Introduction to working with older adults

Question 1

Are older adults working longer than they use to? What percent age 65+ male and females are still working?

Answer 1

Yes
2022: 24% male and 15% female ages 65+ still working

Question 2

Why has the poverty rate in older adults dropped from 30% in 1960 to 10% now?

Answer 2

Medicare played big role in this drop in poverty rate

More older adults can meet daily care needs​

Aging in place better, fewer living in ALFs/SNFs

Question 3

Trends in aging population?

Answer 3

Life expectancy: dropped after Covid-19 by 2.4 years, rebound to 77.5 in 2022​

Alarming increase in obesity: 22% in 1988-1994 to 40% in 2015-2018​

Wide economic disparities with Latino and African-American populations twice as likely to live in poverty vs non-Hispanic whites​

More older adults are divorced and more women living alone​

Caregiving gap, especially for lower-income groups and those with dementia

Question 4

Trends in disease and disability?

Answer 4

79% of people 70 and older have one or more of 7 chronic conditions:​

Arthritis​

High blood pressure​

Diabetes​

Lung Disease​

Stroke​

Cancer​

In those 65 and older, 30% have 3 or more chronic conditions 🡪medically complex patients​

Dementia adds to the complexity!

Question 5

There is some stigma surrounding aging, what is ageism?

Answer 5

Ageism: discrimination against older people because of negative and inaccurate stereotypes​

Message: Being old is something to avoid!

Societal beliefs and attitudes about aging and older adults dominated by narrow and negative stereotypes of how older adults should behave, what they should look like, and expectations of aging​

Example: poor health is inevitable

Older individuals may avoid healthcare or have abnormal stress responses due to stereotypes/bad experiences related to society/healthcare

Question 6

Describe age friendly health systems

Answer 6

The Age-Friendly Health Systems vision is that every older adult in every health care encounter receives evidence-based, age-friendly care that focuses on what matters most to them​

AFHS uses a framework called the 4Ms to guide care of older adults at any point in the healthcare system​

Not a program but rather a shift in how we provide care to older adults

Question 7

What are the 4 Ms of the 4Ms framework?

Answer 7

what matters, medication, mentation, and mobility

Question 8

Describe tailoring care to “what matters” to older adults

Answer 8

Person-centered care seeks to understand and act on what matters most to older adults​

Understand the context of a person’s life and awareness of their personalized health preferences and goals​

Prioritizing what matters especially those with multiple chronic diseases can reduce fragmented or unwanted care​

People have differing ideas about what they consider important to them and about their treatment

Allows patients to advocate for themselves

Healthcare professionals should act on this by including what matters to patient in goal-orientated plan

Question 9

Some conversation considerations for “what matters”?

Answer 9

Cognition: Consider the impact of cognitive status on the patient’s ability to make decisions​

Engage directly with patient even in cases of dementia​

If patient relies on someone else for decision-making, know who that person is​

Health status: Goals and preference likely change with changing health status​

Healthy, independent versus heavy disease burden, functional disabilities​

Identity: Race, ethnicity, language, religion, and other identities impact the view of health, illness, and preferences/willingness to engage in What Matters conversations​

Clinicians may express unconscious biases that can alienate patients

Question 10

Describe medications in context of 4M framework

Answer 10

Avoidance of high-risk medications when possible​

When medications necessary, ensure what matters, mentation, and mobility are not negatively affected by medication​

Regular screening for the 7 medications: benzos, opioids, anticholinergics, sedatives/sleep medications, muscle relaxants, TCAs, antipsychotics​

Polypharmacy associated with negative clinical outcomes including AEs, DDIs, medication non-adherence, reduced functional capacity, multiple geriatric syndromes, higher costs​

DDIs is 50% for those taking 5-9 medications​

DDIs is 100% for those taking 20+ meds​

Almost 10% of ED visits due to drug Aes​

Can lead to decreased functional abilities

Question 11

What are some screening tools used for older adults to ensure proper medications are being taken?

Answer 11

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults​

medications that are potentially harmful to older adults and should be avoided​

these medications have directly led to adverse health outcomes, from falls and delirium to, in severe cases, mortality​

STOPP/START criteria have also been utilized as a powerful tool for preventing inappropriate prescribing​

Screening tool of older person’s potentially inappropriate prescriptions (STOPP) ​

Screening tool of alert doctors to the right treatment (START) ​

Essential to ensure that older adults and their family caregivers are aware of and avoid high-risk medications​

When clinically appropriate, medications are safely deprescribed through dose reduction and discontinuation

Question 12

What is mentation within the 4M framework?

Answer 12

Can we reduce the risk of dementia?​

Older adults who experience depression are at twice the risk for developing cognitive impairment​

Increased physical activity is also a modifiable risk factor for cognitive impairment ​

Cognitive screening recommended once/year: Mini-Cog, SLUMS, MoCA, MMSE​

Positive screens warrant referral for further evaluation by neurologist​

“Clinicians and caregivers are often uninformed in regard to dementia identification and care”​

Proper education of family/caregivers on different rehab strategies can result in positive impacts for older adults with dementia​

Strategies for addressing cognitive impairment: ​

managing symptoms, monitoring progression, and making medication decisions ​

refer the older adult, family, and/or other caregivers to supportive resources, such as the Alzheimer’s Association

Question 13

Relationship between depression and older adults?

Answer 13

Depression​

Not a normal part of aging but common in older adults​

Many medical conditions contribute to depression​

Can be mistaken for dementia or co-exist with dementia​

Negatively affects PT outcomes​

Exercise/activity can reduce depressive symptoms (aerobic ex consistently recommended)​

Suicide​

17th leading cause of death in 65+ ​

More successful with attempts​

PTs need to recognize risk factors and inquire about mental health

Question 14

What are 4 screening tools recommended for depression in older adults?

Answer 14

Evidence supports using one of the following four screening tools: Patient Health Questionnaire2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), Geriatric Depression Scale (GDS), and Geriatric Depression Scale - short form (GDS - 15)

Question 15

What are some factors that may contribute to depressive symptoms ?

Answer 15

sensory limitations (vision and hearing) ​

social isolation ​

losses associated with aging (job, income, and societal roles) ​

loneliness​

bereavement

Question 16

Mentation: Delirium

Answer 16

Prevention, rapid identification, and management of delirium are critical aspects for optimal mental health​

AFHS recommends screening at least every 12 hours, and more often as indicated, when an older adult is in the hospital ​

Older adults with dementia are at increased risk for delirium and worse outcomes

Question 17

What re the 6 risk factors for delirium?

Answer 17

-Dehydration: ​
Ensure oral hydration​

What about swallowing impairments?​

-Cognitive impairment​

Delirium accelerates any pre-existing cognitive loss​

-Sleep deprivation​
Too much stimulus interrupts sleep​

Using earplugs has been shown to delay onset of delirium​

-Immobility​

Lack of OOB time contributes to delirium​

Promote early mobility protocols​

-Visual impairment​

Use patient’s glasses​

-Hearing impairment​

Use hearing aids, if available​

Find other means of communicating (written)

​

Question 18

What are some ways to help a patient with delirium?

Answer 18

Use a calendar and clock in the individual’s room to help orient them to the correct time and day​

Use lighting to orient individual to the time of day: avoid dark rooms during the daytime​

Raise window shades, use room lighting​

”All About Me” board​

Shows preferences​

What makes the individual calm and happy​

Who is important to them​

Pharmacological treatment of delirium is not associated with improved outcomes

Question 19

Describe the mobility aspect of 4M framework

Answer 19

Screening for safe mobility is a requirement for ensuring that older adults are receiving age-friendly care

Assess and manage impairments that reduce mobility, such as pain; impairments in strength, balance, or gait; and high-risk medications

Question 20

How to promote safety and reduce fall risk?

Answer 20

Create safe environment​

Checklist for Safety (CDC)​

Identify daily mobility goals that support what matters​

Use a multifactorial fall prevention protocol (STEADI)​

Avoid restraints in hospital settings​

Avoid high risk medications​

Manage impairments that reduce mobility (pain, balance, gait, and strength)