Exam II Flashcards
Cognitive aging is what kind of lifelong process?
Developmental, occurring from birth to death
Cognitive aging occurs within a frame work of what?
Gains, declines, and stability
Cognitive aging is impacted by what?
Diet, exercise, health habits, and education
What are other factors that affect cognition?
-Neurobiological influences (related to disease process, sensory systems, auditory/visual systems)
-Affective influences (anxiety, fatigue, pain, depression)
Sensory processes
Transmits stimuli from environment to neutral structures, older age declines auditory and visual processing
Perception
Assign meaning to stimuli, older adults utilize situational context and experience to maintain perceptual abilities necessary to function
Sustained attention
Direct to single task, no change comparing younger to older adults
Selective attention
Direct to a task while simultaneously using resources to ignore distracting info, probably no age change
Alternating attention
Switching between two or more tasks, older adults have more difficulty
Divided attention
Allocate attentional resources to two or more tasks at the same time, declines with age
Types of memory
Sensory, short-term, working, long-term
MOST decline with age!!
Sensory memory
Stores incoming info for a very short time
Short-term memory
15-20 seconds stored without rehearsal
Working memory
Stores, maintains, actively manipulates information
Long-term memory (2 kinds)
Declarative- verbal based memory
Semantic- general world knowledge not linked to a specific learning episode
Procedural (non-declarative) memory
-Stores information for motor based skills and behaviors
-Well preserved in later life
Prospective memory
Remember future oriented or scheduled tasks without the use of external memory aids
Executive functioning
-Reasoning, decision making, problem solving, judgement, abstract thought, and logic
-SIGNIFICANT differences from younger to older as task complexity increases as additional cognitive resources are needed
Problem-solving
Older adults tend to use less efficient strategies, persist longer in using erroneous solutions, and produce more errors
Everyday cognition
Utilize cognitive processes in real world contexts, fewer age related differences
Language production and speech comprehension
Older adults OUTPERFORM younger in message production and discourse- like storytelling
Expertise
-High level of skill/knowledge in one area – problem solving, reasoning, memory
-Maintains in later life and helps compensate for other deficits
Implicit processing
-Unintentional, occurs with awareness, effortful- requires moderate to substantial cognitive resources
-Minimal age young to old
Explicit processing
-Intentional, occurs with awareness, effortful – requires moderate to substantial cognitive resources
-Some age related decline in skill
Intellectual abilities (2 types)
-Fluid intelligence – ability to use abstract reasoning, flexibly shift mental set (decline begins around age 70)
-Crystallized intelligence- accumulation of knowledge, experience, acculturation (increases throughout life and maintains in old age)
How do we optimize cognition in later life?
-Physical activity (aerobic, strengthening, balance, and flexibility)
-Mentally stimulating activities
-Social engagement
Benefits of physical activity
Increased cerebral flow, increased neural growth hormone, increased insulin-resistant growth factor, increased brain volume
Benefits of mentally stimulating activities
-Novel and mentally challenging to promote neural growth, development, and plasticity
-Building cognitive reserve reduces chance that ADLs will surpass available resources
Benefits of social engagement
-Promote connectedness by maintaining social contacts and participating in social activities
-Social isolation and lack of perceived support has a detrimental effect on psychological well-being
Mild Cognitive Impairment (MCI)
-The changes in memory and other areas of cognitive function that may be seen in healthy older adults of at least average intellectual functioning
-Not a strong impact on ADLs, IADLs, or leisure
Dementia demographics
4.3% of adults age 70-74 diagnosed with dementia
47.5% of adults over 90 diagnosed with dementia
What is the most common form of dementia?
Alzheimer’s disease (5.2 million living with AD data from 2014)
What are the characteristics of dementia?
-Cannot meet everyday demands of life
-Affects cognition, behavior, and occupational performance
-Irreversible and often progressive
-Memory loss not always first sign
(T/F) Is dementia the inevitable part of aging?
False
(T/F) Dementia is an acquired, persistent impairment in multiple areas of intellectual functioning due to delirium.
False- NOT due to delirium
What is the impact of dementia on behavior and occupational performance?
-Deterioration in their day to day functioning, ability to engage in meaningful occupations decreases
-Safety becomes a concern, increase in need for assistance, support, or supervision
What impact does dementia have on family?
-Informal caregivers have an increase in stress as well as an impact on physical, mental, and emotional well-being
-Financial situations
What are some reasons individuals with dementia are admitted to long term care?
Need skilled care, deterioration of caregiver health, dysregulation and psychotic behaviors/symptoms
Delirium definition
Alteration of mental status characterized by an inability to appreciate and respond normally to the environment
Difference between delirium and dementia
Delirium is often reversible, viewed as a medical problem that can be diagnosed and treated
Delirium makes up ___% of all dementias, ___% are not reversible
13%, 87%
Causes of delirium
-Thyroid disorders
-UTI
-Electrolyte imbalances
-Hormonal imbalances
-Normal Pressure Hydrocephalus (NPH)
-Tumors
-Stroke
-Intoxication
-Withdrawal from substances
-Depression
-Systemic illness
-End stage liver disease
While delirium makes up 13% of all dementias, what are types that make up the remaining 87%?
-Alzheimer’d disease
-Vascular dementia
-Frontal-temporal dementia
-Lewy-body dementia
-Korsakoff’s syndrome
-Huntington’s disease
-AIDS related
-Parkinson’s with dementia
-Multiple sclerosis
Cause of vascular dementia (VaD)
-Strokes or other vascular disorders that decrease blood flow to the brain
-Single brain infarct or multiple lesions
Can a person have VaD and AD? (mixed)
Yes
Subcortical ischemic vascular dementia (SIVD)
Numerous discrete subcortical lesions
Vascular cognitive impairment (VCI)
-Cognitive changes that occur due to vascular lesions
-Can be treated and doesn’t always turn into VaD
-Recognition of VCI may allow for early diagnosis to avoid progressive cog impairment to dementia
Dysexecutive syndrome
-Hallmark of VCI and VaD
-Problems with attention, working memory, planning, and sequencing
Who is at risk for VCI or VaD?
10-30% of all dementias
Advanced age, male, history of stroke, hypertension
Cause of dementia with Lewy bodies (DLB)
Presence of leeway bodies, damaged nerve cells, amyloid and plaque formation similar to AD
What are Lewy bodies?
Clumps of abnormal protein particles
Hallmark- round neurofilament inclusion bodies
Core features of DLB
-Hallucinations (recurrent and well formed)
-Parkinsonian symptoms (gait, tremors, rigidity, bradykinesia)
-Cognitive fluctuations (prominent attention deficits)
-Progressively worsens
-Cognitive features preceded Parkinsonian features (motor)
With DLB what becomes apparent over time?
Memory impairment
More prominent features of DLB
Deficits on attention, visuospatial and executive function
How is clinical diagnosis strengthened for DLB?
-Repeated falls
-Nonvisual hallucinations
-Delusions
-Fainting
-Transient losses of consciousness
Who is most likely to be diagnosed with DLB?
Men over 65 2x more like
DLB is ___% of all dementias
14-20%
Frontotemporal dementia (FTD) age onset
57 years
Range 51-63
Symptoms of FTD
-Gradual but prominent changes in personality
-Behavioral disturbances and changes in how they interact socially
-Can fail to demonstrate basic emotions
-Neglect personal hygiene or dress inappropriately
-Loss of insight and difficulty planning, problem solving
-Little initiation, lack of spontaneity, difficulty regulating behaviors
(T/F) FTD is not a common dementia
False- most common after AD and DLB
(T/F) Patients with FTD have better cued recall and recognition than patients with AD
True
When does dementia typically develop in patients with Parkinson’s?
-Slowly, roughly 10 years after Parkinson’s diagnosis, cognitive skills diminish first
What is the distinguishing feature between PDD and DLB?
Time sequence of symptoms
Parkinson’s disease with dementia (PDD) cognitive impairments
-Global, attention
-Executive function
-Poor performance on speed tests
-Difficulty initiating
-Decreased tasks requiring delayed recall
-Semantic knowledge
-Frontal executive functions
-Speech/language/visiospatial functions
-Difficulty with specific areas of memory
-Changes in executive function (planning, initiation, organization, memory retrieval)
Alzheimer’s disease (AD)
Intellectual impairment/behavior and personality
Irreversible and progressive
Risk factor for AD
Advancing age, serious head injury with loss of consciousness. genetic factors
Diagnosis of AD
Must demonstrate a decline in three or more of the following
-Memory
-Language
-Perception (especially visuospatial)
-Praxis
-Calculations
-Conceptual or Semantic Knowledge
-Executive Functions
-Personality or social behavior
-Emotional awareness or expression
Is memory impairment a required symptoms for diagnosis of AD?
No
Pathology of AD
-Neuritic plaques and neurofibrillary tangles in neocortex and hippocampus of the brain (seen on autopsy) can see shrinkage in brain
-Neurotransmitter deficits primarily in the cholinergic and noradrenergic and serotonergic systems are also evident
-7-20 year course
What happens over time to the brains of patients with AD?
The brain shrinks
Important AD facts
-AD is highly associated with aging, but not income
-Doesn’t discriminate
-Most of the AD population is female
-The elderly population with AD is less educated than the general elderly population
-51% of nursing home residents suffer from dementia, 1/3 have AD
What is the scale used to assess functional abilities in a patient diagnosed with AD?
Functional Assessment Scale (FAST)
Stage 1 of FAST
No difficulty either subjectively or objectively
Stage 2 of FAST
-Complaints of forgetting location of objects
-Subjective work difficulties
Stage 3 of FAST
-Decreased job functioning evident to co-workers
-Difficulty in traveling to new locations
-Decreased organizational capacity
State 4 of FAST
-Decreased ability to perform complex tasks
Stage 5 of FAST
-Requires assistance in choosing proper clothing to wear for day, season, or occasion
Stage 6 of FAST
-Occasionally or more frequently over the past weeks for the following:
A. Improperly putting on clothes w/out assistance or cueing
B. Unable to bathe properly
C. Inability to handle mechanics of toileting
D. Urinary incontinence
E. Fecal incontinence
Stage 7 of FAST
A. Ability to speak limited to approx. less than or equal to 6 intelligible different words in course of average day or in intensive interview
B. Speech ability is limited to use of single intelligible word in an average day or in intensive interview
C. Ambulatory ability is lost
D. Can’t sit up w/out assistance
E. Loss of ability to smile
F. Loss of ability to hold up head independently
Neuromuscular changes with age
-Decrease in muscle strength and power
-Decrease in skeletal muscle mass
-Decrease in number of functional motor units
-Changes in postural alignment
-Bone and cartilage changes
-Changes in balance and gait
-Decrease in max speed of movement and initiation in response to stimuli
-Increase in threshold for vibration sensation (decreased sensitivity)
-Decrease in proprioception
Continuum of functioning
Physically elite, physically fit, physically independent, physically frail, physically dependent
Physically elite
Train on a regular basis in sports competitions, continue to work in demanding occupation
Physically fit
May still work, may participate in activities with folks younger than them, continue to exercise regularly
Physically independent
Participates in IADLs and is still active in leisure and hobbies. May have one+ chronic conditions, function independently
Physically frail
Lives independently with some assist, may be unable to engage in some IADLs
Physically dependent
Cannot perform some ADL/IADL, requires institutional care or full-time assistance
Definition of strength
Force of muscle contractions and ability to generate force quickly
Definition of power
Timing and coordination
Why do strength and power decrease with aging?
-Decrease in number and diameter in myofibrils and certain types of muscle fibers
-Neurological changes that control muscle contraction
What changes occur in strength with aging?
-Minor until age 60, then becomes more rapid
-Isometric & Concentric strength in UE declines less than LE
What changes occur in power with aging?
-Decreases more quickly than strength
-10% greater rate of decrease than strength
-Example of functional activity that requires power is walking or standing up from a chair – timing and coordination of that muscle contraction
What contributes to slowness and incoordination of muscle contractions?
Age related changes in muscle composition
Sarcopenia
Progressive muscle wasting and decrease in strength with aging
Changes in muscle with aging
Less elasticity, more fat, neurological changes, atrophy of some fibers, hypertrophy of others, number of myofibrils
Difference between muscle atrophy and sarcopenia
-Sarcopenia – age related
-Atrophy – shrinking
Difference between muscle atrophy and sarcopenia
-Sarcopenia – age related
-Atrophy – shrinking
What reduces the tension a contracting muscle can generate?
The loss of muscle tissue in combination with decline in skeletal muscle fiber
Physical function
Strength+power+endurance+coordination+balance+flexibility
What are some ways loss of strength affects the physical function of older adults?
-Raking, snowblowing, stairs, get out of bed, cross a street, exit a car, climb stairs etc – all take power and strength
-Reduced ability to balance with decreased base of support and recover from postural perturbation
-Walking speed slowed, stride length decreased
Why are impairments in muscle power more influential than decreased strength on an older adult’s ADL function and mobility?
Decreases more quickly, standing or getting up from a chair requires muscle power…lose ability to do simple movements
What has decreased LE muscle power been correlated with?
Getting out of chairs, stairs
Impaired balance leads to…
More disability…risk increases when combined with muscle weakness
Age related changes to bones
-Loss of bone density
-More susceptible to fracture
Age related changes to the cartilage, joints, and tendons
-Cartilage is more dense, stiff, thins out, deteriorates
-Joints and tendons: tighter, less flexible, has profound effect on ROM
-Matrices of collagen become denser, the collagen structures become stiffer, and the cellular movement of nutrients and wastes becomes impaired
ROM decreases ___% between ages of ___
20-30%, ages 30-70
Osteocytes
Cells in mineralized bone, direct remodeling when fatigue damage and changes in mechanical environment are detected
Osteoblasts
Cells responsible for bone formation
Osteoclasts
Cells responsible for bone resorption
Nonmodifiable factors that contribute to bone health
-Age
-Cellular regulation and vitality
-Gender
-Ethnicity
Modifiable factors that contribute to bone health
-Nutrition
-Exercise
-Body weight
-Hormones
The rate at which bone is lost may be reduced by targeting these factors
(T/F) As elastin decreases, elasticity of the tissue is increased
False- elasticity also decreases
The cartilage in what kind of joints thins and deteriorates the most?
Weight bearing joints
What contributes to joint stiffness?
-Decreased water content
-Decreased hydration
-Decreased elasticity of the joint capsule
-Increased fibrous growth
Functional consequences of connective tissue changes
-Loss of flexibility/increased stiffness
-Loss of ROM
-Associated loss of IADL, ADL, and mobility
-Increase in fall risk
Postural changes/alignment with age
-Flexed posture becomes more common
-Thoracic Hyperkyphosis with a forward head position is typical
-Many older adults develop an altered lordotic curve (flattened or exaggerated), rounded shoulders, and flexed hips and knees
Causes for postural alignment changes
-Muscle weakness
-Decreased ROM
-Loss of spinal flexibility
-Vertebral compression fractures
Age related changes to the nervous system
-Cerebral atrophy
-Increased cerebrospinal fluid space
-Specific neuronal loss
-Reduced dendritic branching
-Increased lipofuscin granules
-Decreased effectiveness of neurotransmitter systems
-Reduced cerebral blood flow
-Diminished glucose utilization
Lipofuscin granules
Considered to be one of the aging or “wear-and-tear” pigments, found in the liver, kidney, heart muscle, retina, adrenals, nerve cells, and ganglion cells
Lipofuscin granules
Considered to be one of the aging or “wear-and-tear” pigments, found in the liver, kidney, heart muscle, retina, adrenals, nerve cells, and ganglion cells
Causes of age-related changes to the nervous system
-Biochemical and morphological changes in the neurons and receptors
-Loss of neurons
-Defects in neuronal transport mechanisms
-Decreases in myelin
-Gradual decreases in the conduction velocity of nerves
-Defects in protein synthesis
-Cumulative trauma
-Oxidative stress and vascular changes
Functional consequences of age-related changes to the nervous system
-Altered gait
-Increased fall risk
-Impaired sensation
-Consequences are highly individual, with some having significant NS changes without associated functional deficits.
Balance, coordination, movement, and function age related changes
-Slowing of eye–hand coordination
-Decreases in interlimb coordination
-Decreases in homolateral hand and foot movements
-Decreases in motor coordination
-Decreases in manual dexterity
Typical changes in gait
-Decreased step length
-Decreased stride length
-Slower walking velocity
-Decreased cadence
-Decreased ankle range of motion
-Decreased push-off with the toes
-Increased double-stance time
-Decreased vertical displacement of center of mass
Assessment of ROM, flexibility, strength & power
-Goniometry
-Observation, especially of specific functional actions
-“Sit-and-reach test” or “back-scratch test”
-Manual muscle test
-“Break” test
-Dynamometer
Break test
Break testing in manual muscle testing, is when resistance is applied to the body part at the end of the available range of motion. It’s called the break test because when a therapist provides resistance the objective for the patient is to not allow the therapist to “break” the muscle hold.
Back scratch test: equipment
Ruler or yardstick
Back scratch test: pre-test
Explain the test procedures to the subject. Perform screening of health risks and obtain informed consent. Perform an appropriate warm-up
Back scratch test: procedure
- Standing position.
- Place one hand behind the head and back over the shoulder, and reach as far as possible down the middle of your back, your palm touching your body and the fingers directed downwards.
- Place the other arm behind your back, palm facing outward and fingers upward and reach up as far as possible attempting to touch or overlap the middle fingers of both hands.
- An assistant is required to direct the subject so that the fingers are aligned, and to measure the distance between the tips of the middle fingers.
If the fingertips touch then the score is zero. If they do not touch, measure the distance between the finger tips (a negative score), if they overlap, measure by how much (a positive score). Practice two times, and then test two times. Stop the test if the subject experiences pain.
Back scratch test: scoring
Record the best score to the nearest centimeter or 1/2 inch. The higher the score the better the result.
Back scratch test: scoring
Record the best score to the nearest centimeter or 1/2 inch. The higher the score the better the result.
Precautions with assessing elders
-Caution regarding osteoporosis, potential for fracture
-Concern about standing endurance/balance
-Avoid valsalva maneuver because of possible cardiovascular problems.
Precautions with assessing elders
-Caution regarding osteoporosis, potential for fracture
-Concern about standing endurance/balance
-Avoid valsalva maneuver because of possible cardiovascular problems.
Management of neuromuscular impairments
Exercise that is tailored to the individual’s goals and needs
Facilitated by self-efficacy and outcome expectations
Barriers to treatment plans for managing impairments
-Fear of falling or injury
-Lack of time
-Lack of social support
-Lack of a physical space to exercise or transportation to the exercise site
-Insufficient resources to either buy exercise equipment or join an exercise facility
Components to include in an exercise plan
Strength and resistance
Flexibility and balance
Strength and resistance components for an exercise plan
-Requires careful monitoring
-Demonstrated to be effective in increasing strength and endurance
-Isometric, isotonic, and isokinetic muscle all shown to be effective
-Simple interventions like walking are effective
Flexibility and balance components for an exercise plan
-Static
-Ballistic
-Proprioceptive neuromuscular facilitation
-Dynamic
-Include a variety of elements
-Provide adequate challenge
What is the most common type of joint disease among older adults and is also a leading cause of disability?
Osteoarthritis (OA)
Cause of OA
Unknown, but related to wear and tear on joints
Nonmodifiable risk factors for OA
Age and family history
Modifiable risk factors for OA
-Obesity
-Physical occupations
-Participation in contact sports
Most common OA sites
-Hip
-Knee
-Spine
-Metatarsophalangeal joint of big toe
-Carpometacarpal joint of thumb
-Interphalangeal joints fingers
Ways to manage OA
Address modifiable risk factors (weight, activity)
Strength training
Medications (analgesics, anti-inflammatories)
Joint replacement
Osteoporosis
Compromised bone density predisposing to risk of fragility fracture
Common fracture sites for osteoporosis
Vertebrae, hip, and wrist
Increased mortality risk following fracture
Management of osteoporosis
-Multicomponent exercise program (resistance and balance training)
-Consultation with PT to ensure precautions are followed
Most common type of amputation
Lower limb, most frequent in older individuals
Greatest risk factor for amputations
Long-term diabetes
Other risks for amputations
Peripheral vascular disease, trauma, cancer
Post amputation difficulties
All aspects of life, psychosocial issues, bereavement
Management of amputations
Team approach
Goals- pain management, return to function, psychosocial issues, reducing risk of recurrence
Interventions- exercise, pain management, functional interventions, psychotherapy
Parkinson’s disease
Progressive, age-related neurodegenerative disease
Cause/characterization of PD
Unknown cause
Characterized by voluntary and involuntary movement dysfunction, resting tremor and rigidity (difficulty in initiating motion)
Nonmotor symptoms of PD
Pain, depression, anxiety, apathy, fatigue, memory impairments, sleep disturbances, and autonomic dysfunction
Management of PD
-Pharmacological (Levodopa)—and/or Deep Brain Stimulation (DBS), thalamotomy, or pallidotomy
-Rehabilitation by both PT (focused on movement strategies) and OT (focused on function)
-Assistive devices
Management of PD
-Pharmacological (Levodopa)—and/or Deep Brain Stimulation (DBS), thalamotomy, or pallidotomy
-Rehabilitation by both PT (focused on movement strategies) and OT (focused on function)
-Assistive devices
Definition of a fall
Any unplanned descent
Event that results in a person coming to rest inadvertently on the ground or floor or other lower level (bed, chair) with or without injury
About __/__ of adults will fall each year
1/3
Outcomes of suffering a fall
High personal and societal costs
Function, quality of life, cost of care
Where do most falls occur
In the home (bedroom and bathroom)
Most common among people living in long term care or during hospital stay
What season are falls most common
Winter
Consequences of falls
About ¼ of falls result in injury
Many people never fully recover to pre-fall functional status
Most common injuries:
-Bruises, contusions, lacerations
-Sprains
-Fractures of pelvis, hip, UE, distal radius, spine, skull, ankle
Death
Consequences of falls
About ¼ of falls result in injury
Many people never fully recover to pre-fall functional status
Most common injuries:
-Bruises, contusions, lacerations
-Sprains
-Fractures of pelvis, hip, UE, distal radius, spine, skull, ankle
Death
Intrinsic risk factors for falls
Internal to older adults such as medical conditions
Extrinsic risk factors for falls
External, environmental, such as slippery floor
Fear of falling
-May be present regardless of whether or not the person has fallen
-Results in anxiety and self restricting activity, diminished quality of life
-May lead to deconditioning which increases fall risk
Fall risk and fall prevention: assessment
Screening :
Previous falls, physical activity, difficulty walking and doing daily activities.
Assessment :
Subjective (e.g., medical and fall history, medications) and objective (e.g., mental status, s strength and balance) measures.
Fall risk and fall prevention: intervention
Process includes:
Identification
Assessment
Management
Implementation
Monitor and review
Fall prevention education has been found to be effective.
Multifactorial interventions are most successful.
Types of intervention: exercise (resistance and balance) and functional interventions (AT, ADL, gait and balance)
Fear of falling interventions
-Improve balance
-Improve muscle strength
-Eliminate environmental hazards using a room-by-room checklist, outside the home or facility (sidewalks, public areas)
-Education and counseling
-Behavioral modification
Global interventions
Environmental
-Assess community risks (e.g., uneven sidewalks)
-Work to remediate these risks
Reduce other risk factors
-Minimize waking up during the night to urinate
-Address postural hypotension
-Manage medications
Goal of rehabilitation
To provide people with the tools they need to attain the highest possible level of independence
Keys to successful rehab
A broad perspective
Accurate identification and management of
-Medical
-Social
-Psychological problems
-Occupational performance
-Physical functioning issues
A thorough understanding of the differences between “normal aging” and pathological changes
An understanding of how these “normal aging” and pathological changes interact with the disablement process.
Relationship of age and disability
Disabilities may be relatively minor, they may be limiting enough to cause older people to require assistance to attend to their personal needs
___% of those aged 70 and older, ___% of those aged 85 and older, have some sort of disability
20%, 50%
Definition of loss
Defined as irrevocable and can be any valued object—a loved person, a job, status, home, a cherished possession, and health.
What is our response to loss?
Grief is our response to loss and often includes the loss of the future as we expect it.
Losses can be…
Losses can be sudden, gradual, anticipated, temporary, or permanent.
Impact of trauma and illness
Loss of sense of self
Loss of connectedness that results from stigma and discrimination
Loss of power from the loss of one’s sense of agency and loss of belief in oneself
Loss of valued roles```````
(T/F) Helping the client process a loss should be focused on the process of healing as opposed to the outcome
True
Ways to help a client process loss
-Dialogue and relationship, discussing grief
-Focus on healing process
-Life review
-Confrontation of the nature of absence and emptiness
-Being present to what is experienced rather than the need for change
Individuals with intellectual disease
-Living longer and have same age-related changes
-Emphasize health promotion
Challenges for individuals living with intellectual disease
-May have had previous negative experience with care providers
-Parents may have been primary care providers and now themselves are aging or dead
Issues for individuals with serious mental illness
-Shorter life expectancy (problems with care access or worse health behaviors)
-Physical issues may be overlooked
Issues for individuals with long-standing physical disabilities
Musculoskeletal problems
Declining energy and strength
Osteoporosis
Stress
Higher levels of pain
Rehab team
Patient and family are essential team members
Multi, inter, and transdisciplinary
Multidisciplinary team
Discipline oriented, with each team member responsible for his or her own unique scope of practice, and the team’s outcome is the sum of each team member’s efforts
Interdisciplinary team
Involve team members in problem solving beyond the scope of their own discipline. The whole team identifies goals for the client; once identified, each team member then works toward goal attainment within their scope of practice
Transdisciplinary team
One team member is chosen to be the primary leader or therapist depending on the specific needs of the client
Benefits of team approach
Improved patient care and outcomes
Improved access to health care
Improved recruitment and retention of health providers
Improved communications among health providers
More efficient and effective employment of health human resources
Improved satisfaction among patients and health providers
Case management
A process comprising a culmination of consecutive collaborative phases that assist clients to access available and relevant resources necessary to attain identified goals
Key elements of case management
Client identification (screening)
Assessment
Stratifying risk
Planning
Implementation (care coordination)
Monitoring
Transitioning
Evaluation
Role of case manager
Facilitates communication between health care providers and ensures that services are not duplicated, while required services are provided, as a means to ensure that case management offers a practical, one-step approach to helping clients coordinate their care
Acute hospitalization setting
Associated with decrease in occupational performance
Disability/injury/illness that requires hospitalization for care
Transitional care facilities
Provide intermediate care or post-acute care
Day hospitals
Assessment, rehab, maintenance, provision of medical, nursing, and social services
Geriatric rehabilitation units (GRUs)
Distinct units housed within community hospitals,
Free-standing rehabilitation hospitals, or
Long-term care facilities
And are staffed by multidisciplinary teams specializing in the management of the medical, social, physical, psychological, and economic well-being of older adults
Geriatric assessment units (GAUs) and geriatric rehabilitation units (GRUs)
Both provide rehab with interdisciplinary team trained in care of the elderly
Attention to medical, psychosocial, and functional issues
Emphasis on medical tx and eval, short term goals
Other settings
Home health
Outpatient/ambulatory care
Respite care
Palliative care
Evaluation (comprehensive geriatric assessment)
Multidimensional, interdisciplinary process that is used to determine an elderly person’s medical, psychosocial, functional, and environmental needs, resources, and problems, and is linked with an overall plan for management and follow-up
Factors that may affect rehab
Personal:
Age
Frailty
Motivation
Depression
Cognitive status
Comorbidities
Environmental:
Family members/caregivers
Living arrangements
Therapist/client relationship
Patient-Driven Payment Model (PDPM)
New payment system for all skilled nursing facilities
-Supports and promotes patient-focused care as the most appropriate way to pay for services
-Based care on unique goals and needs of each patient
(T/F) Medicare limits the amount of therapy Medicare beneficiaries can receive
False- it is not limited and your therapist’s judgement is the key factor in determining the amount of therapy that is received
There are computer programs that predict the amount of therapy needed but these should not be relied on for care
Medicare view on treating cognitive issues
Medicare refers to state law and scope of practice of the treating clinician- therapy can be provided as long as the therapist addresses issues within their scope of practice
(T/F) Medicare does not require patients to receive group therapy in an SNF setting
True- Medicare expects that the needs of the patient are met and therapist implements the most effective interventions to drive the decision of using individual, concurrent, or group tx
Medicare coverage for maintenance therapy
Medicare will pay for services designed to improve or maintain function of patient, improvement or progress is not required
(T/F) Medicare does not pay for therapy for certain diagnoses
False- certain diagnoses trigger additional payments for therapy, but Medicare requires SNFs to provide all medically necessary services regardless of diagnosis
SNF care
Health care given when you need skilled nursing or therapy staff to treat, manage, observe, and evaluate your care
Does Medicare cover custodial care if its the only kind of care you need?
No
Time length of benefit period staying in an SNF
100 days
Medicare coverage- short term care
-For days 1–20, Medicare pays the full cost for covered services. You pay nothing.
-For days 21–100, Medicare pays all but a daily coinsurance for covered services. You pay a daily coinsurance.
-For days beyond 100, Medicare pays nothing. You pay the full cost for covered services. The coinsurance is up to $170.50 per day in 2019. It can change each year
Medicare coverage- long term care
Medicare and most health insurance, including Medicare Supplement Insurance (Medigap), don’t pay for long-term care. This type of care (also called “custodial care” or “long-term services and supports”) includes medical and non-medical care for people who have a chronic illness or disability
Why would someone need skilled nursing or therapy care?
Help improve your condition.
Maintain your current condition, or prevent or delay it from getting worse
Medicaid
A joint federal and state program that helps with medical costs for some people with limited incomes and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid
Original Medicare
Fee-for-service health plan that has 2 parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles)
Medicare Part A
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care
Medicare Advantage Plan (Part C)
A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits
Medicare Advantage Plans
Include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan, and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage
Medicare Preferred Provider Organization (PPO) Plan
A type of Medicare Advantage Plan (Part C) available in some areas of the country in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost
Medicare Private Fee-for-Service (PFFS) Plan
A type of Medicare Advantage Plan (Part C) in which you can generally go to any doctor or hospital you could go to if you had Original Medicare, if the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you may pay when you get care. You must follow the plan rules carefully when you go for health care services.
Medigap Policy
Medicare Supplement Insurance sold by private insurance companies to fill “gaps” in Original Medicare coverage
Benefit period
The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services.
You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods
Coinsurance
An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Usually a percentage
Custodial care
Non-skilled personal care, like help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom.
In most cases, Medicare doesn’t pay for custodial care.
DICE
Describe, Investigate, Create, and Evaluate
Nonpharmalogic management of neuropsychiatric symptoms
Describe
Caregiver describes the problematic behavior. (Context, Social/Physical Environment, Patient perspective, Degree of distress to caregiver and patient)
Investigate
Possible causes of problematic behavior: Patient – side effects of meds, pain, functional limitations, medical conditions, psych comorbidity, severe cognitive impairment/executive dysfunction, poor sleep hygiene, sensory changes, fear, loss of control, boredom.
Create
Provider, caregiver, and team collaborate to create and implement treatment plan. Respond to physical problems, Strategize behavioral interventions. Provide caregiver education/support, enhance communication with patient, create meaningful activities for patient, simplifying tasks, ensuring a safe environment, increase/decrease stimulation in environment.
Evaluate
evaluate if the CREATE interventions have been implemented by caregiver, if they are safe and effective
