility, from the bed to a chair and back. Also available are patient lifts that are operated either by hydraulic-manual pumping or are electric motor. For some, patient slings are a key component when using a lift. The sling is what holds the patient and connects to the lift. Slings
230
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 36 (2015) 228e231
come in many shapes and fabrics and are designed for different support levels and uses. In all there are several assistive devices that when used properly can aid in the safe movement and transfer of overweight residents.
disease, dyslipidemia, metabolic syndrome, diabetes, osteoporosis, and dementia. Geriatricians and primary care providers are increasingly responsible for managing these complex issues.6 Lost in transition
Diseases that are no longer death sentences A growing number of people aged 50 and older in the United States are living with HIV infection. People aged 55 and older accounted for almost one-fifth (19%, 217,000) of the estimated 1.1 million people living with HIV infection in the United States in 2010.5 There are significant differences however between older Americans and younger Americans who have HIV infection. Older Americans are more likely than younger Americans to be diagnosed with HIV infection late in the course of their disease, meaning a late start to treatment and possibly more damage to their immune system. This can lead to poorer prognoses and shorter HIV-to-AIDS intervals. For instance, an estimated 24% of people aged 25e29 who were diagnosed with HIV infection in 2010 progressed to AIDS in 12 months, compared with an estimated 44% of people aged 50e59, 49% of people aged 60e64, and 53% of people aged 65 and older. One reason this may be happening is that health care providers do not always test older people for HIV infection. Another may be that older people mistake HIV symptoms for those of normal aging and don’t consider HIV as a cause. Although they visit their doctors more frequently, older Americans are less likely than younger Americans to discuss their sexual habits or drug use with their doctors, who in turn may be less likely to ask their older patients about these issues. The prevalence of HIV/AIDS in older adults continues to increase, and in 2005, 25% of those infected with HIV were older than 50. Successful treatment regimens allow people to live longer with HIV, but the incidence is also increasing, with older adults accounting for 15% of new HIV cases in 2005. Prevention, diagnosis, and management of HIV/AIDS in older adults are complex issues. The aging immune system may affect response to treatment with highly active antiretroviral therapy (HAART), and there is greater potential for drugedrug interactions and toxicities due to comorbidities and polypharmacy. Patients living longer with HIV are more likely to develop diseases associated with aging, and at an earlier age, than those without HIV. These include coronary artery
A surprising result from the 2000 Census was that Hispanics now outnumber African Americans and have become the majority minority. Statistics reveal that health problems of the three main groups of Hispanics in the United States (Mexican Americans, Puerto Ricans, and Cubans) include diabetes, injuries and violence, substance abuse, HIV/AIDS, limited access to health care, and many other problems shared by the poor and disenfranchised. The health care provider may intervene with Hispanic clients and communities in culturally sensitive ways such as viewing culture as an enabler rather than a resistant force, incorporating cultural beliefs into the plans of care, stressing familialism, taking the time for “pleasant conversation,” refraining from harsh criticism, and involving the community in preventive health care programs. Such interventions require providers who are knowledgeable about the culture, customs, beliefs, and language of the Hispanics within their practice area. Health care providers also need to be alert to and active in health care policy making that will improve access to health care for the growing Hispanic population.7 Younger and more supported Another change is that Medicare, the principle insurance for older adults, now includes a larger population of younger adults that gain Medicare as a result of being disabled. As a result those caring for Medicare beneficiaries are caring for a younger population. An additional change is that many more Medicare beneficiaries are receiving extra help in paying for medical care which includes extra assistance with paying for services and treatments include medications. In fact, some 40% of Medicare beneficiaries qualify for this extra help. While many associate Medicare with older adults, it surprises many that a large number of non-seniors qualify for Medicare. There are in fact 9 million adults younger than 65 years of age qualifying for Medicare. In addition, since these individuals are qualifying for Medicare based on disability rather than age the
Fig. 2. Younger and Receiving Extra Help.
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 36 (2015) 228e231
majority (89%) qualify for extra help. As a result many geriatric providers today are caring for a younger disabled population who have access to extra help. Knowing these extra benefits so that geriatric providers can refer their patients to access these resources through Medicare and Medicaid is instrumental in ensuring appropriate access to services (Fig. 2). In the end what is needed from geriatric providers is an ability to recognize these changes and to make adjustments in one’s practice. Far from what many geriatric providers had learned in their training and practice in just a decade or two ago, today’s geriatrics involves caring for a wide age range of older adults in settings outside the nursing home; these patients include ones that are more likely male and ethnically diverse than those of just a few years ago. Knowing the unique needs of today’s geriatric patients is
231
critical in achieving optimum outcomes for these unique individuals, particularly in the ALC setting. References 1. http://www.cdc.gov/mmwr/pdf/other/su6001.pdf. 2. http://newoldage.blogs.nytimes.com/2013/08/07/high-suicide-rates-among-theelderly/?_r¼0. 3. http://www.cdc.gov/nchs/data/databriefs/db106.pdf. 4. Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society. http://ajcn.nutrition.org/ content/82/5/923. 5. http://www.cdc.gov/hiv/risk/age/olderamericans/. 6. http://europepmc.org/abstract/med/19061274. 7. http://journals.lww.com/tnpj/Abstract/1993/12000/Providing_Culturally_Sensitive_ Health_Care_to.13.aspx.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Assisted Living Column
Richard G. Stefanacci
Daniel Haimowitz
More than little old women. Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD a, b, c, *, Daniel Haimowitz, MD, CMD, FACP d, e, f a
Thomas Jefferson University, School of Population Health, Philadelphia, PA, USA The Access Group, USA Mercy LIFE, Philadelphia, PA, USA d Private Practice, Levittown, PA, USA e Arden Courts of Yardley, PA, USA f Brunswick at Attleboro, Langhorne, PA, USA b c
Boy, have times changed e geriatric care is certainly not what it used to be! Today’s geriatrics care is very different than it was a few years ago when typically physicians treated elderly white women in nursing homes e today it is more common for care to be provided by nurse practitioners in alternative sites such as Assisted Living Communities (ALCs) while the resident is more likely to be of a wider age range from younger and very old, more frail, less Caucasian, heavier and more male. These changes require different skills sets for today’s NPs and nursing staff. Dealing with these new types of geriatric patients requires a major change in our thinking e it’s not just “little old white ladies” any more. Moving home Because of the high cost of facility-based care payers such as Medicare and Medicaid are using financial incentives and funding pressure to steer treatment towards less expensive options. This focus is resulting in care that had historically been provided in nursing homes being shifted to the home and community-based settings such as ALCs (Fig. 1). While Medicare had historically focused senior care with Medicare Part A on hospital care there was a shift for additional care prior to returning to home to the subacute unit within skilled nursing facilities. Because of increasing pressure on resources there is further pressure to move from the skilled nursing facility to the * Corresponding author. Thomas Jefferson University, School of Population Health, Philadelphia, PA, USA. E-mail address: [email protected] (R.G. Stefanacci). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.04.004
ALC and even home and community-based services rendered in those settings. Medicaid is also shifting from the primary payer for nursing home care, to providing coverage for older adults that qualify for nursing home level of care to receive these services in ALCs and even at home. These shifts in focus are resulting in care being providing outside the walls of the nursing home far from where these frail older adults typically received care in the past. To die for In dealing with older males outside of nursing homes in more independent and less structured environments an eye toward identification and prevention of suicide must be appreciated. According to 2010 statistics from the Centers for Disease Control and Prevention, elderly white men have a significant higher rate: 29 per 100,000 overall and even more significant for those over 85 years of age of some 47 per 100,000. This is contrasted with numbers of 12.4 per 100,000 for Americans of all ages.1 Why are suicide rates so high among seniors? It is known that while older people make fewer suicide attempts than the young, they are far more likely to die from them, in part because they rely primarily on guns. “Younger people have more physical resilience and use less lethal means,” said Dr. Yeates Conwell, a psychiatrist at the University of Rochester Medical Center who has studied latelife suicide.2 Beyond mental illness, researchers have identified a cluster of other risk factors in late-life suicide, including physical illness and pain, the inability to function in daily life, fear of becoming a burden and social disconnection. Many of these factors exist with ALC
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 36 (2015) 228e231
229
Fig. 1. Change from Downward Funding Pressure.
residents so ALC staffs need to be aware of the signs of potential suicide especially upon the male residents. Depression is a significant risk factor for suicide. Several diseases and physical problems common among ALC resident may cause symptoms of depression: -
thyroid disorders diabetes Parkinson’s disease multiple sclerosis strokes tumors some viral infections
In addition, the following medications frequently used may cause symptoms of depression: -
blood pressure medication arthritis medication hormones steroids
Once underlying conditions of depression and the depression itself have been treated some residents will require referral to specialized sites available including the Center for Elderly Suicide Prevention where staff and volunteers handle 3000 calls a month to the “friendship line” (a name deemed more acceptable to seniors than “suicide hotline”). They also place 3500 outgoing calls to people considered isolated or otherwise at risk. Another resource is the Veterans Affairs Department’s Veterans Crisis Line.
Weighty issues During the past 30 years, the proportion of older adults who are obese has doubled and by 2050, the number of U.S. older adults, defined as persons aged 65 and over, is expected to more than double, rising from 40.2 million to 88.5 million.3 Both aging and obesity contribute to increased health care service use. Consequently, an increase in the proportion of older adults who are obese may compound health care spending. Obesity causes serious medical complications and impairs quality of life. Moreover, in older persons, obesity can exacerbate
the age-related decline in physical function and lead to frailty. However, appropriate treatment for obesity in older persons is controversial because of the reduction in relative health risks associated with increasing body mass index and the concern that weight loss could have potential harmful effects in the older population. A joint position statement from the American Society for Nutrition and NAASO, The Obesity Society reviewed the clinical issues related to obesity in older persons and provides health professionals with appropriate weight-management guidelines for obese older patients. The current data show that weight-loss therapy improves physical function, quality of life, and the medical complications associated with obesity in older persons. Therefore, weight-loss therapy that minimizes muscle and bone losses is recommended for older persons who are obese and who have functional impairments or medical complications that can benefit from weight loss. All geriatric care providers can assist in promoting these types of weight reduction programs for their overweight older patients.4 While weight reduction is the foundation of optimizing health outcomes for overweight adults there is also the very practical need to know how to physically care for these patients from a mechanical stand point. To that end, all geriatric providers need to know the principles in lifting or moving obese patients. These principles include the following: - Maintain the proper alignment of your head and neck with your spine. - Maintain the natural curve of your spine; don’t bend at your waist. - Avoid twisting your body when carrying a person. - Always keep the person who is being moved close to your body. - Keep your feet shoulder-width apart to maintain your balance. - Use the muscles in your legs to lift and/or pull. - Be certain to get assistance from others when necessary. For those patients where additional assistance is needed a patient lift and sling can be used. These are assistive devices that can help a caregiver transfer a patient, with limited mobility, from the bed to a chair and back. Also available are patient lifts that are operated either by hydraulic-manual pumping or are electric motor. For some, patient slings are a key component when using a lift. The sling is what holds the patient and connects to the lift. Slings
230
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 36 (2015) 228e231
come in many shapes and fabrics and are designed for different support levels and uses. In all there are several assistive devices that when used properly can aid in the safe movement and transfer of overweight residents.
disease, dyslipidemia, metabolic syndrome, diabetes, osteoporosis, and dementia. Geriatricians and primary care providers are increasingly responsible for managing these complex issues.6 Lost in transition
Diseases that are no longer death sentences A growing number of people aged 50 and older in the United States are living with HIV infection. People aged 55 and older accounted for almost one-fifth (19%, 217,000) of the estimated 1.1 million people living with HIV infection in the United States in 2010.5 There are significant differences however between older Americans and younger Americans who have HIV infection. Older Americans are more likely than younger Americans to be diagnosed with HIV infection late in the course of their disease, meaning a late start to treatment and possibly more damage to their immune system. This can lead to poorer prognoses and shorter HIV-to-AIDS intervals. For instance, an estimated 24% of people aged 25e29 who were diagnosed with HIV infection in 2010 progressed to AIDS in 12 months, compared with an estimated 44% of people aged 50e59, 49% of people aged 60e64, and 53% of people aged 65 and older. One reason this may be happening is that health care providers do not always test older people for HIV infection. Another may be that older people mistake HIV symptoms for those of normal aging and don’t consider HIV as a cause. Although they visit their doctors more frequently, older Americans are less likely than younger Americans to discuss their sexual habits or drug use with their doctors, who in turn may be less likely to ask their older patients about these issues. The prevalence of HIV/AIDS in older adults continues to increase, and in 2005, 25% of those infected with HIV were older than 50. Successful treatment regimens allow people to live longer with HIV, but the incidence is also increasing, with older adults accounting for 15% of new HIV cases in 2005. Prevention, diagnosis, and management of HIV/AIDS in older adults are complex issues. The aging immune system may affect response to treatment with highly active antiretroviral therapy (HAART), and there is greater potential for drugedrug interactions and toxicities due to comorbidities and polypharmacy. Patients living longer with HIV are more likely to develop diseases associated with aging, and at an earlier age, than those without HIV. These include coronary artery
A surprising result from the 2000 Census was that Hispanics now outnumber African Americans and have become the majority minority. Statistics reveal that health problems of the three main groups of Hispanics in the United States (Mexican Americans, Puerto Ricans, and Cubans) include diabetes, injuries and violence, substance abuse, HIV/AIDS, limited access to health care, and many other problems shared by the poor and disenfranchised. The health care provider may intervene with Hispanic clients and communities in culturally sensitive ways such as viewing culture as an enabler rather than a resistant force, incorporating cultural beliefs into the plans of care, stressing familialism, taking the time for “pleasant conversation,” refraining from harsh criticism, and involving the community in preventive health care programs. Such interventions require providers who are knowledgeable about the culture, customs, beliefs, and language of the Hispanics within their practice area. Health care providers also need to be alert to and active in health care policy making that will improve access to health care for the growing Hispanic population.7 Younger and more supported Another change is that Medicare, the principle insurance for older adults, now includes a larger population of younger adults that gain Medicare as a result of being disabled. As a result those caring for Medicare beneficiaries are caring for a younger population. An additional change is that many more Medicare beneficiaries are receiving extra help in paying for medical care which includes extra assistance with paying for services and treatments include medications. In fact, some 40% of Medicare beneficiaries qualify for this extra help. While many associate Medicare with older adults, it surprises many that a large number of non-seniors qualify for Medicare. There are in fact 9 million adults younger than 65 years of age qualifying for Medicare. In addition, since these individuals are qualifying for Medicare based on disability rather than age the
Fig. 2. Younger and Receiving Extra Help.
R.G. Stefanacci, D. Haimowitz / Geriatric Nursing 36 (2015) 228e231
majority (89%) qualify for extra help. As a result many geriatric providers today are caring for a younger disabled population who have access to extra help. Knowing these extra benefits so that geriatric providers can refer their patients to access these resources through Medicare and Medicaid is instrumental in ensuring appropriate access to services (Fig. 2). In the end what is needed from geriatric providers is an ability to recognize these changes and to make adjustments in one’s practice. Far from what many geriatric providers had learned in their training and practice in just a decade or two ago, today’s geriatrics involves caring for a wide age range of older adults in settings outside the nursing home; these patients include ones that are more likely male and ethnically diverse than those of just a few years ago. Knowing the unique needs of today’s geriatric patients is
231
critical in achieving optimum outcomes for these unique individuals, particularly in the ALC setting. References 1. http://www.cdc.gov/mmwr/pdf/other/su6001.pdf. 2. http://newoldage.blogs.nytimes.com/2013/08/07/high-suicide-rates-among-theelderly/?_r¼0. 3. http://www.cdc.gov/nchs/data/databriefs/db106.pdf. 4. Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society. http://ajcn.nutrition.org/ content/82/5/923. 5. http://www.cdc.gov/hiv/risk/age/olderamericans/. 6. http://europepmc.org/abstract/med/19061274. 7. http://journals.lww.com/tnpj/Abstract/1993/12000/Providing_Culturally_Sensitive_ Health_Care_to.13.aspx.
