Midterm flashcards

Question

How Experiences/ Personal Characteristics affect ageing

Answer 1

``` Genetics Personality traits Personal attitudes Self-esteem Protective Factors ```

Answer 2

Expectations “Appropriate” functions Value of the individual

Answer 3

Current attitudes | Can views be changed?

Answer 4

UK: more time volunteering, less time working and slightly less sleeping, more self-care/grooming US: less time volunteering, more time working and slightly more sleeping, less self-care/grooming

Answer 5

Definition: unable to do what is necessary/meaningful in his/her life due to external restrictions For what reasons may older adults be vulnerable to occupational deprivation? Lack of opportunities to engage in occupation have negative consequences

Answer 6

Retirement, loss of spouse, loss of job, role as grandparent, caregiver to spouse, late life relocation, health issues (chronic or acute)

Answer 7

Losing meaningful occupations; lack of resources in retirement Might have caregiving roles Establish routine when they retire, plan for retirement; successful transition to retirement; positive outlook

Answer 8

``` Gender Grief Health repercussions Social participation Practice implications ``` 50% woman experience loss of a spouse; experience it more often over the age of 80 Grief: 10-20% chronic experience with grief; other health repercussions; further lack of social participation Informal social participation; fiends, family, neighbors; buffers them from negative outcomes of grief and widowhood Higher informal participation more common in widows rather than those not widows also compared to widowed men Helping clients who have recently suffered a loss to regain social participation

Answer 9

Process differs from relocations in earlier life Health repercussions Control Practice implications More family involvement as compared to early life re-location Making sure to anticipate these conversations that involve relocation, instead of springing it all of a sudden Societal Norms--> Community based services --> Informal Support Systems -->Physical Environment --> Individual Characteristics --> Residential Move Decision

Answer 10

Definition: giving them a say in their health needs; being recognized and promoting people’s abilities to meet their own needs, solve their own problems, mobilize the necessary resources to in control of their life Older adults are one of the most disempowered groups Care model vs. Empowerment model Contributing factors to disempowerment Empowerment model; giving them the control of their care needs Why they might be disempowered 1) Poverty; health needs; 2)not one single heterogeneous group; not all the same, 3) health costs are affected that service providers know that population of older adults is rising, 4) negative stereotypes that society has about older adults

Answer 11

What role does OT play in assisting with life and role transitions and empowerment of older adults? Given the assigned LR chapter, what are possible strategies/activities to use to achieve the goal of, “Describe occupation and make explicit the relationship of occupation to health”? Making sure they are able to maintain heir occupations; how does aging affect occupation; how is their current occupation compared to how their aging and how it influences them

Answer 12

wear and tear theory (including free radical theory) lifespan development theory selective optimization with compensation theory life course perspective continuity theory

Answer 13

``` Biological: Wear and Tear Stochastic Developmental-Genetic Cellular Aging Evolutionary Neuropsychological ```

Answer 14

``` Psychological Life-Span Development Selective Optimization w/Compensation Socioemotional Selectivity Cognition and Aging Personality and Aging ```

Answer 15

``` Sociological Life Course Continuity Theory of Aging Social Exchange Social Constructionist Feminist Political Economy of Aging Critical Perspectives of Aging ```

Answer 16

Address aging processes at the organism, molecular, and cellular levels There is not measureable indictor that someone is aging!! Free Radical Theory when cells and tissues wear down Free radical theory: how cell damage occurs by free radicals; trying to illustrate that damage accumulates over time; eventually leads to cells stop functioning; antioxidants Use fireplace analogy; embers/sparks are free radicals and carpet is the tissue that gets worn down

Answer 17

``` Pollution Metabolism Inflammation Smoking Ionizing Radiation UV light ```

Answer 18

Seek to explain the multiple changes in the individual behavior in the middle and later years of the life span; boundaries addressed are amorphous

Answer 19

Ontogenetic development is biologically and socio-culturally constructed Potential for development is present from infancy >> old age No age or stage is supreme Events at each stage affect future development Development becomes less plastic and opportunities for change are more limited Ontogeny: dev. of embryo to adulthood: birth to death Socially and culturally impacted from birth to death Very distinctly differences; no indiv the same Interrelated lifespan trends contribute to human development: Evolutionary selection benefits decrease Need for cultural resources increases Efficacy of cultural resources decreases The older the person gets, the less natural selection will help them With age, the protective benefits of aging is not as strong; the more we need culture based resources; more practice to maintain the same amount of learning Resources may become les effective for them; increases with age; but also experiencing some other chronic condition

Answer 20

the development of an individual organism or anatomical or behavioral feature from the earliest stage to maturity.

Answer 21

Considered a Life-span Development Theory Fundamental mechanisms: Selection Optimization Compensation Manage the dynamics between gains and losses as one grows older in order to successfully age As one gets older, there are more restrictions in older adults lives, can no longer do what they used to be able to do or prioritize; avoid certain activities due to health status Selection; Loss of hearing may restrict their activity selection Optimization: how to allocate resources for the activities they choose, how do you invest add’l resources? Plan more activities etc; keeping in mind age-related changes in the body: ex: church, but they can no longer drive Compensation: use of alternative methods to be able to achieve the activities they want to achieve; choosing a goal; assistive devices or tech; ex: losing their eyesight but they love the choir, cannot read music; compensate to use ones with braille on it

Answer 22

Consider the context in which aging occurs and the demands of the activities and the environments

Answer 23

To understand older people now, you need to know their past Emphasizes social and cultural factors (at macro>>micro levels) that might influence the aging experience over time Pathways between life phases and circumstances in early life affect later life health Cohort effects, contextual factors that influence them

Answer 24

Trajectories – stable patterns of behavior of health across time Transition; changes in social roles or responsibilities; Retirement Turning point; grad school; life takes a diff direction; changes in ongoing social role trajectories Contextual influences: life history events; safety of neighborhood; health policies; race/gender/SES (Spouse who has poor eating habits) Timing in lives – The interaction between age or stage of the life course and timing of event or transition Linked Lives - dependence of the development of one person on the presence, influence or development of another Adaptive strategies: conscious decisions that people make to improve their health or well-being or social norms that frame the way in which decisions are made to adapt to external changes

Answer 25

Past experiences, decisions, and behaviors form the foundation for the present and future Goal of adapting to changes is to maintain patterns of thought, activities, and habits Strategies used for adaptation come from past experiences (Teaching dance instead of participating in the occupation; diff means and strategy)

Answer 26

``` Nervous Cardiovascular Respiratory Endocrine Hematologic Immune Digestive Genitourinary Muskuloskeletal Integumentary Special senses ```

Answer 27

Changes Loss of neurons and myelin Frontal lobe atrophy Unbalanced neurotransmitters Cognitive changes Altered motor skills Diminished sensory input ``` Loss of neurons; AD, PD Loss of myelin Frontal lobe atrophy Reduced executive functioning Unbalanced neurotransmitters ```

Answer 28

Results Common diseases (e.g., Alzheimer’s) Reduced exec function; slowed reaction and mental processing Less stage 3 and 4 sleep Motor skill changes; motor and postural, gait, shorter more hesitant gait Diminished sensory input; body in space; Slower fine motor and postural reflexes Shorter, hesitant gait Lower proprioception, vestibular sensation, and kinesthesia

Answer 29

``` Changes Increased adiposity Endocardium scarring Loss of autorhythmic cells Decreased cardiac output Decreased max heart rate Atherosclerosis Ulcerations ``` Less efficient nerve conduction Fatty plaques around arteries Postural hypotension; lightheaded standing up too fast Aneurysms: arteries leak or rupture

Answer 30

``` Results Hypertension Quickly tiring and SOB Postural/orthostatic hypotension Stroke, heart attack Aneurysms Peripheral vascular disease Thrombus ```

Answer 31

``` Changes Forced vital lung capacity decreases Lungs lose elastic recoil Loss of surface area of alveoli Stiffening rib cage Decrease O2 saturation ```

Answer 32

Results Decreased tolerance for PA Difficulty expanding rib cage, especially during PA Disease (COPD, emphysema, chronic bronchitis) Pneumonia

Answer 33

``` Changes Decreased efficiency of hormone release Decreased thyroid activity Decreased aldosterone Elevated cortisol response to stress Decreased insulin production; insulin resistance ```

Answer 34

Results Decreased cognitive function, strength, sexual function Reduced metabolic rate and mental alertness, subpar thermo-regulation, increased atherosclerosis Increased BP Hyperglycemia Immunosuppression Disease exacerbation (e.g., diabetes, HTN) NIDDM

Answer 35

Hemotologic Changes | Decreased erythropoiesis 2○ to disease

Answer 36

Results Anemia (hypoproliferative; ineffective erythropoiesis) Hypoproliferative: rate RBC is produced declines; possibly bleeding in digestive tracts Erythropoiesis: Vit B12 deficiency, dietary intake result

Answer 37

``` Immune Changes Decreased # T-cells Altered immune surveillance of cancer cells Slow destruction of thymus Increased autoantibodies ```

Answer 38

Results Infectious diseases Cancer Autoimmune disease

Answer 39

Changes Loosened, browned teeth Dry mouth Weakened structures e.g., tongue) and nerves Alterations in taste/smell Decreased gastric acid Decreased Vit D, B12, iron, and calcium absorption Increased bile in gallbladder Decreased liver detoxification efficiency Slowed motility in large intestine Sphincter weakening

Answer 40

``` Results Dysphagia; aspiration Decreased desire to eat Cognitive function, bone density, anemia Peptic ulcers; gastritis, stomach cancer Osteoporosis Gallstones; inflammation Medication overdose Lengthening of full sensation Inflammation of intestine; diverticulitis Constipation Fecal incontinence Colon cancer ```

Answer 41

Changes Less efficient functioning and loss of nephrons Diminished substance concentration regulation (e.g., Na) Weakened pelvic floor muscles and sphincters Decreased bladder capacity Enlarged prostate Reduced hormones Incontinence and sex affected by pelvic floor weakness

Answer 42

``` Results Proneness to renal failure Difficult to excrete drugs Increased BP Dehydration UTI/kidney damage Urinary incontinence Sexual dysfunction ``` Transient incontinence can be treated Established incontinence not cured but managed Established incontinence types: Overactive bladder Stress incontinence; sneezing; lifting heavy box; weakening sphincter Residual ? Functional incontinence: inability to go when you want to bc of another chronic condition (cant make it to bathroom in time bc of arthritis in hands makes it hard to unzip pants)

Answer 43

Changes *Often associated with females ``` Reduced bone density and mass Collapsing of vertebrae Decreased motor units Decreased number, size, and elasticity of skeletal muscle fibers Decreased synovial fluid Thinned cartilage ```

Answer 44

``` Results Prone to fractures Decreased height Kyphosis Slowed reaction time Decreased strength, endurance, and flexibility Reaction time; falls Might be more sedentary bc of fear ```

Answer 45

``` Changes Slowed skin cell turnover Less melanin Less collagen and elastin Decreased elasticity and hydration Blunted inflammation Subpar sweat gland function Decreased tactile sensitivity Decreased hair follicles and slowed growth Fat layer thinning of face, hands, and feet ``` Changes to the skin (layers and appearance) are the most visible signs of aging Epidermis: Slowed skin turnover rate: usually epidermis is replaced every 28 days but decreases by 30-50% b/w ages 20 and 70 Slower skin turnover, less melanin, and flatter basement membrane= prone to abrasions, bruises, and cancer Dermis: Collagen and elastin decreases = wrinkles and thinning skin Signs of inflammation are blunted = early warning signs of skin damage not obvious Subpar sweat gland function = overheating and heat stroke Decreased tactile sensitivity = increased pain threshold Hair follicles decrease, grow hair slower, and less melanin = thin, white hair that doesn’t protect scalp from sun Subcutaneous: Thinning of this fatty layer in the face, hands, and foot soles = exacerbate foot conditions ``` Higher pain tolerance Melanin reduces Skin cancer more likely Scalp damage Grabbing things may hurt more bc of thinning fat layer ```

Answer 46

``` Results Prone to abrasions, bruises, cancer Thinned skin Pigmentation changes Wrinkles Early signs of skin damage less obvious Thermoregulation issues and overheating Increased pain threshold Thin, white hair Foot conditions ``` Pressure ulcer prevention study Maintaining of core body temp; tend to be colder than everyone else

Answer 47

``` -Taste Changes Decreased taste buds and saliva -Smell Changes Decreased olfactory sensations (hyposmia) Altered mucosal linings and sensations -Touch Changes Decreased info processing ``` ``` Tasting salty (impaired), but can still taste sweet; tends to cause them to add more salt to food; increases hypertension or diabetes Proximity effects social connection; desire to touch or be touched ``` Hyposmia: smelling bad food

Answer 48

``` Results Difficulty differentiating food and taste intensity Dry mouth Decreased appetite; malnutrition Decreased hand function and strength ```

Answer 49

“Ageism is rooted in ‘deeply held human concerns and fears about the vulnerability inherent in the later years of life. Such feelings can translate into contempt and neglect.’” (Butler as cited in Klein & Liu, 2010, p344). ``` beliefs -- That they don’t do much Isolated, grumpy, paranoid about safety Stuck in their ways World is changing around them and they move with changes ```

Answer 50

“Ignoring Talk”: not addressing adult directly, team present “Task Talk”: forgetting about interpersonal comm. that needs to be happening “Elderspeak”: infantilizing, patronizing speech Defined Consequences Older adult responses Effectiveness of communication

Answer 51

``` Some cognitive changes can happen with “normal aging” Problem solving memory Working memory retained Long term (secondary) Very long term (remote) Psychomotor skills Speed of processing Verbal skills Reasoning ```

Answer 52

Intelligence – some research indicates a slowing down at age 25 and continuing through the 70s and 80s! Fluid intelligence – ability to adapt to and use new information (new information, problem solving, reasoning) Crystallized abilities – practical skills and knowledge of the person accumulated over a long period of time

Answer 53

Cognitive Slowing Perceptual speed has been shown to decline with age Reasoning and Problem Solving Decline in speed and efficiency of problem-solving Memory and Attention Sustained attention, attentional capacity, selective/divided attention

Answer 54

Accompanied by complaints of memory impairment in everyday activities Previously known as age-associated memory impairments Acquiring this condition is more likely with the older adult population as they age Many older adults with mild cognitive impairments remain stable without developing dementia

Answer 55

Vocational performance Leisure and daily activities Memory aids and intervention strategies

Answer 56

Cognitive change varies from individual to individual Lab-based data shows age-associated decline Relatively stable cognitive function in older adults throughout the lifespan: must consider context Current research in industrial gerontology shows little decline overall in the performance of healthy older adults in the workplace (Bonder & Bello-Haas, 2009)

Answer 57

``` “Use it or lose it” Cognitive reserve Instances where vocational performance is affected by cognitive declines: Decline in fluid intelligence Increased cautiousness Decreased processing speed Declines in secondary memory Job training and retraining Learning new things, reading new books, etc ```

Answer 58

Normal age-related changes should not affect someone who has been performing the same activities for 40-50 years Direct impact on simple ADL and IADL if sequencing, memory, or planning are impaired Older adults can learn new leisure and recreational skills Leisure activities that stimulate the older adult on a social, cognitive, and physical note, can help maintain cognitive functions If a person gives up something he/she truly loves, it could be a sign of major depression or cognitive decline/dementia

Answer 59

Most of us have used “memory aids” all of our lives! Training is helpful, but follow through with strategies is low Table 7-2 in class text for effects of age-related changes in cognition on ADL (LTM and speed of processing) External and Internal strategies

Answer 60

Not all forms of dementia are progressive Not a part of “normal aging” Dementia is a clinical diagnosis with social implications Increased attention being made to the phenomenology of those living with dementia Reasons for extended care placement

Answer 61

``` Common general signs: Decreased short term memory Decreased problem-solving skills Decreased perceptual skills Personality changes ```

Answer 62

- Alzheimer’s Disease - Vascular Dementia: 10-30% - attention, working memory, abstract thinking, speed of mental processing, males more frequently diagnosed, higher risk as you get older - Dementia with Lewy Bodies – parkinsonism (rigidity in joints, slow ability to start and continue movements) - Frontotemporal Dementia - Parkinson’s Disease with Dementia add'l info Aphasia- inability to understand/express speech Agnosia – can’t recognize sounds/images Apraxia- incoordination with motor or sensory impairments

Answer 63

Most prevalent form of dementia Cause of AD is unknown Predispositions include: female, family history, and ethnicity Head injury with loss of consciousness is linked to the development of AD No significant research thus far on potential remedies for AD

Answer 64

Caused by cerebral vascular damage Person can have AD and VaD: “mixed dementia” Changes to white matter and lacunar infarcts , as well as hippocampal formation atrophy are indicators of cerebrovascular disease – which can lead to dementia (Chui, 2001) Those with VaD demonstrate perseverating behaviors and difficulties with verbal fluency

Answer 65

Lewy Body = round neurofilament inclusion body that holds damaged nerve cell deposits Potential Signs: Parkinsonism Cognitive fluctuations Visual hallucinations Additional indicators: repeated falls, nonvisual hallucinations, delusions, and syncope

Answer 66

3rd most common neurodegenerative dementia syndrome after AD and DLB Includes more focal conditions such as progressive aphasia, semantic aphasia, and frontal dementia with motor neuron disease Early signs: behavioral disturbances, changes in social awareness, and evident changes in personality Additional indicators: Lack of sympathy and empathy is common, poor hygiene and decreased independence with ADL is another indicator of FTD

Answer 67

Many individuals diagnosed with PD will develop dementia Usually develops ~10 years after PD Parkinson’s Disease with dementia (PDD) clinically looks very similar to DLB Slowed psychomotor speed, difficulties with attention and initiation Decline in delayed recall, semantic knowledge, frontal-executive functions, memory and visuospatial functions

Answer 68

Not an easy process! Once memory impairment has been established, must assess which type of memory impairment is present: STM (immediate memory) or LTM (delayed memory) Are other impairments present? Do they effect the person’s everyday life activities? Any behavioral problems? Neuropsychological evaluations and neuroimaging are used The earlier the diagnosis, the better the chance of treating with medications

Answer 69

``` Pre-dementia Mild Moderate Severe Terminal ```

Answer 70

``` Educate family members Evaluate persons with dementia Strengths Impairments Performance areas needing intervention Remediation of cognition is not likely Maintenance and Modification ```

Answer 71

Early Stages of Dementia Difficulty with higher-level executive skills Driving, work, home safety eval and intervention, establishing life legacy Middle Stages of Dementia Home safety, staying engaged in meaningful activities Late Stages of Dementia Difficulty with BADLs Decreasing caregiver burden, enhancing basic care, positioning

Answer 72

Challenges Measuring and Defining: Difficult to operationalize occupational and social functioning Is ADL and IADL sufficient? All people with dementia do not want to work on the same activities in therapy…caution with groups Neuropsychological and cognitive function vs. performance in everyday occupation

Answer 73

``` Identify person’s occupational baseline Information gathering Ask clear and well-directed questions Use standardized or formalized assessment tools (Mini-Cog; Kettle Test), but also use observational skills Goal Attainment Scaling (GAS) Tutoring effects ```

Answer 74

Physical designs of the environment Specialized units for those with dementia Supporting occupational performance Supporting the caregivers

Answer 75

Shifting roles and changes in the family dynamics Learning more about dementia and effects of the disease Offering resources and advocacy groups Caregivers need emotional and self-esteem support Support groups are not well-utilized Define a “new normal” “Just right challenge” - focus on what person CAN do Safety What is the cause of the observed skill difficulty?

Answer 76

Maintain relationships with family and friends Continue to engage in meaningful activity Strategic time use and taking advantage of habits and routines “Error-Proof” the environment and grade activities Avoid difficult activities that are too challenging Change how the task is completed/done Change the demand of the task Change aspects of the physical and social environments as needed Ask “yes-no” questions Use respect, care, and non-controlling conversational strategies Let the loved one be the expert if they have long-term experience with task/activity There is no “right way” to care for someone with dementia – keep trying different strategies until something works! Remember: “problem behaviors” are usually a sign of frustration, fatigue, fear, confusion, or pain – usually an inability to express oneself is coined “problematic” Activity: Dementia part I: Grooming & Hygiene Dementia part 2: Doffing Socks Dementia part 3: Donning Socks

Answer 77

- Assisted Living - Skilled Nursing Facility - Extended Care Facility: “nursing home,” have little outside support, OTs works as consultants here

Answer 78

1. AL - Consultant (most of the people in AL only require minimal assistance with basic ADL and medication management a. OTs Role…foster and enhance habits and routines, personal care skills and simple home care, leisure activities with environmental supports (assistive tech.). SNF - More intensive rehabilitation (sub-acute rehabilitation) 3. ECF - Consultant notes IRF – inpatient rehab facility

Answer 79

- (not going to have nurses and Dr.’s here) - Housing & personalized support for those needing help with ADL - Can still have independence in some areas, but may need help with ADL and medication management - Allow for privacy - For people who do NOT need skilled medical care - Services available: linen service, meals, social activities, local transportation, laundry, housekeeping - OTs Role…foster and enhance habits and routines, personal care skills and simple home care, leisure activities with environmental supports (assistive tech.). - Cost depends on the number of services provided and the type of living arrangement (ie, two bedrooms, suite, etc… - Regulated and licensed at the state level - Private pay, state assistance, Medicaid voucher - Can receive personal care, but not skilled medical care - OT’s role can be consultative in nature, assist with modification and adaptations, programming and promoting safety throughout the facility - Direct services to residents: safety, ADL assessments, IADL assessments & interventions, social activities - Education of direct service staff regarding issues on aging, occupation, and health promotion.

Answer 80

- Require special, 24-hour care for either a short or extended time period - “Bridge the gap” with another level of care - Admitted from acute care hospital - Can be a unit in a hospital or in a free-standing nursing home - Short-term stay: up to 100 days, Long-term stay: as long as needed - OTs Role: Similar to IRF but less intensive (less than 3 hours per day); ADL/IADL; team approach, etc. - Person is admitted from a hospital setting (perhaps prior to going home). Usually require some type of skilled nursing intervention like: TPN (total parenteral nutrition), intravenous medication, wound care - Role of OT and precautions similar to acute rehabilitation; however, intensity is not the same - Person can be sent home after a stay at this setting, or can go back to acute rehabilitation if they need more/can tolerate more intensive & comprehensive therapy.

Answer 81

- Require 24-hour care for an unknown amount time - May transfer from hospital, nursing home, or home - Person needs assistance with self-care - LOS is variable and indefinite - OT Role is direct or consultative in nature - Require 24-hour care for an unknown amount time, “functional recovery” may not be possible, lack of financial resources, or support at home - Classic “Nursing Home”… not SNF. There may be facilities with both, but typically minimal to no OT in this context. - Require Medicaid or Private Pay… - Do not hire Ots full time, work as a consultant

Answer 82

In 2012, approximately 1.4 million people over the age of 65 lived in nursing homes in the United States (www.cms.gov) http://www.cdc.gov/nchs/fastats/nursing-home-care.htm : (1.4 million in 2014) Nursing homes have been constantly changing since 1965. Publications exposing the inefficiencies of nursing home published throughout mid-80s through the 90s In 1986 a report on Improving Quality of Care in Nursing Homes done by the Institute of Medicine & the Omnibus Budget Reconciliation Act (OBRA) of 1987 were seen as catalysts for change Total number of beds: 1,700,000 available CMS beds. The increase in number of beds available for older adults did not result in an increase in the quality of care which was provided Some of the inefficiencies identified by Vladeck’s work were: nurses spending little time with the residents, doctors seldom visiting the residents, physical & chemical restraints on the residents, smell of urine, lack of meaningful occupation, and overall dissatisfaction of care… Federal & state regulations were put into place focusing on the residents’ rights, quality of care, and quality of life, and the development of an assessment tool began (Resident Assessment Instrument which included the Minimum Data Set). An MDS was seen as an initial assessment to screen residents for potential problems, abilities, and preferences Nursing homes were now accountable for adhering to these national & state guidelines. Vlasek, Coburn, Fralich, McGuire & Fortinsky, 1996 expose nursing homes for inadequate care

Answer 83

Legislation which focused on wellness Redefined the concept of long-term care Lack of adherence to regulations created sanctions, such as fines Three main categories of nursing home care: Skilled (ventilator care, high-level medical care after a hospitalization Rehabilitative (improvements expected with discharge to “less restrictive environment”) True long-term care The older adult has plenty of capabilities and abilities and should be treated with respect & dignity. Long-term care insurance and shorter LOS in hospitals are factors contributing to nursing home placement The yearly cost of staying in a nursing home is $75,000 - $80,000; Medicare & Medicaid are funding many (if not the majority) of those residents…so in order for a facility to stay certified, they had to adhere to legislated standards of care. This helped with the shift from custodial care to the restorative model. A resident in a nursing home is sicker, more physically dependent, and more cognitively impaired than he/she has been in the past requiring more skilled services & medical attention. Almost ½ of all persons in a nursing home are 85 years or older and disabled. Only 19% of those residents receive rehabilitation services.

Answer 84

Primary concern has been on functional problems (just like other rehabilitation services) Reimbursement policies have forced therapists to treat specific impairments – instead of working from a top-down approach Restorative nursing programs are supposed to carry out restorative programs and OT can play a huge role in this program; however OT remains consultative in nature Activities/programming in LTC The above is a very reductionist view of occupational therapy. A treatment approach which is criticized by our own as bottom-up and not encompassing our holistic, client-centered, occupational-centered practice! The reimbursement system set up by CMS pays for dependency, not health care promotion and independence. OT is consultative because it’s cheaper for the facility that way. OT still seen as “rehabilitative” vs. health-promoting in nature. Is OT losing ground to other paraprofessionals and/or other health care disciplines?

Answer 85

Our theoretical knowledge base supports engagement in meaningful occupation The regulations say that different types of personnel are equally capable of fulfilling the requirements for a position in a nursing home Long-term care administrators will hire the least expensive for cost-effectiveness. It’s clearly not about “busy work,” but the “busy work” is more affordable Regulations do not specifically name OT as the provider for residents in long-term care in regards to function, activity, etc… However, the short-term acute problems mandate support in activities programming. Federal regulations state that the person holding that position in a nursing home can be: a qualified therapeutic recreation specialist or activities professional, someone with 2 years of experience in a social or recreational program, someone who has completed a training course approved by the state, OR IS AN OT. Using the USC Well- Elderly Study as a springboard, we need to utilize best-practice and evidence to prove to administrators and public policy development that promoting health and well-being IS cost-effective…

Answer 86

Occupational performance: ability to carry out activities of daily living; client, context, and activity interact for the sake of activity completion & satisfaction; leads to engagement in occupations or meaningful activity General activities program: Crepeau (1986) stated, “Events or tasks designed to provide incentive and opportunity to engage in continuing life experiences & hence, to satisfy interests & meet general activity needs (focus on enjoyment, stimulation & repetition of present skills). OTs can also develop programs where communication skills, intrapersonal skills, cognitive and performance skills, independent living skills, social participation, physical skills, as well as psychosocial skills (TO NAME A FEW) can be improved upon…for long-term results. In June of 2006, CMS revised their guidelines to ensure that there is an emphasis on the matching between activities and the interests of the residents, their ages, gender, and level of cognitive functioning.

Answer 87

``` -Nursing Home Staff Overworked Not enough experience Cannot make decisions Feeling undervalued Stress/Worry Not enough help Not being paid enough ``` ``` -Nursing Home Patients Disempowered Not independent Losing function Lack of meaningful activities Boredom Depression Not at HOME ```

Answer 88

In a study by Torres et al (2013), not only is it about occupational deprivation and disempowerment, but communication between interdisciplinary team members is challenging. Fragmented communication among disciplines Fragmented communication leads to increased stress levels Misunderstandings among the different disciplines Gaps between the expectations and responsibilities of each discipline Led many staff to feel unheard, frustrated, and in some cases, angry

Answer 89

``` Examples: The Green House Project – The Eden Alternative Philosophy Wellspring Model LEAP Initiative Village to Village ``` Shift from medical model to a person-centered model Pioneer Network was organized in the 1990s with the purpose of identifying ‘‘deep systematic change’’ that will allow for a ‘‘person-centered’’ focus of care (Fagan, 2003,p. 125). Members of this network include practitioners, researchers, educators, and other professionals who seek to find alternatives to the strictly medical model. In 1992 the Eden Alternative was developed by Thomas and Thomas (Thomas, 1994) to encourage a more homelike environment in the nursing home and to allow direct-care workers to be more involved in decision making. A decade later, Thomas and his colleagues introduced the promising concept of ‘‘Green Houses,’’ which provide a structural alternative in the form of specially designed houses for elderly residents as well as the empowerment of direct-care workers (Green House Project, 2006; also see Keane, 2004). In 1994, another approach, the Wellspring Model, was established to encourage nursing homes to work together to teach line staff the best clinical practices and to move away from the typical nursing home culture of control (Kehoe & Heesch, 2003; Reinhard & Stone, 2001). In 2001, the LEAP initiative was underway to alter how the nursing home workforce was viewed and treated by nursing home management (Hollinger-Smith, 2003; Hollinger-Smith, Ortigara, & Lindeman, 2001). In a fairly recent development, Grant and Norton (2003) identified various stages that nursing homes are expected to go through in the process of culture change.

Answer 90

Empowerment is psychological and structural (Tanni Chaudhuri, Dale E Yeatts and Cynthia M Cready, 2012) Psychological empowerment refers to an individual’s feeling or perception of his/her contribution to the workplace and typically includes meaningfulness of the work, perceived competency or self efficacy, one’s self-determination and one’s perceived impact on outcomes (Thomas & Velthouse 1990, Spreitzer 1995).

Answer 91

Gives frontline staff responsibilities for making decisions related to their practice Model is based on professional values & principles of autonomy, shared decision-making, and engaged participation A decision-making model based on principles of Accountability Equity Ownership It’s not just about changing the physical context….but it’s about empowering the staff, as well… Golanowski et al. (2007) – definition of “shared governance” Gives those involved in direct patient care the responsibility of making decisions related to their practice (Howell et al., 2001). Based on the professional values and principles of autonomy, shared decision making, and engaged participation (Hoying & Allen, 2011). RNs & CNAs are in the best position to make informed decisions because they have first-hand knowledge of their residents (Yeatts et al. 2004).

Answer 92

Provides a way to implement change Improves patient outcomes Improves patient care Increases staff morale Increases job satisfaction (retention of staff) Facilitates personal & professional growth & development Leads to patient satisfaction Increases staff autonomy and decision-making Improves communication between interdisciplinary teams When the staff is happy, the patients are happy and they report overall “more satisfaction and quality of care”

Answer 93

Race of the CNA (certified nursing assistant) Emotional exhaustion Supervisor support Personal characteristics that have been reported to affect a CNA’s structural decision-making include gender, positive attitudes, emotional exhaustion and one’s perceived work CNAs constitute one of the lowest ranks in the medical hierarchy and are paid minimally (Day & Berman 1989). The task of an aide is multifaceted and has several additional challenges: it is physically exacting, involves the risk of infection, is emotionally demanding and can be somewhat unpleasant (e.g. cleaning after patients) (Bureau of Labor Statistics 2009) (Yeates & Cready, 2012).

Answer 94

``` Empower the residents Empower the staff Education to family & caregivers Teaching independence Changing the culture to support meaningful activities Provide meaningful activities to the residents Life balance (work, rest, play) Equipment and modifications Help residents and staff feel valued Help people become HAPPY ```

Answer 95

``` Home Health PACE Adult Day Health Care (ADHC) Continuing Care Retirement Communities (CCRCs) Patient-Centered Medical Homes (PCMHs) ``` ``` other: SNF Nursing home ECF LTC Assisted Living ```

Answer 96

Home health care is a wide range of health care services that can be given in your home for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility (SNF).

Answer 97

For Medicare: You are under the care of a doctor Intermittent skilled care (nursing, PT, OT, SLP) You are homebound: Can’t leave without help Leaving isn’t indicated due to medical condition Home Health is also covered under Medi-Cal and private insurance

Answer 98

Ability to perform daily activities Home safety assessment and fall risk Reduce risk for additional injury or decline Management of chronic health conditions: (Including medication, diabetes, heart failure, COPD, cognitive conditions, behavioral health)

Answer 99

The Programs of All-Inclusive Care for the Elderly (PACE) provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits . In-home services/community services/PACE Center

Answer 100

``` PCP RN MSW PT OT Recreational Therapist or Activity Coordinator Dietitian PACE Center Manager Home Care Coordinator Personal Care Attendant Driver ```

Answer 101

Be 55 or older Live in service area of PACE program Certified as needing nursing home-level of care Be able to live safely in community with PACE services (per CMS regulations)

Answer 102

Perform assessments Home visits and home safety assessment Evaluate need for DME Skilled treatment Supervise maintenance exercises and groups Report progress, problems and recommendations to IDT

Answer 103

Community-based program serving older adults and adults with chronic conditions and disabilities that might otherwise require a higher level of care. Objectives: Restore or maintain optimal capacity for self-care to frail elderly persons or adults with disabilities Delay or prevent inappropriate or personally undesirable institutionalization (California Department of Aging)

Answer 104

``` (most independent) Living at home Independent Living Assisted living facility CCRC Alzheimer's care Hospice care (least independent) ```

Answer 105

The Patient-Centered Medical Home (PCMH) is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. 1. Comprehensive Care 2. Patient-Centered 3. Coordinated Care 4. Accessible Services 5. Quality and Safety pcmh.ahrq.gov

Answer 106

Medicare is a federally funded program available to most U.S. citizens and permanent legal residents who have lived continuously in the country for five years or more and are age 65 or older. Also called hospital insurance, Medicare Part A covers the cost if you are admitted to a hospital, skilled nursing facility, or hospice. It also covers some home health services. Most people are enrolled automatically in Part A when they reach age 65. http://www.aging-parents-and-elder-care.com/Pages/Medicare.html

Answer 107

Settings: Inpatient Hospital Skilled Nursing Facility Rehab Skilled is medically necessary not custodial Hospice Home Health (skilled) Benefits start when the individual first enters a hospital and ends when there has been a break of at least 60 consecutive days since inpatient hospital or skilled nursing care was provided No limit to the number of benefit periods Medicare benefits are provided in 4 parts – A, B, C and D. Part A helps pay for inpatient hospital care, some skilled nursing facilities, hospice care, and some home health care. Part A is premium-free for most people. Most beneficiaries do pay a monthly premium to be covered under Medicare Part B – the part that helps pay for doctors, outpatient hospital care, and some other care that Part A doesn't cover, such as physical and occupational therapy.

Answer 108

``` Out-patient MD Yearly wellness visit Therapy (PT/OT, etc.) DME ED HHS Labs Ambulance Ambulatory surgical centers Supplies and screening ```

Answer 109

Part C allows various HMOs, PPOs and similar health care organizations to offer health insurance plans to Medicare beneficiaries. At a minimum, they must provide the same benefits that the Original Medicare Plan provides under Parts A and B. Part C organizations are also permitted to offer additional benefits such as dental and vision care. But, to control costs, Part C plans are allowed to limit a patient's choice of doctors, hospitals, etc., to just those who are members of their networks. This can be a major disadvantage if a patient's favorite doctor or hospital is not a member of their networks. -Medicare-approved private health insurance plans for individuals enrolled in Medicare Part A and Part B Includes HMOs and PPOs -Private insurance that covers all Medicare services and may also offer extra coverage

Answer 110

Provides a prescription drug plan coverage for individuals who have Medicare Part A and Part B Beneficiaries can: Join a specific prescription drug plan that only provides coverage for drugs Join a Part C health plan that also provides prescription drug coverage Medicare's Part D provides prescription drug benefits through various private insurance companies. For more information, including how to enroll, click on Medicare Prescription Drugs benefit. Like Part B, most people have to pay extra premiums each month to be covered for prescription drugs under Part D. Premiums for Part D vary from state-to-state, and from company-to-company. For more information, visit Medicare's website.

Answer 111

Part A Mandatory payroll deduction (FICA tax) of 1.45% of taxable earnings (paid by each employee and the employer for each) Part B Premium payments deducted usually from monthly SS benefit checks for those who are voluntarily enrolled in the SMI plan (25%) and through contribution from the general revenue of the federal government (75%) Premiums for most people are $104.90/month (2015)

Answer 112

In all states, Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states the program covers all low-income adults below a certain income level. The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP). FMAP varies by state based on criteria such as per capita income.

Answer 113

Once states meet basic Federal requirements, States have the flexibility to design their Medicaid program to fit their own needs within federal guidelines eligibility standards services (scope, types, and amounts) payment rates

Answer 114

``` Hospital Services Physician Services Nursing home care (including custodial) Home health care Laboratory and X-ray services Some optional programs also include services such as dental and vision care ```

Answer 115

``` State (Medicaid) v. Federal (Medicare) Dual eligibles, dually eligible, Medi-Medi 8.9 million people Twice as expensive for Medicare 21% of Medicare enrollees 15% of Medicaid enrollee (60% 65+) 39% of Medicaid costs Covers benefits that Medicare does not Medicare is first payer Medicaid supplements by paying premiums, co-pays, and deductibles ``` The Medicaid population is poorer and in general in worse health than people of comparable age in Medicare or in commercial plans Combined Medicare-Medicaid benefit is rich in terms of benefits but it is generally uncoordinated

Answer 116

50% of LTSS consumers in the US are 65 years of age or older ``` LTSS can be received in two settings: Nursing home Community (home and community-base services) A consumer’s home/ apartment Assisted living ```

Answer 117

``` Personal care services Bathing Meal preparation Medical care (OT, PT, nursing) Goal of LTSS: the consumers needs, preferences, and goals are integrated into the plan of care ```

Answer 118

40% of the LTSS spending is paid by Medicaid 2% by the aging network (e.g. Meals on wheels) Private funding Informal caregivers Long-term care insurance Medicaid Waiver programs

Answer 119

Medicaid was originally established to serve low income individuals Has become a long term care program serving an increasing percentage of frail elders 1/3rd of Medicaid payments go to LTC 60% of this is for persons 65+ pays for 2/3rds of nursing home care covers 1 million of the 1.5 million individuals in SNFs

Answer 120

Passed 1965 to improve community social services for older persons by establishing: Provide grants to States for community planning and social services, research and development projects, and personnel training in the field of aging. Administration on Aging (AoA) to serve as the Federal focal point on matters concerning older person

Answer 121

Nutrition programs Area Agencies on Aging Senior centers State long-term care ombudsman programs Prevention of elder abuse, neglect, and exploitation Elder rights and legal assistance development Intergenerational programs

Answer 122

A civil rights law that was passed in 1990 Prohibits discrimination against individuals with disabilities in all areas of public life, including: Jobs Schools Transportation Public and private places that are open to the general public The purpose: to ensure that people with disabilities have the same rights and opportunities as everyone else

Answer 123

``` Gives civil rights protections to individuals with disabilities similar to other protected groups on the basis of: race, color age, sex, national origin religion It guarantees equal opportunity for individuals with disabilities in: Public accommodations Employment Transportation State and local government services Telecommunications ```

Answer 124

Signed into law in 2008, became effective January 1, 2009 Expanded definition of disability For additional information: https://adata.org/learn-about-ada

Answer 125

``` Improved health Better outcomes Efficient high quality care Value-based care Improve the patient’s experience Increased transparency Public reporting ```

Answer 126

Healthcare reform is calling for a shift to value-based care Payments are based on the provision of high quality care, not volume of care Fee for service ( eg minutes of therapy) ---> Value Based Payment (eg performance)

Answer 127

Reimbursement is based on: Healthcare providers’ achieved rates of pre-specified patient outcomes Adherence to patient-centered scientifically grounded best practice guidelines Facility or provider payments are tied to performance on defined outcomes Targeted outcomes have strong evidence-based interventions Poor performance is tied to financial penalties Objective is to incentivize providers to deliver high quality care

Answer 128

``` Care Collaboration Engaging the patient and caregiver Shared decision making Caregiver & patient training Bundled Payment Initiatives Accountable Care Organizations Comprehensive Joint Replacement Initiative ```

Answer 129

``` Standardize post-acute care assessment data Quality Payment Discharge planning Standardized measures across settings Functional status & cognitive function Skin integrity Major falls Medical needs & conditions ``` “Improving the Medicare Post-Acute Care Transformation Act of 2014”

Answer 130

``` Measure domains to be standardized across post-acute care settings Community discharge Functional status Cognitive function Skin integrity Major Falls Medication reconciliation Potentially preventable hospital readmissions ```

Answer 131

Implementation of new value-based OT and PT evaluation CPT codes (January 2017) Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) Merit-Based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMs) Skilled Nursing Facility Payment Initiatives