Exam Flashcards
(404 cards)
1
Q
Aging Population or “seniors or “older Adults =
A
People above the age of 65 years
2
Q
What’s the population growth rate (seniors)
Median ages over the years:
A
-fastest growing population in Canada- 15.3% of the population in 2013
1956 - 27.5
2006 - 38.8
2056 - expected to reach 46.9 years
3
Q
Indigenous Trends (population)`
A
The proportion of persons aged 65 and over may nearly triple, from 5.9% in 2011 to 15.1% in 2031
4
Q
Factors that contribute to the aging population
A
- Reduced mortality at younger ages
- fertility rates are falling (having less children, children are also surviving more so less pregnancies, and contraception, women in workforce having fewer children)
- Life expectancy in older age is increasing at faster rate in higher-income countries vs. lower-resource setting
5
Q
Life expectancy at birth:
2009/2011:
2036:
A
2009/2011 -79.1 years for males and -83.4 years for females 2036 -84 years for males -87.3 for females
6
Q
Factors that impact life Expectancy
A
Heredity (genics)
Lifestyle (good diet and exercise, healthy habits)
Exposure to toxins in the environment
-Healthcare Access
7
Q
The oldest age to which people can live has changed little
A
The chance of living to be 120 is very small
Madame Jeanne Calment had the longest record lifespan of 122 years (1875 to 1997)
-hearing more people over the age of 100 tho
8
Q
Working age graph (number of working age people for each senior)
A
- slope is going down -there are going to be fewer and fewer people working per senior
- repercussions for seniors
- might affect the age people retire
9
Q
Chronologic age
A
a person’s age in years
10
Q
Biological Age
A
Changes in the body that commonly occurs as people age
-lifestyle factors will affect this
11
Q
Psychological Age
A
How people act and feel
12
Q
Healthy Aging definition
A
as the process of developing and maintaining the functional ability that enables well-being in older age
-Being able to do the things we value for as long as possible
13
Q
Goals of healthy aging
A
Maintaining physical and mental health; avoiding disorders
-remaining active and independent ( consider do they need to be independent to be healthy)
Developing healthy lifestyle habits can help - nutritious diet, exercising regularly, and staying mentally active
14
Q
Different experiences of healthy aging
A
Mavis Lindgren 103, is the most accomplished elder marathoner
-She ran 75 marathons in competition, in a career which did not begin until she was 70 years old and spanned until she was 90
Another perspective of being happy relying on family and friends spending time doing things you love
15
Q
World Health Organization Framework:
Report on Aging and Health (2015)
Address key issues related to the aging population:
A
Diversity of experiences
- inequities
- ageism
- empower older adults
- environments
- perspective of health
16
Q
World Health Organization Framework:
Report on Aging and Health (2015)
Assumptions
A
- Ageing is a valuable if often challenging process
- Older people will experience significant losses
- Older people make multiple crucial contributions to society (not often recognized) -change a perspective to getting old is good
17
Q
World Health Organization Framework:
Report on Aging and Health (2015)
Healthy aging definition
A
The process of developing and maintaining the functional ability that enables well-being in older adults
- in this model healthy aging is represented by functional ability ( comes from pervious definition)
- intrinsic capacity vs functional ability
18
Q
Intrinsic Capacity is affecting by several things (3)
A
Genetic
personal - defined as fixed and both non-fixed (moment in time) (gender, wealth, education, shape our opportunity and what we are exposed to)
health characteristics
- Underlying age-related trends and skills
- Physiological changes and risks factors
- Diseases and injuries
- Changes to homeostasis
- Boarder Geriatric syndrome
19
Q
A public -health framework for healthy Aging: Opportunities for public-health action across the life course
A
High and stable capacity Decling capacity Significant Loss of Capacity Vs (how these change dependent on the capacity of the person) how we can support them health services long-term care Environments Multiple prong approach
20
Q
National Seniors Strategy: 2nd Edition
Identifies:
A
Meeting the needs of Canada’s aging population will require concerted coordination and effort from all levels of government as well as between the private and public sectors
- 12 specific policy issues that Canada faces
- 4 Overarching pillars that can support a National Seniors Strategy for Canada
- 5 fundamental principles
21
Q
National Seniors Strategy: 2nd Edition
the 5 Fundamental principles underlying a national strategy
A
Access Equity Choice Value Quality
22
Q
Pillar 1: Independent, productive and engaged citizens
A
- making addressing ageism, elder abuse and social isolation a national policy
- ensuring Older Canadians do not live in Poverty by Improving their income Security
- Ensuring older adults have Access to Affordable Housing and Transportation options
- Enabling the Creation of Age-friendly physical Environments and Spaces
23
Q
Pillar 2: Healthy and Active Lives
A
Ensuring Canadians are supported to engaged in wellness and prevention Activities that enable healthy aging
- Improving Access to Medically Necessary and Appropriate Medications
- Ensuring OLder Canadians and their Caregivers are Enabled to Participate in Informed Health Decisions Making and Advance Care Planning
24
Q
Pillar 3: Care Closer to Home
A
- Ensuring Older Canadians have Access to Appropriate, High Quality Home and Community Care. Long-Term Care, Palliative and End-of-Life Services
- Ensuring Older Canadians have Access to Care Providers that are Trained to Specifically Provide the Care they Need
- Developing Standardized Metrics and Accountability Standards to Enable a National Seniors Strategy
25
Pillar 4: Support for Caregivers
- Ensuring Older Canadians are Supported in the Workplace
| - Ensuring Caregivers are Not Unnecessarily Financially Penalized for Taking on Caregiving Roles
26
IFA Copenhagen Summit (2016): Reablement and Older People
- meeting of representatives consisting of 4 working groups,
- scientists, medical specialists and researchers in the fields of dementia, other neurodegenerative disorders, frailty, diabetes and technology
- Base is bio psycho model-idea being reablement helps astore their autonomy in their own space and helps reduce their need for supportive care
- Reablement Goal = "enable people to be and to do what they have reason to value
- ->Aim is to engage individuals in a process of identifying their own strengths and capacities during selection of goals/targets and during planning
- ->Older people are encouraged to focus on what they can do (safely) and what they value, instead of focusing on things they cannot do anymore
* making sure they are socially engaged
- Really consistent with occupational therapy, work towards their goal, different approaches, adapting or restoring
27
Active Aging: A Policy Framework (WHO, 2002)
- Is the precursor to the healthy aging framework that was presented earlier
- Active Aging is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age
28
Active Aging: Key Premises
- A life Course Approach
- Goal of Maintaining autonomy and independence as one grows older
- Interdependence (with family, friends, colleges)
29
WHO Active Aging Policy Framework: The determinants of active aging
Active aging in the center
Gender and culture on the outside
```
6 determinants
Health and social services
Behavioural determinants
Personal determinants
Physical Environment
Social Determinants
Economic Determinants
```
the interaction is not clearly represented in the model but does recognize that there is interaction
30
Biological Theories of Aging
| Hayflick Limit Theory
Limited number of cell divisions possible
| -->Impacted by diet, exposure to toxins, pollution or trauma
31
Biological Theories of Aging
| Free radical Theory: `
Aging caused by production of free radical in cells resulting from energy production by mitochondria
-->occurs naturally but accelerated by certain diet, drugs, radiation and pollution
32
Biological Theories of Aging
| Genetic Theories:
Multiple genes influence aging and longevity
**-25% genetic/75% lifestyle and environment**
this is important
33
Psycho-Social Theories
| Disengagement Theory
- Aging is inevitable, and one's abilities, including the ability to come into contact with friends and relations, reduce over time - reciprocal process
- allows older adults to focus on life meaning
- as a result people gradually lose ties with others in their society and become physically inactive and lonely
34
Psycho-Social Theories
| Activity Theory
- Increased engagement in meaningful and creative = increased life satisfaction
- older adults keep physically active and healthy as a result of their significant social engagement
- Keep in mind this relationship is not causal more like a reciprocal
35
Continuity Theory
- People become more like themselves and maintain identifying activities as they age
- People develop habits, commitments, preferences, and other dispositions which become a part of their personality. They are predisposed toward maintaining continuity in these.
- it does not explain variation in activity patterns, people may discontinue or they may choose to learn new ones and this theory does not explain this
36
Productive Aging
- Focus on civic Engagement
- Engagement in activities that create goods or services of value
- Productivity continues throughout life but changes
- Being productive is associated with health and can confer status `
37
Theory of Goal Achievement Strategies
-People set goals in relation to their resources: (time, social economic status, health or social support)
Selective Optimization
-Compensation when usual ways of doing become ineffective
38
Successful Aging
| Definitions
-Feeling of happiness and satisfaction with one's current and past life
Ability to maintain 3 key behaviours/characteristics
- Low risk of disease and disease related disability
- high mental and physical function
- Active engagement with life
Ablest view of aging you have to be successful without disability
39
Successful Aging Older adults perspective 4 components
- Attitude/adaption
- Security/stability
- Health/wellness
- Engagement/stimulation
40
Common themes among successful aging theories
- Productivity (ability to contribute in some way)
- Adaptation (adapt expectations, environment, ability)
- Resilience (cope with changes as they come, continue to keep engaged)
41
Physical Changes
Aging is characterized by changes in anatomical structures and physiological functions of the body
Changes occurs in all the systems:
-Integumentary - skin
-Cardiovascular, Respiratory and Immune Systems
-Digestive, Metabolic and Endocrine
Neuromusculoskeletal
-Genitourinary and Reproductive
42
Skin (physical changes)
- Less elasticity with wrinkles, sags, dryness and extra folds
- Loss of underlying subcutaneous fat tissue
- Reduction in oil production
- slower to heal -->there maybe more prone to infection
- -> seating with older adults --> pressure ulcers --> skin would not heal as well as prone because of the loss of fat
- decreased thermoregulation
43
changes to Cardiovascular System
- Decreased max. Heart rate and takes longer to get back to baseline
- Decreased number of pacer cells in the heart which initiate the heartbeat
- stiffening of cardiac valves, arteries, and veins
- Despite changes the cardiovascular system has considerable reserve and efficiency and effectiveness is generally maintained in normal aging
* important to introduce pacing or energy conservation if they are getting fatigued
44
changes to Respiratory System
- Older adults may experience a moderate decline in respiratory function
- ->decreased in vital capacity
- ->stiffening of chest wall:change in shape, ossification of cartilage, decreased vertebral disc space
- ->weakening of muscles that contribute to breathing
- Increased reliance on diaphragm for breathing - affected by body position
- Decreased mucus production that helps prevent infection
- diaphragmatic breathing --> like putting on your shoes, they might need breaks and look at how you are positioning the trunk. Position so that there chest is open
45
changes to Endocrine System
Decreased growth hormone associated with decreased muscle mass, bone density and increased fat mass
Estrogen - decreased production with menopause. Leads to bone mineral density changes - Osteopenia and osteoporosis
Pancreas - decrease in insulin production
Overall slowed transit through Gastrointestinal system - reflux, constipation, changes in nutrient absorption
-Decreased drug metabolism
46
Changes to the central nervous System
- Cerebral atrophy
- ->Increased in size of lateral ventricles
- ->Particularly in frontal and pre-frontal regions
- ->loss of neurons and white matter
- ->Hippocampus is an area of early cell loss - associated with Alzeimer's disease
- Senile plaques and neurofibrillary tangles
- Decreased in neurotransmitters eg. Decreased cholinergic and dopamine transmission
- Still capable of plasticity
47
Changes to the Peripheral Nervous System
-Decreased in number of lower motor neurons
-Decreased speed of nerve impulses
-Decreased ability of peripheral nerves to regenerate
Causes: associated with decreased myelination and decrease nerve growth factor
48
Changes to bone
- Reabsorption begins to exceed bone deposition - bone density decreased by 1% per year
- Bones become more brittle due to deterioration of collagen matrix
- Bone loss is accelerated post menopause in women and there is increased risk of osteoporosis
- However, regular progressive exercise can result in increased bone mineral density into the 8th decade
* really important to continue and encourage in our clients
49
Joint Structures and Tissues
- Joint capsules and ligaments stiffen and loss of elasticity
- Synovial production decreases; Decreased quality of synovial fluid
- Cartilage thins
- Most people over 70 years old have some osteoarthritis
50
Changes in Muscles
- Decreased in skeletal muscle mass:
- ->decreased in number and size of muscle fibers
- ->increase in connective tissue and fat within the muscles
- Impacts strength, endurance, flexibility, reaction time
51
Changes in Posture
- Increased postural sway
- Changes in spine : head forward position, increased kyphosis and flattened lumbar spine
- Rounded shoulders
- Slightly flexed elbow, hips and knees
- Changes in articular surfaces or joint capsules can lead to valgus or varus deformities of the hips knees and ankles
- impact gait and balance
52
Key threats related to changes with age
| Physical inactivity:
- Physical exercise and activity is important for maintaining health
- Lack of physical activity can lead to spiralling decline in health
- ->Muscle atrophy
- ->Joint stiffness and instability
- -> Less efficient venous return - risk of venous thrombosis, oedema,
- ->decreased cardiac output
- ->bone loss
*thinking about how quickly we can get someone up and active after an injury
53
Key threats related to changes with age
| Frailty
- Age-associated declines in physiologic reserve and function across multiple systems
- Operationally defined as meeting 3/5 criteria:
- ->low grip strength, low energy, slowed walking speed, low physical activity, unintentional weight loss
- Carries an increased risk for poor health outcomes including falls, disability, hospitalization, and mobility
54
Key threats related to changes with age
| Undernutrition, malnutrition and obesity
-Related to unbalanced food intake
-Undernourishment may be under-reported/recognized
(hard to cook for one person, tea and toast kind of diet risk of undernourishment)
-Risk factors:
-->Dysphagia, slow eating, low protein intake, poor appetite and presence of a feeding tube
-->living in long-term care or with long-standing illness
-Leading to increased risk of other illnesses - diabetes, cardiovascular disease, MSK conditions
55
How can OT address these Treats?
Physical inactivity
Frailty
Nutrition
education we can help people at the impairment level,
preventing decline, encouraging participation in physical activity, think about access to services, enabling them to adapt their approach, adapting the task (assistive devices), preparing food do they need help?\
adapting the environment
adapting the task
-Improving the capacity of the person
56
Hand Function
The hand is the most active and important part of the upper extremity
The hand serves as:
- An important creative tool
- An extension of intellect
- A means of nonverbal communication
- A major sensory tactile organ
57
Hand Function
| The health hand has to be able to :
- Undertake extremely fine and sensitive movements
| - Perform tasks requiring considerable force
58
Changes in Hand Function
- Age-related declines in the CNS and PNS
| - A large area of the CNS specifically is devoted to controlling the hands and particularly the thumb
59
Changes in hand function
- Changes in hand function occur as a result of normal aging in both men and women, especially after age 65
- ->sensation, skin, muscle, bone
- Hand pain is prominent cause of disability in older adults
- ->prevalence of hand pain in older adults ranges from 12% to 21%
- Severity of specific hand-related disability including cosmetic concerns, increasing in 80+ yrs., particularly in women
* only a minority of older adults reach out for help for hand pain
60
Changes in hand function
| Common metabolic and skeletal diseases impaired hand function in elderly adults are:
- osteoarthritis
- Rheumatoid arthristis
- Osteoporosis
- Hormonal Changes --> can include skin dryness and thinning
- impact the ability to manipulate and healing
61
Factors affecting function in aging hands
| Intrinsic Factors
Genetic factors
Diseases (osteoarthritis, rheumatoid arthritis,osteoporosis)
Soft tissue changes (muscle tendons, blood vessels and nerves)
Hard tissue changes (bones, cartilages and fingernails)
62
Factors affecting function in aging hands
| Extrinsic Factors
Environmental factors (Ultraviolet, radiation, chemical irritants)
Physical activities (work related, recreational, sports, and hobbies)
Nutrition
Traumatic injury
63
Sensory Changes in the Aging Hand
- Senses and sensory integrity decline with aging
- Functional sensory input is essential for well controlled manipulation of small objects during activities of daily living
- Tactile impairments alone does not explain the effects of age on a pick up and grasp task
64
Skin Changes in the Aging Hand
- Less elasticity with wrinkles, dryness
- Slowed repair processes
- Older adults are more likely to feel cold in their hands due to the poor blood flow
* -Reduced sensitivity to local heat sources or slower reflexes
- ->increase incidence of burns to the hands
* important to think about when thinking about safety
65
changes to fingernails
- Nails are important tools for fine grip strength and manipulation
- Nail changes include
- ->Discoloration with changes in colour from white-pink to yellowish-grey
- ->changes in contour (longitudinal ridges, or less concave shape)
- ->changes in the thickness and roughness of the nail surface
- ->decreased rate of fingernail growth
66
Muscle Strength
- After 60 years of age: decline in grip strength, by as much as 20-25%
- ->loss/decrease of number and length of muscle fibers, particularly in the Thenar muscle group
67
Bone ans joints (norms)
- Age related (over 70 yr) declines in wrist flexion (12%),wrist extension (41%) and ulnar deviation (22%)
- ->decline progresses with increasing age
- After the age of 50, the bone density of the hand decreases by approx 0.72% per year
- Aging hands and finger bones are especially prone to osteoarthritis (small bones and go through a lot of use) \
68
Bones and joints
| Impacts of osteoarthritis of the fingers include:
- Pain, swelling, joint deformities
- Bone spur formation
- Restricted range of motion of wrist and fingers
- Difficulty in performing manual activities that require grip and pinch
69
Aging hand - Functional Concerns
- Difficulty with tasks involving hand strength and coordination
- ->fine dexterity
- ->bilateral coordination
- ->fine-grip tasks
- ->hand-force control
- ->speed of hand-arm movements
-Reduced vision in older adults may contribute to challenges with fine motor tasks
70
Ergonomics Devices for Aging Hand
- Many of the common tools of everyday living are not designed for older adults consider potential age-related changes
- Example: cell phone (buttons are too small and too close, screens are hard to read for older adults with impaired vision)
- May need to modify tools and instruments of daily living for older adults
- Example: cutlery, pens, scissors, nail clippers
71
Gait and Balance Disorders in Older Adults
- Aging does not always come with gait disorders (up to 20% of older adults maintain normal gait patterns)
- Approx 30% of persons 65 and older have difficulty walking
- Approx 20% of older adults require a mobility aid to ambulate
- Prevalence of abnormal gait among older adults in hospital settings and living in long term care home is higher
72
Gait and Balance Disorders in Older Adults
| Gait and balance disorders are
- Common and a major cause of falls in older adults
- Associated with increased morbidity and mortality
- Related with reduced level of function
73
Medical Conditions & Risk Factors Associated with Gait And Balance Disorders
- Affective disorders and psychiatric conditions
- Cardiovascular diseases
- Infectious and metabolic diseases
- Musculoskeletal disorders
- Neurologic disorders
- Sensory Abnormalities
- Other Factors (e.g. other medical conditions)
74
Changes in Gait with Aging
Reduction in gait velocity and step length
- Increased stance width
- Increased time with both feet on the ground
- Bent Posture
- Less force at the moment of push off
75
Evaluation of Gait and Balance
1. History (i.e fall history, medical history, surgical history)
2. Current medication review (ie. number, dosage, type)
3. Physical examination (i.e. affective/cognitive, cardiovascular musculoskeletal, neurological. sensory, vitals)
4. Gait and balance performance testing (i.e. observation, functional Reach Test, Timed Up and GO Test)
5. Presence of environmental hazards (i.e. clutter, electrical cords, poor lighting , low chair, slippery surface)
76
Interventions for Gait and Balance
Falls lead to: injury, disability, loss of independence, and limited quality of life
- Early identification of gait and balance disorders and appropriate intervention prevent dysfunction and loss of independence
- A multifactorial evaluation followed by targeted interventions is the most effective strategy for falls prevention
- Effective options for patients with gait and balance disorders include OT, PT, and exercise therapy (things like tai chi)
- insoles to improve static and dynamic balance
77
Sexuality in Older Adults
| A significant number of older adults report that sexual intimacy is an important aspect of their long-term relationships
Many older people continue to have enjoyable sex into their 80s and beyond
Sexual satisfaction correlates with:
-relationship satisfaction
-Medical health
-reliance on fewer vs prescription medications
-Traditional vs a more creative approach to intimacy
78
Sexuality in older adults
| Changes related to age and/or illness may lead to misunderstandings (e/g interpreted as lack of interest
Research suggests that rates of sexually transmitted illnesses among elderly populations are increasing
- At risk older adults are less likely to use condoms
- Health practitioners may be less likely to bring up health sex practices with these patients
79
Sexual Desire in Older Adults
Women over age 75
- ->less likely to have a partner than older man
- ->less positive attitude toward or interest in sexual activity than men of the same age
- Men with or without a partner have:
- ->more frequent sexual thoughts, fantasies, and feelings of sexual desire (and self-stimulation) than women, with or without partners
80
Age and Medical-related changes in men
- Decreased desire (loss of libido) caused by:
- ->medical problems, depression, anxiety, medication side effects, alcohol consumption, or lack of information about the range of sexual activities that could be pleasurable
- older men require:
- ->more physical penile stimulation
- ->longer time to achieve erection
- ->duration of orgasm is shorter and less intense
81
Age and Medical-Related Changes in women
Aging affects the sexual response, including fewer and weaker orgasms related to:
- Hormonal changes, body image, relationship and family issues, and medical conditions
- Older women tend to have:
- -> Less pleasure sexual activity (less level of estrogen)
- ->Vaginal dryness and weakening of tissue (pain and irritation during intercourse)
- ->Risk of infection (fragile mucous membranes)
82
Barriers to Sexuality and intimacy
- body image, beliefs and values regarding sexual expression (e.g., outside marriage)
- Lack of knowledge about or comfort with their sexuality
- Lack of opportunity for sexual experiences
- Lack of privacy in communal living environments
- Fear of becoming the topic of conversation among staff and others
- Attitudes of adult children toward their elderly parents' sex lives
- Lack of healthcare provider comfort with raising the topic
83
Implications (sexuality and intimacy)
suggested conversations starters:
Are you sexually active? If yes then "Do you have any questions regarding your sexuality that you'd like to discuss?"
"Oftentimes as people age they experience changes in their bodies that impact sexual function. Is there anything happening with your body, or your partner's body, that is making you uncomfortable?"
84
What is our role as occupational therapist (sexuality and intimacy)
- Referral
- Education
- Advocacy
- Positioning for pain or function
- Energy Conservation
85
Sensory Changes
Touch, vibration, pressure
- ->decreased structure and number of touch receptors
- -->decreased speed of processing
- ->change to circulation
-Affects hand function, balance, safety, (burns, wounds)
Pains:
- Not well understood
- May go unreported
86
Vision
- Reduced lens accommodation - presbyopia, and retinal illumination
- Can affect perception of colour, depth, and distance of field
- Common eye conditions with age: cataracts, glaucoma, macular degeneration, diabetic retinopathy
87
Hearing
Hearing loss -common chronic condition of aging
- ->most marked at higher frequencies
- Intrinsic factors - cell loss in nervous system and stereocilia, thickening of tympanic membrane, decreased elasticity of the ossicular chins and atrophy of the cochlea
- Extrinsic factors - exposure to noise, smoking, high fat diet
88
Taste and Smell
-Large number of older adults complain of changes in taste and smell
-Decreased ability to detect and discriminate between sweet, salty, bitter and sour
-->medication side effects
-Decreased smell identification
Functional Implications: pleasure, safety, nutrition
89
Implications of sensory loss
- Communication
- social isolation
- safety
- Occupational Performance
90
Age-related cognitive changes
| -Declining cognition is a major threat to older adults with respect to participation and quality of life
- ->Impact may be subtle but annoying for older adults
- ->all cognitive abilities do not decline with age
- ->for many tasks and occupational roles the benefits of decades of experience may far outweigh decrements associated with memory impairment
91
Age-related cognitive changes
Understanding patterns of preserved and impaired cognitive function provides groundwork for understanding the impact on occupational performance
- Goal of OT interventions is to
- ->Promote cognitive health
- -> Assist older adults to understand these changes
- ->Develop strategies to enhance functioning
92
cognitive changes: Arousal and Sleep
Changes to frontal lobe can lead to changes in arousal and sleep patterns
- increased in sleep-related disorders
- Sleep disturbances are commonly associated with depression, Alzheimer's disease, cardiac, respiratory and musculoskeletal conditions
- Sleep disturbances can impact functioning (physical, increase risk of falls, impact cognition)
93
cognitive changes: Intellectual changes
- Crystalized intelligence remains intact (knowledge of learned information and facts)
- Fluid intelligence is impacted (perception of complex relationships, reasoning, problem-solving adapting to new situations)
- ->speed decreased
- ->ability to draw on better problems solving strategies
- -> Significant changes in adults <80 may indicate pathology
94
Cognitive Changes: Attention
- Sustained attention: - not impacted by aging
- Selective Attention -Difficulty determining which information is relevant or irrelevant to a particular task and filtering out external distractions
- Divided attention - decreased ability to attend to details of two competing stimuli - better performance when one task involves procedural memory
95
cognitive changes: memory
- Short-term memory remains intake with age
- Working memory and long-term episodic memory - substantial age-related deficits
- Prospective and remote memory are more stable
- Semantic and procedural long-term memory are minimally affected
- Semantic memory (Vocabulary, word knowledge) can be enhanced with advancing age
96
Cognitive Changes: Speed of Processing
- Decreased speed at which information is processed in working memory
- ->slowing in the peripheral and central nervous systems
- ->Slowed sensory processing
- Leads to increased reaction time and increased time to process and retrieve new information
- ->score may be influenced by test relevancy
97
Cognitive Changes: Executive function
- Planning, abstract thoughts, decision-making, cognitive flexibility, and use of appropriate behaviours account for most of the cognitive decline seen in aging
- Decrease in speed and efficiency of problem solving
- Abstract reasoning
- -> Decline in mental flexibility and set shifting in reasoning tasks
98
Intervention strategies to promote learning and occupational engagement (cognitive)
(LOTS OF ANSWERS)
-Assist clients to understand mechanisms of memory and the issues they may be experiencing (normalize it what is happening)
-Guide clients to develop strategies related to attention and working memory e.g. paying extra attention
-Attention is enhanced when information is presented through more than one modality (auditory, and written)
-Use emphasis to direct attention to what is to be learned (bold, highlight)
-Minimize distractions
-Allow Self-Pacing
-Allow time for processing, reduce content presented, slow speech rate/pause, increase exposure time
-Encourage active verbalization (talk aloud) and elaboration of new information vs just rehearsal
-Interest enhance attention - asses what the client already knows, make information relevant
-Provide clear instructions for organizing a complex task - Logically group information and focus on essential aspects
-Build on what the client already knows - associate new information with previous learned information
Encourage organisational strategies, use of routines' and habit development - always put your keys in the same place
-Reduce stress and anxiety
-Mnemonic strategies: visual associations, acronyms, rhymes
-External strategies: lists, calendars, placing objects in conspicuous places
Cognitive training can delay cognitive and functional decline
99
ACTIVE Study - Advanced cognitive training for independent and vital elderly
RCT with 2800 adults aged 65-94 with age related cognitive decline at risk of loss of independence
-Study Design
Participants were randomly assigned to 1-4 groups:
10 session group training for
-->memory
-->Reasoning
-->Speed of processing
-no-contract control group
-For the 3 treatment groups, 4-session booster training was offered t 60% random sample 11 months later
100
ACTIVE Study - Advanced cognitive training for independent and vital elderly
RCT with 2800 adults aged 65-94 with age related cognitive decline at risk of loss of independence
Memory Training focused on Verbal episodic memory
- teaching of mnemonic strategies for remembering
- Word lists and sequences of items,
- Tect material, and
- main ideas and details of stories
- instruction in strategy or mnemonic rules
- individual and group feedback on their performance
101
ACTIVE Study - Advanced cognitive training for independent and vital elderly
RCT with 2800 adults aged 65-94 with age related cognitive decline at risk of loss of independence
-Reasoning training focused on the ability to solve problems that follow a serial pattern
- Identifying patterns in a letter or number series or in everyday activities
- abstract reasoning tasks as well as reasoning problems related to activities of daily living
- individual and group exercises
102
ACTIVE Study - Advanced cognitive training for independent and vital elderly
RCT with 2800 adults aged 65-94 with age related cognitive decline at risk of loss of independence
Speed-of processing training focused on Visual Search Skills
- Increasingly complex speed tasks on a computer:
- ->Decreasing stimuli duration
- Adding a distraction
- ->Increasing the number of concurrent tasks, or
- ->presenting targets over a wider spatial expanse
103
ACTIVE Study - Advanced cognitive training for independent and vital elderly
RCT with 2800 adults aged 65-94 with age related cognitive decline at risk of loss of independence
Results:
Results:
2 years: each intervention improved the targeted cognitive ability compared with baseline durable to 2 years
10 years: Participants in each intervention group reported less difficulty with IADLs, memory, reasoning
-At mean age of 82, approx 60% of trained participants vs 50% of controls were at or above their baseline level of self-reported IADL function
-The reasoning and speed-of-processing interventions maintained their effects on their targeted cognitive abilities
104
Cultural Views of Older Adults:
- Negative views
- Positive Views
- Older adults with meaningful roles at home or in community are more active, healthier, have higher self-worth. and better well being
105
Ageism
- Stereotyping or discriminating against people based on their age
- Six-in-ten Canadian seniors report being treated unfairly or differently because of their age
- One-in-three Canadians state they have treated someone differently because of their age
- One-in-five Canadians say older Canadians are a burden on society -Working with seniors is not "sexy"
- Ageism is not an old person's problem it is a societal problem and a collective responsibility
106
Three Common Forms of Age Discrimination
1) Being Ignored or treated as though they are invisible
2) Being Treated like they have nothing to contribute
3) Assumption that they are incapable
107
What older Adults Say About Discrimination
| People assume.....
```
..... I have nothing to contribute
.....I'm incompetent
...... I have memory loss
..... I am slow
.... I am hard of hearing
.... People treat me like a child
```
108
Sources of Age Discrimination
- Young People
- Employers
- Government
- Healthcare system/healthcare professionals (e.g., not accepted as a patient by family physician)
- Local Businesses
- Family members
- Peers
109
Practice Implications: Ageism
- Be aware of your values systems and beliefs related to aging and how these for or do not fit with those of your clients
- Be sensitive to client's cultural needs and preferences (diversity) of older clients
- Avoid infantilising older clients - consider them as equal partners in every stages of therapy process
- Promote awareness - advocacy
110
Social Participation: Patterns with Age`
- Social Participation decreased with age - but only after 75
- People living at home with a spouse or other(s) have a higher level of social participation
- People 85 and over report lowest participation in recreation compared to other areas of participation
- Health problems such as osteoarthritis, respiratory problems, and hypertension are negatively associated with participation
111
Social Networks: Loneliness and Social Isolation
- Living alone is not social isolation, if regular contact with a variety of relatives a friends is maintained
- Loneliness is having fewer social ties or friends than a person expects, desires, or feels
- Social isolation is diminished quality, type, frequency, and emotional satisfaction of social network and social participation
112
Loneliness and Social Isolation
| Among older people (especially over 80s): risk of all social networks shrinking
- ->vulnerability to losing relationships through retirement, illness and relocation
- ->difficulty in maintaining networks (e.g. declining health)
- ->Death of people close to them (e.g spouse)
113
Social Isolation
-Affects 10% to 20% of adults over age 65
Associated with
- Poor physical and mental health
- -> depression, dementia and suicide risk
- Increased risk of hospitalization and mortality
- Neighbourhood variables (e.g. transportation and other services, incidence of crime)
- Income, living situation, information access
114
Social Participation and Support
- The perceived availability of social support can be a source of:
- ->general positive affect
- ->enhanced self-esteem
- ->feeling of belonging and security
- The effects of stress on well-being can be reduced if an individual feels that they will receive the necessary support form their social network
115
Types of Social Support
- Types of social support (family members, neighbours, or friends, professionals):
1. Emotional
2. Informational
3. Instrumental/Practical Support
- Peer Support
- Volunteering
- Reciprocity is important in relationships
116
Support Networks
1) Local Family Dependent
2) Local integrated
3) Local self-contained
4) Wider Community-focused
5) Private Restricted
117
Local Family Dependent
having close ties with at least some family members who live close at hand (at least within 8-10km)
- ->Regular contact, offering assistance and emotional support
- ->more common among windowed older adults, and people with poorer health conditions
- Close ties with at least some family members
118
Local integrated
Ties with friends and neighbours as well as family members living locally
- -> close ties with church and voluntary bodies, social network, developed over a long period, may be larger
- ->have better health conditions
- Friends and neighbours as well as family members living locally
119
Local self-contained
Supports consist of only a few relatives, sometimes emotionally as well as geographically distant
- ->unlikely to know many people in the local community, but may be reliant on neighbours in time of emergency
- Only a few relatives, sometimes emotionally as well as geographically distant
120
Wider Community-focused
- Larger number of ties with the local community (e.g. member of local clubs, societies, charitable organizations)
- ->Little needs for assistance
- Generally well, in good or fair health
- Large number of ties with the local community
121
Private Restricted:
Minimal contacts with a few friends
- May be due to a life-long pattern of extreme independence or, lack of seeking out friends
- Minimal contacts with a few friends
122
Social Networks
| -There is no association between network types and depression or dementia
Older people living in
- Local integrated networks have greater level of happiness
- Sheltered accommodations with locally integrated networks feel more active and less lonely
123
Formal Social Support
- Formal support (social and health care professionals) provides a valued support and network for the client
- Health professionals enable older adults to achieve better outcomes through:
- ->Continuing relationships
- ->Listening effectively
- ->Collaborating decision making
- Seeking. and accepting professional help can be a source of discomfort and stigma
124
Pets
- The evidence to support psychological health benefits from pet ownership is mixed
- Pet's loyalty and affection could be seen as a form of unconditional emotional support
- Benefits of having a pet (dog or cat) for older adults
- ->Maintain engagement in activities of daily living (better self-care)
- ->contribute to sense of identity
- ->health promoting (more activ routines)/Walk further
- ->Improve social context (valued sense of connection)
125
Dysfunctional Social Contexts
- Social context can have harmful effects on physical and psychological well-being of the older people (e.g. disempowering and infantilising behaviour with older adults)
- May be exacerbating when supports networks are shrinking or are under heavy strain (eg. demands of caregiving)
- Private networks with minimal outside contact are capable of hiding abuse
126
Social Context and Occupations
- Social context influences quality and quantity of: leisure occupations
- ->Life satisfaction
- ->well-being
- Engaging invalued leisure occupations offer a buffer against stress
- Rich social network provides more opportunities to stay active and engaged
- Engaging in more social activities promotes longer life expectancy for older adults
127
Practice Implications: Social Networks
- Client's approach and lifestyle are important factors in engaging older adults with different social networks
- Consider use of a family-centred approach
- ->Partner with client and carers to achieve mutually acceptable solutions
- ->Use family structures, friendships, and social contacts as sources of support
- Enhance social network to improve community integration, engagement in valued leisure activities and health
128
Practice Implications: Social Networks
- Consider group based-therapy or supports groups (shared experiences and coping strategies) empower and assist isolated older adults
- Consider meaning ful and desirable activity, person's abilities and social network history before encouraging client to participate in a social activity
- Consider intergenerational projects
- Social Prescribing
129
Emotional Well-Being
- Fro 50 to 70 yrs, positive emotions increase and negative emotions decrease
- ->before and after those ages, patterns differ across specific emotions
- Overall, older adults have a higher positive-relative-to-negative emotional experience than younger adults
130
Emotions Predict Longevity
Factors related to:
Longer life
Shorter life:
Longer life: Positive emotions, happiness
| Shorter life: Negative emotions, regrets
131
Emotion and physiology -Stress
- With high levels of sustained emotional arousal, older adults have greater difficulties returning to homeostasis than young adults
- Stress situations for older adults:
1) Social isolation
2) Neurological dysfunction
3) Exposure to chronic and unpredictable stressors
4) Overload of predictable stressors
132
Depression
Rate of depression in older adults is lower than younger adults
- Older adults' symptoms of depression is more harmful than younger adults
- ->decreasing cognitive, physical, and social functioning
- ->increased risk of morbidity (e.g. cardiac events). risk of suicide, self neglect, mortality
- Depression may be present as a lifetime illness or as late-life condition
133
Depression
| Older adults tend to present with physical symptoms be emotional ones
-Sleep disturbances
-Fatigue
-Psychomotor retardation
impaired cognition
-Loss of interest in living
-Hopelessness about the future
134
Depression
| -Risk of depression in older adults is increased with sudden events in later life including:
- Financial difficulties/socioeconomic disadvantages
- A new illness or disability/a family member with a new illness or disability,
- Retirement /change in living situation
135
Anxiety
- Feeling of worry, nervousness, or unease
- More common than depression in older adults (mixture is common)
- ->similar risk profiles
- Frequently related to fear of falling and/or is comorbid to other illnesses
- ->reduced activity level
136
Aging in Place Definitions
- The Centers for Disease Control and Prevention- "the ability to live in one's own home and community safely, independently, and comfortably , regardless of age, income, or ability level
- Social Development Canada - "Aging in place means having the health and social supports and services you need to live safely and independently in your home or your community for as long as you wish and are able."
137
Goals of Aging in Place
| -The goals of aging in-place can be seen from two perspectives
- Older persons and their families; most older people prefer to stay in their homes/communities as long as possible because it provides them with control over their lives, it enables them to keep their identity and well-being
- Policy makers; institutional care is much more expensive than the provision of care in the community at the older individual's home. The high public expenditures on nursing-home care urged policymakers as well as professionals to provide alternatives to serve frail older adults in their communities
138
What does it mean to older adults (aging in place)
- The overarching message around aging in place was that older people wanted to have choices about their living arrangements and access to services and amenities
- Also notable was that the phrase "aging in place", so popular among policy makers and service providers, was not familiar to most of the older people who participated in our research
- "Aging in place" was perceived as an advantage in terms of sense of attachment or connection and feelings of security and familiarity in relation to both homes and communities. Aging in place related to a sense of identity both through independence and autonomy and through caring relationships and roles in the places people live.
139
Realities of Aging in Place
- Aging in place independently, in a safe, comfortable, environment of one's choice, is philosophically attractive, whether it refers to one's home, community dwellings, or a special facility. However, the idyllic dreams of restful recreation, vacation travel, or visits to relatives are often economically or physically impossible
- There are issues that challenge an aging adult's safety, health, and economic security beyond the choice of location.
- ->intrinsic and extrinsic factors threaten possibilities for safe and sound health in the residence of one's choice
- -> Disparities exist between the older adult's desire to live independently, realities of declining health and function, and the financial ability to secure adequate housing
140
Barriers/Facilitators
| Environment
- Physical
- Institutional
- Social/support
- Geographical
141
Barriers/Facilitators
| Personal
- Physical/cognitive
| - Socioeconomic
142
Barriers/Facilitators
| Occupation
- Valued occupations
- Task demands
- Roles and Responsibilities
143
Naturally Occurring Retirement Communities
- Naturally occurring retirement communities (NORCs) are broadly defined as communities where individuals either remain or move when they retire
- The NORC program model is based on the idea that many older adults reside in communities that were not planned as senior housing, yet over time contain a significant proportion of older adults relative to the number of younger residents
- The model involves identifying such communities and developing partnerships among stakeholders within them -including older adults, service providers, building owners and managers, and local government officials - to meet local needs to support aging in place and to enhance older adults' quality of life
144
The village Model
- Are membership-driven, grassroots, non-profit organizations
- Are run by volunteers and paid staff
- Coordinate access to affordable services
- Provide volunteer services including transportation, inspiring health and wellness programs, home repairs, social and educational activities
- Offer access to vetted and discounted service providers
- Are based on the needs of your community
- Are one-stop-shopping. Villages do anything their members need to age safely and successfully in their own homes
- Positively impact isolation, interdependence, health and purpose of their individual members to reduce overall cost of care
145
Age-friendly Communities
- Population approach to enhance positive health, social participation and health equity in aging
- Encourages active aging by optimizing opportunities for health, participation and security by adapting its structures and services to be accessible to and inclusive of older people with varying needs and capacities
- In Canada, all provinces have initiated age-friendly community processes
- ->approximately 800 communities have launched age-friendly initiatives
146
Neighbourhood Facilitators
- Enable greater positive health, social participation, and health equity
- Examples
- ->Living close to services: grocery stores, health services, public transportation, banking services and social clubs,
- ->Neighbourhood perceived as friendly and supportive
- Neighbourhoods perceived to be physically adapted to the needs of older people (accessibility and distance to services) heightens feeling of safety
147
Neighbourhood Barriers
- Personal capabilities might be challenged or exceeded by environmental obstacles
- Example
- ->physical barriers
- ->Inaccessibility of services and amenities
- ->Social stress
- ->Resource inadequacy
148
Characteristics of Age-friendly communities
- outdoor spaces and buildings
- Transportation
- Housing
- Opportunities for Social Participation
- Respect and Social Inclusion
- Civic participation and employment
- Communication and information
- Community Support and Health Services
149
Guiding Principles
| Prevention and Management of Elder Abuse
- Respect personal value
- Recognize the right to make decision
- Seek consent or permission
- Avoid ageism
- Know that abuse can happen anywhere
- Involve the older adult in decision making
- Respect atomony
- Respond appropriately
150
Types of Abuse: the 5 categories
```
Physical/sexual
Financial
Psychological
Neglect
Denial of entitlements
```
151
Types of Abuse:
| Physical/Sexual
-Pushing shoving, unexplained bruises
152
Types of Abuse:
| Financial
-Misuse of property or funds
153
Types of Abuse:
| Psychological
Hurtful words "put-downs"
154
Types of Abuse: Neglect
-Intentional or unintentional failure to provide for basic needs
155
Types of Abuse: Denial of entitlements
Censoring mail
156
Barriers to disclosure
| -the older adult may:
- Not recognize the situation as abusive;
- Not know where to go to get help;
- Fear escalation;
- Worry about what will happen if when others find out;
- Feel humiliated
- Take blame for the abuse;
- Fear loss of connection;
- Believe that family honour is jeopardized;
- Have a history of abuse; and/or
- Feel as though they have limited evidence
157
Warning signs and what to do
| Elder abuse
- Be aware of changes in mood, behaviour, routines, or physical health
- Ask key questions (see support or legal services as needed)
- Responding to situations:
- ->Don't judge
- ->Understand and acknowledge
- ->Do not deny
- ->Engage safety planning (consider community resources)
- Encourage the person to seek help
158
Elder Abuse and the Pandemic
Social isolation
- Accessing care/supplies
- Financial hardship
- COVID-19 anxiety
- Caregiver burden/hardship
159
Tools for Assessment (elder abuse)
- BASE: Brief Abuse Screen for the Elderly
- BLI: Being Least Intrusive - An orientation to practice for front-line workers responding to abuse of aboriginal older adults
- CASE: Caregiver abuse screen
- DMEA: Defining and measuring elder abuse
- IOA: Indicator of Abuse
160
Taking action (elder abuse)
- Reporting and disclosure of information
- Mandatory reporting
- ->It's your responsibility to find out if/when you need to report and under what circumstances
- Ontario - in the community there is generally no duty to report, but if a person resides in a LTC/retirement facility there is a duty to report abuse, neglect as well as risk of harm to residents. Abuse within a LTC/retirement facility in Ontario must be reported to the Ministry of Health and Long Term Care or the Retirement Homes Regulatory Authority
161
Frailty - What is it
Variety of definitions
Common Descriptions
Variety of definitions
- Challenge to define and diagnose
- Systematic review highlighted 15 different components
Common Descriptions
-Vulnerability to physical, emotional and social factors
physical factors
- General lack of strength
- More vulnerable to disease and/or disability
- Decreased health more quickly/ increased difficulty with recovery
Emotional and social Factors
- ->Lack of emotion or social support
- -> Social isolation, increased risk of abuse
162
Frailty - What is it
| Phenotype Model:
3+ of the following
- weight loss
- Reduced muscle strength
- Reduced gait speed
- Self-reported exhaustion
- Low energy expenditure
163
Frailty - What is it
| -Cumulative Deficit Model
- Clinical Frailty Scale
- Accumulation of deficits
- Increased risk of adverse outcomes
- Continuum from very fit to terminally ill
164
Clinical Frailty Scale
4 vulnerable
5 mildly Frail
6 Moderately Frail
-prevention area
165
Frailty - What are the numbers
| -prevalence
10% 65+
25-50% 85+
Projected increase of 67% in 2025 from 2017
166
Best Practices Guidelines
1. Engage in efforts to prevent frailty
- Use PT and OT to improve strength and function to support older adults to live at home'
- Interventions that encourage physical activity have positive results
- ->Decreased rates of hospitalization and fewer falls
2. Manage the burden of frailty for older adults
- Make the burden of frailty for older adults
- ->use team-based models
- ->encourage patient decision making
3. Support caregivers in their efforts to prevent, delay, manage frailty
- Address economic security
- Engage caregivers in decision making
- Provide education and support
167
Best Practices Guidelines More
- Older adults should be assessed for the presence of frailty during all encounters with health care
- ->gait speed, TUG, PRISMA
- look for cause if older person with frailty shows a decline in function
- Many older people with frailty in crisis will manage better in the home environment with appropriate support systems
- Refer to geriatric medicine and/or geriatric psychiatry
- Recommend or complete a comprehensive geriatric assessment (CGA)
-fragility is not
decline in function on its own --> will not make people frail what is contributing and what can we do about it
168
Comprehensive Geriatric Assessment
Screening
- Screen those at risk
- Identify concerns
Assessment
- Multi-disciplinary assessments
- Diagnostic investigation
Interventions
- Goal-based treatment
- System Navigation
Follow-up
- Recommendations, Monitoring
- Re-assessment
169
Domains of a Comprehensive Geriatric Assessment (CGA)
- Medical
- Social support
- Safety
- Falls
- Physical Assessment
- Physical Environment
- Mental Health
- Cognition
- Functional Status
170
Geriatric 5Ms
```
Mind
Mobility
Medications
-Multi-Complexity
-Matters Most
```
171
Geriatric 5Ms
| Mind
Mentation, Dementia, Delirium, Depression
172
Geriatric 5Ms
| Mobility
- Impaired gait and balance
| - Fall injury Prevention
173
Geriatric 5Ms
| Medications
- Polypharmacy
- Deprescribing
- Optimal prescribing
- Adverse medication effects and burden
174
Geriatric 5Ms
| Multi-Complexity
- Multi-morbidity
| - Complex bio-psycho-social situations
175
Matters Most
-Each individual's own meaningful health outcome, goals, and care preferences
176
Interprofessional CGA Competencies
Competencies Framework
- 6 practice areas
- 99 behavioural statements
Self-Assessments Tool
- Self-rating scale
- Self-reflective practice
- Action plan
Learning Compendium
- 250 free online resources
- 20 fee-based
- 15 college/university
177
Comprehensive Geriatric Assessment
| -Competencies: 6 practice areas and 99 behaviour statements
- Core Geriatric Knowledge
- Screening, Assessment and Risk Identification
- Analysis and Interpretation
- Care Planning and Intervention
- Interprofessional Practice
- Professional Practice
178
Comprehensive Geriatric Assessment
- Competencies: 6 practice areas and 99 behaviour statements
- Core Geriatric Knowledge
-Demonstrates fundamental understanding of physiological and biopsychosocial mechanisms of the aging processes, related to changes to functioning and the impact of frailty
179
Comprehensive Geriatric Assessment
-Competencies: 6 practice areas and 99 behaviour statements
Screening, Assessment and Risk Identification
-Gather patient medical and social history and clinical data in sufficient depth to inform care planning and effective clinical decision making
180
Comprehensive Geriatric Assessment
- Competencies: 6 practice areas and 99 behaviour statements
- Analysis and Interpretation
-Conduct accurate analysis of assessment findings and clinical information to develop a complete understanding of the patient's story. Integrate assessment findings within and across domains to formulate a cohesive clinical impression
181
Comprehensive Geriatric Assessment
- Competencies: 6 practice areas and 99 behaviour statements
- Care Planning and Intervention
-demonstrate expertise in treatment, education, goal setting, future and advance planning. With patients and their identified support network, formulate comprehensive, collaborative care plans focused on optimization of function and quality of life
182
Comprehensive Geriatric Assessment
- Competencies: 6 practice areas and 99 behaviour statements
- Interprofessional Practice
Demonstrate and support interprofessional geriatric practice. Recognize and engage in inter-organizational collaboration through understanding of the roles of internal and external team members, and demonstrate the ability to identify appropriate opportunities to refer to collaborating teams/individuals
183
Comprehensive Geriatric Assessment
- Competencies: 6 practice areas and 99 behaviour statements
- Professional Practice
-Demonstrate core values, behaviours, and skills required to provide comprehensive, team based geriatric care. Demonstrate confidence in evaluating and maximizing own professional scope to optimize geriatric practice.
184
CGA The method (flow Chart)
Geriatric Problems:
- falls
- incontinence
- Decline in Function
- Confusion
Comprehensive Geriatric Assessment
(medical, physical, cognitive, Mental, Social, Environment)
Non Reversible
- Education
- Adaption
- Support Services
Reversible
- Treatment
- Rehabilitation
185
CGA: The approach: Uncovering the WHY?
```
what is(are) the problem(s)?
-Ex falls, decline in function, confusion, etc.
```
Who has the problem?
-->client, family, health practitioner, geriatric assessor
Is this New and Different
- ->Onset - When did this start?
- Progression - What is the trajectory ?
- ->Improving, declining, stable
What is the cause of the problem?
-Medical, Physical, Cognitive, Menal
What needs to be done about it?
-Diagnose, Optimize/Treat/Support
186
Chronic Care Model
```
Components of a system that encourages high-quality chronic disease management
Community
-Organization of health Care
-->Self-Management Support
-Delivery System Design
-Decision Support
-Clinical Information Systems
-Purpose to develop productive interactions between patients who take care and provide who have the necessary resources and expertise
```
187
Self Management
- Having the skill and confidence necessary to manage daily tasks and live well with chronic health condition including:
- ->Goal Setting
- ->Problem-Solving
- ->Monitoring progress and problems
- Self Management Support: Support from healthcare providers to increase confidence, knowledge and skills for self-managament
188
Five Core Self-Management Skills
- Problem-solving
- Decision Making
- Resource utilization
- Forming of a patient/health care provider partnership
- Taking action
189
Problem-Solving Process (cycle)
- Goal
- Plan
- Do
- Check
- Generalize
190
Decision-Making
- Part of Problem-Solving
- Day to day health related decisions
- ->Need information to make informed decision
- Use of Decision Aids
191
Resource Utilization
- How to find and utilize resources
- May involve helping clients seek out resources from many sources
- May need to teach clients to use resources
192
Forming of a client/health care provider partnership
- Involves being able to
- ->report accurately the status and progression of the disease (signs, symptoms, variations)
- Make informed choices about treatment
- Discuss choices with the health care provider
193
Taking Action
- Taking action is a skill necessary for changing a behaviour
- Can involve making a short-term action plan is carrying it out
- An action plan involves a period of 1 or 2 weeks and is very behaviour specific
- This means that the person should be able to accomplish the behaviour this week
- The behaviour should be something that the person is fairly confident he or she can accomplish
194
Self-Management in OT
- Self-management is about being in charge of one's life and managing one's condition, instead of being managed by that condition
- Self-management is recognized as an effective approach to managing chronic health conditions by empowering patients to understand their conditions and take responsibility for their health
- The client-centred nature of occupational therapy is ideal to support self-managament
195
OT goals related to Self-Management for Older Adults
- Health Promotion - Developing coping strategy, behaviours, habits, routines, and lifestyle adaptions
- Individualizing adaptations to effectively perform health management
- Teaching and incorporating health management tasks into existing habits
- Addressing performance deficits in ADLs an IADLs
- Teaching strategies to incorporate energy conservation and activity modification techniques into daily activities
196
Evidence for Health Promotion with Older Adults in OT
| CDSM ad mCDSM group interventions: strong evidence for improved occupational performance
- disease related problem solving, action planning, and decision making
- Skill mastery related to topics such as medication management, communication, nutrition, and exercise
- Individualized goal setting
- Coping strategies e.g. for pain and fatigue
- Focus on increasing participants' confidence
197
Evidence for health Promotion with Older Adults in Older Adults in OT
- Non-CDSM group health promotion Interventions delivered over an extended period: strong evidence for improving occupational
- Combined interventions: similar finding
- Most included goal setting and education
| - Many included a problem solving, addressed coping skills, or provided opportunity for practice and skill mastery
198
Health Promotion in OT
- The Well Elderly Study - Lifestyle Design
- layout
- RCT
- Culturally diverse men and women, independent-living older adults comparing
- ->Preventive OT
- ->Social interaction group
- ->No intervention
199
- The Well Elderly Study - Lifestyle Design
| - findings
Preventative OT program: weekly group sessions
- Topics: health-relevant behaviours, transportation, personal safety, social relationships, cultural awareness, and finances.
- Emphasis on understanding of each elder's unique characteristics and life circumstances and designing an individually tailored plan
- Program delivery: didactic presentations, peer exchange, direct experiences and personal exploration with occasional group outings or 1:1 sessions
- Significant health, function, an quality of life benefits
200
Barriers to Health Promotion in Practice
- Clients' complex health conditions
- Limited client openness to change
- Organisational and professional obstacles
- ->Misunderstanding of OT's role in health promotion
201
Caregiving (older adults roles)
| -Top 5 productive occupations of older adults:
- Home maker, volunteer, caregiver, paid employee and student
- Caregiving usually refers to:
- ->providing unpaid care for someone close
- ->includes a personal commitment to the other person's well-being
202
Caregiving roles of older adults include
- Caring for grandchild
- Caring for a spouse/partner , sibling, friend
- ->89% of spousal caregivers are over the age of 65 and 53% are over the age of 75
- 17% of children will provide care to their parents at some point in their life
203
Caregiving Task
-Transportation
-Housework
-Grocery shopping
-Meal preparation
-Managing finances
-Arranging/supervising outside services
-Assisting with ADL's
Medical - Related tasks:giving medications, wound management, administering enemas
204
Caregiver Burden
- Caregiver burden is the caregiver's negative perception of physical, psychological, social, economic or spiritual impact of providing care
- 80% of spouse caregivers of older people with dementia experience caregiver burden
- Not impacted by care recipient's health, independence in ADL's and pain
- Impacted by reduced independence in IADLs and memory function
- Also related to amount and type of social support available
205
Caregiver Burden
| Caregivers report poorer general health including
- Poorer mental health
- More role limitations due to physical health
- More role limitations due to mental health
- High pain intensity
- More Frequent sleep problems
206
Caregiver Burden
| Younger caregivers report better physical health but higher level of depression and caregiver burden
Caregiver burden can lead to
- Loss of income, benefits, job security, and career opportunities
- Disruption in social lives
207
Zarit Burden Interview
Do you feel that your relative asks for more help than he/she needs?
Do you feel that because of the time you spend with your relative that you don't have enough time for yourself?
Do you feel stressed between caring for your relative and trying to meet other responsibilities?
Do you feel embarrassed over your relative's behaviour ?
Do you feel angry when you are around your relative?
Do you feel that your relative currently affects your relationship with other family members or friends in a negative way?
Are you afraid what the future holds for your relative?
208
Positive Aspects of Caregiving
-Caregiving may be viewed as an extension of marital role or relationship
Caregiving can provide:
-->companionship
-->caregiving is fulfilling/rewarding
-Caregiving provides a sense of duty/obligation
-Enjoyment
209
Working with Caregivers
| Focus on the caregiver important for three reasons
- Caregivers tend to be neglected population
- Caregivers face very difficult situations over time
- Caregiver tried and rejected many interventions on their own.
The caregivers' extensive experience in addressing difficult caregiving issues often requires the occupational therapists to go beyond simple solutions
210
Working with Caregivers
| 5 interrelated aspects of collaborating with caregivers:
1. Intense listening - really hearing
2. viewing the caregiver as the expert
3. Validating the caregiver' efforts
4. Helping the caregiver to transfer existing strategies to other problem areas
5. Reframing the caregiver situation
211
Reframing
| Three components
- Showing caregivers that it is permissible, even desirable to take time for themselves
- Enabling caregivers to release expectations of themselves and their family member that no longer produce positive results,
- Showing caregivers a different standard by which to judge the effectiveness of their strategies
- Reframing may be facilitated by connecting caregivers with support systems such as alzheimer's and church support groups
212
OT interventions to Support Caregivers
Home Environmental Skill-Building Program (ESP)
Intervention
- Education about the disease process and the impact of environments on care recipient behaviours
- Problem-solving techniques to identify antecedents and consequences of targeted problems behaviours'
- Technical skills to modify the home
213
OT interventions to Support Caregivers
Home Environmental Skill-Building Program (ESP)
Structure
Outcome
Structure: five home visits and one telephone session, over 6 months. Maintenance for 6 months consisted of 1 home visit and 3 brief telephone sessions
Outcomes: 6 months: improved skills, less need for help providing assistance, and fewer behavioural occurrences
12 months: improved affect, trend for maintenance of skills and reduced behavioral occurrences
214
CGA: The approach: weighing the facts
- Subjective self-report
- By client
Subjective collateral
- By family
- By other health practitioners
Objective
- Standardized testing
- Observations
- Home environment
Integration
-Gathering comprehensive data comprehensively
215
CGA: along the Continumm of Care
Home
-Geriatric Assessment Outreach Teams
Community
- Primary Care Geriatric Assessment Clinics
- Geriatrician Clinics
- Geriatric Day Hospitals
Emergency Room
-Geriatric Emergency Management Programs (GEM)
Hospitals
- Geriatric Consultations
- Inpatient Geriatric Assessment Units
- Inpatient Geriatric Rehabilitation Program
216
Regional Geriatric Programs of ONtario
- Provides a comprehensive network of specialized geriatric services and complex needs.
- By working in collaboration with primary care physicians, community health professionals, and others to meet the needs of the most frail and vulnerable seniors
217
Interprofessional Care
- The importance of both disciplines in preventing, delaying, improving, frailty
- ->quality of life, remaining at home, function, decrease injury
- Co-existing journey of
- ->frailty
- ->cognitive decline
- ->Mobility changes
- How can you inform each other-whether as an individual or as a team?
- ->during assessment, treatments. What are you seeing?
218
Multimorbidity among Older Adults
- Older people often have multiple medical problems, different patterns of disease presentation, slower response to treatment and requirements for social support,
- high incidence of secondary complications of disease and treatment
- Can lead to rapid decline if not treated early
- Need for rehabilitation
- Importance = of social and environmental factors
219
Multimorbidity among Older Adults
- Multimorbidity = coexistence of several chronic diseases in the same individual
- 67.5% of older adults have two or more chronic diseases (spanish study); 31.3% (canadian study).
- ->This rate increases with age
- A canadian study found the prevalence of multimorbidity (3+ diseases) was significantly higher if the person was
- A women
- Older
- In lowest income quintile
- Had less than high school education
- Of Indigenous status
- Born in Canada
220
Multimorbidity among Older Adults
| Factors among those aged 65 years and over:
- Low income
- indigenous status
- Inactivity
- High Stress
- Obesity
- People with multimorbidity have a higher risk of becoming care dependent
- -> Particularly those with neurological illnesses
221
Common Causes of illness and disability with aging
| -42% of multimorbidities in older adults consisted of three of the following (German study):
- hypertension,
- Lipid metabolism disorders,
- Chronic low back pain,
- Diabetes mellitus,
- Osteoarthritis and
- Chronic ischemic heart disease
222
Common causes of illness and disability with aging
Hospitalized older patients in Spain
-Most frequent health problems:
- Immobility
- Urinary incontinence
- Hypertension
- Falls
- Dementia/cognitive decline
- Diabetes
- Arrhythmia
223
Geriatric GIants
- Terms coined by Prof. Bernard Isaacs to highlight the major illnesses associated with aging
- Although the major causes of mortality in the elderly are cancers, heart diseases and stroke, the Geriatric Giants reflect the gigantic numbers of older adults affected and the giant impact on the independence of older adults
224
Geriatric Giants
| -Major illnesses
- Incontinence
- -Immobility
- Instability (falls)
- Intellectual impairment (Dementia)
- iatrogenic - induced inadvertently by medical treatment or diagnostic procedures
- ->Polypharmacy
- ->Transmission of infection from healthcare providers
- ->Surgical errors
225
Incontinence
- involuntary loss of urine
- Incontinence carries a HUGE social stigma, reduces life space and mobility and is a financial and social burden to caregivers
- Aging causes smaller bladder capacity and weakening of urethra and pelvic floor muscles
- ->males - urethra obstructed by prostate gland
- ->Females the urethra may be traumatised by frequent pregnancies
- Kidneys become less responsive to sodium loss and to antidiuretic hormone-less able to concentrate the urine.
226
Type of Incontinence
PERSISTENT
-STRESS: involuntary loss of urine during the act of laughing, coughing or exercise
URGE: leakage of urine because of the inability to delay voiding after the sensation of bladder fullness is perceived. "Must go now!"
-OVERFLOW (NEUROGENIC): Frequent dribbling of urine, usually after stroke or benign enlarged prostate
-FUNCTIONAL: Due to physical and cognitive impairment
-Dementia, depression, inaccessible toilet facilities
227
Assessment - incontinence
- Impact on occupation
- Medical/biological contributing factors
- Cognitive function
- Behavioural strategies being used/motivation to be continent
- Ability to get to the toilet and manage clothing
- Absence of environmental barriers to continence
228
Intervention - incontinence
Goal: decrease impact on occupational engagement - Social participation
- increase knowledge and understanding
- Improve access: modification of environment
- Adaptive Approaches
- -> establish routines, adult incontinence products
- Referrals
229
Immobility
| Often multifactorial:
- Musculoskeletal - OA: pain, muscle weakness and deconditioning
- Heart disease/COPD, CHF, SOB and loss of endurance
- CNS-Stroke: Muscle weakness, abnormal gait, poor proprioception
- Cataracts, Macular degeneration: poor vision
- Falls
230
Immobility
- Increases both the informal and formal care needs
- Inactivity increases the risk of
- ->Incontinence
- ->Pressure ulcers
- ->Osteoporosis
- ->Other health conditions
-Results in the limitation of life space and occupational engagement
231
Instability
- Falls are common and preventable source of mortality and morbidity in the elderly
- In a one year prospective study of persons ages 75 years and above
232
Instability
- Falls are common and preventable source of mortality and morbidity in the elderly
- In a one year prospective study of persons ages 75 years and above
- -> 32% fell at least once
- 24% had serious injury
- Most falls multifactorial - person, occupation, environment factors
- Major sequelae and morbidity of falls is hip fractures (more common in women with osteoporosis)
233
What factors contribute to falls in older adults?
| What do you need to consider in providing falls interventions with older adults
- Unstable surfaces, hills, curbs
- Poor sleeping habits
- Incontinence
- fear of falling
- Improper footwear
- Cognition and attention to the environment
Strategies
- quiet environment with no distraction
- Repeat back to you the instructions
- Repetition
- Written instructions
- Coloured stickers
234
```
Intellectual impairment (Dementia )
-Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains:
```
- Learning and memory
- Executive function
- Complex attention
- Perceptual-motor
- Social cognition
- Language
235
Intellectual Impairment (dementia)
- Cognitive deficits interfere with independence in everyday activities
- -> person requires assistance with complex IADLs (paying bills, managing medications)
- Cognitive deficits are not exclusively attributable to delirium
- Cognitive deficits are not better explained by another mental disorder (eg. major depressive disorder, schizophrenia)
236
Driving habits of older drivers (age 60-70)
| Compared to 20-30 yr age group `
- Fewer trips,
- Drove fewer minutes
- Less likely to drive at night
- Fewer high decelerations and speeding events
237
Driving habits of older drivers (age 60-70)
| Compared to 40-50 year age group:
- Less likely to drive during peak morning traffic
| - Less likely to drive on high-speed roads
238
Risks -Driving
- Increasing mortality and morbidity among older drivers
- Driving -related accidents are the leading cause of accidental deaths for person 65 to 75 years old in Canada
- Adults > 75yrs have a 3.5 time higher crash rate per miles driven compared to drivers aged 35 to 44 years
239
Driving among older adults
Driving is associated with
- ->convenience
- -> independence
Driving cessation
- Places the burden of transportation on family and caregivers
- Difficult in rural communities where alternative transportation is limited
- Associated with depression, isolation, and decreased quality of life
240
When should older drivers stop driving
| Considerations
- Sensory abilities - vision, hearing
- Physical abilities - Rom, pain
- Perceptual and cognitive abilities - scanning, attention, visual processing and reaction time
- Chronic conditions and medication
- Driving experience
241
Considerations during assessment
| Driving habits - many driver adjust their driving
- Stop driving at night
- Avoid highways
- Stick to familiar routes
- Drive during low traffic times - daytime during the week
- Accessibility, availability and knowledge of transportation options
- Regulatory requirements
242
Interventions to improving driving
-Education combined with on-road training: strong evidence for improved driving performance
-->education alone is not effective in reducing crashes.
Visual processing speed training:
--> fewer risk maneuvers during on-the-road testing
-->reduced reaction times on a simulator
-->preliminary evidence for decreasing at-fault crashes
-Eye scanning training - to increase peripheral awareness
--> limited evidence
-Flexibility/range of motion training - moderate evidence that physical training improves driving performance
243
Pharmacy - older adults
- Often defined as 65 years of age or older
- age is a continuum
- Principles of prescribing for older adults apply increasingly as frailty increases
- Frailty is defined as a progressive decline involving multiple body systems marked by a loss of physiologic reserve
- Overall frailty and physiologic reserve
- Overall frailty and physiologic age should be considered over chronological age when caring for older adults
244
Ontario Drug Benefits
- Ontario Drug Benefits (ODB) Seniors Program
- At age 65 automatically qualify for eligible prescription drug costs to be covered through ODB, must:
- Reside in Ontario
- Valid Ontario Health Card
- Yearly deductible $100, maximum dispensing fee $6.11 per prescription
- Program year August 1 to July 31
245
Polypharmacy
| Definition
- The use of multiple medications
- ->5 or more medications concurrently
- ->Inappropriate or more medications than clinically indicated
- Older adults typically have more chronic medical conditions that require treatment than younger adults
- On average elderly patients receive prescriptions from 3 different prescribers
246
Polypharmacy
| Prescribing Cascade
the prescribing of a new medication to treat a symptom that has arisen from an unrecognized adverse drug reaction (ADR) related to an existing therapy
247
Polypharmacy
| -nonprescription, dietary supplements and natural health products (NHPs) also contribute
- Patient's often don't consider these products " medications" because they are "natural"
- may not inform their health care team about taking
- Nonprescription products have potential ADRs and drug interactions when prescribed medications
- In Canada supplements and NHPs are not regulated in the same way that prescription drugs are
248
Polypharmacy
| -Direct to consumer advertising not allowed by Health Canada
- Through American TV stations Canadians will often see commercials for drugs
- Many of these drugs are not yet on the Canadian market
-Concern that advertising drugs encourages inappropriate prescribing and use of newer more expensive agents
- Abundance of health information on the internet
- -> Questionable accuracy and reliability
249
Polypharmacy
-2016 CIHI data indicates, 6% of Canadian seniors were prescribed 5 or more drug classes 25% were prescribed 15 or more drug classes
The number of medication classes prescribed is higher for seniors living in a health care institution
- Electronic medical records (EMRs) and pharmacies are not connected
- ->duplication of therapy, drug interaction and ADRs
250
-multiple medications/prescribers increase the client's risk
- ->drug interactions, ADRs and hospitalizations
- Seniors prescribed 10-14 classes of medications are 5x more likely to be hospitalized for an ADR than those prescribed 1-4 classes
251
Considerations prior to prescribing or represcribing
- GOALS of care to comfort or to cure
- Limited life expectancy versus time to benefit
- Evidence to support use in the frail elderly or very elderly
- Individualized patient centred approach
- Minimization of pill burden
252
Opportunities to minimize polypharmacy
- Transitions of care, especially hospital discharge
- Comprehensive medication review, interdisciplinary approach
- ->asses patients goal of care
- ->assess medication management and adherence
- ->assess evidence to support ongoing medication use in older adults
- Simplify to reduce number of dosing times per day and overall pill burden
- Deprescribe, medication tapers often required
- make one change at a time, start with low hanging fruit
- clear communication with community pharmacy
253
Comprehensive Geriatric Assessment
-Multidimensional and interdisciplinary process
- Determines a frail older person's medical, psychological and functional abilities
- Social History
- -> education, former occupation, supports and advanced care planning
- Functional History
- -> IADLs, ADLs, Hearing, vision, Gait and Balance Assessment
- Comprehensive Medication Review
- Collateral History
- Geriatric Review of Systems
Allows for the development of a coordinated care plan to guide current and future treatment decisions
254
Geriatric Review of Systems
- Falls (any falls in the last 6 months)
- ->if yes, orthostatic, gait and balance assessment
- Cognition (any concerns about your memory)
- Incontinence (bowel and bladder, any accidents)
- Mood (how would you describe your mood)
- Pain (any issues)
- Changes in appetite or weight (any changes)
- Vision or hearing difficulties (any)
255
Comprehensive Medical Review
1. Best possible medication history
2. Assess medication adherence
3. Identify drug therapy problems
a) can this be caused by a drug?
b) can this be cured or treated by a drug?
4. Identify high risk medications
5. Identify age related changes in pharmacokinetics
6. Reconcile medications and communicate changes with patient's care team
256
Medication Adherence
- The extent to which a person takes medications as prescribed
- Medications non-adherence can be intentional or unintentional
- As the number of medications and medication regimen complexity increases so does the risk of medication non-adherence
- ->adherence is higher for once or twice daily medications versus those that are three or hours times daily
- Adherence implies a collaborative, cooperative approach between the client and physician or pharmacists in which the client mutually partakes in the treatment decision and medication regimen
257
Medication Adherence
| Examples of Medication non-adherence
- Forgetting to take a dose of medication
- Taking more or less than prescribed
- Stopping a medication on own accord due to ADrs or cost
- Not filling a new medication because benefits are unclear or fear of ADR
- Skipping a medication dosage by choice
- Taking someone else's medication
- Skipping a dose of medication due to a physical barrier
258
Medication adherence Aides
- Daily routine
- Calendars
- Medication charts
- Pill organizers
- Blister packages
- Scheduled alarms
- Reminder calls
- Nursing or family administration
259
Medication Adaptive Devices
- Large print labels
- Non-child proof tops
- Pill splitter
- Eye Drop Squeezers
- Spacers for inhalers
260
Drug Therapy Problem
- Untreated condition
- Improper drug selection
- Dose is too low
- Dose is too high
- Failure to receive a medication
- Adverse drug reaction (ADR)
- Drug interaction
- Drug use without indication
261
Identify High risk medications
- High risk medications have increased risk of ADRs in the elderly
- These classes of medications have been associated with an increased risk of ER visits or hospitalizations
Drugs that increase:
- bleeding risk
- Risk of hypoglycemia
- Falls risk
- Risk of memory loss
- Anticholinergic activity
262
Identify Age related changes
| Pharmacokinetics - changes with age
Absorption - reduced first pass metabolism and reduced gastric motility
Distribution-(water loss, fat tends to increase, albumin may decrease)
Metabolism - Hepatic blood flow reduced
Elimination - kidney function generally declines with age, drugs that are eliminated by kidneys can accumulate in the body
263
Identify Age related changes
| Pharmacodynamic changes with age- clinical effect
-Increased receptor sensitivity (increase sedative effects from drugs)
decreased receptor sensitivity (decreased response to drugs)
-Decreased baroreceptor function - Increased risk of orthostatic hypotension
-Increased response to medication
264
Safe medications Use in Older Adults
- Limit the number of medications prescribed
- Determine which drugs are still providing benefit
- Consider age related changes in pharmacokinetics and pharmacodynamics
- ->smaller doses often required in older adults to elicit the same therapeutic effect
- ->when initiating new therapies, start low and go slow
- Consider targeted deprescribing for unnecessary and inappropriate medications in older adults
- ->Deprescribing: a structured process of reducing medication burden and harm while improving quality of life
- Simplify medications to reduce pill burden and polypharmacy
265
OT role in Safe Medication Use
- Identify polypharmacy in older adults and those at risk of medication related ADRs
- Recognize that ADRs may have a negative effect on a client's ability to achieve OT treatment goals
- As part of functional assessment ask client's what a typical day looks like for them with regards to organizing and managing medications
- Advocate for clients to promote and educate on medication adherence and the use of adherence tools
- Encourage clients to keep an up-to-date list of medications and bring it to all medications appointments
- Work with the interdisciplinary team to ensure medications are taken in a safe and effective manner
- Liaise with the patient's physician pharmacist as required
266
Mild Cognitive Impairment (MCI)
| Grey zone between normal aging and early dementia
- cognitive impairment greater than expected for their age
- Functioning independently
- Do not meet the commonly accepted criteria for dementia Diagnosis
- Lack of consensus
- MoCA
- 26/30 - high false positive
- 23/30 - overall more accurate
267
Prevalence and incidence of MCI
- 10% of Canadians >65 yr have some form of MCI - often undetected
- Study of cognitively normal persons, aged 70-89 years, followed for a median of 3.4 years
- ->Incidence of MCI was 6.36^
- ->men (7.24%) vs women (5.73%)
- ->< or equal 12 years of education: two times higher than those with .12 years of education
- ->Rate of conversion from MCI to dementia ranges from 10%-16% per year
268
MCI subtypes
4 subtypes
- single domain, memory type
- single domain, non-memory type
- multi-domain, including memory domain
- multi-domain without memory involvement
-Amnestic MCI = memory involvement
269
Mild Cognitive Impairment
```
Cognitive complaint
-not normal for age
not demented
-Cognitive decline
-Essential normal functional activities
```
MCI
Memory impairment
Yes Amnestic MCI
Memory impairment only
Yes -->Amnestic MCI Single domain
NO --> Amnestic MCI Multiple Domain
No Non-Anestic MCI
Single non-memory cognitive Impairment
Yes -->Non-Amnestic MCI single Domain
NON-Amnestic MCI Multiple Domain
270
Interventions For MCI
-Neuroplasticity in MCI
--> preserved abilities to learn new information and adapt behaviours
Cognitive Reserve
-->Existence of brain mechanisms able to cope with cerebral damage by using pre-existing or compensatory cognitive processes
-associated with educational level, occupational attainment, premorbid IQ, leisure, and cognitively and mentally stimulating activities
-People with high cognitive reserve reduced risk of developing dementia compared to individuals with low cognitive reserve
Use of internal and external strategies
--> need to establish the best paths for clients to adapt to external aids to increase continued use
-Individual goal-oriented rehabilitation appears promising
-Aerobic exercise
271
Dementia Prevalence
2013-2014 data:
- 402000 older adults were living with dementia in Canada
- 7.1% of all people 65 and older
- 2/3 were women
- Prevalence doubles every 5 years among older adults
- ->for less than 1% in those age 65 to 69 to about 25% in those age 85 and older
272
Type of Dementia
| Alzheimer's
History
-Gradual, progressive onset
Signs and Symptoms
- memory loss, especially for names and recent events
- Language deficits
- Rapid forgetting
- Impaired visuospatial skills
- Normal gait and neuro exam early
- Later affective disturbances; behavioural symptoms such as aggression
Pathology/Imaging
- Generalized atrophy (esp. medial temporal)
- Beta amyloid plaques
- Neurofibrillary tangles
273
Types of Dementia
| Vascular
History
-Abrupt or gradual onset
Signs and symptoms
- Focal neurological signs
- Signs of vascular disease
Pathology/Imaging
- strokes
- Lacunar infarcts
- White matter lesions
- Vulnerable to cerebrovascular events
274
Types of Dementia
| Lewy Body
History
-Insidious onset, progressive with fluctuations
Signs and symptoms
- fluctuating cognition
- Visual Hallucinations
- Neuroleptic sensitivity
- Shuffling gait
- Increased tone
- Tremors
- Falls
Pathology/Imaging
- Generalized atrophy
- Lewy bodies in cortex and midbrain
275
Types of Dementia
| Frontotemporal
History
-Insidious onset, typically in 50s-60s; rapid progression
Signs and symptoms
- Disinhibition
- Social inappropriate
- Behaviour
- Poor Judgement
- Apathy, decreased motivation
- Poor executive function
Pathology/Imaging
- Frontal and temporal Atrophy
- Pick cells and pick bodies in cortex
276
Differentiating the 3D's
Delirium, depression and dementia
- Differentiating among the three presents common and challenging diagnoses for older adults
- Presentations can be atypical
- Great deal of overlap exists between these syndromes
- All three can exist in the same patient at the same time
277
Delirium
Acute onset of altered level of consciousness, inattention, disorganized thinking, memory impairment, disorientation, and perceptual disturbances, often with fluctuations in symptoms
-Wide range of causes - often multifactorial
278
Delirium - Hyperactive form
Agitation, restlessness, irritability, combative outburst, and hallucinations that are often disturbing symptoms to the patient's family
279
Delirium Hypoactive form
-Somnolence, decreased vocalizations and motor activity, and cognitive detachment
280
Delirium Mixed
combination of hyperactive and hypoactive
281
Depression
- Older patients often deny feelings of depression or anxiety
- More likely to present with vague or nonspecific symptoms:
- ->pain, headache
- ->unintentional change in weight/appetite,
- ->chronic constipation
- ->irritability, agitation
- ->fatigue, insomnia, hypersomnia
- ->weakness
- ->decreased concentration and memory
282
Differentiation (3Ds)
- Sudden or gradual onset
- Pattern of cognitive deficits-altered attention, Confusion, mainly memory
- Potential for underlying medical complications - infection, medication related, substance abuse
283
Dementia: assessments
Screening: MMSE, MoCA, Clock Drawing Test
Cognitive Tests:
- Cognistat
- CAMCOG
- Cognitive Competency Test
- Domain specific test: memory attention, executive function
Structured observation:
- AMPS
- Cognitive Performance Test
Proxy Report
284
Interventions for Dementia
- Delaying or preventing the onset of dementia by 1 year could translate into 1 million fewer numbers of cases than predicted by the year 2050
- Ideally, the prevention of disease and promotion of health should target individuals who are not symptomatic
- The field of cognitive aging is now moving toward identification of non-symptomatic individuals who have underlying AD pathology that can be detected by using biomarkers and neuroimaging technologies
285
Rehabilitation/Retraining
- Some promising evidence for clients in the early stages of dementia
- ->errorless learning
- ->emphasize procedural memory
- ->repetition and consistency - same cues and steps
- ---> One step commands
- ->collaborative goal setting - frequent reminders re goals and purpose
- ->positive feedback
286
Enabling Engagement
- check for comfort
- Promote control -offer limited choices
- "Just right Challenge"
- ->work with continuing abilities
- ->Fit with lifelong habits, roles, values
- Appropriate level of cueing/Assist with initiation as needed
- ->verbal, tactile, visual, demonstration, guidance
- Begin at a step where the person can succeed
- Minimize distraction; Allow time
- Repeat Instructions
- Adapt task/Environment
287
Adaptions of Environment And Activities
- Chose collaboration with caregivers
- Establish routines
- Visual cues: sticky notes, lay out clothes, tape barriers across doorways
288
Adaptions of Environment And Activities
- Chose collaboration with caregivers
- Establish routines
- Visual cues: sticky notes, lay out clothes, tape barriers across doorways
- Alert systems for falls or wandering
- Opportunity for engagement - social, places to "rummage"
289
Cognitive Stimulation
Cognitive stimulation offers a range of enjoyable activities providing stimulation for thinking, concentration and memory
-Usually in social setting, such as a small group.
Benefits for:
-Cognitive function remained at 1-3 months follow-up
-->self reported quality of life and well-being
-->staff ratings of communication and social interaction
-No differences in mood, activities of daily living, general behavioural function or problem behaviour
-Little evidence to support cognitive training and cognitive rehabilitation
290
Montessori Based Dementia Programs
-Use real life material
-Progress from simple to complex
-Organize material top to bottom, left to right
-Break down activities into component parts and practice one component at a time
-Activities are tailored to individual's physical and cognitive capacities
-Limited vocalization to demonstrate activities; make the activities and materials self-correcting
Outcomes: increased constructive engagement and positive affect were heightened; improved eating behaviour
291
Sensory Stimulation
| Snoezelen:
- May enhance exposure to a variety of sensory experiences
- May decrease incidences of BPSD (behavioral and psychological symptoms of dementia)
- May not be appropriate for clients who are agitated or experience challenges with attention
- Limited evidence
292
Sensory Stimulation
| Music Therapy
-May reduce depression
293
Dementia: Responsive Behaviours
- Difficult, challenging, or aggressive Behaviours
- Reframed as "responsive" - Response to distress
- Behavioural framework
- ->Take a breath, stop and think
- ->Path A - Objective examination of the problem: triggers, patterns disrupted routine
- ->Path B - examine own feelings (frustration, anger, fear)
- ->Path C - Examine multiple issues that may be contributing to the response
294
Path C: Examine multiple issues
| Physical Issues:
-Disease, pain/discomfort, fatigue, dehydration, medication issues, impaired motor skills, functional ability, diurnal rhythm disturbance
295
Path C: Examine multiple issues
| Psychological issues:
-Fear, depression, helplessness, threatened independence, anxiety, previous personality
296
Path C: Examine multiple issues
| Cognitive Issues:
-Difficulty processing information, inability to make choices/express views, confusion
297
Path C: Examine multiple issues
| Physical/social environment issues
-Distractions, unfamiliar routine, inconsistency of tasks/caregivers
298
Intervention Approaches
- Calm approach, Listen to the client, empathize
- Maintain a trusting relationship
- Adress possible issues (e.g comfort, distractions, inconsistencies)
- Assist staff in care settings to know the person's life storey
- Communicate effectively (relevant information, simple steps)
- Avoid situations where reasoning is required
- Offer choices when possible (no more than two choices)
- If the client objects to a particular, procedure, reduce the amount of assistance offered
- Decrease challenging social situations
- Use distraction techniques e.g. look at pictures or out a window
299
Intervention Approaches
| Environment
- Use adequate lighting
- Provide a safe area for physical activity
- Reduce noise and clutter
- Providing rocking chairs (as a source to ease tension)
- Providing areas and corners that promote exploration and discovery as well as privacy
300
International working focusing on policy and legislative changes (he is worked in the United States)
-ADA
-21 st Century Technology Act
AODA
-Bill c-81: an assessable Canada Act
-Other legislative Changes
301
Hearing Loss in Canada
| Fastest growing disability
- 1 in 5 canadians experience report some degree of hearing loss
- As the population ages this is expected to grow
- Hearing loss in younger people is rapidly increasing
302
Challenges living with hearing
- Increased social isolation
- Increased risk for other conditions (diabetes, depression)
- Higher rate of unemployment
Impact of Covid-19 on people living with Hearing Loss
303
Adaptive technology - Personal
-Fm system ( hearing aid in his ear and a box around his chest)
-hearing aid (today becoming much smaller)
-text messaging
-cochlear implant (device you need surgery for) - you need to see if you can be a candidate not everyone can not get it
->-only 24 frequencies most people get thousands
-smaller fm system (one fm system can look like a pen)
-TTY text communication
-Side kick (instant message)
-Caption telephone (allows someone to call someone and an operator is listening and typing out the information.
-video phone, using sign language or an interpreter
-pocket talking
-vibrating alarm clock
-Just eat
-Grocery gateway
-uber
(don't have to go to a bank, call a taxi, or order dinner-really helps people with hearing loss )
304
Acoustic baffles and panels
in atrium to improve sound absorption
| and reduce reverberation resulting from the vaulted ceiling (no echoing)
305
Specialized loop systems
i reception desks on floor 1 and 3 to improve speech understanding. People who wear hearing aids with telecoils (T-coil) will hear receptionists directly and clearly, even if background noise is present
306
Natural Privacy glazing
allows natural light to fill space, but ensures facial expressions and sign language remain obscured to those outside of meeting room
307
High NRC (noise reduction coefficient) flooring and ceiling tiles
to reduce reverberation (echo) and improve sound absorption
308
Improved lighting
(25% brighter than standard office spaces) to facilitate face-to-face communication
309
Low electromagnetic interference dimmer switches
-allow for user preference on lighting and avoids interface to those wearing hearing aids with telecoils
310
Wider Corridors
- improved mobility access for those using wheelchairs or walkers
- Facilitate effective face-to-face communication required for lip/speech reading and observing facial expressions
- Facilitate effective sign language communication as hand and arm movements are unobstructed
311
State of the art soundproof sound suite
-Full assessment of hearing and speech understanding ability conducted in
312
Assistive listening system (loop system and sound field system)
Conference hall is equipped with this system for improving understanding in meeting
313
Conference Hall
- Large visual monitors to simultaneously project live captioning and interpreting during presentations
- Acoustically optimized walls and ceilings to reduce reverberation and negative effects from background noise
- High contrast colours between floors, baseboard and walls to help those with visual challenges to identify space changes in environment
314
Under sink clearance and touch faucet
for improved mobility access
315
Low vision
-Visual impairment that is not corrected by standard eye glasses, or medical or surgical treatment and affects one's functional ability
316
The "low Vision Problem"
- Prevalence of low vision will double in 20 years
- Vulnerable sub-population
- ->Diabetic, current smokers, memory problems, lower income
- ->isolated (45% of SELHIN rural)
- ->Higher risk patients:
- -->2x risk of falls, 4x risk of hip fractures
- -->3x risk of depression
- -->3 years earlier in long term care facilities
- ->multiple co-morbidities
317
Three main types of interventions for low-vision
- Medical
- Surgical
- Rehabilitation
318
Vision Rehabilitation Medicine Objective:
-Reduce the functional impact of a visual impairment so that independence, productive activity and life satisfaction can be maintained
319
Low Vision Rehabilitation (multidisciplinary Approach)
- Optometry
- NFPO: CNIB - Vision loss rehab
- Opticianry
- Social Work/Counsellors
- Orient and Mobility
- Low vision Specialists
- Occupational Therapy
- Ophthalmology
320
Rehabilitation plan for low vision
- independent living skills
- Orientation and mobility
- Training and education
- Counselling and technology
- Assistive devices
- Community engagement
- Self-management strategies
321
characterizing vision
- Visual Acuity
- Contrast Sensitivity
- Visual field
322
Visual Acuity
- Visual Acuity is a measure of visual angle
- 100% contrast
Visual acuity refers to your ability to discern the shapes and details of the things you see
323
Visual Fields
- A measure of functional loss
| - Scotoma = "localized field deficit"
324
Microperimetry
| measures
1. Fixation stability
- How much your eyes move when you look at things
2. evaluates the Preferred Retinal Locus (PRL)
- The area of retina that is used to look at things when central vision is no longer an option
3. Characterizes scotomas
- Blind spots
325
Common Causes of vision loss in older adults
- Diabetic Retinopathy
- Age Related Macular Degeneration
- Glaucoma
- Stroke
326
Mr Brown:
20/40 visual acuity (ETDRS)
Early Treatment Diabetic Retinopathy Study.
contrast sensitivity - moderate decreased
Visual field -Central Relative Scotoma
Medical Management and Potential Rehab Strategies:
Medical management:
- smoking cessation
- Multivitamin
- Cholesterol/HTN optimization
- UV protection
Rehab strategies:
- Improved task lighting - temperature, Luminance
- Enhance contrast - computer, video magnifier
- Minimal magnification
327
Ms. Silva
Visual Acuity: 20/210 OU (ETDRS) Oculus Uterque.
Contrast Sensitivity -significant decrease
Visual -visual field:
-Preferred Retinal Locus: Superonasal, bordering region of geographic atrophy
-Perimetry: -Absolute Central Scotoma
-Boarding region of depressed retinal sensitivity
Medical management:
- smoking cessation
- Multivitamin
- Cholesterol/HTN optimization
- UV protection
- Anti-VEGF therapy
Rehab strategies:
- Adaptive skills and techniques
- Optimal/digital magnification
- Advanced technology
- ID cane
328
```
Mr. Carp
diabetes
Visual Acuity: 20/60 (ETDRS)
Contrast Sensitivity -moderate decrease
Visual -visual field:
-Preferred Retinal Locus: Foveal
-Perimetry: Minimal central depression
```
Medical management:
- System Glucose control
- Intraocular injections: Anti-VEGF, Steroid
- Laser
- Surgery
Rehab strategies:
- Magnification (ex. optical/digital, smart phone) -training with accessible features on smartphone
- Contrast
329
Ms Marchenko -glaucoma
-lol reported 3 times: They took my drivers license. Can you get it back for me?
-I also can't read, I bumped into things, I've had many falls etc....
Visual Acuity: 20/20 (ETDRS)
Contrast Sensitivity -normal
Visual -visual field:
-Preferred Retinal Locus: Foveal
-Perimetry: *Bilateral constricted fields within 5 degrees
Medical management:
- Reverse telescopes/prisms
- Minimal magnification
- Adaptive skills and techniques
- O and M
Rehab strategies:
- OCR
- Audio books
- Audible device (watch)
- Voice-over features on smart device
- O and M (orientation and mobility)
330
Glaucoma
| Treatment Options
- Drops to decrease production, increase outflow
- Laser to increase outflow
- Surgery to increase outflow
331
Orientation and mobility
- Scanning techniques
- Using auditory cues
- Training on long cane
- Taught be o and M specialist at vision Loss rehab ontario, CNIB
332
Stroke
| Patterns of Vision loss
- Right homonymous hemianopia
- Macula Sparing LHH
- Macula Involved Watershed
- Right Superior Quadrantanopia
333
mr. Berger (stroke)
-Difficulty reading
-bumping into door frames
acuity pretty normal (20/25)
normal contrast sensitivity
Visual field - only seeing left side
rehabilitation strategies
1. Optical (prisms): improve visual perception by distorting or replacing part of the intact visual field
- Gotlieb lens
- Chadwick Lens
- Pelli Lens
2) Eye Movement Therapy
- Scotoma awareness
- Structured "scanning" training
3. Other reading strategies
- Ruler/line guide (LHH)
- Voluntary saccades (RHH)
- Vertical/angled text
- Scrolling text
4. Orientation and mobility techniques
334
Summary of low vision
- Location and extent of pathology along visual pathway will dictate:
1) Visual function
2) Functional Deficit
-Rehabilitation strategies reflect type and extent of functional deficit
335
Mr. Jones
-Diabetic Retinopathy
-Vision: moderate vision loss
-Contrast sensitivity: significantly diminished
-Microperimetry: moderate fixation stability, ring scotoma
Reading: moderate CPS (critical print size)
-minimal reserve
-right and left-sided errors
Luminance: high luminance improves low-contrast reading
```
Rehabilitation plan
american academy of Ophthalmology Low vision Guidelines suggests addressing the following five areas:
-reading
-Safety
-ADLs/IADLs
-Participation
-Well-being
```
Identified areas of focus for Mr. Jones:
- reading
- Mobility
- Diabetes management
- Technology use
- Social Engagement/volunteering
336
Reading
| Visio Enhancement:
-Use lighting, magnification, contrast and visual skills as appropriate to read with modified independence
337
Reading
| Vision Substitution:
-Use Audio Books, OCR, software to listen to preferred reading material
338
Safety
-Fall prevention strategies:
Strategies to manage:
- ->medications
- ->personal health
- ->food preparation
- ->cell phone use
- Orientation and mobility training to navigate in the surrounding environment
339
Instrumental Activities of Daily Living
- Computer accessibility
- Communication ex. cell phone, computer
- Watch TV
- Cooking
- Shopping
- Financial management
- Glare Management strategies
340
Participation
- Participate in community/social/leisure activities
- Make use of transportation resources
- Explore employment/volunteer opportunities
341
Well-Being
- Support groups
- Social worker
- Counselling
- Supporting participation and engagement in meaningful activities
342
Assistive Technology Specialists
assess and determines the configuration of hardware and software that best matches an individual’s functional vision, lifestyle, environment, and access needs. Assistive Technology Specialists also inform individuals of available funding and resources, and authorize and/or support applications to relevant funding (e.g. Ontario’s Assistive Devices Program).
343
Certified low Vision Therapists (CLVT; also known as Low vision Specialists [LVS])
use functional vision evaluation instruments to assess visual acuity, visual fields, contrast sensitivity function, other components of functional vision as required (e.g., color vision, stereopsis, visual-perceptual and visual-motor function), and reading and writing skills as they relate to vision impairment and disability. CLVTs educate individuals about their eye condition and vision health, which enhances motivation for change. CLVTs consider physical, psychosocial, and environmental factors to help engage individuals in skills training and ultimately, more positive outcomes. The overall goal is to promote optimal use of the individual's functional vision, to determine the optical vision aids and techniques that best match the individual’s identified goals and sight enhancement needs. CLVTs also provide assistance with accessing any available funding for required devices.
344
Certified Orientation and Mobility Specialists (SOMS or O and M)
provide instruction to help develop or relearn the skills and concepts to travel safely and independently within the home and in the community. O&M Specialists provide services across the life span, teaching infants and children in pre-school and school programs, as well as adults in a variety of community-based and rehabilitation settings.
345
Certified Vision Rehabilitation Therapists (CVRTs; also known as Independent Living Skills Specialists [ILS]),
provide instruction in the essentials skills for daily living and support in adjustment to vision loss, with an emphasis on maintaining independence and autonomy while being supported throughout the vision loss process. Training covers a range of skills – from safe and effective methods of cooking to adapted techniques for doing household tasks like laundry, banking and personal care. CVRTs teach individuals to use accessible technology (e.g., screen magnification or screen reading software, smartphones and mobile devices) to read and write, access library services, and complete other tasks (e.g., identifying items). They also teach individuals to read and write Braille, when identified as necessary by the Specialist.
346
Early Intervention Specialists
provide family-centred support for families of children with visual impairment, birth to school age, and other team members. Early Intervention Specialists provide opportunities for learning by promoting optimal use of a child’s functional vision and other senses in a variety of activities and settings, and ensuring the environment, materials and adult interactions are accessible.
347
(Low Vision) Ophthalmologists
are doctors of medicine who specializes in the diagnosis and treatment (both medical and surgical) of eye disorders, as well as diagnosing systemic diseases that manifest in eye. Ophthalmologists sub-specializing in low vision rehabilitation perform low vision assessments to characterize individuals’ remaining vision and visual function and develop rehabilitation plans based on identified safety risks and individuals’ goals.
348
Occupational Therapists (OTs)
enable participation and engagement in meaningful occupations. Depending on the area of practice, OTs use various assessment (e.g., performance measures, task analysis, etc.) and intervention approaches (e.g., self-management, problem solving, assistive devices, environmental modification, coaching, etc.). Vision rehabilitation is an emerging area of practice for OTs in most provinces. Our OT collaborates with individuals at intake to identify performance issues and develop a preliminary rehabilitation plan that guides them to the most appropriate services at the right time and place. This may include facilitating collaboration between SOVRS and other key members within the circle of care (e.g., Care Coordinators). As SOVRS evolves, the resources and programming to support system navigation will continue to grow to meet the unique needs of individuals across the SE LHIN.
349
Aging with disability
- growing with longer-standing, early-onset disabilities (such as intellectual disability, spinal cord injury, stroke)
- Due to improvements in the medical care and rehabilitation individuals with physical disabilities acquired in early adulthood are now living a near normal life expectancy.
350
People aging with disability face unique stressors:
- Body systems age faster than in the non-disabled peers leading to faster and more severe onset of health of health conditions
- These secondary conditions can have profound negative effects on the quality of life and participation
351
Aging with Disability
| Considerations
- Experience living with disability
- Ability to adjust to changing needs and have these needs met
- Availability of supports
- ->aging caregiver
- ->Changes in social supports
352
Aging with SCI (the videos of the two men in wheelchairs)
What stood out for you related to occupational performance and engagement?
What are some considerations for health promotion as a person with SCI ages?
- two men had different opinions
- things to notice
- one was prepared for the future, thinking about long-term care because he knows his wife will not be able to support him long-term and getting comfortable with that fact and transitions.
- Where the other one did not want to switch to a power wheelchair it took calling the fire department multiple times in order for him to let go of his dignity and transition to a power wheelchair
353
Preparing before going to do a home assessment the types of questions you should think about
-What questions do I have about the case?
What do I want to know more about before my first visit?
How can I prepare for my visit?
What resources can you access?
354
(intellectual or developmental disability)
| -Significant limitations in cognitive functioning and/or adaptive functioning, which:
a) originated before 18 years of age
b) are likely to be lifelong
c) Affects areas of major life activity, such as personal care, language skills or learning abilities, the capacity to live independently as an adult
355
Intellectual functioning of IDD
85% mild
10% moderate
4% severe
1% profound
356
Adaptive functioning with a mild intellectual functioning
- likely had learning problems in school
- might have problems holding a full-time job without supports; might need income supports if low-skill jobs are scarce
- Can usually manage personal care with minimal support
- Often can use a mobile phone and text messaging
- Might need help to manage finances and schedules
- Limited ability to understand abstract ideas and make general claims based on particular instances
- Typically has capability to make familiar health care decisions independently, possibly with accomodations
357
Communication with a mild intellectual disability
verbal and knows more words than just those used in their daily lives. Have also learned vocabulary from other sources (e.g. reading, school, TV). More than just a functional vocabulary.
- Uses a variety of sentence types (simple to complex) and communication opinions, ideas, new, events, aspirations.
- Might have significant difficulties in expressing ideas and feelings in words
- Use language to initiate and interact
- Conversational difficulties might exist
- Ability to understand and use abstract language but might have difficulty describing events in sequence
- Can usually follow meaningful, simple 3-step commands
358
Health service Context
| timeline
1876-first institution is opened in ontario
1960-more than 10,000 people living with IDD are living in institutions
1970-disability activists call for community integration
1981-Federal government promotes deinstitutionalization
1987-Ontario commits to close 16 institutions in 25 years
2009-final 3 institutions close
2014- 14,300 people with IDD on residential waitlist in ontario
359
Health service use (IDD)
- 30-day repeat Emergency department visits (nearly 2X higher)
- 30 day repeat hospitalization (3 times higher )
- Alternative level of care (6 .5 times higher)
- Long-term care (17.5 times higher)
- Premature mortality (4 times higher)
360
Aging with IDD
aging population with IDD who are living longer
| -many with chronic complex disabilities, and high levels of frailty
361
Aging Cargivers
- due to death, ill health, or increasingly complex needs of their aging adult child
- Parents of individuals with IDD spend more time caregiving per week than any other informal caregivers in Canada
362
Vision (aging with IDD)
- Glaucoma = cloudy looking eyes
- Macular degeneration -= biotchy circles in the middle of eye; these can cause headaches, pain and nausea-look for signs
- Decreased peripheral vision
- Decreased night time vision
- Eyes can become more dry and itchy
363
Brain changes (aging with IDD)
- Dementia: gradual personality changes, forgetfulness, mixing up people, losing abilities, language losing abilities, language loss
- Delirium: sudden changes; risks are higher
- Depression: rates are higher
364
Hearing (aging with IDD)
- Wax build up is more common
| - May have harder time locating noises
365
Bowels and Bladder (aging with IDD)
- Harder to hold urine for longer periods of time
- As metabolism slows, constipation increases
- May los control of bladder and bowels more easily
366
Bones and Joints (aging with IDD)
- bones become more brittle, increasing the risk of fracture. If people have previous fractures, they may have pain
- Arthritis is common as joints lose lubrication
- Balance troubles are common.
367
Feet (aging with IDD)
-It can be harder to clean and care for feet. Skin can also become dry. Aside from being painful, any blisters, sharp toenails, or wounds to the feet can cause a person to walk off balance. This increases the risk for a fall
368
Lung (aging with IDD)
- Swallowing difficulties lead to high rates of aspiration (when food/saliva/vomit gets caught in the lungs).
- Diseases in the lungs are common cause of death
- Lung capacity and function decreases, making it harder to do activities
- More rest may be needed
369
Prevalence of falls in adults with IDD
- People with IDD experience similar rate of falls as older adults in the wider population but at a younger age.
- 25-40% of adults with IDD who live in the community experience at least one fall in 12 month period
- Falls are one of the most common causes of injury in this population
- Gap: Despite the serious problem of falls in this population of IDD there has been no investment to date in developing falls prevention strategies and interventions
370
Fall cycle
- Fall
- Participation Restriction for Safety
- Decline Balance, Strength
- Increasing immobility and need for increased support
- Early admission to care facilities
371
Service Gaps (working with IDD)
Stressed and fragmented residential service system
- ->long waitlists
- ->inappropriate placements in long-term care
Limited options for families and professionals
- ->as needs increase, services from both the MOHLTC (e.g. home care, LTC) and the MCCSS (e.g., group home, case management) may be required and overlap
- Significant barriers in accessing health services, including palliative care services
- Predicting the need for palliative care can be particularly challenging
- May either delay a move and/or force quick decisions and abrupts relocations
372
The nuts and bolts of healthcare
health care information and resources on health care conditions that commonly affect people with IDD
373
The OT roles with working with people with IDD
- Identify and implement aging in place supports
- Functional assessment
- Home safety
- Mobility and fall risk
- Engagement in meaningful activities
- Community safety and engagement
- Caregiver support and training
- Sensory Processing and Self-regulation
- Assistance with transition to residential care (if needed)
374
The OT roles with working with people with IDD
| diagram
- Professional
- Communicator
- Scholarly Practitioner
- Collaborator
- Change Agent (47%)
- Expert in Enabling Occupation
375
Continued inattention to adults with IDD in occupational therapy is not only a missed opportunity for the profession, but an inadvertent perpetuation of their marginalization
-As a profession who distinct value is to enhance health and quality of life through participation in occupations, occupational therapists have a professional responsibility to address the needs of adults with IDD to ensure their connections with and participation and inclusion in the fabric of everyday life
376
Considerations for assessment (individuals with IDD)
- limited available standardized measures for adults with IDD
- When assessing consider:
- Consent
- Multiple assessments (consider frequency and duration)
- Occupation-based assessments
- Ecologically relevant contexts
- Involving caregivers (with consent)
- Including client and caregivers in goal setting
- Creating structure and reviewing plans
- Offering choices
- Communication approaches
377
Communicate Care- care is her acronym ( individuals with IDD)
- Communicate Clearly (using accessible communication aids if needed)
- Attentively listen and observe (+ comprehension checks and give more time)
- Responsively address concerns
- Engage the client and others as needed
Reflect in and on action
378
International Consensus Statement
-Person-centred approach + aging in place is a priority
379
Considerations for intervention
1. Frailty must be considered earlier than in general population
2. Improvement and maintenance are visible goals
- Intersectoral collaboration is needed to coordinate comprehensive, multidisciplinary assessments and actions
4. Safety is a priority
5. Planning for the future is important
6. Informal and formal caregivers also have needs
7. Evidence must be grown
380
Common OT interventions
1. Environmental Adaptations
2. Adaptive equipment
3. Task analysis and modification
4. Skill-building
5. Client and caregiver education
6. Functional Mobility
381
Approaching an intervention
| -think about
- context
- timing
- level of support needed
- Individual vs group
- Accessible communication strategies
- Environmental cues
382
Summary (adults with IDD)
- Adults with IDD are living with more complexities and experience cognitive decline and frailty at a younger age
- Life transitions require different/greater supports as periods of change that are among the most challenging for people with IDD and their caregivers
- Health checks, monitoring/screening and communication tools used within the application of the H.E.L.P framework, support crucial assessments, referrals and care planning
- OTs are well positioned to support individuals with IDD as they are
383
Retirement
- Retirement can have a profound impact on a person's life
- Work provides
- ->identity
- ->financial benefits
- ->structure
- ->social networks
- Retirement can have both positive and negative impacts
384
Canadian stats (retirement)
- Average age of retirement 64.3
- Avergae CPP retirement pension = $8, 303 per year (2018)
- Maximum Old Age security pensions = $7,075 per year
- Average household expenditures (65 and older) = 58,121 (survey of household spending 2016)
385
Retirement
| -Occupational transition
- three phases
- ->preparation
- ->worker to retiree transition
- Adjustment to retirement
- Patterns
- ->complete cessation of work
- ->gradual
- ->intermittent
386
Potential (OT role in retirement)
- Enabling identification of interests and activities
- Promoting Implementation of meaningful occupations
- Assisting in time use planning and restructuring
- Supporting, planning and building of occupational identities through meaningful creative occupations
- Improving understanding of role changes in retirement
- Facilitating understanding of emotional, social and financial impacts on self and others
387
Transition to supported or long-term Care
- Giving up one's home to move into a supported care environment is a major life transition
- Often promoted by health problems
- Challenges or the new environment
- Discontinuity with previous environment
- Changes to occupation
- ->role loss and taking on new, less valued roles
- With Western cultures, being cared for by other is less valued than being able to maintain levels of performance
388
Facilitating transition
| -Indicators of successful adaptation to long-term care
- ->having one's care needs met
- ->developing a sense of identity
- ->having social connections
- ->experiencing continuity of lifestyle
- Maintaining a sense of control over one's life.
389
Facilitating transition - possessions
| Our possessions support occupational performance by:
- Providing opportunities for being in control
- -> choosin what to have in our immediate surroundings, and where things should be placed
- ->controlling the use and care of our pressessions
- ->Serving as reminders of valued roles
- ->providing evidence of friendships
- ->promoting memories of significant events
Possessions can give us a sense of "who we are, where we have come from and where we are going", and serve as a statement of our enduring identity
390
End of life Care
- Each year 180,000 Canadians need end-of-life care
- Each death affects the immediate well-being of an average of five other people, or over one million Canadians
- All people of all ages in Canada have the right to quality end-of-life care that allows them to die:
- ->with dignity
- ->free of pain
- ->surrounded by their loved ones in a setting of their choice
391
End of Life Care - Definition
| Likely to die within the next 12 months
- death is imminent (expected within a few hours)
- Advanced, progressive, incurable condition
- general frailty and coexisting conditions that mean they are expected to die within 12 months
- existing condition if they are at risk of dying from a sudden acute crisis in their condition
- life threatening acute conditions caused by sudden catastrophic events
392
Advanced care planning
| Determination of directives for future care in anticipation of future loss of mental capacity.
-If the person has mental capacity, their current wishes override any prior wishes they have have started
393
Advanced care planning
| Advanced decisions to refuse treatment (ADRTs) are legally binding
-if the person loses mental capacity and the ADRT is valid and applicable to the current situation
394
Advanced care planning
| Statements of wishes are not legally binding
-Provide a guide to the person's priorities and preferences if they are too unwell to discuss or have lost mental capacity
395
Medical Assistance in dying (maid)
Legal medical treatment in 2016-bill c-14
- Assistant should be available to a competent adult where:
- ->the person affected clearly consents to the termination of life
- ->the person has a grievous and irremediable medical condition that causes enduring suffering that is intolerable to the individual in the circumstances of his/her condition
Excludes
1. Mature minors (youth under 18 yrs)
2. Consent to MAID via advance request or directives
3. The sole underlying medical condition is a mental disorder
396
Medical assitance in dying
- All patients interested in seeking MAID are eligible to receive an assessment
- Eligibility is decided on a case by case basis
- Must be a voluntary request
- Person must provide informed consent to MAID even after being made aware of other means available to relieve their suffering including palliative care
397
MAID requirements
- written request that is signed and dated after the person has been informed that they have a grievous and irremediable medical condition
- Signature must be witnessed by two independent witnesses
- Two independent medical assessors must affirm that the person is eligible
- The assessor and provider must believe that the person has capacity
- Person must be given opportunity to withdraw the request during the assessment and before MAID is provided
- Mandatory 10 clear day waiting period between the time the written signed request is made and the provision of MAID - can be expedited
398
End of Life Care - Goals
- Relieve pain and suffering
- Provide comfort
- Maintain or improve safety
- Prevent injuries
- Control client's symptoms
- Client accepts death and acknowledges limits of curative medicine
- Enhance quality of life
399
Hospice Care
- Focuses on palliation of chronically ill, terminally ill or seriously ill patient's pain and symptoms
- Attends to client's emotional and spiritual needs
- Places or programs to meet the needs of dying patients
- Assists to control chronic pain
- Allows a person to die a simple death
- Gives people love, care and comfort
400
OT Role in End of Life Care
- Promote participation in meaningful occupations over the course of disease progression
- Promote adaptation and coping with the challenges associated with life-limiting illness by reframing occupational goals and expectations
- Support capacity to attend to affairs and the development of legacy
- Assist with management of symptoms such as fatigue, breathlessness and pain through assessment, education, counselling, task design an equipment prescription
401
OT Role in End of Life Care
- Provide support to the person to remain in/return to the place of care of their choice
- -Assessment and promotion of the person's ability to manage safely within their own home.
- ->targeted interventions, such as education and environmental modifications, address identified goals and plan for future needs
- Provide support, education and training to informal caregivers to reduce risk of injury, negative experiences and complex bereavement
402
Recommendations to Promote OT Role in End of Life Care
- Continue to develop partnerships with relevant organizations and stakeholders -->promote access to end-of-life care -->promote quality of life and meaningful occupations
- Promote the development of research among stakeholders to provide the best practices in end-of-life care
403
Diverse Perspectives (LGBTQ2S)
- don't make assumptions -take time to find out
- ask them their pronouns
- Call out your colleagues
- very diverse experiences are not identical
404
Social and Cultural Dimensions
non-compliant (not doing what the recommendations)
- ->sometimes people have a bad day and don't want to complete their exercises
- Try making a. connection with them (even if its small)
- valuable to take a couple of minutes out of your day to figure out why they are having a hard day
- ->grief can cause physical pain
- cree are more patient and subtle
