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AGING AND LONG TERM CARE:
A Comprehensive Review
ABSTRACT
The number of people over 65 years of age represented 12.4% of the population in
the year 2000 but is expected to grow to be 19% by 2030. That means that 72.1
million older people will be seeking health care from a variety of sources in the next
20 years. This creates an environment in which specialists in geriatric health are
highly sought after to deal with the specific and various issues that affect aging
patients. These patients are highly likely to have chronic health issues that require
long term care, either in a specialized facility or in the home. A proactive approach
to managing older patients’ health is necessary to ensure that each patient gets the
highest quality of care.
LEARNING OBJECTIVES
1. Identify the most common housing scenarios for aging patients.
2. Describe the best practices of communicating with older patients.
3. List common geriatric syndromes and disorders.
4. Recognize symptoms of elder abuse.
5. Differentiate between normal memory loss and true memory disorder.
6. Describe the emotional burden of chronic illness on an older patient.
7. Discuss the cultural impact on end of life decisions.
8. Specify appropriate interventions for depression in aging patients.
9. Identify common sexual health disorders in aging patients.
10. Explain the moral and legal obligations of euthanasia.
11. Develop a treatment plan for an aging adult with a chronic illness.
12. Explain strategies for dealing with over-involved family members of a long
term care patient.
13. Explain strategies for dealing with under-involved family members of a long
term care patient.
14. Identify end-of-life options for a chronically ill patient.
15. Explain the emotional impact of multiple morbidities on an aging patient.
16. Recognize strategies for assisting aging patients with medication
management.
17. Discuss the challenges of long term care for non-geriatric patients.
18. Match aging patients to the appropriate living environments.
19. Explain the reporting process for elder abuse.
20. Identify critical team members in an aging patient’s treatment plan.
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OUTLINE
I. Introduction
II. Living Environments
A. Hospitals
B. Skilled Nursing
C. Residential Care
D. Assisted Living
III. Common Health Issues
A. Malnutrition
B. Aspiration/Choking
C. Falls
D. Memory disorders
E. Depression
F. Sexual health
G. Alcohol Abuse
IV. Elder Abuse
A. Risk factors
B. Signs
C. Reporting
V. End of Life
A. Hospice
B. Euthanasia
VI. Developing Treatment Plans
A. Frequency of visits
B. Medication management
C. Geropsychology pharmacology/Cognitive Management
D. New/future therapies
VII.
Cultural Issues
A. Communication
B. Adherence to treatment
C. End of Life Decisions
D. Family support
VIII. Family Members
A. Power of Attorney
B. DNR
IX. Conclusion
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Introduction
The United States is the third most populous country and constitutes approximately
4.5% of the total world population. Currently, the U.S. population is about 308.7
million persons and has increased two fold since 1950. In addition, the US
population is now qualitatively different from what it was in 1950. The Population
Reference Bureau reports that the United States is getting larger, older, and more
diverse. In the coming decades, specifically between 2010 and 2050, the U.S is
expected to see a rapid growth in its older population. In 2050, it is expected that
the total population of US citizens aged 65 and older will reach 88.5 million, which is
more than twice its population in 2010. Between 2010 and 2050, the 65+
population is expected to roughly double. Approximately one in 5 will belong to this
age group in 2050. Currently this rate hovers around one in 7.7. This growth in the
elderly population will far exceed the growth in younger age groups or categories. In
the same period, the total number of people in the 85+ age group (oldest adults) will
witness a far more rapid growth than the growth of older adults 65+. The 85+
population will increase three fold from 5.8 million in 2010 to approximately 19
million in 2050. This surge in the elderly population will have far reaching
implications. As the United States ages, the demand for long term care for the
elderly will increase dramatically and their need for health services is expected to
also grow. Currently, more than 6 million elderly in the United States require some
kind of long-term care, with about a third of these requiring more substantial care.
Currently, Medicare finances medical care for almost all the elderly US citizens.
However, support for long-term care is often beyond the scope of Medicare.
In the US, most long-term care for the elderly is provided by families, relatives and
friends. Medicaid is a state program supported by the Federal government and
provides long-term care financing for low-income families. However, long-term care
for the elderly continues to be a major challenge for the country. Elderly who require
long-term care often do not receive the quality or amount of care they may wish,
need or prefer. In addition, the financial burdens on the society and the family are
often quite heavy.
The county, society, and healthcare providers face a huge problem and
dissatisfaction in terms of quality, scope, and financing of long-term care services.
Despite a consistent growth in home-care services, nursing homes continue to
dominate the long-term care services system, and the government is still struggling
to manage its social and financial resources. Changing demographics in the US pose
a further challenge. It is estimated that that the demand for long-term care among
the elderly will more than double in the next three decades [1]. This exponential
growth further exacerbates concerns about long term care for elderly. The key
variables required to address this problem are institutional and non-institutional
elderly care, quality of care, integration of acute and long-term care, and the
adoption of sustainable financing strategies for those who require long-term care. As
the population of elderly increases in the US, questions surrounding long-term care
will increasingly shape the quality of life for aging Americans.
In addition, approximately 10 million out of the county’s 26.2 million older
households have at least one family member with a disability. It has been observed
that the rates of disability increases with age. In 2007, approximately four percent of
the 65+ Medicare population utilized long-term care facilities such as nursing homes.
Another two percent lived in community housing. However, the picture changes
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drastically among the oldest adults. Among people in the 85 and older category, in
2007, approximately seven percent lived in community housing and about 15
percent resided in long-term care facilities [1].
Older age is also associated with an increased prevalence of chronic diseases [1] and
sensory dysfunction [2]; changes in cognition [3]; poor balance [4]; increased rate
of falls, fall-related injuries, and death [4, 5]. In addition, physical activity and
community engagement declines in the elderly. This also leads to overall declines in
health [5]. These age-related changes may substantially impact the healthcare and
long-term care in the coming decades because the use of health-related services and
long term care is strongly correlated to increasing age [6].
FUTURE PROJECTIONS FOR THE ELDERLY POPULATION IN THE US
The number of US citizens who require long-term care will jump from
approximately 12 million today to 27 million in 2050 [7].

Baby boomers will start turning 65 between 2011 and 2029 [8]. During this
period, 10,000 Americans will turn 65 every day [9].

By 2030, the number of Americans in the age group of 65 and older will be
approximately 72 million, or approximately 19% of the total U.S. population
(up from over 40 million or 13% in 2010) [10].

By 2050, the number of elderly Americans will jump to almost 89 million,
which constitutes approximately 20% of the total U.S. population

The percentage of the U.S. population that is age 85 and older will increase by
more than 25% by 2030 and by 126% by 2050 [10].

From 2010 to 2030, Alaska (+217%), Nevada (+147%), Arizona (+119%) will
witness highest population growth of those age 85 and older.

Life expectancy in the U.S. has increased significantly over the last century
and will continue to increase. An individual born in 2010 has an average life
expectancy of 79 years, compared to almost 52 years in 1910 [11, 12].

Life expectancy is higher for women than men. For those born in 2010,
projected life expectancy for women is about 81 years, compared to 76 years
for men [11]

Between 2000 and 2030 the number of Americans with chronic disease or
conditions will increase by approximately 37%, an addition of 46 million
people [12]

Twenty-seven million individuals with chronic diseases or conditions in the
U.S. population will also experience functional impairment [13, 14].
As of 2012, there are 5.2 million people age 65 and older who have been diagnosed
Alzheimer’s disease. By 2025, the number of people age 65 and older with
Alzheimer’s disease is estimated to increase by 30% to 6.7 million. By 2050, this
number may undergo a three-fold increase to approximately 11 million to 16 million
[15].

By 2020, approximately 12 million elderly will need long-term care. The majority of
these people, about 70%, will be provided care at home by their family and friends.
A recent study has reported that older adults have a 40 percent chance of entering a
nursing home [15]. Approximately 10 percent of those nursing home residents will
stay there for five years or more.
The cost of long-term care may vary depending on the type of care, location of the
provider, and location of the elderly. The table below compares the different
services.
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Help with
activities of
daily living
Help with
additional
services
Help with
care needs
Range of
costs
CommunityBased
Services
Yes
Yes
No
Low to
medium
Home Health
Care
Yes
Yes
Yes
Low to high
In-Law
Apartments
Yes
Yes
Yes
Low to high
Housing for
Aging and
Disabled
Individuals
Yes
Yes
No
Low to high
Board and
Care Homes
Yes
Yes
Yes
Low to high
Assisted
Living
Yes
Yes
Yes
Medium to
high
Continuing
Care
Retirement
Communities
Yes
Yes
Yes
High
Nursing
Homes
Yes
Yes
Yes
High
Living environment
Long-term care (LTC) for the elderly or the younger disabled individual is an
essential component of health and social systems and encompasses a wide variety of
medical and non-medical services including the personal needs and the activities of
daily living (ADL) of the elderly [16]. Long-term care can be provided at home, in
the community, in nursing homes, or in assisted living. Increasingly, long-term care
also encompasses a higher level of medical care that requires the expertise of skilled
health providers to address the complexities of multiple chronic conditions associated
with aging. The need for LTC is impacted by changes in the physical, mental, and/or
cognitive functional capacities of the elderly which in turn are greatly influenced by
the environment. The type and duration of LTC are complex issues and usually
difficult to predict. The goal of LTC is to make sure that an elder who is not fully
capable of long-term self-care can maintain the highest possible quality of life, with
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the high degree of independence, participation, autonomy, individual fulfillment, and
dignity.
Appropriate and adequate LTC includes respect for an individual’s values, wishes,
needs and preferences. Elderly who need home-based LTC may also require other
services, such as physical or mental health care and rehabilitation, together with
social financial and legal support. LTC may be provided formally or informally.
Facilities that provide formal LTC services usually make provisions for living
accommodation for those elderly who need round-the-clock supervised care, which
may include professional healthcare services, personal care and services such as
housekeeping, meals and laundry [17]. Such formal LTC services are provided by
nursing home, residential continuing care facility, personal care facility, etc. Home
health care is LTC provided formally in the home and may encompass several clinical
services such as nursing, physical therapy and other activities such as installation of
hydraulic lifts or the renovation of kitchens and bathrooms. These services are
generally directed and ordered by a physician or other professional. Informal LTC at
home is provided by family members, near and dear ones and volunteers. It is
estimated that approximately 90% of all home care is provided informally without
any monetary compensation [18].
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Temporary long term care
(Required for short term care over
few weeks or months)

Rehabilitation from a hospital
stay

Recovery from illness

Recovery from injury

Recovery from surgery

Terminal medical condition
Ongoing long term care (Required
for care over several months or
years)

Chronic medical conditions

Chronic severe pain

Permanent disabilities

Dementia

Ongoing need for help with
activities of daily living

Need for supervision
Home-Based Services
Services from Unpaid Caregivers
Home-based LTC encompasses health, personal, and other types of support services
to help the elderly stay at home and live as independently as possible. This type of
care is usually provided either in their own home or at a family member's home. Inhome services can be short-term or long-term depending on the condition of an
individual. For example, an individual may need these services postoperatively for
few days (short term) to adequately recover from an operation. On the other hand,
an individual may require ongoing in-home services for a longer term. The majority
of home-based services provide personal care, such as help with activities of daily
living i.e. bathing, dressing, etc. These services are often also provided free of cost
by immediate family members, friends, partners, and neighbors. Such informal care
is the dominant form of care for elderly in the US as well as throughout the world,
despite the immense burdens that it places on the provider.
Services from Paid Caregivers
Trained paid caregivers are also available for home-based LTC services. Health care
professionals including nurses, home health care aides, and therapists may provide
these services. These paid services may also be provided by:
 Home health care workers
 Friendly visitor/companion services
 Homemaker services
 Emergency response systems.
Home Health Care
These services may include nursing care to help an individual recover from surgery,
an injury, or illness. It usually involves part-time medical services advised by a
physician for a particular event or condition. Home health care may also provide
different types of therapies including physical, occupational, or speech therapy. If
required, provisions can also be made for temporary home health aide services.
Homemaker Services
Homemaker services can be utilized without a physician's recommendation. Personal
care includes help with activities of daily living such bathing, grooming and dressing.
These services also provide help for meal preparation and simple household chores.
These agencies do not need to be approved by Medicare to provide their services.
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Friendly Visitor/Companion Services
Friendly visitor or companion services are usually offered by volunteers from the
community who regularly pay short visits to elderly people who live alone are too
weak to take care of themselves.
Emergency Response Systems
These advanced systems automatically respond to medical and other emergencies
with the help of electronic monitors and other resources. This type of service is
particularly helpful for those who live alone or who are at risk for falls. This is a paid
service.
ELEMENTS OF HOME-BASED LONG-TERM CARE























Assessment, monitoring, and reassessment
Health promotion, health protection, disease prevention, postponement of
disability
Facilitation of self-care, self-help, mutual aid, and advocacy
Health care, including medical and nursing care
Personal care, e.g. grooming, bathing, meals
Household assistance, e.g. cleaning, laundry, shopping
Physical adaptation of the home to meet the needs of disabled individuals
Referral and linkage to community resources
Community-based rehabilitation
Provision of supplies (basic and specialized), assistive devices and
equipment (e.g. hearing aids, walking frames), and drugs
Alternative therapies and traditional healing
Specialized support (e.g. for incontinence, dementia and other mental
problems, substance abuse)
Respite care (at home or in a group setting)
Palliative care, e.g. management of pain and other symptoms
Provision of information to patient, family, and social networks
Counseling and emotional support
Facilitation of social interaction and development of informal networks
Development of voluntary work and provision of volunteer opportunities to
clients
Productive activities and recreation
Opportunities for physical activities
Education and training of clients and of informal and formal caregivers
Support for caregivers before, during, and after periods of caregiving
Preparation and mobilization of society and the community for caring roles
NURSING HOME CARE
Nursing homes provide a comprehensive range of medical services, which includes
24-hour supervision and nursing care. More than 1.5 million elderly in the United
States have spent time in a nursing home, and around one of two nursing home
residents need assistance with all activities of daily living [19]. By, 2050, the total
number of US citizens requiring LTC is expected to increase two fold [19]. Nursing
homes may vary in size and scope of services. They may offer short-term care, post
hospitalization rehabilitation and hospice care. The majority of nursing homes
employ community physicians to provide care. The principal goal of nursing home
care is to maximize resident autonomy, function, dignity, and comfort. Nursing
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homes also provide a sense of community where elderly can engage in social
activities and make social bonds with other people. Care in a nursing home includes
several different levels of care:
Skilled Nursing Care
This type of care is provided on a physician’s recommendation and requires the
professional skills of a registered nurse or a licensed practical nurse. It is offered
either directly by or under the supervision of a registered nurse.
Intermediate Nursing Care
This care is provided under periodic medical supervision and encompasses physical,
psychological, social, and other restorative services. This nursing care is provided by
a skilled registered nurse and includes the observation and the recording of signs
and symptoms.
Personal or Custodial Care
This type of care can be offered by individuals without medical training. The main
goal of custodial care is to meet the personal needs of the elderly, including feeding
and personal hygiene.
Elements of Palliative Care for Nursing Home
Stage of disease or frailty
Element
Early
Middle
Goals of care Discuss
Discuss resident's
diagnosis and understanding of
prognosis;
prognosis, benefit
likely course
versus burden of
of disease;
therapies
diseasemodifying
Reevaluate goals
therapies;
of care and
resident's
resident
goals, hopes, expectations
and
Prepare resident
expectations
for shift in goals
for treatment Encourage focus
on important
Provide
tasks,
resident
relationships,
education
financial and legal
materials
issues
regarding
diagnosis,
palliative care
resources
Programmatic Recommend
Recommend
support
initiation of
initiation of visiting
visiting nurse, nurse, home care
home care,
case
Consider palliative
management, care (home or
applicable
hospital), hospice,
Residents
Late
Discuss resident's
understanding of
diagnosis,
disease course,
and prognosis;
appropriateness
of diseasemodifying
treatments; goals
of care and any
necessary shifts
Bereavement
Screen
surviving
loved ones for
complicated
bereavement
Review course
of care
Address
questions and
concerns
Assist resident in
planning for a
peaceful death
Encourage
completion of
important tasks
Recommend
initiation of
palliative care
(home or
hospital), case
management,
hospice, PACE
Discuss
hospice post
bereavement
services,
mental health
referral,
support
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Stage of disease or frailty
Early
Middle
home
subacute
modifications rehabilitation, case
management,
Review
PACE
prognostic
factors for
resident's
condition(s),
relevant
clinical
practice
guidelines
Financial and Recommend
Reassess adequacy
legal planning professional
of financial,
assistance
medical, home
with financial care, and family
planning,
support; long-term
long-term
care planning
care, future
insurance
Consider hospice
needs; legal
referral, Medicaid
counsel with
eligibility
expertise in
assessment
health care
issues;
protection or
transfer of
financial
assets
Family
Inform
Recommend
support
resident and
support/counseling
family about
for caregivers;
support
respite care;
groups; ask
caregiver visit with
about
his or her personal
practical
physician; help
support
from family and
needs; listen friends
to concerns;
encourage
Discuss role and
home
benefits of hospice
modifications care
to reduce
caregiver
Provide dialogue
burden
for caregiver
concerns and
Provide
needs; information
resident
on practical
education
resources, stress,
materials
depression, and
regarding
adequacy of care
Element
Late
Bereavement
groups
Consider nursing
home with
hospice/palliative
care services if
there is
substantial
caregiver burden
Review financial
resources and
needs, financial
options for
personal and
long-term care
(including
hospice and
Medicaid if
resources are
inadequate for
goals)Explicitly
recommend
hospice
Complete
necessary
documents,
including
death
certificate
Advise remote
family and
friends to visit
the resident
Send
bereavement
card, contact
family, attend
funeral
Address caregiver
need for support
groups,
counseling,
personal health
care, respite
services
Listen to
concerns,
maintain
contact
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Element
Cultural
support
Spiritual
support
Stage of disease or frailty
Early
Middle
diagnosis, as
well as
general
caregiver
tasks and
support
Understand
Understand
acculturation, approaches to
traditions,
medical decision
health beliefs making, issues of
disclosure and
consent
Observe for
spiritual
themes or life
stories that
are sources of
distress or
support
Late
Bereavement
Address advance
directives, endof-life care
planning, care
intensity
Recognize
specific
cultural
practices of
surviving
family
members and
caregivers
Assist
surviving
loved ones
with finding
meaning,
hope, comfort,
and inner
peace
Explore spiritual
Assist resident
issues to develop a with resolving
deeper sense of
conflicts,
healing
receiving
forgiveness, and
grieving
PACE = Program of All-Inclusive Care for the Elderly.
Adapted from Morrison RS, Meier DE. Clinical practice. Palliative care. N Engl J
Med. 2004;350(25):2587.
COMMUNITY BASED LONG-TERM CARE
Community-based long-term care can be offered in many types of settings and by
many kinds of care providers. Some of the specific kinds of services that offer
community- based long-term care include:
Home Health Care
Home health care includes –
 Skilled nursing services
 Personal care
 Health aide services, and
 Physical, occupational, or speech therapy
ASSISTED LIVING FACILITY
Assisted living facilities provide care to individuals in a residential facility and can
include supportive services, personal care, or nursing services. Supportive services
usually include housekeeping, laundry, assistance with meals, and arranging for
transportation. Personal services offer the elderly direct, hands-on help with
activities of daily living. Assisted living forms a bridge between nursing homes and
home care. These facilities offer a homelike environment for elderly requiring or
anticipating assistance with activities of daily living but who do not need 24-hour
nursing care.
These facilities provide an environment that resembles more of a home than a
hospital. The facilities have suites or private rooms and locked doors. There may be
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provision for fireplaces, gathering areas with couches, gardens, atriums, etc.
Frequent outings are also planned. Many assisted living facilities also allow home
health agencies to provide services for residents. Some assisted living facilities
provide specialized care for Alzheimer's patients. Medicare does not cover the costs
of assisted living.
Adult Day Care
Adult day care is care provided in a nonresidential, community-based group program
that caters to the needs of functionally impaired elderly. These facilities provide a
number of health, social, and support services during the day. According to a recent
survey, there are more than 4,600 Adult day care centers nationwide; however,
more than 9000 such centers are needed. Adult day care services provide an
alternative to caregivers by providing a daytime care environment outside of the
home.
Respite Care
Respite care offers personal care, supervision, or other services to an individual to
provide temporarily relief to that individual’s care provider and/or family member.
These services are generally provided at the individual’s home or in another home or
homelike setting. In some cases, it can also be provided in a nursing home.
HOSPICE CARE
Hospice care primarily offers symptom and pain management, and supportive
services to terminally ill individuals and their families. Hospice is a form of palliative
care for terminally ill individuals. Hospice care provides compassion, support and
dignity to the patients during the process of dying.
Providers involved in the hospice care








Family caregivers
The patient' s personal physician
Hospice physician (or medical director)
Nurse
Home health workers
Social workers and trained volunteers
Clergy or other counselors
Speech, physical, and occupational therapists, if needed
Principal aims of hospice care
Manages the patient's pain and symptoms;
Helps the patient with the emotional, psychosocial and spiritual aspects of
dying

Provides needed medications, medical supplies, and equipment;

Coaches the family on how to care for the patient;

Delivers special services like speech and physical therapy when needed;
Makes short-term inpatient care available when pain or symptoms become too
difficult to manage at home, or the caregiver needs respite time; and Provides
bereavement care and counseling to surviving family and friends.


Eligibility hospice from Medicare
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



Eligible for Medicare Part A (Hospital Insurance), and
The doctor and the hospice medical director certify that the person is terminally
ill and potentially has less than six months to live, and
The person or a family member signs a statement choosing hospice care
instead of routine Medicare covered benefits for the terminal illness, and
Care is received from a Medicare-approved hospice program.
Eligibility for Hospice
Common terminal conditions and the medical criteria indicative of advanced illness.
Patients are eligible for hospice only if all of the following conditions are satisfied.
Attending physician certifies that patient has a terminal condition with an expected
life span of 6 months or less.
Patient decides to forego life prolonging therapies.
The patient does not have to be a DNR to be eligible for hospice. No home hospice
can refuse to admit a patient just because s/he opts to remain a “full code”.
However, this could potentially represent a “red flag” regarding full understanding of
the focus of hospice care on symptom management as opposed to curative disease
modifying treatment. This should be fully explained to the patient and fully
documented. As an example, patients with advanced congestive heart failure (CHF)
should remain on their ACE inhibitor and diuretics as tolerated as these treatments
are considered palliative and help control many symptoms. These treatments may
be life prolonging, but in a hospice setting they are understood to be primarily
palliative.
Diagnoses include:
 Advanced End Stage Senescence or Debility
 Cancer
 Amyotrophic Lateral Sclerosis (ALS)
 Liver Disease
 Pulmonary Disease
 Dementia
 HIV
 Stroke and Coma
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Patterns of development of home-based long-term care services at
different stages of economic development







Lowestincome
economies
Almost all care
is informal
Direct care is
informal
Largely
voluntary
community
workers
(payment in
kind), some
training
No personal
care, or homemaking, making
but counseling,
simple clinical,
responsibilities,
and dispensing
of supplies
Also community
development
role
Professional
staff in a
supervisory role







Low-income
economies
Almost all care
is informal
Paid local
community
workers
More training of
these workers
No personal
care or homemaking but
counseling,
simple clinical,
responsibilities,
and dispensing
supplies
Also community
development
role
Professional
staff in a
supervisory role







Middle-income
economies
More limited
informal care
Paid local
community
workers
Some personal
care and homemaking and less
clinical care
Professional
staff involved in
more direct
home care
Emergence of
some socialsystem-based
home care
Growing
institutional care








High-income
economies
More pressure on
availability of
informal care
Few community
health workers
Specialized
personal care
and homemaking workers
with no clinical
or community
development
roles
Varying
professional
training for
these workers
and concern for
overprofessionalizati
on
Professional
home care
highly
developed
Institutional
care of major
importance
Segregated
social and
health-based
home-care
systems
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LONG-TERM CARE HOSPITALS (LTCHs)
LTCHs account for a small percentage of total Medicare spending, but have been
growing for the last few years. These are acute care hospitals, which also focus on
providing care to patients who stay in the facility for more than 25 days. These
hospitals offer specialized treatment to patients who may have several comorbidities, but with a relatively good prognosis assuming adequate medical
treatment and supervised care. Some patients are transferred from the intensive or
critical care units of the hospital. LTCHs offer a comprehensive rehabilitation
program, respiratory therapy, pain relief and management and head trauma
management.
Malnutrition in the Elderly
An aging population is one of the biggest social changes that have occurred in the
last few decades and is primarily due to improved standards of living. By 2050, it is
estimated that the elderly will outnumber children under the age of 14 years [20].
Globally and in the US, the elderly population is very diverse, ranging from very
healthy, active and fit independent individuals, to very weak, frail and dependent
older people with chronic disease and varying degrees of disabilities. Currently
approximately 13% of our population is over 65 years old. This is expected to
increase to about 20% by 2050. Globally, the elderly population will also increase
dramatically in the next 30 years [21]. Today, it is estimated that approximately
two thirds of general and acute hospital beds are occupied by individuals over 65
years of age, and those over 75 years occupy the beds for longer times. [22]. The
elderly bear an increased burden of disease that also affects their nutritional status.
In addition, as we age, we experience changes in body composition and metabolism
that also affect our nutritional status.
Body composition of elderly people
Fat mass increases untill about 75 years of age, and then remains stable or
decreases [23–55]. In addition, it is believed that central fat accumulation increases
with aging, while appendicular fat mass decreases [23- 26] Several studies have
linked this pattern of fat distribution to an increased risk of diabetes, stroke,
hyperlipidemia, cardiac disease, and hypertension, [27] and all these conditions are
commonly seen in elderly population. Fat free mass (FFM) decreases with age, and
generally starts declining around 40–50 years. [23, 24, 28, 29] This loss accelerates
further due to a reduction in skeletal muscle, and bone mineral density, particularly
in older women. Several studies have shown that even a 10% loss of lean tissue in
previously healthy people can lead to poor immunity, increased susceptibility to
infections, and subsequently increased mortality [30, 31]. Therefore, elderly with
greater FFM loss are prone to various types of disease and infections.
Etiology of Weight Loss
Weight loss in elderly can be categorized into three distinct types:

Wasting: This is an involuntary weight loss predominantly caused by
inadequate dietary intake. Chronic disease and psychosocial factors play an
important role. Wasting in elderly may be seen with a background of
cachexia, sarcopenia or both.

Cachexia: This is an involuntary loss of free fat mass (FFM) or body cell mass
(BCM), which is caused by increased catabolism, and increased protein
degradation leading to changes in the body composition. However, weight
loss may not be present in the beginning. Cachexia is observed in several
chronic diseases such as congestive heart failure, rheumatoid arthritis, HIV
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
infection, and cancer, and also in conditions associated with metabolic stress
such as trauma, decubitus ulcers and infections. Concentrations of the certain
cytokines i.e. interleukin 1 (IL1), tumor necrosis factor a (TNFa) and IL6 are
higher than normal in patients with cachexia and weight gain is associated
with a reduction in these levels [32].
Sarcopenia: This is an involuntary loss of muscle mass, which is primarily
due to aging and not the effect of age associated chronic or co-morbid
diseases. Hormonal, neural, and cytokine activity with lack of physical
activity play an important role in the development of sarcopenia. A recent
study has observed that inflammatory cytokines TNFa and IL1b prevent the
development of functional muscle fibers [17].
Comparison of the characteristics of undernutrition due to anorexia, cachexia and
sarcopenia
Anorexia
Cachexia
Sarcopenia
Anorexia
+
++
−
Weight loss
+
++
+/−
Fat loss
++
++
0
Muscle loss
+
+++
++
Proteolysis
−
++
+
Hypertriglyceridemia
−
++
+
Anemia
+
++
−
Insulin resistance
−
++
+
Elevated cytokines
+/−
++
+/−
Increased C-reactive protein
+: present; –: absent.
−
++
−
Malnutrition in the Older Population
Malnutrition is the state of being poorly nourished due to either the lack of one or
more nutrients (undernutrition), or the excess of nutrients (overnutrition). The
elderly usually suffer from undernutrition. In the older population, malnutrition is an
important issue that has been observed in hospitals, [33] residential care, [34] and
in the community [35].
The prevalence of malnutrition in the general hospital population hovers around 11%
to 44%, but can rise in the elderly to 29%– 61% [33]. Aging is not the sole factor
for malnutrition in the elderly: many other changes linked to the aging process can
cause malnutrition [36]. For example, the elderly may have loss of smell and taste
acuity, poor dental and oral health, and decreased physical activity, all of which may
adversely impact food intake [37]. Any change in food or nutrient intake may cause
malnutrition with it’s potentially life threatening and serious consequences. Many
research studies have observed a close relationship between the severity of
malnutrition and increased duration of hospital stay, treatment costs, return to
normal life, [38, 39] and readmission rates [40]. Therefore, the treatment as well as
prevention of malnutrition among the elderly population represents a major
challenge for our health care system.
Causes of Malnutrition
The causes of malnutrition among older people are varied, but can be categorized
into three main types: medical, social, and psychological.
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RISK FACTORS FOR MALNUTRITION IN ELDERLY
Medical factors

Poor appetite

Poor dentition, other oral problems and dysphagia

Loss of taste and smell

Respiratory disorders: emphysema

Gastrointestinal disorder: malabsorption

Endocrine disorders: diabetes, thyrotoxicosis

Neurological disorders: cerebrovascular accident, Parkinson’s disease

Infections: urinary tract infection, chest infection

Physical disability: arthritis, poor mobility

Drug interactions: digoxin, metformin, antibiotics

Other disease states:cancer
Lifestyle and social factors

Lack of knowledge about food, cooking, and nutrition

Isolation/loneliness

Poverty

Inability to shop or prepare food
Psychological

Confusion

Dementia

Depression

Bereavement

Anxiety
Additional risk factors in a hospital setting

Food service—sole nutritional supply is hospital food, limited choice,
presentation may be poor

Slow eating and limited time for meals

Missing dentures

Needs feeding/supervision

Inability to reach food, use cutlery, or open packages

Unpleasant sights, sounds, and smells

Increased nutrient requirement, for example, because of infections,
catabolic state, wound healing, etc

Limited provision for religious or cultural dietary needs

Nil by mouth or miss meals while having tests
Appetite
It is clear that several factors play a role in appetite regulation. Poor appetite or
anorexia is one of the most common causes of malnutrition and is mediated by a
number of factors. Energy intake decreases with age, [41,42] and the elderly are
susceptible to micro-nutrient deficiencies with a poor energy intake [43]. The exact
mechanism behind this reduction is still unknown but several possible hypotheses
have been developed. It is believed that aging is often linked with poor food intake
regulation. It has been suggested that elderly fail to reduce their energy
expenditure during these periods of negative energy balance [44]. The elderly take
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longer to regain their lost weight, and are susceptible to risks associated with
malnutrition during this period.
Researchers have also shown that satiety is determined by a complex process
involving the hormone cholecystokinin (CCK) and the relaxation of the stomach wall.
CCK levels are higher in older people with slow gastric emptying, both of which play
an important role in early satiety [45]. In addition, the elderly have a reduced
stomach capacity. Therefore, the stomach wall stretches earlier thus causing early
satiety [46]. Compared to young adults, the elderly are also less responsive to the
volume of the stomach contents, as measured by hunger ratings [47]. It is
suspected that the ghrelin (hunger hormone) level is reduced with aging, trauma or
illness. Aging also causes the dysregulation of peptide hormones such as CCK,
peptide-YY, oxyntomodulin, glucagon-like peptide 1, and pancreatic polypeptide.
These hormones play an important role in the regulation of appetite. Older people
usually have reduced levels of growth and sex hormones, but have increased levels
of catecholamines and glucocorticoids [32]. This hormonal imbalance leads to
elevated levels of cytokines such as TNFa, IL1, IL6, and serotonin which increase
catabolism and can cause anorexia. These cytokines are also elevated in chronic
inflammatory diseases, trauma, and various infections. Furthermore, the brain and
neurotransmitters play an important role in the regulation of food intake. It is
believed that aging leads to low levels of endogenous opioids in the brain as well as
loss of opioid receptors [48]. The elderly have reduced levels of nitric oxide and
endogenous opioids, which play an important role in food intake regulation.
Taste and smell
A poor sense of taste and smell are also held responsible for the loss of appetite as
they are associated with decline in the pleasantness of food [49]. Taste also plays a
crucial role in the cephalic phase response that prepares the body for food digestion.
Taste is also an important factor for the modulation of food selection and meal size
by increasing the pleasure of eating and satiety [50]. Aging is associated with loss of
taste and smell that can also be exacerbated by certain medications and diseases
[50, 51]. The exact cause of taste loss is still not known. It is believed that aging
leads to reduction in the number of taste buds, and a decrease in the functioning of
taste receptors which play a key role in taste sensation [50].
Many drugs such as antihistamines, lipid lowering agents and others can alter the
sensation of taste and smell. The exact mechanism by which these medications alter
taste or smell is still unknown. Some research studies have observed that improving
the food flavor can enhance nutritional intake and cause weight gain in nursing home
and hospital patients, as well as in the healthy elderly [52, 53].
Oral health and dental status
Poor oral health and dentition can significantly impact food intake in the elderly.
Poor oral health and dentition can cause difficulty in chewing, speaking, dryness of
mouth, and can impact relationships with others [54- 56]. In these studies, it was
shown that energy intake was lower in edentate elderly people with poor energy
intake with concomitant deficiencies of micronutrients (calcium, iron, vitamins A, C
and E, and some B vitamins), fiber, and protein.
Dysphagia
Dysphagia can also lead to malnutrition due to poor food intake [57].
Disease and disability
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In the elderly, disease may increase the risk of malnutrition. It has been observed
that rates of hospital malnutrition, and worsening malnutrition increases during
illness. Additionally, some drugs can adversely affect food intake. Compared to
other age groups, the elderly take more medications and are therefore more likely to
have these adverse side effects.
Lifestyle and social factors
It has been observed that burden of disease, stress, poor appetite, and vision are
independent determinants of food intake in elderly [58]. Lifestyle factors may also
contribute in the development of malnutrition. Other determinants of food intake
are:

Knowledge of cooking

Social isolation and loneliness

Food attitudes and beliefs

Certain psychological factors such as stress , depression, and bereavement

Availability of services and assistance

Oral health and dentition

Food expenditure

Food availability

Degree of functional disability

Appetite status

Disease status
Dementia and confusion
Several studies have observed a close relationship between cognitive impairments
and malnutrition in elderly. It has been observed that there is an inverse relationship
between food intake and cognition, indicating that impaired cognition may adversely
impact the ability or the desire to eat [59]. Progressive dementia process is
characterized by frequent weight loss and an altered eating pattern. Uncontrolled
weight loss is a distinctive feature in the latter stages [60]. Approximately 50% of
the elderly with Alzheimer’s disease lose the ability to feed themselves eight years
after diagnosis [61]. Furthermore, it has been observed that even in early stages of
Alzheimer’s disease, some patients may experience slower oral manipulation of food
and a slower swallow response [62]. A recent study conducted on nursing home
patients with dementia done to investigate the cause of unintentional weight loss,
found a close association between weight loss in demented elderly and the process of
choosing food, bringing the chosen food to the mouth, and chewing [63]. Several
studies have also observed that major changes in feeding ability develop during
dementia and subsequently lead to weight loss and malnutrition.
Depression and other psychological factors
Several studies have observed that depression leads to malnutrition and weight loss
in the elderly [64-66]. Bereavement can also adversely impact eating behaviors and
food intake [67]. Stress and anxiety can impact pattern food intake. For example, it
has been found that low or depressed moods may push people to eat more,
particularly comfort food. Some people may resort to fasting also.
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Common single nutrient deficiency diseases
Deficient
Disease
nutrient
Clinical presentations
Pellagra
Niacin (Vit
B3)
Beriberi
Thiamine (Vit Dry: Parasthenia, footdrop, loss of reflexes Wet:
B1)
Edema, dyspnea, heart failure
Wernicke’s
syndrome
Thiamine (Vit
B1)
Confusion, sixth nerve palsy, coma
Scurvy
Vitamin C
Petechiae, bleeding
Xeropthalmia
Vitamin A
Keratitis, blindness
Dermatitis, diarrhea or constipation and dementia
Effects of protein energy malnutrition
Death
Pressure ulcers
Hip fracture
Falls
Weakness
Fatigue
Anemia
Edema
Cognitive abnormalities
Infections
Immune dysfunction
Thymic atrophy
Decreased delayed hypersensitivity
Decreased helper T cells (CD4+)
Decreased lymphocyte response to mitogens
Decreased response to immunizations
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Assessing Malnutrition
Initial screening for malnutrition in the elderly includes an accurate measurement of
weight and height and assessment with a screening tool such as the Mini Nutritional
Assessment (MNA). [68] Clinical judgment plays an important role in the
identification of patients at risk for malnutrition [69]. Proper assessment of function
is important because functional decline may lead to malnutrition or result from it.
Weight and Body Mass Index
Weight loss is an important indicator of malnutrition. Parameters for the assessment
of elderly in long-term care settings are as follows [70-76]:
 Severe weight loss is defined as greater than 5% weight loss in 1 month,
7.5% weight loss in 3 months or 10% weight loss in 6 months.
 Failure to thrive can be defined as a 25% weight loss with no identifiable
cause.
 Measurement of weight and height are necessary to determine body mass
index. A BMI of 21 or less is often consistent with malnutrition in older adults
and has been linked to higher mortality. It should trigger intervention [77].
Even in overweight individuals, weight loss is associated with a greater incidence of
morbidity and mortality [78-79].
Body Mass Index
2
Classification
Underweight
Normal
Overweight
Obesity Class
BMI(kg/m )
<18.5
18.5–24.9
25.0–29.9
I
II
III
30.0–34.9
35.0-39.9
>40
Height
It is important to measure height accurately. The best way to measure the height of
an older adult is to use height at the knee to determine overall height.
Estimating Stature Based on Knee Height
AGE (years)
6–18
19–60
MEN
White
S = 40.54 + (2.22
S = 71.85 + (1.88
KH)
KH)
Black
S = 39.60 + (2.18
X = 73.42 + (1.79
KH)
KH)
WOMEN
White
S = 43.21 + (2.14
S = 70.25 + (1.87
KH)
KH) – 0.06 A)
Black
S = 46.59 + (2.02
S = 68.10 + (1.86
KH)
KH) – (0.06 A)
>60
S = 59.01 + (2.08
KH)
S = 95.79 + (1.37
KH)
S = 75.00 + (1.91
KH) – (0.17 A)
S = 58.72 + (1.96
KH)
Undernutrition in older adults
The simplified nutrition assessment questionnaire (SNAQ)
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1. My appetite is
A. very poor
B. poor
C. average
D. good
E. very good
2. When I eat
A. I feel full after eating only a few mouthfuls
B. I feel full after eating about a third of a meal
C. I feel full after eating over half a meal
D. I feel full after eating most of the meal
E. I hardly ever feel full
3. Food tastes
A. very bad
B. bad
D. good
E. very good
4. Normally I eat
A. less than one meal a day
B. one meal a day
C. two meals a day
D. three meals a day
E. more than three meals a day
Instructions: complete the questionnaire by circling the correct answers and then
tally the results based upon the following numerical scale: A = 1, B = 2, C = 3, D =
4 and E = 5. Scoring: if the mini-SNAQ is <14, there is a significant risk of weight
loss.
Screening-Mini Nutritional Assessment
A Has food intake declined over the past 3 months due to loss of
appetite, digestive problems, chewing or swallowing difficulties?
0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake
B Weight loss during the last 3 months
0 = weight loss greater than 3 kg (6.6 lbs)
1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss
C Mobility
0 = bed or chair bound
1 = able to get out of bed / chair but does not go out
2 = goes out
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D Has suffered psychological stress or acute disease in the past 3
months?
0 = yes
2 = no
E Neuropsychological problems
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems
F1 Body Mass Index (BMI) (weight in kg) / (height in m2)
0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2.
DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED
F2 Calf circumference (CC) in cm
0 = CC less than 31
3 = CC 31 or greater
12-14 points: Normal nutritional status
8-11 points: At risk of malnutrition
0-7 points: Malnourished
Screening MNA
A Has food intake declined over
the past 3 months due to loss of
appetite, digestive problems,
chewing or swallowing
difficulties?
0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake
B Weight loss during the last 3
months
0 = weight loss greater than 3 kg (6.6
lbs)
1 = does not know
2 = weight loss between 1 and 3 kg
(2.2 and 6.6 lbs)
3 = no weight loss
C Mobility
0 = bed or chair bound
Ask patient or caregiver or check the
medical record
• “Have you eaten less than normal over
the past three months?”
• If so, “is this because of lack of
appetite, chewing, or swallowing
difficulties?”
• If yes, “have you eaten much less than
before, or only a little less?”
Ask patient / Review medical record (if
long term or residential care)
• “Have you lost any weight without
trying over the last 3 months?”
• “Has your waistband gotten looser?”
• “How much weight do you think you
have lost? More or less than 3 kg (or 6
pounds)?”
Though weight loss in the overweight
elderly may be appropriate, it may also
be due to malnutrition. When the weight
loss question is removed, the MNA® loses
its sensitivity, so it is important to ask
about weight loss even in the overweight.
Ask patient / Patient’s medical record /
Information from caregiver
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1 = able to get out of bed / chair but
does not go out
2 = goes out
D Has suffered psychological
stress or acute disease in the past
3 months?
0 = yes
2 = no
E Neuropsychological problems
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems
F1 Body Mass Index (BMI)
(weight in kg) / (height in m2)
0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
• “How would you describe your current
mobility?”
• “Are you able to get out of a bed, a
chair, or a wheelchair without the
assistance of another person?” – if not,
would score 0
• “Are you able to get out of a bed or a
chair, but unable to go out of your
home?” – if yes, would score 1
• “Are you able to leave your home?” – if
yes, would score 2
Ask patient / Review medical record / Use
professional judgment
• “Have you been stressed recently?”
• “Have you been severely ill recently?”
Review patient medical record / Use
professional judgment / Ask patient,
nursing staff or caregiver
• “Do you have dementia?”
• “Have you had prolonged or severe
sadness?”
The patient’s caregiver, nursing staff or
medical record can provide information
about the severity of the patient’s
neuropsychological problems (dementia).
Determining BMI
BMI is used as an indicator of appropriate
weight for height (Appendix 1)
BMI Formula – US Units
• BMI = ( Weight in Pounds / [Height in
inches x Height in inches] ) x 703
BMI Formula – Metric Units
• BMI = ( Weight in Kilograms / [Height
in Meters x Height in Meters] )
1 Pound = 0.45 Kilograms
1 Inch = 2.54 Centimeters
Before determining BMI, record the
patient’s
weight and height on the MNA® form.
1. If height has not been measured,
please measure using a stadiometer or
height gauge (Refer to Appendix 2).
2. If the patient is unable to stand,
measure height using indirect methods
such as measuring demi-span, arm span,
or knee height. (See Appendix 2).
3. Using the BMI chart provided
(Appendix 1), locate the patient’s height
and weight and determine the BMI.
4. Fill in the appropriate box on the
MNA®
form to represent the BMI of the patient.
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5. To determine BMI for a patient with an
amputation, see Appendix 3.
Note: If the BMI cannot be obtained,
discontinue use of the full MNA® and use
the MNA®-SF instead. Substitute calf
circumference for BMI on the MNA®-SF.
F2 Calf circumference (CC) in cm
0 = CC less than 31
3 = CC 31 or greater
Additional Information
G Lives independently (not in a
nursing home)?
Score 1 = Yes
0 = No
H Takes more than 3 prescription
drugs per day?
Score 0 = Yes
1 = No
I Pressure sores or skin ulcers?
Score 0 = Yes
1 = No
J How many full meals does the
patient eat daily?
Score 0 = One meal
1 = Two meals
2 = Three meals
K Selected consumption markers
for protein intake Select all that
apply.
Ask patient
This question refers to the normal living
conditions of the individual. Its purpose is
to determine if the person is usually
dependent on others for care. For
example, if the patient is in the hospital
because of an accident or acute illness,
where does the patient normally live?
• “Do you normally live in your own
home, or in an assisted living, residential
setting, or nursing home?”
Ask patient / Review patient’s medical
record
Check the patient’s medication record /
ask nursing staff / ask doctor / ask
patient
Ask patient / Review patient’s medical
record
• “Do you have bed sores?”
Check the patient’s medical record for
documentation of pressure wounds or
skin ulcers, or ask the caregiver / nursing
staff /doctor for details, or examine the
patient if information is not available in
the medical record.
Ask patient / Check food intake record
if necessary
• “Do you normally eat breakfast, lunch
and dinner?”
• “How many meals a day do you eat?”
A full meal is defined as eating more than
2 items or dishes when the patient sits
down to eat.
For example, eating potatoes, vegetable,
and meat is considered a full meal; or
eating an egg, bread, and fruit is
considered a full meal
Ask the patient or nursing staff, or check
the completed food intake record
• “Do you consume any dairy products (a
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• At least one serving of dairy
products (milk, cheese, yogurt) per
day?
Yes
No
• Two or more servings of legumes or
eggs
per week?
Yes
No
• Meat, fish or poultry every day?
Yes
No
Score 0.0 = if 0 or 1 Yes answer
0.5 = if 2 Yes answers
1.0 = if 3 Yes answers
L Consumes two or more servings
of fruits or vegetables per day?
Score 0 = No
1 = Yes
M How much fluid (water, juice,
coffee, tea, milk) is consumed per
day?
Score 0.0 = Less than 3 cups
0.5 = 3 to 5 cups
1.0 = More than 5 cups
N Mode of Feeding?
Score 0 = Unable to eat without
assistance
1 = Feeds self with some difficulty
2 = Feeds self without any problems
glass of milk / cheese in a sandwich / cup
of yogurt / can of high protein
supplement)
every day?”
• ”Do you eat beans / eggs? How often do
you eat them?”
• “Do you eat meat, fish or chicken every
day?”
Ask the patient / check the completed
food intake record if necessary
• “Do you eat fruits and vegetables?”
• ”How many portions do you have each
day?”
A portion can be classified as:
• One piece of fruit (apple, banana,
orange, etc.)
• One medium cup of fruit or vegetable
juice
• One cup of raw or cooked vegetables
Ask patient
• “How many cups of tea or coffee do you
normally drink during the day?”
•”Do you drink any water, milk or fruit
juice?”
“What size cup do you usually use?”
A cup is considered 200 – 240ml or 78oz.
Ask patient / Review patient medical
record/
Ask caregiver
• “Are you able to feed yourself?” / “Can
the patient feed himself/herself?”
•”Do you need help to eat?” / “Do you
help the patient to eat?”
• “Do you need help setting up your
meals (opening containers, buttering
bread, or cutting meats)?”
* Patients who must be fed or need help
holding the fork would score 0.
** Patients who need help setting up
meals (opening containers, buttering
bread, or cutting meats), but are able to
feed themselves would score 1 point.
Pay particular attention to potential
causes of malnutrition that need to be
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O Self-View of Nutritional Status
Score 0 = Views self as being
malnourished
1 = Is uncertain of nutritional state
2 = Views self as having no
nutritional problems
P In comparison with other people
of the same age, how does the
patient consider his/her health
status?
Score 0.0 = Not as good
0.5 = Does not know
1.0 = As good
2.0 = Better
Q Mid-arm circumference (MAC) in
cm
Score 0.0 = MAC less than 21
0.5 = MAC 21 to 22
1.0 = MAC 22 or greater
R Calf circumference (CC) in cm
Score 0 = CC less than 31
1 = CC 31 or greater
24-30 points-Normal nutritional status
17-23.5-At Risk of Malnutrition
<17 Malnourished
addressed to avoid malnutrition (e.g.
dental problems, need for adaptive
feeding devices to support eating).
Ask the patient
• “How would you describe your
nutritional state?”
Then prompt ”Poorly nourished?”
“Uncertain?”
“No problems?”
The answer to this question depends upon
the patient’s state of mind. If you think
the patient is not capable of answering
the question, ask the caregiver / nursing
staff for their opinion.
Ask patient
• “How would you describe your state of
health compared to others your age?”
Then prompt ”Not as good as others of
your age?”
“Not sure?”
“As good as others of your age?”
“Better?”
Again, the answer will depend upon the
state of mind of the person answering the
question.
Q
Mid-arm circumference (MAC) in cm
Score 0.0 = MAC less than 21
0.5 =
Measure the mid-arm circumference in cm
Calf circumference should be measured in
cm
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Undernutrition in older adults
The ‘Meals on Wheels’ mnemonic for treatable causes of weight loss
Medications
Emotional (depression)
Alcoholism, anorexia tardive dyskinesia, abuse (elder)
Late life paranoia
Swallowing problems
Oral problems
Nosocomial infections, no money (poverty)
Wandering/dementia
Hyperthyroidism, hypercalcemia, hypoadrenalism
Enteric problems (malabsorption)
Eating problems (e.g. Tremor)
Low salt, low cholesterol diet
Shopping and meal preparation problems, stones (cholecystitis)
Laboratory Studies
Laboratory analysis for an elderly patient suspected of malnutrition should assess the
presence of disease and conditions that cause weight loss or loss of appetite. A
complete blood count screens for infection and anemia, particularly megaloblastic
anemia due to B12 or folate deficiency. A complete thyroid profile to detect
hypothyroidism and hyperthyroidism is also required. A comprehensive metabolic
panel including total protein and albumin, serum electrolytes and liver function tests
should also be conducted. Urinalysis and stool analysis should also be conducted to
detect infection and bleeding. Some of the important markers of malnutrition in
elderly include albumin, transferrin, retinol-binding protein and thyroxine-binding
prealbumin [80]. Among all these markers of nutrition, serum albumin is considered
to be more accurate as it is predictive of mortality and other outcomes in older
people. However, these proteins are also affected by inflammation and infection;
therefore, they have limited usefulness.
Transferrin is a more sensitive indicator of early protein-energy malnutrition;
however, it is not reliable in conditions such as iron deficiency, chronic infection,
hypoxemia, and liver disease [81]. A low total lymphocyte count indicates a poor
prognosis and is independent of low serum albumin [80, 82] Malnutrition is also
associated with age-related immune impairments, including decreased lymphocyte
proliferation [83]. No biochemical marker or screening test can clearly indicate
malnourishment.
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Management of malnutrition
Only 1% of elderly individuals who are independent and healthy are malnourished;
however, approximately, 16% of community-dwelling elderly in the US consumed
fewer than 1000 calories per day [84, 85]. Management of malnutrition in the
elderly focuses early on offering ample food choices with high nutrient density and
high caloric value after which additional caloric supplements can be considered. It
also focuses on the early diagnoses and treatment of treatable causes of
malnutrition. Provision of adequate food forms the basis of the management of
malnutrition. A recent study has observed that caloric supplementation is associated
with decreased length of hospitalization and mortality [86]. Amino acid
supplementation rich in leucine has been found to increase production of muscle
protein and muscle function [87]. Oral calorie supplements should ideally be taken
between meals. [88] Improving food taste, enhancing flavors, good ambience and
time spent feeding impaired elderly also help in treating malnutrition [89-91].
There are two major orexigenic or appetite stimulant drugs (megestrol acetate and
dronabinol) which may be used for the management of malnutrition. Megestrol
acetate causes increased food intake and leads to weight gain [92]. It is more
effective in women than in men. Megestrol acetate should be given with food for
better absorption. A nanoparticle form of this drug is better absorbed during
starvation. The major adverse effect of this drug is increased risk of deep vein
thrombosis. Megestrol acetate should not be prescribed to elderly confined to bed.
Its efficacy increases in combination with olanzapine [93]. Dronabinol is also an
effective medication that leads to a small increase in appetite as well as weight gain.
It is also used as palliative care drug as it decreases nausea, increases enjoyment of
food and life. Testosterone in combination with a caloric supplement can also lead to
weight gain and decreases hospitalization in the frail elderly [94].
Gastrointestinal tube feeding can be a life saving option for those elderly who are
unable to swallow. However, tube feeding should be used selectively.
Aging is associated with decreased vitamin D level [95]. Low level vitamin D in the
body is associated with fractures, muscle atrophy, falls and an increased rate of
mortality. Adequate supplementation with 800–1000 IU vitamin D daily may help the
elderly manage low levels of vitamin D.
Anemia due to malnutrition is commonly seen in elderly [96]. Iron deficiency anemia
is the most common, but vitamin B12 and folate deficiency are also seen in the
elderly. Iron deficiency anemia is observed in individuals having a low iron and
ferritin level. Transferrin receptors should be measured to differentiate from the
anemia of chronic disease. Methylmalonic acid levels should be assessed in people
with borderline low levels of vitamin B12. Treatment of vitamin B12 deficiency
includes either 1000 IU of vitamin B12 orally daily or injections of 1000 IU of vitamin
B12 weekly for 4 weeks.
Iron deficiency anemia is treated with oral iron once a day for 6 weeks. Reticulocyte
count should be measured after 1 week of treatment. If the reticulocyte count
doesn’t increase, malabsorption may be a possibility and parenteral iron may be
required in such cases.
Zinc deficiency may be seen in elderly with diabetes mellitus and cancer or who are
on diuretics [97]. The role of zinc supplementation remains uncertain.
Interventions that may be necessary for the management of undernutrition,
malnutrition and nutritional deficiencies may include one or more of the following
actions:
 Liberalize diet by removing or changing dietary restrictions
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







Encourage use of flavor enhancers
Increase frequency of small meals
Add liquid food supplements between meals
Addition of meat, peanut butter, or protein powder to increase protein intake
Diagnose and treat depression with medications that antidepressants that do
not exacerbate malnutrition
Replace or discontinue drugs that may lead to anorexia
Evaluate dysphagia, swallowing impairment and the ability to manage eating
Obtain social services assessment of living situation of community-dwelling
adults [98].
The hospital and skilled nursing facilities present additional factors that impact
nutrition. Interventions that may be carried in the institutional setting for the
management of malnutrition in the elderly include:
 Ensure that patients have all the necessary sensory aids such as dentures,
glasses, hearing aids, etc.
 Make sure that the elderly patient is seated upright close to 90 degrees.
 The elderly in a long-term care facility should preferably take their meals in
the dining room.
 While taking meals, food and utensils should be kept unwrapped or in open
containers and should be within the patient's reach.
 The elderly should be given ample time to eat, facilitating their potentially
slower pace of eating
 Consider the ethnic food preferences of the elderly and allow families to bring
foods that the patient loves to eat.
 If an elderly person must be fed or requires assistance, give adequate time
for chewing, swallowing, and clearing throat before another bite. The person
assisting the patient should develop a good rapport with that patient.
 Those with dementia may need to be reminded to chew and swallow and may
benefit from finger foods.
 The patient’s family should be encouraged to be present at mealtime and to
assist in feeding.
Clinical signs and nutritional deficiencies
System
Sign or symptom
Nutrient deficiency
Skin
Dry scaly skin
Zinc/essential fatty acids
Follicular hyperkeratosis
Vitamins A, C
Petechiae
Vitamins C, K
Photosensitive dermatitis
Niacin
Poor wound healing
Zinc, vitamin C
Scrotal dermatitis
Riboflavin
Thin/depigmented
Protein
Easily plucked, hair loss
Protein, zinc
Transverse depigmentation
Albumin
Spooning
Iron
Night blindness
Vitamin A, zinc
Hair
Nail
Eyes
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System
Mouth
Neck
Abdomen
Extremities
Neurological
Sign or symptom
Nutrient deficiency
Conjunctival inflammation
Riboflavin
Keratomalacia
Vitamin A
Bleeding gums
Vitamin C, riboflavin
Glositis
Niacin, pyridoxine, riboflavin
Atrophic papillae
Iron
Hypogeusia
Zinc, vitamin A
Thyroid gland enlargement
Iodine
Parotid gland enlargement
Protein
Diarrhea
Niacin, folate, vitamin B12
Hepatomegaly
Protein
Bone tenderness
Vitamin D
Joint pain
Vitamin C
Muscle tenderness
Thiamine
Muscle wasting
Protein, selenium vitamin D
Edema
Protein
Ataxia
Vitamin B12
Tetany
Calcium, magnesium
Parasthesia
Thiamine, vitamin B12
Ataxia
Vitamin B12
Dementia
Vitamin B12, niacin
Hyporeflexia
Thiamine
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Dysphagia
Introduction
Dysphagia can be defined as any impairment in the swallowing process [102] and is
a frequent health concern in our aging population. Individuals with physiological or
anatomical impairments in the mouth, pharynx, larynx, and esophagus may
experience dysphagia [102]. Dysphagia also increases the risk of malnutrition and
pneumonia. Dysphagia is observed in 68% of elderly nursing home residents [105],
around 30% of elderly admitted to the hospital [106], approximately 64% of patients
after stroke [107, 108], and up to 13%–38% of elderly who live independently [109111].Predisposing factors for dysphagia in the elderly include alterations in
swallowing physiology and chronic diseases. In the US, approximately 300,000–
600,000 individuals suffer dysphagia every year [99]. It is believed that around 15%
of the elderly population experience dysphagia [100].According to a recent study,
from 2002–2007, dysphagia referral rates among the elderly in a single tertiary
teaching hospital increased by 20%.70% of the referrals were for individuals above
the age of 60 [101]. In 2010, it is suggested that approximately 6 million elderly
were at risk for dysphagia.
Aging effects on swallowing function
Aging leads to reductions in muscle mass and connective tissue elasticity resulting in
poor range of motion [103] and a loss of strength [104]. These changes may
adversely affect the process of swallowing. Most commonly, a subtle and
progressive slowing of the swallowing processes occurs in the elderly. Over time,
these subtle but cumulative changes may cause dysphagia and affect the upper
airway [103]. In addition, low moisture in the oral cavity, poor taste, and smell
acuity can also lead to poor swallowing in the elderly. However, the predominant
factor responsible for dysphagia in the elderly is the presence of age-related disease.
Dysphagia and its sequelae
The swallowing process is complex and many diseases and conditions can affect this
vital function. Neurological diseases such as dementia, carcinoma of the esophagus
and head/neck and, and metabolic impairments also may play an important role in
the development of dysphagia. Dysphagia in the elderly is also linked with increased
mortality and morbidity [112]. Common complications of dysphagia in the elderly
include pneumonia and malnutrition.
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Conditions that may contribute to dysphagia
Neurologic disease

Stroke

Dementia

Traumatic brain injury

Myasthenia gravis

Cerebral palsy

Guillain–Barré syndrome

Poliomyelitis

Myopathy
Other

Any tumor involving the digestive or
respiratory tract

Iatrogenic diagnoses

Chemotherapy

Radiation therapy

Medication related

Other, related diagnoses

Severe respiratory compromise
Progressive or neurologic disease

Parkinson’s disease

Huntington disease

Age-related changes
Rheumatoid disease

Polydermatomyositis

Progressive systemic sclerosis

Sjögren’s disease
Adapted from Groher ME, Crary MA. Dysphagia: Clinical Management in adults and
children. Maryland Heights, MO: Mosby Elsevier; 2010
Dysphagia and nutrition in stroke
Dysphagia is commonly seen after a stroke with estimates ranging from 30%–65%
[107, 108, 113, 114]. Approximately 300,000–600,000 individuals experience
dysphagia because of stroke or other neurological disorders [115]. Many individuals
regain functional swallowing within the first month following an episode of stroke
[108]; however, some individuals experience difficulty in swallowing even beyond 6
months [107, 116]. Common complications associated with dysphagia following
stroke include malnutrition [117], pneumonia [118, 119], dehydration [108, 117],
poorer long-term outcome [108, 116] increased rehabilitation time and the need for
long-term care assistance [120], increased length of hospital stay [121], increased
mortality [108, 114, 118] and increased health care costs [108]. These
complications adversely impact the social and physical well being of the elderly, the
quality of life of both elderly and caregivers, and the proper utilization of health care
resources [115]. During the acute phase of stroke, around 40%–60% of elderly
patients report swallowing impairments [107, 108]. These impairments also
accentuate malnutrition. Although the risk of malnutrition is increased in the presence of dysphagia post-stroke, [122] pre-stroke factors must be taken into account
when assessing nutritional status and predicting stroke outcome. Around 16% of
stroke patients present with malnutrition. The risk and prevalence of malnutrition to
22%–26% at the time of discharge from acute care [123-125]. Although, nutritional
deficiencies and dysphagia often coexist, malnutrition is usually not associated with
dysphagia in the acute phase of stroke [126]. In fact the prevalence rate of
malnutrition has increased up to 45% in the post acute rehabilitation phase [127].
Poor food intake during acute hospitalization associated with dysphagia may lead to
malnutrition during subsequent rehabilitation [122].
Dysphagia and pneumonia in stroke
Post-stroke pneumonia affects up to one-third of acute stroke patients [128, 129].
Pneumonia accounts for approximately 35% of post-stroke mortality [130]. The
majority of stroke-related pneumonias are thought to be caused by dysphagia and
the subsequent aspiration of food. Aspiration can be defined as entry of liquid or food
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into the airway below the level of the true vocal cords [131]. Aspiration pneumonia
is the entry of swallowed materials (gastric or oral) into the airway that causes a
lung infection [102]. A recent study has observed stroke patients with dysphagia
have a 3-fold increase in pneumonia risk, while the risk of pneumonia increases up
to 11-fold among patients after aspiration [118].
Dysphagia and dementia
Dysphagia is a common feature of dementia. Approximately 45% of elderly patients
with dementia experience some degree of swallowing impairment [132]. Different
presentations of dementia lead to varying degree of swallowing or feeding difficulties
[133-36]. These patients usually have a slowing of the swallowing process [112].
Additionally, elderly patients with dementia usually face problems with self-feeding.
Dementia, dysphagia, and other related feeding dysfunctions may cause malnutrition
and nutritional deficits which combined with other factors can lead to pneumonia and
even death. The presence of dementia in elderly is closely associated with higher
hospital admission rates and overall higher mortality [137].
Dysphagia and nutrition in community dwelling older adults
Dysphagia contributes to poor nutritional status due to the reduced or altered oral
intake of food/liquid. Dysphagia plays a role in the development of malnutrition, and
malnutrition in turn can lead to poor functional capacity. Therefore, dysphagia plays
an important role in the process of frailty among older patients [138]. A study
conducted on elderly residing in community dwelling showed that approximately
37.6%.of the patients reported dysphagia [111], approximately 5.2% of these
elderly reported the use of a feeding tube at some point in life, and around 12.9%
took nutritional supplements to achieve an adequate daily caloric intake [111].
Several studies have observed that elderly patients with dysphagia living in the
community are also susceptible to malnutrition.
Dysphagia and pneumonia in community dwelling older adults
Recent findings indicate the potential association between dysphagia, pneumonia,
and nutritional status in community dwelling elderly. The risk of community-acquired
pneumonia increases in elderly, particularly in those older than 75 years [139-141].
Furthermore, deaths from pneumonitis due to aspiration are increasing [142,143].
Dysphagia in the elderly also greatly increases the susceptibly to pneumonia [144].
ASSESSMENT AND PREVENTION
Video fluoroscopy is considered to be the gold standard to study dysphagia.
Fiberoptic endoscopic evaluation may also be considered if video fluoroscopy is not
available [145]. Some doctors recommend these tests only for patients who fail a
reliable clinical swallowing assessment [146].
Clinical Symptoms of Aspiration:

Abrupt manifestations of certain respiratory symptoms (severe coughing
and cyanosis) associated with drinking, eating, or the regurgitation of
gastric contents.

A change in voice (hoarseness or a gurgling noise) after swallowing.

Small-volume aspirations that lead to minimal or no symptom are
frequently seen in elderly and are usually not detected until these progress
to aspiration pneumonia.
Aspiration Pneumonia:
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



Elderly individuals with pneumonia frequently usually experience fewer
symptoms than young adults: therefore, aspiration pneumonia is usually
detected late and is under-diagnosed in the elderly.
Delirium is frequently observed in elderly with aspiration pneumonias.
Tachypnea or increased respiratory rate is an early sign indicating pneumonia
in elderly patients; other important symptoms of aspiration pneumonia
include fever, chills, pleuritic chest pain and findings of crackles on
auscultation of lungs.
High risk elderly patients should be monitored closely for aspiration
pneumonia.
Dysphagia management
The presence of a strong relationship between swallowing process, nutritional status,
and pneumonia among older patients indicates a role for dysphagia management in
the elderly population. Successful and optimal swallowing interventions/techniques
also help in the management of malnutrition and pneumonia. A number of dysphagia
management techniques and tools can be used for the treatment of dysphagia.
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Swallowing management
Dysphagia management requires multi-pronged strategies; no single strategy is
appropriate for all older patients with dysphagia. Alternate sources of nutrition may
be required for optimal nutrition. Compensatory strategies are also helpful for the
continued safe oral intake of food. Compensatory strategies also include postural
adjustments, swallow techniques or maneuvers, and diet modifications [112].
Finally, speech therapists can play a key role in the management of patients with
dysphagia.
Postural adjustments
Changes in body and/or head posture are common compensatory techniques that
may help in reducing the risk of aspiration or residue [147]. Postural changes can
help alter the speed and flow direction of a food which leads to a safe swallow [112].
However, some research studies suggest that active rehabilitation efforts are better
than these strategies for the prevention of pneumonia and malnutrition [148].
Examples of postural adjustments
Technique
Performance
Body posture changes
Lying down
• Lie down/angled
• Reduce impact of
gravity during
swallow
Side lying
• Lie down on
stronger side
(lower)
Head posture changes
Head
• Raise chin
extension/chin up
Head flexion/chin
tuck
Head rotation/head
turn
• Tucking chin
towards the chest
• Turning head
towards the weaker
side
Intended
outcome
Reported benefit
• Increased
hypopharyngeal
pressure on bolus
• Increased UES
opening
• Slows bolus
• Provides time to
adjust/protect
airway
• Reduced
aspiration
• Propels bolus to
back of mouth
• Widens
oropharynx
• Improves airway
protection
• Reduces residue
after swallow•
Reduces aspiration
• Reduced
aspiration
• Better bolus
transport
• Reduced
aspiration
• Less residue [62]
• Reduced
aspiration
Swallow maneuvers
Swallow maneuvers are different variation of normal swallowing process in order to
facilitate increased safety or efficiency of the swallow function. For instance, the
supraglottic and the super supraglottic swallow techniques involve a voluntary breath
hold and associated laryngeal closure to facilitate better swallowing and protect the
airway during this process [112]. Another technique called Mendelssohn maneuver
facilitates relaxation of the upper esophageal sphincter [149]. Another popular
maneuver is the ‘hard’ swallow that increases swallow forces leading to less residue
or airway compromise [150, 151]. Unfortunately, there are limited and inconclusive
data on the efficacy of these techniques [152-154]; therefore, verification of the
impact of these maneuvers using swallowing imaging studies should be conducted to
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ascertain the potential effect of these maneuvers before initiation of these
compensatory strategies.
TYPES OF SWALLOW MANEUVERS
Performance
Swallow
maneuver
Supraglottic
Hold breath,
swallow
swallow, and then
gentle cough
Super supraglottic
swallow
Effortful swallow.
Also called ‘hard’ or
‘forceful’ swallow
Mendelssohn
maneuver
Hold breath, bear
down, swallow, and
then gentle cough
Swallow ‘harder’
‘Squeeze’ swallow
at apex
Intended
outcome
Reduce aspiration
and increase
movement of the
larynx
Reported benefit
Increased lingual
force on the bolus•
Less aspiration and
pharyngeal residue
Improve swallow
coordination
Increased
pharyngeal
pressure and less
residue [67,68]
Reduced residue
and aspiration [69]
Reduces aspiration
Diet modifications
Modifying the consistency of food is the cornerstone of compensatory intervention for
elderly with dysphagia [37]. Thickened liquids are a common compensatory
technique that is offered to elderly in hospitals and long-term care facilities [70]. It
is believed that thickened liquids aid in controlling the direction, speed, duration, and
clearance of the food [70].
Modified food diets
Solid foods can be modified to promote safe swallowing and proper nutrition.
LEVELS OF MODIFIED DIET
Level
Description
Four Levels in the National dysphagia diet
Level 1: dysphagia
Homogeneous, cohesive,
pureed
and pudding like. No
chewing required, only
bolus control
Level 2: dysphagia
mechanically altered
Moist, semi-solid foods,
cohesive. Requires
chewing ability
Level 3: dysphagia
advanced
Soft-solids. Require more
chewing ability
Examples of recommended
foods
Smooth, homogenous cooked
cereals
Pureed: meats, starches (like
mashed potatoes), and
vegetables with smooth sauces
without lumps
Pureed/strained soups
Pudding, soufflé, yogurt
Cooked cereals with little texture
Moistened ground or cooked meat
Moistened, soft, easy to chew
canned fruit and vegetables
Well moistened breads, rice, and
other starches
Canned or cooked fruit and
vegetables
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Thin sliced, tender meats/poultry
Level 4: regular
No modifications, all
No restrictions
foods allowed
Adapted from Groher ME, Crary MA. Dysphagia: Clinical management in adults and
children. Maryland Heights, MO. Mosby, Elsevier; 2010.
Feeding dependence and targeted feeding
Those elderly patients with stroke and dementia may become dependent upon others
for feeding because of cognitive dysfunction and/or certain physical limitations.
Feeding dependence may lead to an increased aspiration risk and associated
complications in elderly patients with dysphagia. Such patients may require specific
training on feeding. Other techniques may be required to monitor the intake of food
in order to provide increased safety, decreased fatigue, and improved feedback on
swallowing during the course of the meal [131]. Eating in environments without
external stimuli and distractions is also helpful, particularly in skilled nursing or longterm care health care facilities. Introduction of angled utensils, cups without rims,
etc, may also be beneficial for elderly patients with dysphagia [37].
Provision of alternate nutrition
Alternate nutrition strategies can be the best form of compensation. Optimal and
adequate non-oral feeding can benefit elderly with malnutrition and nutritional
deficiencies. Malnutrition in the elderly together with other factors may lead to
cardiovascular disease, poor cognitive function, impaired immunity, and poorly
healing or non healing pressure ulcers and wounds [155, 156].
Swallow rehabilitation
The principal aim of swallow rehabilitation is overall improvement in process of
swallowing. Exercise-based swallowing techniques may be employed to facilitate
better functional swallowing, prevent or minimize dysphagia-related complications/
morbidities, and improve swallowing physiology [157-160]. Some of the exercisebased approaches for swallow rehabilitation are discussed in the table below.
Exercise-based swallow rehabilitation approaches
Focus
Reported benefit
Intended
outcome
Lingual resistance
• Strengthening
• Increased tongue • Increased tongue
tongue with
strength
muscle mass
progressively
• Improved
• Increased
increasing intensity swallow function
swallow pressure
• Reduced
aspiration
Shaker/head-lift
• Strengthening
• Improve strength • Increased larynx
suprahyoid muscles of muscles for
elevation
• Improve
greater upper
• Increased upper
elevation of larynx
esophageal
esophageal
• Increasing upper
sphincter opening
sphincter opening
esophageal
• Less post-swallow
sphincter opening
aspiration
EMST (expiratory
• Strengthening
• Improve
• Better
muscle strength
submental muscle• expiratory drive
penetrationtraining)
Improve expiratory • Reduce
aspiration scores in
Program
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MDTP (McNeill
dysphagia therapy
program)
pressures for better
airway protection
penetration and
aspiration
• Swallow as
exercise with
progressive
resistance
• Improve
swallowing
including strength
and timing
Parkinson’s disease
• Increased
maximum
expiratory pressure
• Increased
submental muscle
electromyography
activity during
swallowing
• Improved
swallow strength
• Improved
movement of
swallow structures
• Improved timing
• Weight gain
Falls in Elderly
Falls may be defined as a sudden, unintentional change in position of an elderly
leading to a position at a lower level, on an object, the floor, or the ground, other
than as a consequence of seizure, sudden onset of paralysis, or an external force
[161].
There are number of factors that contribute to increased incidence of falls in elderly
Falls can be life threatening and can severely impact the quality of life, general
health, and the independence of elderly persons.
Falls in the elderly are caused by complex interactions among the various risk
factors, which may characterized as intrinsic (patient related) or extrinsic (external
to the patient) [162-164]. It is estimated that approximately 30-40% of communitydwelling elderly fall at least once per year [165-166]. In the elderly, falls are among
the leading causes of fatal and nonfatal injuries [167]. The mortality rate due to falls
is around 10 per 100,000 persons for elderly individuals in the 65-74 years age
group and 147 per 100,000 persons for elderly individuals in the 85 years or older
age group [168].The economic burden for fall-related injuries among communitydwelling elderly in 2000 was estimated to be approximately $19.2 billion [169].
Another study has projected that by 2020 this cost could shoot up to $43.8 billion
[170]. It is important to note that majority of falls among elderly are preventable
[171].
Unintentional injuries are one of the leading causes of death in elderly, with falls
accounting for two-thirds of such deaths [172]. In nursing homes, fall rates increase
by two fold when compared with the non-institutionalized population [173]. Falls in
the elderly are associated with poorer survival [174] and great financial burden
[175-176]. Falls are the main cause of the traumatic spinal cord injury in elderly
[177]. Additionally, even non-injurious falls adversely impact the individual’s quality
of life, lead to an increased fear of falling [178], and limit mobility and activity [179].
The prevalence of risk factors associated with falls in elderly is greater in the nursing
home setting and the majority of elderly residents have multiple risk factors [180].
Some of the well established risk factors in the long-term care setting include
muscular weakness, poor balance and gait, poor vision, cognitive and functional
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dysfunction, delirium, orthostatic hypotension, certain medications, urinary
incontinence and co-morbidities such as depression, stroke, arthritis, etc. [181].
In 2010, the overall rate of reported nonfatal fall injury episodes was 43 per 1,000
and elderly who were more than 75 years of age had the highest rate.
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Risk Factors for Falls in Older Persons
Non-modifiable Risk Factors
Modifiable Risk Factors
Age older than 80 years
Environmental hazards
Arthritis
Medications (especially psychoactive)
Cognitive impairment/dementia
Polypharmacy (four or more prescription
Female sex
medications)
History of cerebrovascular accident or
Metabolic factors
transient ischemic attack

Dehydration
History of falls

Diabetes mellitus
History of fractures

Low body mass index
Recently discharged from hospital (within

Vitamin D deficiency
one month)7
Musculoskeletal factors

Balance impairment

Foot problems

Gait impairment

Impaired activities of daily living

Lower extremity muscle weakness

Musculoskeletal pain

Use of assistive device
Neuropsychologic factors

Delirium

Depression

Dizziness or vertigo

Fear of falling8

Parkinson disease

Peripheral neuropathy
Sensory impairment

Auditory impairment

Multifocal lens use

Visual impairment
Other

Acute illness

Alcohol intoxication

Anemia

Cardiac arrhythmia

Inappropriate footwear

Obstructive sleep apnea

Orthostatic hypotension

Urinary incontinence
SCREENING AND ASSESSMENT
1. The elderly patient should be asked about his or her history of falls during
the past year.
2. An elderly person who reports a fall should be asked about the frequency
and circumstances of the fall(s).
3. The elderly should be asked about their difficulties with walking or balance.
4. The elderly who present for medical attention due to a fall, report a history
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of recurrent falls in the past one year, or report problems in walking or
balance should undergo a multifactorial fall risk assessment.
5. Older persons presenting with a single fall should be evaluated for gait and
balance.
6. The elderly who have fallen must be assessed for gait and balance.
7. The elderly who are unable to perform or perform poorly on a standardized
gait and balance test should be provided a multifactorial fall risk
assessment.
8. A multifactorial fall risk assessment is also needed for elderly who exhibit
unsteadiness.
9. A fall risk assessment is not required for an elderly person who has only
had a single fall and has no significant difficulties with balance, gait or
unsteadiness.
10. Only a clinician (or clinicians) with appropriate skills and training should
assess the elderly.
11. The multifactorial fall risk assessment must encompass the following:
Focused History
a. History of falls in detail
b. Medication review:
c. History of relevant risk factors.
Physical Examinations
a. Comprehensive assessment of gait, balance, and mobility levels and
lower extremity joint function
b. Neurological function including assessment of cognition,
proprioception, lower extremity peripheral nerves, reflexes,
assessment of extrapyramidal , cortical, and cerebellar function
c. Muscle strength (lower extremities)
d. Cardiovascular status
e. Assessment of visual acuity
f. Examination of the feet and footwear
Functional Assessment
a. Assessment of activities of daily living (ADL) skills
b. Assessment of the individual's perceived functional ability and fear
related to falling
Environmental Assessment
a. Environmental assessment including home safety.
INTERVENTIONS
Elderly Living In the Community
1. After a thorough multifactorial fall risk assessment, direct interventions
should be initiated tailored to the identified risk factors, together with an
optimal exercise program.
2. A strategy to reduce the risk of falls should include multifactorial assessment
of known fall risk factors and management of the risk factors identified.
3. The components most commonly included in efficacious interventions were:

Adaptation or modification of home environment

Withdrawal or minimization of psychoactive medications

Withdrawal or minimization of other medications

Management of postural hypotension
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Management of foot problems and footwear
Exercise, particularly balance, strength, and gait training
4. All elderly individuals who are at risk of falling should be provided an exercise
program that encompasses balance, gait, and strength training. Flexibility
and endurance training should also be preferably included, but not as sole
components of the program.
5. Intervention should include an educational component complementing and
addressing issues specifically pertaining to the intervention being provided,
tailored to individual cognitive function and language.
6. All such interventions should be carried out by healthcare professionals and
other qualified healthcare professionals.
7. If indicated, psychoactive drugs/medications and should either be minimized
or withdrawn, with appropriate tapering.
8. The aim should be to reduce either the total number of medications or dose
of the medication medications. All medications should be reviewed, and if
required minimized or withdrawn.
9. Exercise should be included for fall prevention in community-residing elderly.
10. An exercise program such as Tai Chi or physical therapy that targets
strength, gait and balance, is an effective intervention for the reduction of
falls.
11. Exercise programs should be individualized according to the physical abilities
and health profile of the elderly. Programs should only be recommended by
qualified health professionals or fitness instructors.
12. An older person should not wear multifocal lenses when walking, especially
on stairs.
13. Postural hypotension in the elderly should be should be adequately treated.
14. Dual chamber cardiac pacing should be considered for elderly with
cardioinhibitory carotid sinus hypersensitivity who experience unexplained
recurrent falls.
15. Those elderly who have proven vitamin D deficiency should be supplemented
with vitamin D supplements with at least 800 IU per day, and least 800 IU
per day should be offered to elderly with suspected vitamin D deficiency or
who are otherwise at an increased risk for falls.
16. Foot problems should be investigated and optimal treatment should be
provided to those elderly living in the community.
17. The elderly should be advised that walking with shoes of low heel height and
high surface contact area may reduce the risk of falls.
18. Health care professionals should carry out home environment assessment.
Intervention should also encompass a multifactorial assessment and
intervention for those elderly who have fallen or who are prone to falls.
19. The intervention should encompass removal of recognized hazards in the
home, and evaluation and interventions to promote the safe performance of
daily activities.
20. Educational and informational programs are an important component of a
multifactorial intervention for the elderly.


OLDER PERSONS IN LONG-TERM CARE FACILITES
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1. Multifactorial interventions to reduce the risk of falls should be
contemplated for those elderly in long-term care settings.
2. Exercise programs should also be contemplated to reduce the risk of falls
in those elderly living in long-term care settings. Special care is needed
to reduce the risk of injury in frail individuals.
3. Vitamin D supplements (minimum of 800 IU per day) should be given to
those elderly living in long-term care settings with suspected or proven
vitamin D deficiency.
4. Vitamin D supplements (minimum of 800 IU per day) should be
considered in those elderly residing in long-term care settings who have
impaired gait or balance or who are otherwise are susceptible to falls.
Memory Disorders in Elderly
Memory loss is the impaired ability to learn new information or to retrieve previously
learned information. It is a common cognitive change in the elderly. An individual
with memory loss in most cases will exhibit measurable delayed recall i.e.
impairment in the ability to recall recently learned information. However, memory
loss actually can indicate impairment in another cognitive domain that may present
as memory loss. For instance, trouble finding the right word is indicative of a
language impairment or inattention associated with depression, particularly if the
patient themselves report the loss [182-86]. Dementia may be defined as a
progressive decline in more than one cognitive domain that interferes with activities
of daily living.
The most common causes of dementia include Alzheimer’s disease, frontotemporal
dementia, and dementia with Lewy bodies. Another cause of memory loss is MCI or
mild cognitive impairment, which includes people who do not have functional
impairments that meet the criteria for dementia but whose cognitive function falls
between the changes associated with normal aging and dementia.
Prevalence of Alzheimer’s disease and Other Dementias
The elderly population in the USA is expected to increase from approximately 35
million today to more than 70 million by 2030, a 2 fold increase [187]. With this
rapid growth in the population of elderly, long term care of chronic diseases such as
Alzheimer’s disease (AD) will assume greater importance. AD is the fifth-leading
cause of death for elderly [194].In 2012, approximately 5.4 million Americans had
Alzheimer’s disease, and around 5.2 million people were elderly [188]. One in eight
elderly individuals, or approximately 13% have AD.
Almost half of those elderly who are age 85 and older have AD. Of those with AD,
approximately 4% are under the age of 65, 6% are between 65 and 74, 44% are
between 75 and 84, and 46% are 85 or older [188]. Women are more susceptible to
AD and other dementias then are men. Of the 5.2 million elderly with AD, 3.4 million
are women. Women tend to live longer on average than men and this is believed to
account for the increased risk of AD. [189,190]. Approximately 53 new cases per
1,000 people occur in those 65 to 74.This increases to 170 new cases per 1,000
people for those between the ages of 75 to 84. The incidence rises to 231 new cases
per 1,000 people for those over the age of 85[191]. In the future, the elderly
population is expected to increase due to advances in the medical field, as well as
improvements in social and environmental conditions [192]. Additionally, the baby
boom generation is reaching the age group with the greater susceptibility to AD and
other dementias. On average, a person with Alzheimer’s will spend more years (40
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% of the total number of years with Alzheimer’s) in the most severe stage of the
disease than in any other stage [195]. Elderly patients with AD will spend much of
this time in a nursing home [195]. Elderly patients with AD and other dementias
require more and longer hospital stays, SNFs or skilled nursing facility stays and
home health care visits.
 Hospitals: In 2008, there were 780 hospital stays per 1,000 Medicare
beneficiaries in the elderly with AD compared with only 234 hospital stays per
1,000 Medicare beneficiaries without these conditions [197].
 Skilled nursing facility: In 2008, there were 349 skilled nursing facility
stays per 1,000 beneficiaries with AD and other dementias compared with 39
stays per 1,000 beneficiaries for people without these conditions [197].
 Home health care: In 2008, approximately 23 % of Medicare beneficiaries
who were elderly with AD and other dementias had at least one home health
visit during the year, compared with only 10 % of Medicare beneficiaries
without these conditions [198].
Approximately 60-70 % of elderly with AD and other dementias reside in the
community compared with 98 % of elderly without such conditions [197, 199].
Approximately two-thirds of elderly with dementia die in nursing homes, compared
with only 20 % of cancer patients and 28 % of people dying from all other causes
[196]. People with AD require long term care for an extended period of time: this
also impact’s public health concerns. Of those elderly patients with AD and other
dementias who live in the community, approximately 75 % live with someone and
the remaining 25 % live alone (197). Many people with AD and other memory
deficits also receive paid services at home; in adult day centers, nursing homes, or in
more than one of these healthcare settings.
Use of Long-Term Care Services by Setting
The majority of elderly persons with AD and related conditions who live at home
receive unpaid help from friends and family, but some opt for paid home and
community-based services, such as personal care and adult day center care.
• Home care. It is estimated that approximately 37 % of elderly persons who receive
mainly nonmedical home care services have cognitive impairment consistent with
dementia [200-202]. In 2011, the average cost for a non-medical home health aide
was $21 per hour [199].
• Adult day center services. Approximately 40% of elderly who go to adult day
centers have dementia [203, 204]. In 2011, the average cost of adult day services
was $70 per day [199].
• Nursing home care. Approximately 64% of Medicare elderly beneficiaries residing
in a nursing home have AD and related conditions [197]. In 2011, approximately
47% of all nursing home residents had a diagnosis of dementia in their nursing home
record [205].
• Alzheimer’s special care units. In June 201, nursing homes had a total of 80,866
beds in Alzheimer’s special care units [206].
While normal aging is generally associated with a decline in cognition and memory,
this decline is not linked to memory disorders. Several factors such as genetics and
neurodegenerative processes play an important role in causing memory disorders.
While with aging,one may experience minor changes in memory and thinking, these
changes do not significantly impact the activities of daily living. Some of the
differences between normal age-related memory loss and Alzheimer’s disease
include:
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




In normal age-related memory loss, the individual might forget part of an
experience, but an individual with AD will forget the whole experience.
In normal age-related memory loss, the individual who forgets something will
eventually remember the information; however, this is not case with AD.
In normal age-related memory loss, the individual can generally follow
instructions, both verbal and written, without problems, but an individual with AD
progressively loses this ability to follow instructions.
In normal age-related memory loss, the use of notes and other types of
reminders is beneficial; however, people with AD progressively become less able
to benefit from memory aids.
In normal age-related memory loss, people can still manage their activities of
daily living, but those with AD become progressively dependent as they cannot
manage their activities of daily living.
Common Causes of Symptoms of Mild Memory Loss in Elderly Patients
Cause
Typical Historical and
Comments
Clinical Features
Alzheimer
disease
Insidious onset of losses in
memory, language, and
visual, spatial and executive
function with largely normal
results on neurologic
examination
Frontotemporal
dementia
Two broad patterns of clinical
manifestations:
Pattern 1) profound changes in
personality and social conduct
and
Pattern 2) changes in
expressive language or in
naming and comprehension
Pattern of cognitive decline is
similar to that of AD plus at
least two of the following:
visual hallucinations,
fluctuating cognition, and
parkinsonian signs (rigidity,
falls, masked face)
Lewy body
dementia
Mild cognitive
impairment
Memory or other cognitive
problems in the setting of mild
deficits on cognitive testing
and relative preservation of
other cognitive functions
Depression
(major
depression,
dysthymia, or
Depressed mood plus 2 weeks
of at least four of the
following:
 diminished interest in
Patients may appear depressed
because of social withdrawal.
Extrapyramidal signs, such as
rigidity, may be present, but
they are mild and do not
antedate the cognitive
symptoms.
The disease category includes
Pick disease (pattern1) and
progressive non-fluent aphasia
and semantic dementia (pattern
2). Pattern 1 patients show
executive function deficits;
errors in memory, if any, are
the result of inattention.
Can be confused with Parkinson
disease. Parkinsonian signs
include poor responsiveness to
L-dopa replacement therapy.
Use of phenothiazine- based
antipsychotic agents can
precipitate marked worsening of
parkinsonism.
History will show no clinically
meaningful functional
impairment as a result of
cognitive deficits.
Patients may progress to
dementia, especially Alzheimer
disease.
Impairments can be found in
measures of cognition, but they
are typically mild. These
generally improve with
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subsyndromal
depression
Medications
Cerebrovascular
infarcts
activities of daily living,
 More than or equal to 5%
change in body weight over
1 month
 Changes in sleep,
 Psychomotor agitation or
retardation,
 Fatigue,
 Feelings of worthlessness or
guilt,
 Diminished ability to think
or concentrate,
 Recurrent thoughts of
death*
Cognitive impairment following
a medication change
or addition
Cognitive impairment following
the onset of a stroke
Medical
illnesses that
impair brain
metabolism
successful treatment of the
depression.
Patients will report memory
loss, but testing of delayed
recall will generally show mild if
any impairment. Several
symptoms of depression can
overlap with dementia, such as
diminished ability to
concentrate, social withdrawal,
and sleep disruption.
Common causes include
medications with
anticholinergics or sedative
effects.
With the exception of large
strokes and major hemorrhages,
the precise contribution to
cognitive dysfunction of CT- or
MRI-defined infarcts and T2
hyperintensities on MRI remains
unclear.
Thyroid testing is warranted as
part of an initial work-up of a
patient with documented
memory loss.
Illnesses that cause hypoxia,
hepatic disease, and
endocrine disorders such as
hypothyroidism and
hyperparathyroidism
* Referral to a neurologist is warranted for a patient who has cognitive impairment
as well as neurologic signs such as focal muscle atrophy, fasciculations, dysarthria,
abnormal voluntary eye movements, or limb weakness that cannot be explained by a
stroke. CT= computed tomography; MRI= magnetic resonance imaging. * These
symptoms apply to major depression.
Signs of Age Related Normal
Memory Loss
Signs of Memory Loss Due to Other
Causes
Forgetting an appointment occasionally.
Memory loss that disrupts daily life.
Memory loss, especially recently learned
information, is often the most clinically
important sign of a potential problem.
Not sure what day of the week it is while
on vacation.
Not sure what day of the week it is
during a routine schedule.
Getting lost occasionally while in new
circumstances.
Getting lost in familiar places.
Trouble with vision or spatial issues that
can be corrected with glasses or cataract
surgery.
Difficulty judging distance which may
lead to falls or minor car accidents.
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Inability to remember a word that’s on
the tip of your tongue.
Routine inability to recall words. Or
calling a person or animal by the wrong
name regularly. Also includes finding
ways to describe an object because the
person can’t recall the object’s real
name.
Losing things occasionally.
Routinely losing things – particularly
losing the same thing over and over.
Temporary agitation or anxiety in
normally stressful situations.
Regularly becoming easily agitated and
anxious over small things.
Making a regretful decision every once in
a while.
A marked change in judgment resulting
in poor decisions or even being taken
advantage of by a scam, etc.
Care giving and daily life
Caring for an elderly with memory issues requires a multilevel approach. Patients
should be kept active by focusing on their positive abilities and avoiding stress.
Routines for dressing and bathing should be conducted in such a way that the patient
feels a sense of independence. Simple techniques such as finding clothes with large
buttons, Velcro straps, or elastic waist bands can make it easier for the patient to get
dressed. Finances must be properly managed preferably by involving a trusted
family member or friend. Any activity should be done in a stepwise manner.
Furthermore, visiting and talking to the patient with memory issues is very
important. The approach towards the elderly should always be respectful and simple.
It is important to talk one-on-one to the patient, especially if the individual lives
alone to order to prevent or minimize social isolation and increase mental stimulation
[207]. When caring for an elderly individual with memory problems, it is important to
provide them independence in a respectful way.
Memory care
Memory care is a long-term care option for elderly patients who cannot properly
accomplish at least two areas of daily living (ADLs) because of dementia, Alzheimer’s
and other memory and cognitive disorders. Memory care is specifically meant and
designed for individuals with a level of cognitive impairment making it unsafe for
them to continue to stay at home, but who do not need the intensive care of a skilled
nursing facility. Memory care allows the elderly with memory loss to maintain a
degree of independence within the safe and secure environment of a residential
facility with a professional healthcare staff. These units are usually incorporated as
separate care units of assisted living communities. In such facilities, elderly are
provided 24-hour support and programs that ensure a high quality of life coupled
with increased safety. These elderly reside in private or semi-private units and have
scheduled activities and programs that are designed to enhance memory under the
supervision of trained staff members. In these facilities, common spaces are
provided to increase activities and socialization.
Adult Day care
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Adult Day care is designed for elderly with at least late-mild to moderate dementia.
The facility provides structured and safe daily activities that reduce patient’s
boredom and anxiety as well as caregiver distress.
Nursing Home care
Among all the other long term care facilities, nursing homes provide the most
comprehensive service with highly skilled and professional staff members, but offer
the least independence for the patients. They are also the most expensive long term
care option. Elderly should preferably be placed in the nursing home when there is
greater risk of malnutrition, illness and fall-related and other injuries, especially for
those individuals who live alone.
Depression in the Elderly
Depression is a mental disorder which manifests as a state of low mood and aversion
to activity that may negatively impact on individual’s thought process, behavior,
feelings, world view, and physical well-being [208]. Individuals with depression may
experience sadness, emptiness, hopelessness, anxiousness and irritability.
Depressed people may experience anhedonia, an aversion to pleasure seeking
activities such as sex, exercise or social activities. Depression in the elderly is
common and widespread globally. It is generally undiagnosed, and often goes
untreated. It is also the most treatable disorder which affects approximately 15% of
elderly, 20 % of hospitalized elderly patients, and over 40 % of elderly nursing home
residents. Depression is common in elderly, but it is not a normal part of aging
[209].
The prevalence of depression in the elderly in the United States and globally is
around 1-5%, with several research studies reporting prevalence rates at around 1%
[210]. There are over 35 million elderly Americans and approximately 7 million
experience some form of depression. Approximately 2 million experience clinical
depression and around 5 million experience milder forms of depression. In the US,
approximately one third of nursing home residents experience depression. The
disorder may develop at any time during patient’s placement in a nursing home. A
study conducted on nursing home residents observed that 14% of patients had
clinical depression, and only 20% of these patients were provided antidepressant
treatment. Depression in the elderly is severely under-recognized and under-treated.
Depression is a mood disorder that is the most prevalent mental health problem
among the elderly; however, it should be remembered that the majority of elderly
are not depressed. Depression may lead to significant suffering and distress among
the elderly [211]. It also can result in mild to severe impairments in physical,
mental, and social functioning [211]. The presence of depression in elderly usually
adversely impacts the course and complicates the treatment of other co-morbid and
chronic diseases [212]. Those elderly with depression visit the doctor and hospital
more frequently, use more medication, and stay for longer in the hospital [211].
Finally, depression in majority of cases is a treatable condition [212].
It is estimated that major depression in elderly persons living in the community may
range from less than 1% to about 5% but increases to 13.5% in those who need
home healthcare and to 11.5% in hospital settings. Other studies have estimated
that major depression for those in long-term care ranges from 6-24%, and minor
depression and dysthymia may range from 30-50%. Depression among the elderly is
usually is underdetected in long-term care facilities and if detected, is often
inadequately treated [213].
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Depression in the elderly with higher sociotropy score (indicating a higher or
excessive need for interpersonal relationships) is closely associated with stressful life
events related to loss or disruption, whereas depression in the elderly with a higher
autonomy score is closely associated with negative events linked to achievement
[214]. It is observed that depressed individuals behave in ways that tend to increase
the risk of stressful events in the future [215]. Rumination, (a compulsive focused
attention on negative feelings and experiences from the past) which has been
associated with decreased social support may play a key role in the development of
depression. A stressful event, such as the loss of loved ones is known as
bereavement. Depressive symptoms are a natural emotional reaction to loss, but
symptoms that persist for more than two months may indicate depression. Some
researchers believe that depression associated with bereavement is actually
complicated grief, which is manifested by symptoms of traumatic distress and
separation distress [216]. However, some argue that complicated grief and major
depression have a lot in common with few differences [217]. A recent study on
depression in elderly observed that bereavement greatly increased (tripled) the risk
of depression [218]. However, the risk of depression due to bereavement is less for
the elderly than for the middle aged.
It seems that the elderly are often better equipped to handle the loss of loved ones
than younger adults because of better adaptation capabilities [218]. Compared to
females, males are more susceptible to depression after the loss of a spouse. Men
also remain in depression for a longer period of time. For females, financial stress is
the major mediator of depression or depressive symptoms, whereas for males, the
major mediator is household chores or management [219]. Providing adequate care
for a loved one can also trigger stress which becomes more common with advancing
age. However, recent studies have found no significant differences in depression
between caregivers and non-caregivers [220]. It has been found that the risk of
depression is higher among individuals caring for a person with dementia than
among those caring for a person with a physical disability [221]. Furthermore, rates
of depression increase significantly in the caregiver if the care recipient has severe
distress behavior problems [222]. Some researchers believe that the rate of
depression increases in these caregivers because of their restricted normal activities
[223]. Co-morbidity of depression with other disorders is common and adversely
impacts the course of the depression, increases disabilities, economic burdens, and
use of health care services. Common medical illnesses that are associated with
depression include cardiovascular disease, diabetes, stroke, hypertension, cancer,
and osteoarthritis. In the nursing home setting, the predominant clinical entities
include major depressive disorder, dysthymic disorder, minor depression and
depression concurrent with Alzheimer’s disease.
DIFFERENTIAL DIAGNOSIS OF DEPRESSIVE SYMPTOMS IN NURSING
HOME PATIENTS
Major Depressive Disorder: Presence of at least 5 of 9 depressive symptoms
(shown below in the next table) for at least 2 weeks and impaired social
functioning.
Minor Depression: Not meeting above criteria but significant sub-threshold
symptoms
Dysthymia: Low-grade depression symptoms that are chronic for more than two
years
Depression in Alzheimer’s disease: Specific criteria proposed that require only
3 symptoms, with irritability as a qualifying symptom
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Differences from younger adults
Depression in the elderly may have distinctive signs and symptoms as compared to
those in younger adults. Compared to young adults, the elderly are less likely to
exhibit cognitive-affective symptoms of depression such as worthlessness, or
dysphoria [224]. The elderly also complain more frequently about sleep
disturbances, insomnia, fatigue, loss of interest in living, and hopelessness [225].
The elderly also complain about poor memory and loss of concentration. Common
clinical findings include slower cognitive function and executive dysfunction [226]. It
has also been found that depressed elderly women experience more appetite
disturbances than men, whereas elderly men experience more agitation [227].
Depression is difficult to diagnose when symptoms arise because of a medical
condition. Depression is usually either over diagnosed or under diagnosed in the
presence of another disease such as cancer that may cause weight loss and fatigue.
Depression manifests itself with different signs and symptoms among patients with
neurological syndromes. Depression that develops after a stroke is less likely to
include dysphoria and is more prominently characterized by vegetative symptoms
[228]. This is particularly seen in patients who have right hemisphere damage.
Milder forms of depression is associated with Parkinson's disease. Additionally,
dysphoria and anhedonia are seldom seen when compared to depression in the
elderly without neurological disease [229]. Depression seen in patients with
Alzheimer disease is diagnosed only when three or more symptoms of major
depression are present, excluding lack of concentration, but including non-somatic
symptoms such as social withdrawal and irritability. Depression in patients with
vascular dementia, compared to depression in patients with Alzheimer disease, is
characterized predominantly by vegetative symptoms such as weight loss, fatigue,
and myasthenia (muscular weakness). [230]
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Depression: Risk and Protective Factors in Elderly
General risk factors that increase risk throughout life
Biological risks
 Hereditary/Genetics
 Females are at higher risk
 Low serotonin or high cortisol (neurotransmitters)
 Low testosterone (can affect females as well as males)
 High blood pressure or hypertension
 Stroke
 Medical illness and overall poor function (e.g., problems walking)
 Alcohol abuse and dependence
Psychological risks
 Personality disorder
 Neuroticism (neurosis = poor ability to adapt, inability to change one's life
patterns, and the inability to develop a richer, more complex, more satisfying
personality)
 Learned helplessness
 Cognitive distortions (overreaction to life events; misinterpret life events;
exaggerate their adverse outcomes; catastrophizing too much)
 Lack of emotional control and self-efficacy (low skills to control emotions and
low belief in one's capacity to succeed at tasks)
Social risks
 Stressful life events and daily difficulties
 Bereavement (grief experienced by loss of a loved one due to death)
 Socio-economic disadvantage (being poor or having a low income)
 Impaired social support (lack of friends and family for fellowship and support)
Risk and protective factors especially important in late life
Biological risks
 Genetics
 Low DHEA (a pro-hormone)
 Poor blood flow in the brain (ischemia)
 Alzheimer’s Disease
Protective factors
 Socio-emotional selectivity (focus on the positive for the remainder of life)
 Wisdom (applying life’s lessons in a positive way to deal with today’s
challenges)
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American Psychiatric Association DSM-IV-TR criteria
• Five or more of the following symptoms present for a minimum of 2 weeks:
– Depressed mood
– Loss of interest or pleasure in activities
– Changes in weight or appetite
– Insomnia or hypersomnia
– Psychomotor agitation or retardation
– Low energy
– Feelings of worthlessness
– Poor concentration
– Recurrent suicidal ideation or suicide attempt
Atypical presentation of depressed older adult
• Deny sadness or depressed mood
• May exhibit other symptoms of depression
• Unexplained somatic complaints
• Hopelessness
• Helplessness
• Anxiety and worries
• Memory complaints (may or may not have objective signs of cognitive
impairment)
• Anhedonia
• Slowed movement
• Irritability
• General lack of interest in personal care
Workup of Depression in Nursing Home Patients
Screening: Geriatric Depression Scale
-Present illness history including assessment of suicidal ideation, current
medications
-Past history including antidepressant trials
-Cognitive screen: MMSE
- Laboratory tests: Basic metabolic panel, complete blood count, TSH, free T4,
serum B12 and folate levels, serum albumin in case of poor nutrition
-EKG if a tricyclic antidepressant is being considered
-Polysomnography if a sleep disorder is suspected
-MRI to confirm diagnosis of vascular depression
MMSE, mini-mental state exam; TSH, thyroid-stimulating hormone;
EKG, electrocardiogram; MRI, magnetic resonance imaging
Screening for depression in the elderly may require Geriatric Depression scale or
other screening tools.
Geriatric Depression Scale – Short Form
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Think over the past week and answer the questions below as “yes” or “no.”
* = 1 point
1)
Are you basically satisfied with your life?
Yes
2)
Have you dropped many of your activities and interests?
*YES
No
3)
Do you feel that your life is empty?
*YES
No
4)
Do you often get bored?
*YES
No
5)
Are you in good spirits most of the time?
Yes
6)
Are you afraid that something bad is going to happen to you?
*YES
7)
Do you feel happy most of the time?
Yes
8)
Do you often feel helpless?
*YES
9)
Do you prefer to stay at home, rather than going out and doing new things?
*YES
10) Do you feel you have more problems with memory than most people?*YES
*NO
*NO
No
*NO
No
No
No
11) Do you think it is wonderful to be alive now?
Yes
*NO
12) Do you feel pretty worthless the way you are now?
*YES
13) Do you feel full of energy?
Yes
14) Do you feel that your situation is hopeless?
*YES
No
15) Do you think that most people are better off than you are?
*YES
No
No
*NO
TOTAL * SCORE =
If the * score is 10 or greater, or if numbers 1, 5, 7, 11, and 13 are answered with a
*, then the individual may be depressed and they should consult with their doctor or
other qualified health professional. Health professionals should proceed with a
referral and/or treatment plan as necessary.
There are several treatment options that are available for depression which includes
pharmacotherapy with antidepressants, psychotherapy or counseling, or
electroconvulsive therapy. Some patients may require a combination of these
treatment options.
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Treatment of Depression in Nursing Home Patients
Major depressive disorder: Citalopram, sertraline, or paroxetine. If no response
at 6 weeks, then switch to venlafaxine (extended release), or bupropion (slow
release), or mirtazapine. If no response, consider ECT.
Add psychotherapy if appropriate
Psychotic depression: SSRI + antipsychotic medication, or ECT
Persistent minor depression or dysthymia: Either SSRI or psychotherapy
alone
Depression comorbid with Alzheimer’s disease: SSRI and/ or behavioral
therapy
ECT, electroconvulsive therapy; SSRI, selective serotonin reuptake inhibitor
Sexual issues associated with elderly population
Globally, the last few decades have witnessed an enormous increase in life
expectancy. In the US, the aging of the ‘baby boomer’ generation, and the openness
regarding sexual behavior in the society has resulted in an aging population that
considers sexuality as being important.
Gender differences in sexuality
There is no doubt that sexuality, and its expression, remains important to both
elderly men and women [231]. There are gender differences in the incidence of
remaining sexually active into our older years. Several studies have observed that
for both genders, male and female, there is a decline in sexual activity with age;
however, sexual interest, sexual activity and the quality of sexual life seems to be
consistently higher in elderly men compared to elderly women [232]. With aging,
these gender differences seem to increase. In one research study conducted on the
elderly in the 75–85 years age group, it was found that around 38.9% of men
compared to 16.8% of women were sexually active [233]. These men also reported
a greater degree of interest in sex, approximately 41.2% elderly men compared to
only 11.4% women. They also had a higher quality of sex life (70.8% expressing
satisfaction compared to 50.9%) than women. It is becoming increasingly
acknowledged that the sexual behavior and function for women remains distinct from
that of men [234]. As women age, they experience a noticeable decrease in sexual
activity and libido (interest in sex) compared to men, but women also experience
comparatively less distress than men with the same symptoms. This behavior in the
females may well reflect different psychosocial factors [235] which include overall
health status, and relationship, presence or absence of a partner and life satisfaction
[236]. With aging, both men and women show an overall reduction in sexual
frequency when a partner loses interest in sex, but women lose interest more than
men [237]. For older women, life stressors, past sexuality and mental health
problems, contextual factors, are more significant predictors of sustaining their
sexual interest than physiological status alone [238].
Although it is generally believed that sexual desires tend to decrease with age,
several studies have observed that sexual patterns remain unchanged throughout
the life span.
The elderly continue to enjoy sexual relationships throughout their lives. A recent
study conducted on US elderly revealed that reported sexual activity was around
73% in the age group of 57-64, 53% in the age group of 65-74 and 26% in the age
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group 75-84. The expression of sexuality among the elderly leads to a higher quality
of life achieved by fulfilling a natural urge. Although the need to express sexuality
persists among the elderly, they are more prone to many co-morbid medical
diseases or conditions. In addition, the normal aging process may hinder the
expression of sexuality. Also, the medications and other therapies required for the
management of co-morbid disease may also lead to reduction in sexual response.
Approximately 50% of elderly Americans reported at least one sexual problem.
Women complained of low sexual desire (43%), vaginal lubrication difficulties (39%),
and inability to climax (34%). Erectile dysfunction was the most common problem
among elderly men.











Common Barriers That Preclude The Elderly From Having Sex
Physiological and biological changes
Illness and/or decline of health (self or partner)
Impotence
Feelings of guilt (i.e. cultural and/or generational attitudes about sex)
Widow’s Syndrome
Lack of freedom
Lack of privacy
Lack of a partner
Fear of what others will think or say
Inability to discuss issues and concerns with healthcare professionals
Low self-esteem
Physiological changes associated with aging
Aging leads to changes that influence the vascular, endocrine, and neurological
systems. These changes impact sexual arousal and sexual performance.
Men
In elderly men, the most frequent sexual dysfunction reported is erectile dysfunction.
This is considered to be partly due to hormonal changes and underlying conditions
affecting the gonads as well as the neurological and vascular systems [239]. The
treatment of erectile dysfunction encompasses assessment of risk factors such as
cardiovascular, lifestyle modifications and a trial of PDE-5 inhibitors, if not
contraindicated. There is a strong association between erectile dysfunction and
metabolic syndrome which should be thoroughly evaluated in elderly men with
erectile dysfunction. With aging, free testosterone declines by 1–2% each year from
the age of 45–50 years. Similar declines are witnessed in the levels of
dehydroepiandrosterone (DHEA) with increased levels of follicle stimulating
hormone/luteinizing hormone (FSH/LH) and sex hormone binding globulin (SHBG)
[240]. Even if the serum testosterone levels are at normal or high levels, free
testosterone (testosterone available to tissues) declines between the ages of 40–70
years. Furthermore, with aging DHEA and dehydroepiandrosterone sulphate (DHEAS), precursors of testosterone also decline 2–3% per year. Marked falls in these
hormones and precursors can cause lead mood changes, low energy levels,
decreased strength, decreased libido and erectile dysfunction [241]. Elderly men
with symptoms of androgen deficiency may benefit from hormone replacement.
Women
In the aging woman, the most common sexual dysfunctions reported are a lack of
libido and lack of arousal. With the post-menopausal phase, there is a consistent
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decline in female hormones leading to atrophy of the vaginal and vulval membranes,
increased urinary frequency and urinary incontinence, and urogenital prolapse.
These changes also lead to vaginal dryness and dyspareunia, decreased libido, and
inability to achieve climax or orgasm. Medical treatment includes hormone
replacement therapy, which may be local or systemic.
Changes In Sexual Function in Elderly
Normal changes in sexual function
in Elderly Men
• Erections may require more intense or
prolonged physical stimulation
• There is a longer time for erectile
response
• There may be a less rigid erection with
some softening during sexual activity
• Decreased intensity of ejaculation
• Decreased ejaculatory volume
• Delay in ejaculation
• Increased refractory period
Normal changes in sexual function
in Elderly Women
• Decreased clitoral engorgement
• Decreased vaginal lubrication
• Decreased breast swelling
• Decreased vasovaginal congestion
• Diminished pre-orgasmic sweating
• Diminished orgasm intensity
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Common Sexual Problems for Elderly
A. Lack Of Interest / Decreased Desire

Self or partner not interested in having sex

Hormonal changes (i.e. menopause and post menopausal status,
testosterone levels) may result in low sexual desire

Fear of pain and/or discomfort

Cognitive decline and/or impairment

Change in relationship status- single, divorced, widow(er), etc.
B. Female Sexual Dysfunction

Decreased sexual function and responsiveness

Dyspareunia- pain associated with intercourse

Estrogen deficiency

Difficulty with lubrication and reduced elasticity of vagina and vulva

Delayed or absent orgasm

Multiple medical ailments and chronic diseases which may affect sexuality

Psychological factors

Increased body sensitivity
C. Male Sexual Dysfunction

Delay of erection

Decreased tension of scrotal sac

Loss of testicular elevation

Erectile Dysfunction (ED)- inability to achieve or maintain an erection
adequate for sexual intercourse

ED is commonly caused by (1) vascular disease and (2) neurologic disease

Adverse medication side effects

Endocrine problems

Psychogenic issues- i.e. relationship conflicts, performance anxiety,
childhood sexual abuse, etc.
Institutionalized care
Several studies have reported that elderly residents wish to remain sexually active in
long term care settings. There are several barriers that prevent elderly patients from
engaging in sexual activity in institutionalized care facilities. Sexuality in assisted
living facilities or nursing homes is not commonly discussed; however, the focus is
gradually shifting as several studies report that many elderly couples are sexually
active. In today's society, many assisted living facilities allow overnight stays for
spouses and family members of residents.
Barriers to sexual activity in Institutionalized Care
• Lack of privacy
• Attitude of family
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•
•
•
•
•
Attitude of staff
Lack of an able sexual partner
Physical limitations and poor health
Cognitive impairment and dementia
Lack of finances for education of staff or to institute changes
Other medical conditions
Continued good health of an elderly person is associated with a higher rate of sexual
activity as well as sexual satisfaction. However, morbidity increases with aging and
many co-morbid diseases or conditions adversely impact sexuality and sexual
dysfunction. The normal sexual response may change with impairment of central or
peripheral physiology because of various diseases and conditions [242]. Sexual
dysfunctions can all be caused or worsened by medical conditions and the drugs or
other treatment options used. Therefore, it is crucial to investigate elderly individuals
and couples who complain of sexual difficulties for serious underlying medical
conditions.
Role Of Healthcare Providers in Long Term care Settings
Treat elderly with respectful and non-judgmental attitudes
Conduct thorough sexual health assessments/histories
Ask direct, straightforward questions about sexual activity and attitudes
Educate patients and their caregivers about topics in sexuality and aging
Provide appropriate treatment options
Recommend treatments and adaptations for sexual problems
Listen to patients’ sexual concerns
Incorporate patients’ sexuality into counseling
Provide appropriate referrals to specialists as needed
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Geriatric
Syndrome
DIFFICULTY
SWALLOWING
MALNUTRITION
BLADDER
CONTROL
PROBLEMS
SLEEP PROBLEMS
DELIRIUM
DEMENTIA
FALLS
OSTEOPOROSIS
Common Geriatric Syndromes in Older People
Description
Age-related physical changes, medication side-effects,
dementia and certain other illnesses can make swallowing
difficult. This may lead to malnutrition and related problems.
Other problems may be choking and aspiration (food or liquid
“going down the wrong pipe”).
Older adults usually need fewer calories than younger adults,
but may need more of certain nutrients, such as calcium,
vitamin D, and vitamin B12. Malnutrition can present as weight
loss or weight gain. This can lead to other problems, such as
weakness and increased falls, bone disorders, and diabetes.
Many things can cause bladder control problems, or “urinary
incontinence,” including an overactive bladder muscle, urinary
tract infections, constipation, delirium, heart disease, diabetes,
dementia, medication side effects, and difficulty getting to the
toilet in time. Urinary incontinence can lead to problems such
as falls, depression, and isolation.
Sleep problems can affect quality of life and can contribute to
falls, injuries and other health problems. Many factors can
affect an elderly person’s sleep, including stress, anxiety,
depression, delirium, dementia, certain drugs, alcohol, and
medical problems such as pain, arthritis, nerve problems,
breathing difficulty, heartburn, and frequent trips to the
bathroom at night.
Many older adults who go to the Emergency Room or are
admitted to the hospital develop delirium. Delirium is a state of
sudden confusion that can last days, weeks or even months.
Drug side effects, dehydration, thyroid problems, pain, urinary
tract and other infections, poor vision or hearing, strokes,
bleeding, or heart or breathing problems can cause delirium.
Older people can develop serious and life-threatening
complications and loss of function, if delirium isn’t recognized
and treated quickly.
Alzheimer’s disease and “vascular dementia,” (caused by a
series of small strokes), are two common forms of dementia.
While some healthy older people find it harder to remember
things or carry out certain mental activities, this doesn’t
necessarily mean they have dementia. Dementia gets worse
over time and can severely limit the ability to function.
Falls are a leading cause of serious injury in older people.
Among other things, safety hazards in the home, medication
side effects, walking and vision problems, dizziness, arthritis,
weakness, and malnutrition can boost risks of falls. Like other
geriatric syndromes, falls usually have more than one cause.
Osteoporosis, or “thinning bones,” is a condition that makes
the bones of older adults more fragile and easy to break. A diet
that doesn’t have enough calcium and vitamin D, too little
exercise, smoking, too much alcohol, certain medications, and
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PRESSURE
ULCERS
VISION
PROBLEMS
HEARING
PROBLEMS
DIZZINESS
FAINTING
DIFFICULTY
WALKING OR
“GAIT PROBLEMS”
certain medical conditions such as thyroid problems, can
increase the risk of osteoporosis. Osteoporosis is also more
common in people with a family history of this condition
Also known as “bed sores,” pressure ulcers are skin and tissue
damage caused by constant pressure on skin and the “soft
tissue” underneath it. These can be painful and lead to serious
infections. Smoking, being underweight, poor diet, low blood
pressure, diabetes, heart disease, kidney failure, and bladder
problems can increase the risks of developing pressure ulcers.
Common vision problems among older adults include
nearsightedness, glaucoma, cataracts, diabetic eye disease,
presbyopia, (age-related changes in the eye that make it hard
to see close-up), and macular degeneration (damage to the
center of the eye that can result in a loss of central vision).
Hearing loss is the most common sensory problem among
older adults.
The word “dizziness” is often used to describe feelings of
spinning, almost fainting, falling, or lightheadedness. These
feelings can make it harder to walk and can increase an elder’s
risk of falls. Many things may cause dizziness, including low
blood pressure, vision problems, inner ear problems, anxiety,
and medication side effects. There is often more than one
cause.
Fainting, or briefly passing out, is increasingly common with
age and leads to falls, and potentially significant injury. There
are many possible causes, including low blood pressure, low
blood sugar levels, and irregular heartbeat. In older people
there is often more than one cause.
This is usually due to a combination of age-related health
problems or diseases such as arthritis, bone and muscle
problems, Parkinson’s disease, poor circulation, dizziness,
changes after a stroke, vision problems, loss of strength, and
even fear of falling.
Older Adults & Substance Use
Alcohol and substance abuse among the elderly is a hidden national epidemic. It is
believed that about 10% of this country’s population abuses alcohol, but surveys
revealed that as many as 17% of the over-65 adults have an alcohol-abuse problem.
One study found that 2.5 million older adults and 21% of older hospital patients had
alcohol-related problems. Elderly alcohol abusers can be divided into two general
types: the "hardy survivors," those who have been abusing alcohol for many years
and have reached 65, and the "late onset" group, those who begin abusing alcohol
later in life. The latter group’s alcohol abuse is often triggered by changes in life such
as: retirement, death or separation from a family member, a friend or a pet, health
concerns, reduced income, impairment of sleep and/or familial conflict. Because
alcohol has a higher absorption rate in the elderly, much like it does in women, the
same amount of alcohol produces higher blood alcohol levels, causing a greater
degree of intoxication than the same amount of alcohol would cause in younger male
drinkers.
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Alcohol abuse in this generation is complicated by the use of prescription and overthe-counter (OTC) medications. The elderly spend over $500 million yearly on
medications. Combining medications and alcohol frequently result in significant
adverse reactions. Due to a reduction in blood flow to the liver and kidneys in the
elderly, there can be a 50% decrease in the rate of metabolism of some medications,
especially benzodiazepines. Additionally, chlordiazepoxide (Librium) and diazepam
(Valium) have such long half lives (often several days) in the elderly that prolonged
sedation from these drugs, combined with the sedative effects of alcohol, can
increase the risk of falls and fractures. The benzodiazepine user may become
confused and take extra doses or other medications, causing overdose or death.
Serious consequences can result solely from OTC medication use, as well as
combining them with alcohol. Laxatives, for example, can cause chronic diarrhea,
which can lead to sodium and potassium imbalance and cause heart rhythm
irregularities. Antihistamines, another popular OTC medication, can cause confusion;
cold medications can elevate the blood pressure and lead to strokes. Caffeine is
frequently added to OTC medications and can cause anxiety and insomnia. Often,
mixing alcohol and the OTC medications increases the occurrence of side effects and
can intensify negative consequences.
Nicotine dependence is also a significant problem in the elderly, due both to their
addiction and boredom. Use early in life sets the stage for morbidity and mortality
from this addiction. Over 400,000 people in the U.S. die each year from smokingrelated diseases. Elderly smokers not only continue to impair their respiratory
systems, but are also more apt to die from respiratory diseases. Nicotine
replacement products work successfully in this group, especially when combined with
behavioral, supportive and other therapies.
WHAT TO LOOK FOR?
The problem of elderly substance abuse may be difficult to detect when the elderly
live alone. Friends and family may be reluctant to even consider that there may be a
problem and medical evaluations often do not reveal substance abuse. Consideration
should be given to the presence of a drug and/or alcohol problem if there is memory
loss, depression, repetitive falls and injuries, legal problems, chronic diarrhea, labile
moods, malnutrition and recent isolation. Elderly women are more likely to have a
diagnosed or undiagnosed depression. Prescription drugs, particularly
benzodiazepines, may be abused by these women.
The Center for Substance Abuse Treatment published a list of signals that may
indicate an alcohol or medication - related problem in the elderly:
Memory trouble after having a drink or taking a medication
Loss of coordination ( walking unsteadily, frequent falls)
Changes in sleeping habits
Unexplained bruises
Being unsure of yourself
Irritability, sadness, depression
Unexplained chronic pain
Changes in eating habits
Wanting to stay alone much of the time
Failing to bathe or keep clean
Having trouble concentrating
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Difficulty staying in touch with family or friends
Lack of interest in usual activities
Elder abuse
Elder abuse is "a single, or repeated act, or lack of appropriate action, occurring
within any relationship where there is an expectation of trust, which causes harm or
distress to an older person [243].” The central part of elder abuse is the
"expectation of trust" by the elderly toward their abuser. Elderly people are more
active and independent today than ever before. Elder abuse is predominantly a
hidden social problem as it is usually committed within the confines of the elderly
person's home, mostly by the immediate family members [244]. In addition, elder
abuse victims usually do not report this crime for a number of reasons which
includes fear of loss of independence, fear of others' disbelief, fear of being
institutionalized or losing their sole social support, and fear of being subject to future
retaliation by the perpetrator(s). [245-247]. Cognitive decline in elder abuse victims'
and ill health is also responsible for under reporting of their abuse [248]. Lack of
proper training of healthcare professionals regarding elder abuse can also lead to
under reporting of their abuse [249].
With the growth in US population, the problem of elder abuse has slowly come to the
forefront. Each year, approximately 4 million elderly Americans are victims of
different forms of abuse. Those elderly persons who suffer abuse usually experience
worsened financial and functional conditions and progressive dependency, feelings of
helplessness and loneliness, poor self-rated health, and increased psychological
agony. Studies have also observed that the elderly who experience abuse have a
tendency to die earlier than those who have not been abused, even in the absence of
chronic or life-threatening conditions or disease. Elder abuse is a complex social
problem which is not confined to older adults with poor financial status [250]. Elder
abuse also happens in community settings, as well as institutional settings like
nursing homes and other LTC facilities. In 2008, approximately 3.2 million Americans
resided in nursing homes [251]. In 2009, more than 900,000 American lived in
assisted living settings [252].
In a recent study conducted on elderly people, it was observed that approximately
7.6%–10% of the participants experienced abuse in the prior year [253-254]. This
study did not include financial abuse [255]. Another study estimated that only 1 in
14 cases of elder abuse is reported or comes to the attention of authorities [256]. In
a recent survey, major financial abuse was reported by older people at a rate of 41
per 1,000 surveyed, which was even higher than self-reported rates of physical ,
emotional, and sexual abuse or neglect [257]. Elderly abuse also exists in healthcare
institutions such as nursing homes, hospitals, and other LTC facilities. A survey of
nursing-home staff suggests the abuse rates may be high. The survey observed that
approximately 36% the staff witnessed at least one incident of physical abuse of an
elderly patient in the previous year. At least 10% of the staff committed at least one
act of physical abuse towards an elderly patient, and around 40% of nursing staff
admitted to psychologically abusing patients. Another study found that
approximately 90% of abusers were immediate family members, usually adult
children, spouses, partners, and others [258].
There are several types of elder abuse which includes [259, 260]:
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




Physical: This type of abuse can range from slapping to severe beatings and
restraining. It also includes false confinement, or providing excessive or
improper medication
Psychological/Emotional: This includes any type of behavior (coercive or
threatening) that causes fear, mental anguish, or emotional pain to the elder. It
may take verbal forms such as name-calling, constantly criticizing, bullying,
accusations, blaming, ridiculing, or non verbal forms such as shunning, ignoring,
etc.
Financial abuse: This encompasses forceful, illegal or unauthorized use of an
individual’s property, money, or other valuables. The financial abuse is usually
accomplished by deception, misrepresentation, undue influence, coercion, etc.
Other forms of financial abuse include deprivation of money or property. It also
includes scams by strangers via fraudulent investment schemes, predatory
lending, and lottery scams [261].
Sexual abuse: This can range from inappropriate touching, sexual exhibition
to rape. Sexual abuse is probably the least reported form of elder abuse.
Neglect: This form of abuse ranges from food deprivation to emotional
deprivations. In such cases caregivers intentionally deprive the physical, social,
or emotional needs of the elderly. Neglect can include failure to provide
adequate medications, clothing, and assistance with activities of daily living.
Neglect can also include failure to pay the bills for the elderly or to manage the
financial aspects of the older person. In rare cases, family caregivers can also
neglect unintentionally, also known as passive neglect, because of their own lack
of resources knowledge, or maturity.
Some U.S. state laws [262] also recognize the following as a form of elder abuse:

Abandonment: Elder abuse also includes desertion of an elderly person by
care providers or by an individual who has the physical custody of an elder that
might endanger their health or welfare [263].

Rights abuse: This is an important aspect of elder abuse which is
increasingly being recognized and encompasses forceful denial of the rights (civil
and constitutional) of an elderly individual who is not declared by court to be
mentally incapacitated.

Self-neglect: Elderly people neglecting themselves by not caring about their
own health or safety. Self-neglect is treated as conceptually different from elder
abuse.

Institutional abuse. This refers to physical or psychological abuse, as well
as rights violations in settings where care and assistance is provided to
dependant elderly or others.
Warning Signs
The ability to detect the warning signs of elder abuse is the key to its prevention.
Signs of elder abuse may vary according to the type of abuse the elderly person
experiences. Each form or type of abuse has distinct signs and symptoms associated
with it. Caregivers with past history of substance abuse or mental illness have a
greater likelihood of committing elder abuse than other individuals [264]. Elder
abuse can be difficult to detect if subtle in nature. Therefore, any suspicion must be
taken seriously and concerns should be immediately and properly addressed.
WARNING SIGNS OF ELDER ABUSE
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Physical Abuse
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Verbal/Emotional/Psychological
Abuse
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Sexual Abuse
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Financial Abuse or Exploitation



Bruises or grip marks around the arms
or neck [265]
Repeated unexplained injuries
Rope marks or welts on the wrists
and/or ankles
Dismissive attitude or statements
about injuries
Refusal to go to same emergency
department
for repeated injuries
Uncombed or matted hair
Poor skin condition or hygiene
Unkempt or dirty
Patches of hair missing or bleeding
scalp
Any untreated medical condition
Malnourished or dehydrated
Foul smelling
Torn or bloody clothing or
undergarments
Scratches, blisters, lacerations or
pinch marks
Unexplained bruises or welts
Burns caused by scalding water,
cigarettes or ropes
Unresponsive and uncommunicative
Unreasonably frightened or suspicious
Lack of interest in social contacts
Evasive or isolated
Unexplained or uncharacteristic
changes
in behavior
Withdrawn
Confused or extremely forgetful
Depressed
Helpless or angry
Hesitant to talk freely
Secretive
Unexplained vaginal or anal bleeding
Torn or bloody underwear
Bruised breasts or buttocks
Venereal diseases or vaginal infections
Life circumstances don’t match what is
known about the individual’s financial
assets
Large withdrawals from bank
accounts, accounts that have been
switched; unusual ATM activity
Signatures on checks don’t match the
older person’s signature
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Caregiver Neglect
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Lack of basic hygiene, adequate food
and water, or clean and appropriate
clothing
Sunken eyes or loss of weight
Person with dementia left
unsupervised
Untreated pressure bedsores
Lack of medical aids (glasses, walker,
teeth, hearing aids, medications)
Risk factors
Risk factors that contribute to the elder abuse may be identified at the individual,
relationship, community, and socio-cultural levels.
Individual
Risks at the individual level include dementia of the elderly, alcohol and substance
abuse and the presence of mental disorders in the perpetrator. Other individual-level
factors include female gender and a shared living situation. Elderly women are
particularly at higher risk of neglect through abandonment especially if they are
widowed and with poor financial status. Women are also more frequent victims of
persistent and severe forms of elder abuse and injury.
Relationship
A perpetrator’s dependency, particularly financial, on the elderly also increases the
risk of elder abuse. Poor family relationships can also lead to elder abuse because of
increasing frustration and stress as elderly becomes more dependent with aging.
Family members have less spare time to provide adequate care for elderly which
may become a burden, increasing the risk of elder abuse.
Community
Social isolation of elderly people as well as caregivers coupled with absence of social
support is an important risk factor for elder abuse. The elderly may become prone
to isolation because of poor physical and mental health or due to loss of family and
friends.
Socio-cultural
Socio-cultural factors that may increase the risk of elder abuse:

Depiction of elderly as weak, frail and dependent.

Erosion of the intimacy and bonds between generations of a family.

Issues of inheritance and land rights that may adversely impact distribution of
wealth and power within families.

Migration of family members, particularly young couples, leaving elderly
parents alone, in societies where elderly were traditionally cared for by their
offspring.

Poor financial ability to pay for care.
Within healthcare settings or institutions elder abuse is likely to occur when:
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There are poor standards for health care and health care facilities for elderly
people.
The staff is poorly trained, underpaid, and overworked
There is a poor physical environment
The policies are pro-institution rather than pro-residents.
Level
Risk Factors
Individual (victim)
Sex: women
Age: older than 74 years
Dependence: high levels of physical or intellectual disability
Dementia, including Alzheimer’s disease and other types of
dementia
Mental disorders: depression
Aggression and challenging behavior by the victim
Sex: men in cases of physical abuse and women in neglect
cases
Mental disorders: depression
Substance abuse: alcohol and drug misuse
Hostility and aggression
Financial problems
Stress: caregiver burnout
Financial dependence of the perpetrator on the victim
Dependence of the perpetrator on the victim (emotional and
accommodation)
Intergenerational transmission of violence
Long-term history of difficulty in the relationship
Kinship: children or partner
Living arrangement
Social isolation: victim lives alone with perpetrator and both
have few social contacts
Lack of social support: absence of social support resources
and systems
Discrimination because of age: ageism
Other forms of discrimination: sexism and racism
Social and economic factors
Violent culture: normalization of violence
Individual
(perpetrator)
Relationship
Community
Societal
Health Consequences
Compared to elders who have not been abused, those who undergo abuse have been
found to have increased (three fold) risk of mortality [266]. A recent study has
shown that victims of elder abuse have had substantially greater levels of
psychological distress and lower perceived self-efficacy than the elderly who have
not been victimized [267]. Furthermore, elderly who are victims of violence have
additional health care problems than other older people, including osteoporosis,
arthritis, depression, hypertension, and cardiovascular disease [268].The impact of
elder abuse also leads to a significant economic burden. The direct medical costs
due to elder abuse were estimated to be $2.9 billion in 2009 [269].
The health consequences of elder abuse are varied and can be very serious. Elder
abuse can clearly adversely affect an individual’s quality of life [270].
Health Consequences Of Elder Abuse
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
Declining functional abilities

Increased dependency

Increased psychological stress

Greater sense of helplessness

Deteriorating psychological status

Increased mortality and morbidity

Depression and dementia

Undernutrition or malnutrition

Mortality or Death
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Elder Abuse- Prevention

The first and most important step toward preventing elder abuse is to
recognize that no individual should be subjected to abusive, humiliating,
neglectful, or violent behavior.

Education is the one of the principal means of preventing elder abuse.
Concerted efforts should be made to educate the public about the needs and
problems of elderly and the risk factors associated with elder abuse

Respite care: Every caregiver needs time alone, free from the stresses
associated with elder care. Respite care is particularly important for
caregivers of the elderly with Alzheimer’s disease or other forms of dementia.

Social contact and support can be very helpful to the elderly as well as to
family members and caregivers. Elderly individuals with expanded social circle
tend to have fewer stresses and tensions. The probability of abuse increases
with an increasing isolation of elders.

Counseling can be beneficial for behavioral or personal problems of an elderly
or the caregivers.
Reporting Abuse
Any individual who suspects that elder abuse has occurred should report the
incidence because the abuse can continue and may escalate if there is no
intervention. All cases of elder abuse should be reported to the Elder Abuse Provider
Agency agencies in the area. If an individual is in doubt about elder abuse, it is
always better to err on the side of caution and report the situation. If elderly abuse
occurs in a long-term care facility, such as a nursing home or residential care facility,
one may call the local Long-Term Care Ombudsman, local law enforcement agency,
etc. A complaint can be filed with the appropriate state regulatory agency. If the
suspected abuse occurs anywhere other than in a facility, reports should be made to
the local law enforcement or local county Adult Protective Services Agency. Each
county Adult Protective Services agency (APS) is responsible for providing assistance
to the elderly who are abused or are functionally impaired, and who are unsuspecting
victims of exploitation or neglect, including self neglect. The agency investigates
reports of abuse that occur in private homes, hospitals, clinics, social day care
centers and adult day care centers. Some professionals (healthcare physicians,
hospital staff, dentists, chiropractors, social workers, registered nurses and law
enforcement officers) are mandated to report the suspicion of elder abuse or neglect
of a resident in a licensed nursing facility.
END-OF-LIFE CARE ISSUES
End-of-life care may be defined as health care for patients in the last few day or
hours of their lives, and all individuals with a terminal condition or illness such as
cancer that is progressive, advanced, and incurable will require end-of-life care.
End-of-life care requires addressing a number of issues and decisions, including
patients' right to self-determination (to live or die), medical experimentation, and the
efficacy and ethics involved with medical interventions. End-of-life also touches
upon the burden associated with it such as rationing and the allocation of resources
in hospitals and healthcare system. Such decisions also involve medical
considerations, bioethics, and economic factors.
Another prime consideration is the individual patient’s autonomy. Finally, it all
depends upon the wishes of the patients and their families to decide whether to
pursue further medical treatment or withdraw life support [271]. It is estimated that
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approximately 27% of Medicare's annual $327 billion budget ($88 billion) is spent in
end of life care [272, 273].
As the elderly confront the end of life issues, they and their families usually face
tasks and decisions that encompass a number of choices ranging from simple to
extremely complex. The issues can be medical, psychosocial, spiritual, legal, or
existential in nature. For instance, dying elderly and their families are faced with
choices and dilemmas about the type of caregiver help and whether to receive care
at healthcare institution or home. Dying people and their family may have to make
decisions regarding the amount of family involvement in decision-making and care
giving.
Ethical guidelines for physicians pertaining to end of life care depend upon several
factors which include beneficence, non-maleficence, patient autonomy and
resources. In recent decades, society has recognized the important role of patient
autonomy, a key issue in the end of life care. Patient autonomy is the right of
patients to make decisions about their medical care without their health care
provider trying to influence the decision. In some cases, patient’s decision regarding
end of life care may differ from that of family members and health care providers’
recommendations [274]. In such a scenario, every physician should make sure that
the patient is fully informed about their condition. Patient's goals for care should be
established as early as possible [275]. In addition, when discussing patient
preferences about life sustaining treatments, healthcare providers should accurately
explain to the patient any possible benefits and burdens about life sustaining
treatments [276]. Another key ethical principle is the appropriate stewardship of
resources. This is particularly important in end-of-life care when life sustaining
treatments can be a burden because of cost and time involved in the treatment.
Effective Communication Tips at the End-of-life
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Ensure a quiet location for communication
Allow appropriate time for the interaction
Involve the family in all communication
Involve the family in all communication
Speak from a seated position
Assess patient understanding
Use open ended questions to gauge understanding and invite the patient
perspective
Accept and address emotions of patients and loved ones
Educate patient and family on disease state(s)
Inquire about and address cultural issues
Demonstrate reflective listening
Express empathy
Disclose all benefits and risks to treatment as well as alternative therapy
Speak objectively in an evidence-based manner
Suggest all appropriate resources to patients and their families including
psychiatric care, pastoral support, and social services
Identify and discuss advance directives
Establish patient goals and develop a plan
The healthcare workers role at the end of life
Healthcare workers have to confront many challenges in the management of end-oflife care. The general approach of healthcare givers and physicians is to preserve
life; however, patients have the right to choose the objectives and goals of their own
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medical care. The main role of healthcare providers near the end of life is to
coordinate and administer optimal medical and psychosocial care for the patient. In
addition, healthcare workers should educate and advise the elderly patient and
family to help in the decision making process [277]. Physicians and healthcare
providers must take on the appropriate level of involvement keeping in view the
patient and family perspectives and wishes [278, 279].
Ethical Issues at the End-of-life*
To enhance End-of-life care physicians and other healthcare providers
should:

Respect the dying patient's needs for care, comfort, and compassion.

Communicate promptly and appropriately with patients and their families
about EOL care choices, avoiding medical jargon.

Elicit the patient's goals for care before initiating treatment, recognizing that
EOL care includes a broad range of therapeutic and palliative options.

Respect the wishes of dying patients including those expressed in advance
directives. Assist surrogates to make EOL care choices for patients who lack
decision making capacity, based on the patient's own preferences, values,
and goals.

Encourage the presence of family and friends at the patient's bedside near the
end-of-life, if desired by the patient.

Protect the privacy of patients and families near the end of life.

Promote liaisons with individuals and organizations in order to help patients
and families honor EOL cultural and religious traditions.

Develop skill at communicating sensitive information, including poor
prognoses and the death of a loved one.

Comply with institutional policies regarding recovery of organs for
transplantation.
 Obtain informed consent from surrogates for postmortem procedures.
*Excerpted from: American College of Emergency Physicians: Ethical Issues at the
End-of-life; Ann Emerg Med 2008; 52:592.
Hospice and palliative care
Hospice and palliative care facilities provide several services associated with end of
life care which helps patients and loved ones in the transition towards death. These
facilities provide care to preserve the quality of life and to provide pain relief.
Hospice also provides support to cope with the psychological stresses associated with
the end-of-life [280].
Hospice and palliative services are available at the patient's home, hospitals and
acute and chronic care facilities [281]. Hospice services have been covered under
Medicare since 1983[282].
Palliative care is gaining importance and is helpful in prolonging life and extending
survival. Proper palliative care helps elderly patients to shift attention from their
condition to their wishes for how they choose to spend the remaining time of life.
It is important to note that palliative care does not begin when life-prolonging care
ends. Rather, these two approaches of care can be used concurrently. The role of
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the physicians and healthcare providers is to strike a balance between these two
approaches to provide the most optimal, effective and individualized care for the
elderly patients. Appropriate changes in palliative care may be made in order to
improve end-of-life care. A recent study stressed the need for appropriate use of a
palliative care team for terminally ill patients [283]. Many studies have reported that
compared with white Americans, minority groups are less likely to benefit from
hospice care. When compared with European Americans, elderly African Americans
and Latinos have a greater likelihood of dying at home and have less likelihood of
getting hospice care.
Pharmacologic management of symptoms at the end-of life is a complex much
debated issue. Sedatives can be effectively used for refractory symptoms, especially
dyspnea and agitation, which cannot be managed with other forms of therapy [284].
Some researchers and physicians argue that the use of pain medications may
accelerate patient's death. However, majority of healthcare providers agree that if
the provider's intent is to relieve suffering, an unintentional effect of influence on the
time of death is legally, ethically, and morally acceptable [285-289].
Common Symptoms at the End-of-life

Pain

Dyspnea

Anxiety

Depression

Guilt

Nausea

Constipation

Insomnia

Weakness

Fatigue

Delirium
Cultural and spiritual issues
Cultural issues, especially pertaining to the end-of life, care are becoming
increasingly significant as the US has become more diverse. End-of life care and
decision making should reflect cultural traditions and beliefs of the patient; however,
it is important not to generalize that all members of a given culture have similar
attributes. Cultural may influence the type of end of care a person desires. For
example, patient autonomy is very important to people living in America and Europe
[290]; however, other cultures, especially Korean and Hispanic, believe that decision
making is the responsibility of the family [291]. Many Hispanics believe that they
should not control life's processes and thus are less likely to be interested in advance
care planning [292]. Japanese people usually take a reserved approach and
sometimes are reluctant to share personal information or feelings with healthcare
givers or physicians [293]. Indian patients, on the contrary, tend to be more open
and develop a deeper interaction with their treating physicians. They are more
complaint to doctor’s advice. These attitudes must be considered and taken into
account when providing end of life care.
One area that significantly varies among different cultures is the communication of
bad news. In the US a physician usually fully discloses the patient's actual condition
or prognosis irrespective of its severity. In Chinese and Hispanic cultures, this is
considered to be inappropriate and family members tend to hide bad news or
prognosis from the patient. Healthcare staff have an ethical, moral and legal
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obligation to fully inform a patient of their condition. In addition, physicians should
explain the rationale behind full disclosure, and that it equips the family member and
the patients to make appropriate decisions regarding treatment and end of life care
issues.
It is important to reiterate that cultural behaviors should not be generalized or
stereotyped and should not be applied to all members of the culture [294, 295].
Clinicians need to understand that cultural variation does exist and should try to
understand each of their patients' cultural values.
Spiritual issues and concerns play an important role in the end-of-life care for many
patients. A recent review identified 11 dimensions for end-of-life spirituality which
includes:

meaning and purpose in life

self-transcendence

transcendence with a higher being

feelings of communion and mutuality

beliefs and faith

hope

attitude toward death

appreciation of life

reflection upon fundamental values

developmental nature of spirituality

Conscious aspect of spirituality [296].
Religious issues, particularly at the end of life, are important to each individual
patient and should be addressed appropriately.
Advance care planning
An advance directive is a legal document that allows patients to decide their
treatment wishes to be carried out in case they are unable to make their preferences
known.
DNR order, living will and durable power of attorney for health care are the most
common forms of advance directives. A living will is a record declaring a patient's
provisions for their care. A durable power of attorney for health care is when a
patient proactively assigns a surrogate decision maker in case they are unable to
make their medical decisions known. Patient’s spouse or other family member is
usually the durable power of attorney, but a trusted friend can also fulfill the duty. It
is important that elderly openly discuss their end-of-life issues and preferences with
their surrogate decision maker for optimal utilizing the purpose of this form of
advance directive.
Advance directives fulfill several key purposes, especially the communication of
elderly patient wishes regarding end-of-life care.
Many elderly have their personal preferences with regards to cardiopulmonary
resuscitation or CPR [297]. These preferences vary broadly, and are dependent on
several factors, including patient’s age, state of health, and clinical setting [298,
299].
Recent studies have indicated that majority of patients do not desire full resuscitative
efforts [300, 301]. Healthcare providers and families, in absence of advance
directives, often misjudge the patient's end-of-life wishes [302- 306]. Medicare and
Medicaid providers have to inform patients of their rights regarding advance
directives [307].
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However, there is still poor public awareness regarding patient care and rights at the
end-of-life [308, 311]. Furthermore, it has been found that individuals who have
advance directives do not properly understand their implications [308, 309, 312]. All
these elements associated with end-of-life issues further complicate the role of the
physician and outcomes for the patient; however, it is the clinician’s responsibility to
communicate and inform elderly individuals of their rights as patients. In a recent
study it was observed that only 10-30% of patients have completed advance
directives [313-317]. The ideal advance directive should facilitate a system to honor
directives that encompasses the following:

It is comprehensive

It preserves patient autonomy

It is easily understood by everyone involved [318].
Informed consent and decision-making capacity
Informed consent is a fundamental right of a patient that protects patient autonomy
with regards to treatment options. Consent to medical treatment is not essential in
certain extraordinary or emergency circumstances. However in most clinical
scenarios, informed consent must be obtained from the patient or from the family in
case the patient is not capable [322]. Informed consent requires three key
components or elements: decisional capacity, delivery of information, and
voluntariness. Informed consent can be obtained from only if the patient has
adequate decision making capacity. Several factors are involved to determine the
decision making capacity of the patients which includes patient’s capacity to receive
and process information, and effectively communicate their wishes [325]. Patient’s
decision making capacity can be impacted by certain conditions such as pain,
depression, anxiety, intoxication, side effects of certain drugs, medication and
several others [324-326]. A validated systematic process should be followed to
minimize bias and standardizes the measurement of capacity in each individual
situation.
Hospice Care
The concept of hospice was first initiated in 1967 by English physician Dr. Dame
Cicely Saunders. In the US, the concept of hospice care emerged in the mid 1970s.
In 1982, hospice care was included in the Medicare program. Hospice services
include professional nursing care, personal assistance with ADLs (activities of daily
living,) rehabilitation therapy, dietary, psychosocial and spiritual counseling for
elderly patient and family, respite care, volunteer services, availability of medical
drugs and devices essential for palliative care, and family bereavement services after
the patient’s death. Hospice care is provided by team which includes nurses, social
workers, nursing assistants, other health professionals, and pastoral services, under
the guidance and management of the patient’s own primary care physician or
hospice program.
In the US, majority of elderly patients can utilize Medicare Hospice benefits (MHB).
For an older adult to use hospice care, a physician must certify that the individual
has a greater probability of dying within 6 months if the terminal disease such as
incurable cancer, chronic disease, etc follows its anticipated course. The patient is
reassessed periodically, in the beginning after each of the first two 90-day periods,
and then 60 days after that to document continued determination in the patient’s
condition and assess if the hospice care continues to be appropriate.
Despite Medicare Hospice Benefit, there is a tendency to provide ICU (Intensive Care
Unit) hospitalization for end-of-life care [447] , which is both expensive as well as
often futile. Nursing homes are usually reluctant to have patients die on their
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premises and under their care. Hence, when an elderly comes close to death, the
patient is usually shifted to the nearest hospital and admitted to the ICU.
KEY MEMBERS OF HOSPICE CARE
Members
Duty
Primary
Physician




Hospice
Physician




Nurse






Home
Health Aide


Social
Worker



Provides the hospice team with medical history
Oversees medical care through regular communication
with the hospice team
Provides orders for medications and tests, signs death
certificate, etc.
Determines his or her level of involvement on a caseby-case basis with the hospice medical director
Provides expertise in pain and symptom control at the
end of life
Works closely with the hospice team and primary
physician to determine appropriate medical
interventions
Makes home visits on an as needed basis
May oversee the plan of care, write orders, and consult
with patient and family regarding disease progression
and appropriate medical interventions on a case-bycase basis
Visits patient and family in the home or nursing home
on regular basis (biweekly to 3-4x per week, depending
on the specific needs of the patient)
May provide on-call services (24 hours a day, 7 days a
week for emergencies)
Assesses pain, symptoms, nutritional status, bowel
functions, safety, and psychosocial-spiritual concerns
Educates patient and family about disease progression,
use of medications, daily care needs, and other aspects
of the overall plan of care
Educates and supervises nursing assistants
Provides emotional and spiritual support to patient and
family to cope with functional limitations, caregiver
stress, and grief
Assists patient with activities of daily living such as
bathing and dressing
Provides a variety of other services depending on
assessment of need
Attends to both practical needs and counseling needs of
patient and family based on initial and ongoing
assessment
Arranges for durable medical equipment, discharge
planning (from hospital to home), funeral/burial
arrangements
Serves as liaison with community agencies (such as
Department of Human Services, Department of Aging,
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


Chaplain
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
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

Volunteer


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


Public Aid office)
Assist family in finding services to address financial
needs and legal matters (Power of Attorney, Wills)
Provides counseling related to family communication
Assesses patient and family anxiety, depression, role
changes, caregiver stress
Provides general grief counseling
Provides patient and family with spiritual counseling to
address questions of hope, meaning, despair, fear of
death, relationship with divine, need for forgiveness,
loss of life purpose
Assists patient and family in sustaining their religious
practice and in drawing upon religious/spiritual beliefs to
cope with illness, dying, and grief
Ensures that patient and family religious or spiritual
beliefs and practices are respected by the hospice team
(e.g. dietary restrictions, rituals to be observed at the
time of death, disposition of the body)
Serves as a liaison with the patient/family faith
community and clergy
May conduct funeral and memorial services for patients
and families as requested
Provides hospice staff with spiritual care and counseling
Provides respite care to family members
May assist with light housekeeping or grocery shopping
Helps patients stay connected with community groups
and activities
Facilitates special projects such as memoirs/legacy
work, letters to family, and massage therapy
May provide community education and outreach
May assist with office work
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Services Offered by Hospice
For the Patient

Hospice works with the patient’s family or nursing home staff in order
to provide optimal care to the dying patient.

Goals of care (realistic and achievable) are established and a care plan
developed to help achieve these goals.

The hospice team is geared to relieve patient’s pain and other
symptoms because of end stage disease and other conditions.

Medications are prescribed by the hospice or primary physician, and
are usually bought by family members from the designated pharmacy.

Laboratory services that are essential for the symptom control and are
necessary for treatment are provided by the hospice program.

Ambulance services are also made available when the condition is
related to the terminal diagnosis, and comes within the scope of the
care plan.

Assistance in activities of daily living may be provided by family,
friends, paid caregivers and/or nursing home staff with hospice staff
providing only an educational and supervisory role.

The majority of hospices provide 1-2 hours of care by a home health
assistant or aide for particular needs such as bath service.

Essential durable medical equipment such as a hospital bed, oxygen,
walker, etc is provided by hospice.

Counseling is provided by the hospice to help patients cope with their
end of life issues. Hospice staff may also help the patient regarding
legal or financial business issues and in making funeral arrangements.

Religious care is provided either directly by the hospice chaplain or
through community church.
For Caregivers/Family Members

Counseling services for caregivers and family members to better cope
with stress, depression, anxiety, role changes, family conflict, grief, as
well as religious and spiritual concerns.

Respite care may be made available to family either by volunteers or,
by paid staff either in the hospital or at home.

Education to family to provide hands on care to patients, for optimal
use of prescribed medications, for knowledge about the disease, its
progression, signs and symptoms of the dying process, normal grief
response, coping mechanism of dealing stress, etc.

Practical assistance pertaining to legal issues, Powers of Attorney,
Living Will, and accessing community services.

Assistance related to cremation/burial arrangements and with
funeral/memorial services.

Bereavement care can also be made available.
Benefits of hospice care
Several research studies have observed that family members are more satisfied with
hospice or palliative care when compared with hospitalization [327]. Compared to
hospitalization, hospice provides better care with greater consumer satisfaction
[328].
A research study conducted on CHF (chronic heart failure) patients found that such
patients live longer, an average of 29 days, under hospice care [329]. Furthermore,
hospice care is generally associated with a decreased financial burden [330].
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Barriers to hospice use
Death of an elderly individual with end-stage disease cannot be predicted with
accuracy. It has been observed that mandated assignment of a 6-month time period
as per Medicare has itself become a barrier to end of life care [328] Physicians and
other healthcare professionals are reluctant to refer a patient to hospice as they may
consider it a medical failure because they are trained to prolong life. The National
Hospice Foundation has reported that approximately three-fourth of US citizens do
not have adequate information regarding hospice care. They do not know that
hospice care can be provided in the home and around 90% do not know that hospice
care is fully covered through Medicare.
Euthanasia and physician-assisted suicide
Euthanasia and physician-assisted suicide are highly emotional and complex issues in
American medicine. Euthanasia is the intentional ending of the life of an individual
who has an incurable or terminal illness [331]. Physician-Assisted Suicide can be
described as a practice in which the physician provides a patient with a lethal dose of
a drug/medication, upon the patient's request, which the patient intends to use to
end his or her own life [332]. In a physician-assisted suicide, the physician offers the
necessary means or information and the patient performs the act, whereas in
euthanasia only the physician performs the intervention. Currently, physicianassisted suicide is legal in the states of Oregon and Washington, whereas euthanasia
is illegal in every state [333]. Euthanasia is, however, legal in the Netherlands and
Switzerland. Interestingly, many individuals as well as social groups support
legalization of both euthanasia and physician-assisted suicide [333]. Despite this
support, physicians must follow the laws of the state. Physicians must explain their
legal obligations in case the patient expresses wishes regarding euthanasia or
physician-assisted suicide. When treating such patients, physicians should try to
understand the root cause of their feelings. Many patients may consider euthanasia
or physician-assisted suicide due to fears that may be allayed with proper education
about their condition and disease as well as with effective palliative treatment.
EMOTIONAL BURDEN
Advances in the medical field and the quality of health care has made rapid strides in
the last few decades resulting in lower mortality rate from disease and increased life
expectancy, particularly in developed countries. However, the extended survival of
individuals with severe chronic disease has increased the emotional burden on the
patient as well as on the caregiver. People now survive for longer period of time
even with severe chronic disease, but there is a high emotional and financial cost of
this prolonged treatment and continuous medical surveillance, particularly for the
elderly in long term care. Such patients go through tremendous stress and yet the
emotional aspect of their condition is generally overlooked. Most physicians
understand the impact of a disease on the emotional functioning of the patient.
Despite significant improvement in the management and treatment of chronic
conditions, challenges still remain regarding recognition and management of the
emotional and other psychological impact of chronic disease or illness.
Chronic medical illness
Mental disorder/illness and chronic disease
Patients with chronic diseases usually have to make adjustments regarding their
lifestyle, ambitions, and employment. Many face great emotional upheaval and
distress about their condition before adjusting to it. But some patients are unable to
cope up with the predicament and are susceptible to psychiatric disorders, such as
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depression or anxiety. In a recent research study of general medical admissions, it
was observed that approximately 13% of men and 17% of women had symptoms of
an affective disorder [334]. Approximately 20-25% of patients with chronic illness
such as rheumatoid arthritis or diabetes had a concomitant affective disorder [335].
Furthermore, the rate of affective disorders further increases among those elderly
patients with cancer or those undergoing acute care. This rate may exceed 30%
[336] which is significantly higher than the prevalence of depression in the
community, which hovers around 4%-8% [337].
Diagnosis of depression is difficult in patients with chronic disease. Physical
symptoms such as impaired appetite, impaired sleep, fatigue, and lack of energy
may be present due to the disease. Sometimes medications, such as steroids,
prescribed to a patient for treating a medical disorder may affect the patient’s mood.
In other cases, the disease process itself may be the culprit. For instance, infection
and hypoxia in a patient with COPD may affect the brain and patient’s mood. The
functional limitations due to a chronic condition or disease generally cause
“understandable” distress, which is difficult to differentiate from a depressive
disorder [338]. There is a fine line between an adjustment reaction and depression.
Therefore, the clinician should determine the patient’s risk factors for depression
such as previous episodes of depression, pain, a major disability, etc. Other
prominent risk factors include unemployment, financial burden, and a lack of
emotional support [339].It has been observed that there is strong association
between physical illness, depression and disability [340] and increased use of
hospital and medical outpatient services [341]. Despite these complexities and
difficulties, it is necessary to diagnose and treat depression in elderly with chronic
diseases. Even mild cases of depression can prevent an older adults to seek medical
care and adhere to treatment plans.
Depression and hopelessness, commonly observed in elderly people with chronic
conditions may adversely impact the coping ability of the patient and may negatively
affect family relationships [339]. It has been observed that the patient with a
terminal medical condition who commits suicide is also suffering from some kind of
depressive illness [342]. Depression in the elderly with chronic disease is also
associated with significant increases in disability and adverse physical outcomes
[343]. Patients who have symptoms of depression after a CVA (cerebrovascular
accident) have an increased rate of mortality [344] and disability along with a
reduced capability to perform activities of daily living [345]. The clinical course of
cardiovascular illness or disease is also affected by depression. Several studies have
observed that there is an increase in mortality rate due to cardiovascular disease
among elderly patients with depression [346]. The process of diagnosis as well as
treatment in patients with depression is often difficult and complex. Antidepressant
drugs may lead to a deterioration in the patient’s medical condition. In addition,
there is a risk of drug interactions, and conditions such as chronic renal hepatic or
renal failure may alter drug metabolism [347]. Therefore, selection of an
antidepressant requires a thorough determination of the risks and benefits [347].
Antidepressant drugs show high efficacy in elderly who are medically ill, [347] and
these drugs are well tolerated in majority of patients (around 80%) with cancer
without significant adverse effects [348]. The optimal treatment of depression in
such patients also encompasses a combination of cognitive and supportive
psychotherapies.
Chronic disease superimposed on mental illness
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The development of a chronic medical disease in elderly patients with an underlying
mental disorder may result in an exacerbation of their symptoms as well as
deterioration in their functioning. Diagnosis of medical conditions in elderly with an
underlying psychotic disorder is complex and difficult as such patients may be
incapable of communicating their symptoms or may not give their symptoms priority.
Physicians, especially psychiatrists, have an important role in helping these patients
to better understand the medical issues they encounter and in determining their
capacity to make informed decisions [349]. It has been observed that after an
episode of major depression the overall risk of myocardial infarction greatly
increases by 4-5 times, provided the other medical factors are controlled [350].
Depression in women is associated with decreased bone mineral density [351]. Thus,
depression may contribute to the development of chronic medical diseases or
conditions.
Physical symptoms as an expression of emotional impairment/dysfunction
The development of new symptoms in an elderly patient with a previously stable
condition may point towards emotional distress. The exacerbation of an established
illness and its symptoms may indicate depression, adjustment problems, or complex
social or relationship problems. The cardinal symptoms of the somatoform disorders
are physical complaints, extreme fear of physical illness, or the unwarranted and
excessive pursuit of treatments, medical or surgical [352]. Such problems can
sometimes be very difficult to manage, and the most difficult to help [353]. Effective
communication between the elderly and the doctor [354] can reduce the risk of
chronic disability and morbidity [355].
Maintaining the patient's hope
For patients and their families, hope is a key component of the coping mechanism.
The clinician has an important role in engendering hope. Maintaining realistic hope is
crucial for long-term survivors of HIV infection [356] and breast cancer [357]. It is
important that all the factors such as anxiety, fear, etc that may accompany severe
and chronic illness are discussed with the patient to help them keep a positive
outlook and maintain realistic hope. A study conducted on women with breast cancer
reported that patients who pursued alternative treatments had greater levels of
psychological morbidity [358]. It is possible that the pursuit of alternative treatments
might indicate the patient’s higher degree of distress [359].
Moving towards the terminal phase
Recognizing that the patient is approaching end of life can be a distressing
experience for all the staff. In certain cases, the patient may become reluctant to
discuss issues related to end of life, or change in treatment goals, but in others, the
treating clinician’s avoidance may prevent or reduce the chance for the patient to
raise these issues [360]. The staff may become reluctant to abandon more
aggressive management. It has been observed that treating clinician’s assessment of
treatments may be different from that of the elderly patient with terminal cancer
[361]. In some cases, patients with a chronic illness may experience a high level of
satisfaction in terms of their quality of life. Also, treating physicians may
underestimate the quality of life experienced by elderly patients. Patients may give
greater importance to their mental health, whereas doctors may give more attention
to patients’ physical limitations.
Treatment issues
Adverse effects of treatment
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The side effects of certain treatments may cause anger and frustration. These
feelings may develop due to various symptoms and an emotional reaction to changes
taking place in the patient’s body. In some case these changes may be attributed to
the effect of certain drugs/treatment on the patient’s mood. The treating doctor may
also feel guilty about these side effects. Additionally, patients who are extremely
demanding, angry, or resentful may trigger feelings of rage and frustration in the
healthcare staff.
Compliance
Although medical adherence may improve the course of a disease, the clinician
cannot promise a cure. In certain chronic diseases, such as diabetes, despite
medical compliance, systemic impairments may still occur. Sometimes the patient
and the treating physician may have conflicting ideas regarding the proposed
treatment. For example in chronic fatigue syndrome, cognitive therapy and exercise
have a beneficial effect, but this is often not understood or accepted by the patient
or by their family. If patients and their families do not comply with such treatment,
long-term care of the elderly patient may be adversely impacted.
Psychosocial aspects of care
Psychosocial interventions have become an important constituent of routine medical
care. For example, in patients with rheumatoid arthritis, the use of stress reduction
interventions have lead to substantial improvements in managing feelings of
helplessness, difficulty in coping, dependency, and pain [362]. It has been observed
that simple psychosocial interventions that encourage patients with chronic
conditions such as asthma and rheumatoid arthritis to express the psychological
impact of their disease have lead to substantial improvement in these patients [363].
The families of elderly patients with chronic disease or conditions are more
susceptible to depression and have a greater likelihood of experiencing psychological
symptoms.
Emotional Burden for health professionals
Recognizing of the cost of caring
Clinicians who treat elderly patients with a chronic condition should never ignore
their own needs. Clinicians can get overwhelmed by the emotional requirements of
their patients. In one study, it was observed that approximately 50% of the
clinicians experienced high levels of emotional exhaustion. The sense of despair and
frustration is particularly greater if the patient rejects medical treatment, or if the
patient’s condition deteriorates despite the best efforts of the healthcare
professional. If the patient commits suicide, this problem can become exacerbated.
Factors that shape responses
Confronting feelings related to long term care of elderly may bring out a range of
responses from clinicians and other health professionals. These responses may
include withdrawal from the elderly and in some cases total rejection, blaming the
patient for his condition, or taking excessive personal responsibility for the patient’s
present condition or failure to recover. These factors may lead to either undertreatment or over-treatment of the patient. It is important to note that health
professionals and clinicians do not work in a vacuum. Medical care for elderly,
particularly long term care has increasingly become a complex clinical and ethical
issue that demands public scrutiny and economic viability and accountability. All
these issues and complexities may cause further concern among treating clinicians
and other healthcare staff.
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Education and training
The clinician’s response to the long term care of elderly depends on their life time
experiences and training [364]. In hospital settings, short-term encounters with
patients with severe chronic disease may provide inexperienced medical graduates
with clarity about deficiencies in their training. It is important for healthcare
professionals to equip themselves regarding the challenges of understanding and
responding adequately and appropriately to the psychological, social, and cultural
aspects of patient’s illness and health. Clinicians with a distorted view of the disease
course, the role of treatments, the emotional and psychological needs of patients can
exhibit potentially distorted responses. Many healthcare professionals may also
experience stress while providing care and emotional support for patient’s families.
Medical education should include information pertaining to the emotional aspects of
patient’s diseases and its impact on the patient, the patient’s family, and the
healthcare staff and doctors treating them.
Team membership
In a multidisciplinary team, it is easier for a doctor to discuss the challenges
associated with care, and share the burden of care. This may reduce the emotional
burden on the treating doctor. Non-governmental agencies and other support groups
can also be helpful in providing education, support, and advocacy for patients.
Clinicians have a key role in linking all such social groups with the patients.
Self-care
Clinicians and other healthcare professionals should try to exert control over the
amount of their clinical work and their own priorities. Clinicians should reflect on the
emotional aspects of their work. Clinicians cannot provide quality care to the patient
if they themselves are not in the best of their health i.e. physically, emotionally, as
well as spiritually.
FAMILY CAREGIVERS
Family caregivers are usually the patient’s family members, friends, or neighbors
who provide unpaid assistance related to an elderly person with an underlying
physical or mental disability [365]. Family caregivers are a key component of long
term care as they provide a substantial amount of the care for the elderly. A recent
study reported that approximately 26.5% of all American adults today are family
caregivers. Approximately 44 million Americans age 18 and older are estimated to
be providing unpaid assistance and support to the elderly and disabled adults who
live in the community. Approximately 1.4 million children ages 8 to 18 provide care
for an elderly or an adult relative; 72% are caring for a parent or grandparent, but in
majority of case they are not the sole caregiver [366]. Around 30% of family
caregivers caring for elderly are aged 65 or over; another 15% are between the ages
of 45 to 54 [367].
Family caregivers provide approximately $450 billion worth of services annually. In
the US, the family caregiver is usually a woman who spends an average of 20 hours
or more per week. The number of men providing unpaid caregiver services is also
significant (NAC & AARP, 2004). Approximately 21% of both the African-American
and Caucasian populations are family caregivers, while around 18% of AsianAmericans and 16% of Hispanic-Americans are providing informal care (NAC & AARP,
2004). Caregivers usually perform their duties full time. They help in various
household chores and activities of daily living which includes cleaning, bathing,
dressing, cooking, medical care adherence monitoring, and other activities of daily
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living (ADLs). Family caregivers who take care of the elderly with Alzheimer's disease
often provide more assistance in ADLs than non-Alzheimer's caregivers because
various impairments associated with Alzheimer’s disease. Family members are,
therefore, the major providers of long-term care which includes personal assistance
with essential, everyday activities, especially for elderly with disabilities. Family
caregivers perform a wide variety of tasks and spend substantial amounts of time.
Many caregivers assist elderly with severe disabilities (Alzheimer’s disease) for a
substantial period of time each week, often over a long period of time, which can
extend to several years. Both, care recipients as well as caregivers, value their
relationships, care giving usually comes at significant price which can adversely
impact caregivers’ health, resources, and job. By reducing this cost, public policy can
support and strengthen the family caregiver’s capacity to provide better care.
The role of family caregivers
Long-term care consists of providing assistance and services to elderly and others
who, due to their age or disabling conditions, are not able to perform activities of
daily living such as preparing meals, bathing, using the toilet, etc. Some patients
require assistance in instrumental activities of daily living (IADLs) as shopping
preparing meals, managing medications, and doing light housework. Approximately
78 % of adults receiving long-term care at home depend entirely on informal care
i.e., assistance from unpaid family caregivers. The rest of the adults receive support
from professional paid providers such as personal assistants and home care aides i.e.
formal care. Around 8% depend on formal care alone whereas 14% use this formal
care in conjunction with informal care. Even among adults with significant disabilities
i.e. limitations in three or more ADLs, approximately two-thirds depend solely on
informal care. Family caregivers also offer hands-on assistance with ADLs such as
bathing and eating, to the elderly in hospice care, nursing homes and other
residential settings. In addition, caregivers also assist their family member,
neighbor, or friends learn about patient’s long-term care needs and arrange for
appropriate services.
Impact On Caregiver’s Health
Care giving can be a positive and rewarding experience; however, it can also impact
adversely on a family caregivers’ mental and physical health and can cause a
significant financial burden.
When compared with non-caregivers, caregivers may experience more health
problems such as chronic pain, and poor immunity. In one study it was observed
that over a period of time, a caregiver may lose the subjective experience of health.
Care giving can adversely impact one’s mental health as well. Family caregivers
tend to report greater levels of stress, emotional and cognitive problems when
compared with non-caregivers. It is estimated that approximately 40-70% of
caregivers experience depression, and around 25-50% of them meet the diagnostic
criteria for major depression. Caregivers who experience stress while providing care
are more susceptible to adverse physical and psychological effects such as signs and
symptoms of depression, anxiety, poor sleeping patterns and other health related
activities. Compared to their male counterparts, female caregivers fare worse and
experience higher levels of anxiety and depressive symptoms and lower levels of
subjective well-being, life satisfaction, and physical well being. Family caregivers
also have to cope up with financial burden which, on average, is $2,400 per year. In
addition, family caregivers may experience loss in wages and other work related
benefits because of repeated absence and reduced working hours.
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Signs of stress in a caregiver

Feeling overwhelmed

Altered sleeping patterns

Significant weight gain or weight loss

Fatigue

Anhedonia

Extended frustration

Increased irritability

Anxiety

Depression

Frequent headaches, bodily pain or other physical problems

Drug abuse, including prescription drugs







COPING TIPS FOR CAREGIVERS
Educate yourself about the disease your family member is facing and how it
may affect his or her behavior, pain level, etc.
Find sources of help for caregiver tasks. Contact family, friends, neighbors,
church/synagogue/mosque or workplace, Area Agency on Aging or other
organizations. Keep looking!
Protect your personal time for something you enjoy or something you need to
get done.
Try to find time for exercise, eating well and sleeping enough.
Use your personal network of friends and family for support or find a support
group for caregivers of dementia patients in your area.
Watch out for symptoms of depression (such as crying more, sleeping more
or less than usual, increased or decreased appetite or lack of interest in usual
activities). Notify your doctor if symptoms of depression are present.
Consider how you will feel and what you will do after the care giving ends.
The Caregiver Burden
Caregiver burden may be defined as the physical, emotional and financial toll of
providing care to the patient [368]. Among all the questionnaires that have been
developed to quantify caregiver burden, the Zarit Burden Interview is the most
frequently and widely used scale for assessing caregiver burden.
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THE ZARIT BURDEN INTERVIEW
Please circle the response the
Never
Rarely
Someti
best describes how you feel.
mes
Never
1. Do you feel that your relative
0
1
2
asks for more help than he/she
needs?
2. Do you feel that because of
0
1
2
the time you spend with your
relative that you don’t have
enough time for yourself?
3. Do you feel stressed between
0
1
2
caring for your relative and
trying to meet other
responsibilities for your family
or work?
4. Do you feel embarrassed
0
1
2
over your relative’s behavior?
5. Do you feel angry when you
0
1
2
are around your relative?
6. Do you feel that your relative
0
1
2
currently affects our
relationships with other family
members or friends in a
negative way?
7. Are you afraid what the
0
1
2
future holds for your relative?
8. Do you feel your relative is
0
1
2
dependent on you?
9. Do you feel strained when
0
1
2
you are around your relative?
10. Do you feel your health has
0
1
2
suffered because of your
involvement with your relative?
11. Do you feel that you don’t
0
1
2
have as much privacy as you
would like because of your
relative?
12. Do you feel that your social
0
1
2
life has suffered because you
are caring for your relative?
13. Do you feel uncomfortable
0
1
2
about having friends over
because of your relative?
14. Do you feel that your
0
1
2
relative seems to expect you to
take care of him/her as if you
were the only one he/she could
depend on?
Quite
Nearly
Frequently Always
3
4
3
4
3
4
3
4
3
4
3
4
3
4
3
4
3
4
3
4
3
4
3
4
3
4
3
4
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15. Do you feel that you don’t
have enough money to take
care of your relative in addition
to the rest of your expenses?
0
1
2
3
4
16. Do you feel that you will be
unable to take care of your
relative much longer?
0
1
2
3
4
17. Do you feel you have lost
control of your life since your
relative’s illness?
0
1
2
3
4
18. Do you wish you could leave
the care of your relative to
someone else?
0
1
2
3
4
19. Do you feel uncertain about
what to do about your relative?
0
1
2
3
4
20. Do you feel you should be
doing more for your relative?
0
1
2
3
4
21. Do you feel you could do a
better job in caring for your
relative?
0
1
2
3
4
22. Overall, how burdened do
you feel in caring for your
relative?
0
1
2
3
4
Total Score (Out of 88)
Interpretation of Score: 0 – 21 little or no burden, 21 – 40 mild to moderate
burden, 41 – 60 moderate to severe burden, 61 – 88 severe burden
Score values and interpretation are guidelines only, as discussed in: Hebert R, Bravo
G, and Preville M (2000). Canadian J Aging 19: 494-507.
Several studies have shown that a caregiver’s role can be daunting, stressful and
burdensome. Care giving can be a chronic stress experience and may lead to
physical and psychological stress over long periods of time, particularly during long
term care. The caregiver often goes through extended periods of unpredictable and
uncontrollable phases that may affect their ability to provide care.
Families often are the main provider of home care and support for elderly,
contributing services that amount to hundreds of billions of dollars annually. Nurses
and social workers now play an important critical role in providing advice and support
to caregivers.
Support System for caregiver
Care giving can be very stressful, affecting the physical, psychological, and economic
well being of an individual; therefore, a good support system is essential to reduce
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the burden of family care giving. The following resources may be beneficial in
promoting and supporting physical, psychological, and economic well being of family
caregivers:

Family Caregiver Assessment - A support plan is necessary to evaluate the
requirements of family caregivers, and make appropriate referrals

Caregiver Education and Counseling – This may facilitate identification of
available resources and make suitable decisions regarding long term elderly
care

Respite Care – This is helpful in providing temporary relief to the caregiver
who constantly cares for an elderly. It may also be helpful for an individual
who may be at risk of abuse or neglect

Individual and Group Therapy – This therapy may help family caregivers to
better manage the stress associated with care giving. In addition, it can allow
the caregiver to sustain a better sense of balance between work and family

Financial Support – This kind of support can help to reduce the economic
burden of family care giving.

Additional Support Services - Adult day care, home health care, legal
assistance, and home delivered meals can significantly ease the burden of
family care giving
Positive Effects of Care giving
About one third of family caregivers report no adverse effect on their physical and
emotional well being. This is particularly true in the early stages of care giving.
Even when care giving leads to greater levels of stress and depression, caregivers
often look at the positive aspects of the care giving. They feel good about
themselves and care giving to their loved ones gives meaning to their lives, makes
them learn new skill sets, and increases their bonding with the patient. It has been
observed that people in supportive social relationships are happier and healthier and
live longer than those who live in isolation. Recent studies have shown that care
giving may be just as beneficial to health as receiving support. It has been observed
that people who extend instrumental support to others have comparatively lower
five-year mortality rates than people who don’t help others.
Family physicians may have a substantial impact on the health and overall well-being
of caregivers. By carefully assessing the caregiver's level of burden, the physician
can identify caregivers who are susceptible to physical and emotional problems.
Physicians can better educate family caregivers on coping strategies and techniques
to reduce their own health burden. Physicians can also provide the holistic approach
to care for family caregivers to better equip them for this challenging role.
Communication with Elderly
In the US, older adults visit their doctor an average of eight times per year, which is
significantly more than the general population’s average of five visits per year
[369]. With an increasing number of older patients, it is necessary for care providers
to better understand and enhance effective communication. The communication
process is complex and is usually further complicated by increasing age. One of the
biggest hurdles physicians face when communicating with elderly patients is that
they are comparatively more diverse and heterogeneous than other age groups.
Their life experiences and cultural backgrounds usually affect their perception about
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the disease, its treatment and their ability to communicate effectively with care
providers [370]. Communication is also impacted by the normal aging process,
which may result in sensory loss, slower processing of information, poor memory,
declining power and influence over their own lives, and separation from family and
friends [371]. When elderly patients need to communicate effectively with their
healthcare providers, life and physiologic changes due to aging make it a tough task.
Physicians should pay particular attention to this aspect of communication, as poor
communication can lead to incorrect diagnoses and treatment plans[372].
Communication tips for physicians
It is important for healthcare providers to make a connection with older patients both
physically and emotionally. This connection facilitates better communication of
necessary information and instructions.
Effective communication with elderly patients is therefore necessary and can be
achieved with the following tips.
1.
Time: Physicians should spend more time with older patients compared to
others. Several research studies have observed that elderly patients receive less
information from physicians than patients of other age groups, despite the fact
that elderly desire more information from their healthcare providers. Elderly
patients need additional time because they tend to have greater need for
information and their ability to communicate declines which makes them more
nervous and unfocused. Therefore, physicians should plan for this interaction,
and should not appear to be in a hurry or uninterested. Elderly patients can sense
this which may hinder effective communication.
2.
In case the patient’s native language is not English, determine whether older
adult can communicate better in that language; ask the family; and if required use
an interpreter. Also the health care providers should look for auditory and visual
impairments. Elderly should be asked about prior use of hearing aids and glasses
and assure the use of these devices in the hospital.
3.
Distractions. When communicating with older patients, the physician should
avoid distractions. Patients, especially elderly, want to spend a quality time with
physician and to feel important. Researchers have observed that if a physician
gives the patient their undivided attention in the first 60 seconds, patients think
that a meaningful amount of time was spent interacting with them [373]. Of
course, it is vital to pay full attention to the elderly during the entire visit, but the
initial minute can make a difference. When communicating with elderly patients, it
is also important to reduce the amount of auditory and visual distractions, which
includes other people and background noise [374, 375].
4.
Positioning. When talking to a patient, the physician should ideally sit face
to face with them. Some elderly patients have visual and auditory loss, and
reading the physician’s lips may be important for them to receive correct
information [376]. Sitting in front of the patients increases their focus and also
reduces distractions. Research studies have observed that a patient’s medical
compliance greatly increases following encounters in which the physician interacts
with the elderly face to face [377].
5.
Eye contact. Along with positioning, it is also important to maintain eye
contact when communicating with older patients. Eye contact is a powerful form of
nonverbal communication and it indicates to the patients that you are interested
in them and it increases the bond with and the trust in healthcare providers.
Maintaining proper eye contact creates a more positive, comfortable environment,
helps elderly patients in opening up and offers additional information.
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6.
Power of listening. The most frequent complaint elderly have about their
treating physicians is that they are not good listeners [378]. Good and effective
communication with older patients requires good listening. Many problems
associated with noncompliance, particularly in older patents, can be reduced or
eliminated by attentively listening to the patients. In a recent study, it was found
that doctors listen for first few seconds only before they interrupt, which may
result in missing important information patients are trying to convey [379].
7.
Speak slowly, clearly and loudly. The rate at which an elderly person
comprehends and learns is generally much slower than people of other age
groups. Therefore, the rate at which a care provider provides information impacts
an older patient’s ability to learn, comprehend and remember the information
[374, 376]. The instructions should be provided clearly, slowly and loudly enough
for elderly patients to hear you.
8.
While communicating with the elderly, healthcare providers should use short,
simple words and sentences. This way the patient understands and follows
doctor’s instructions. Medical terminology or jargon should preferably be avoided
as it is difficult for the layperson to comprehend. Healthcare providers should use
words and phrases that elderly are familiar and comfortable with [373].
9.
Stick to one topic at a time. Physician should avoid information overload as
this may confuse elderly patients. A long, detailed explanation to an elderly
patient may lead to poor communication. The information should be preferably
provided in a stepwise fashion. For example, while discussing hypertension with
an elderly, physician should first talk about the heart; second, about blood
pressure; and third, about treating blood pressure.
10.
Instructions should be simple and written. Instructions to the patients should
be simple to facilitate good communication and to avoid confusion. Instructions
should be written in a basic, easy-to-follow format. Written instructions provides
an opportunity for the elderly to later review and better comprehend what the
healthcare provider wants to convey in a comparatively relaxed environment
[374]. One approach is to provide an information sheet with a summary and
explains the steps in simple language. Posting the necessary information on a
bulletin board or the refrigerator or can help elderly patients keep instructions
fresh in their mind [374].
11.
Use charts, models and pictures. Visual aids (objects, pictures, posters) can
greatly help the elderly better comprehend their medical condition and treatment.
Pictures can be of immense help as patients can easily take them home for future
reference [376].
12.
Frequently summarize the most important points. Physician should ask
patients to repeat instructions after they have discussed the most important
points with elderly. If the patient has not understood your instructions, simply
repeat the instructions as repetition leads to greater recall. The nurse or
pharmacist should also repeat instructions for prescription drugs and offer a
combination of written and oral instructions [380]. It is important that instruction
should be rephrased after few repetitions as the elderly patient may get frustrated
and ignore the information. Instructions should ideally be provided in the
presence of a family member or friend to make sure that the information is
understood [376].
13.
Allow time for questions. Patients should be given an opportunity to ask
appropriate questions after the physician has explained everything related to the
treatment and other relevant information. This approach allows the patients to
express their fears or apprehensions. It also helps the physician to gauge
whether the patient has understood the information and instructions that the
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physician had given. In case of any doubt, the physician may take the help of a
staff person to review the instructions.
Healthcare staff can contribute immensely in making a physician’s communication
more effective by providing a relaxed and informative environment so that the
patient is well prepared for a consultation. For effective communication, healthcare
staff should do the following:
1.
Schedule older adults earlier in the day. Older patients generally get fatigued
in the later part of the day, and medical offices/healthcare facilities usually get
busier as the day progresses. Scheduling the elderly earlier in the day is better as
the surrounding environment is quieter and will allow more time to be spent with
the patient.
2.
Greetings are important. Greetings are a small gesture that makes the elderly
feel important and comfortable. Staff members as well as physicians should
warmly greet the patients and should introduce themselves by stating their names
and position [381].
3.
Good Environment. Patient should be kept in a quiet, comfortable area.
4.
Make things easy to read. Optimum lighting in the healthcare facility, waiting
and exam areas is necessary. Proper lighting facilitates better communication as
it increases the patient’s ability to read pamphlets, instructions, and other
materials related to their healthcare. It also helps them to better interpret facial
expressions and with lip reading. Easy-to-read signs posted throughout the
healthcare facility/ practice can also aid in providing important information, since
some elderly may be hesitant to ask seemingly simple questions [378].
5.
Escort the patients. In some cases, assisting the elderly patient from one
place to another (room to room) may be necessary. The staff should ensure that
the elderly is relaxed comfortable and that any immediate needs are filled.
6.
Periodically check the patient. The staff should periodically check an elderly
patient, especially if s/he is unattended.
7.
Keep the elderly patient comfortable, relaxed and focused. This approach is a
key component for effective communication with an elderly to obtain reliable
information. Small gestures such as lightly touching the patient’s shoulder, arm or
hand will make them comfortable and relaxed and increase their trust in the
healthcare providers. Patient should preferably be called by their preferred name
[378]. It is also important to realize that some patients will prefer their formal
names (i.e. Mrs. Smith or Mr. Doe) while others are comfortable with healthcare
staff using their first name.
8.
Goodbye is courteous. It is always better to tell patients goodbye after the
visit is over [381]. This makes the patient feel important and comfortable for
future visits.
IMPORTANT COMMUNICATION TIPS FOR EFFECTIVE COMMUNICATION
WITH THE ELDERLY
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1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Allow extra time for older patients.
Minimize visual and auditory distractions.
Sit face to face with the patient.
Don’t underestimate the power of eye contact.
Listen without interrupting the patient.
Speak slowly, clearly and loudly.
Use short, simple words and sentences.
Stick to one topic at a time.
Simplify and write down your instructions.
Use charts, models and pictures to illustrate your message.
Frequently summarize the most important points.
Give the patient a chance to ask questions.
Schedule older patients earlier in the day.
Greet them as they arrive at the practice.
Seat them in a quiet, comfortable area.
Make signs, forms and brochures easy to read.
Be prepared to escort elderly patients from room to room.
Check on them if they’ve been waiting in the exam room.
Use touch to keep the patient relaxed and focused.
Say goodbye, to end the visit on a positive note.
Assessment of language abilities is required to comprehend elderly patient’s
communication impairments and facilitate communication.
ASSESS RECEPTIVE ABILITIES
FACILITATE COMMUNICATION BY:
Can the patient understand a yes/no
choice?
Can the patient read simple instructions?
Can the patient understand simple verbal
instructions?
Can the patient understand instructions
given with physical cues?
Can the patient make a choice when
presented with two objects or options?
ASSESS EXPRESSIVE ABILITIES
Does the patient have difficulty finding
the correct word?
Ask simple, direct questions that
require only a yes or no response.
Provide instructions in a place that is
easily visible to the patient.
Use short, simple sentences. Use onestep instructions to enhance the
individual’s ability to process, e.g. it’s
time to wash (smile; pause); I will
help you (pause and proceed). Avoid
slang, idioms, and nuances.
Use gestures. Model the desired
behavior (e.g., eating).
Be sensitive to the fact that although
the person may not understand
words, he/she often can read your
body language, sincerity, and mood.
Limit choices; too many options will
cause confusion and frustration
FACILITATE COMMUNICATION BY:
If you are sure of the word the person
is trying to say, repeat it. If not sure,
don’t guess because that will increase
the person’s confusion and frustration.
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Does the patient have difficulty creating
sentences or a logical flow of ideas?
Does the patient curse, use offensive or
aggressive language, or exhibit
aggressive or combative behaviors?
Does the patient avoid verbalization
altogether or mutter in various tones
Read nonverbal communication that may
seem meaningless to others?
Listen for meaningful words and ideas.
Try to identify the key thoughts and
ideas. Do not dismiss person as
“totally confused”.
Don’t reprimand. Respond to the
emotion not the words.
Validate feelings. Assess for unmet
needs, including those related to
misperceptions, hunger, thirst,
toileting needs, pain, etc.
Read nonverbal communication that
may seem meaningless to others?
Anticipate needs.
TREATMENT
Medication Management
For elderly, especially who live alone, it is important to adhere to a medication
regimen.
Non-adherence to medication is an important determinant to place elderly in the
nursing home [382]. Elderly patients are the largest consumers of prescription
medication and polypharmacy (the concurrent use of 4 or more medications) can be
a particular concern. With advancing age, however, they are susceptible to numerous
adverse reactions associated with a drug or the interactions of these drugs.
Approximately 30% of hospital admissions of elderly patients are medication related,
with around 11% associated with medication non-adherence and around 10–17%
related to adverse drug reactions [383–385]. In addition, the elderly have narrow
therapeutic range and need close monitoring, particularly when they are taking
multiple medications [415].
Risk factors
There are multiple factors that are associated with poor medication management in
elderly. Those elderly in the age group of 66–74 are generally more compliant than
those elderly in the age group of 75 and older because aging often leads to poor
comprehension of medication instructions and adherence [386- 388]. Living
arrangements influence the elderly patient’s medical compliance, and those who live
alone are susceptible to medication errors [389-390]. Furthermore, those elderly
with chronic disease, particularly depression, have a greater chance of nonadherence to their medication [391-394].
Several risk factors linked to poor medication management are items that are more
prevalent in elderly patients living in the community. These factors include physical
impairments such as poor vision, cognitive impairment, etc. The elderly are more
susceptible to adverse events because of complexity of their care rather than aging
[395]. A study conducted on elderly patients who took five or more medications
observed that approximately 35% of them experienced adverse drug reactions. In
addition, elderly with complex regimens had problems naming and explaining the
indication of medications had a higher risk for medication non-adherence [396].
There is a direct correlation between the degree of medication complexity and
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medication non-adherence. Non-adherence to medication increases with increased
number of prescribed medications [397, 398].
Medication Reconciliation
Medication reconciliation is the first step in helping older adults in the medication
management process. Several studies have shown discrepancies from 30-66% in
what medications were prescribed and the actual medications the elderly was taking
[399, 401]. Another problem is determining exactly what medications the elderly are
taking in a long term facility or at home. Several studies have shown that 10–74
percent of medications prescribed for elderly were inappropriate [402-404]
Medication Procurement
One of the most common causes of medication non-adherence in older adults is
inability to fill or refill prescriptions [405-407]. Elderly persons with adequate
insurance coverage for medications are more compliant [408].
Medication Knowledge
It has been observed in several studies that less than 25% of elderly patients knew
the consequences of noncompliance or toxic side effects. Patient education is very
important to help the elderly with medication management. Patient knowledge of
drugs greatly improves adherence with medications [409].
Physical Ability
Poor vision and low dexterity, which are commonly seen in elderly patients, are
associated with poor medication self-management [410].
Cognitive Capacity
Cognitive impairment is associated with poor drug compliance [411]. In such cases,
pill box organizers are helpful in increasing medication adherence. Medication
schedules as well as calendars are also helpful [412, 413]. Electronic monitoring is
also an effective tool to increase compliance.
Intentional Non-adherence
One study conducted on chronically ill elderly who were initiating a new medication
found that approximately 33% of them did not take their medication as prescribed.
Furthermore, half of the time, non-adherence was deliberate [414]. The reasons
behind the non-adherence should be investigated. For example, this could be an
early sign of dysphagia and adherence may be increased by using a liquid form of
the medication. Non-adherence may also be the result of a lack of understanding of
the need for the medication or frustrations about understanding the timing and
dosages. Finally, non-adherence can be the result of unreported adverse effects of
the medication which should be investigated with the potential to change dosages or
the prescription.
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Strategies for assisting aging patients with medication management
Medication Reconciliation
1. All the medications, prescribed and non-prescribed, should be reviewed and
should include over-the-counter medications, vitamin supplements, and herbs
[416].
2. The elderly should be screened for adverse drug reaction and interactions.
Adverse drug interactions should be reported to the physician [416].
3. Medical diagnosis, primary or secondary, related to each prescribed medication
should be identified. In case the medical diagnosis is unknown, request the
diagnosis from the prescribing provider [416]
4. For the elderly, apply Beer’s criteria for inappropriate medication [417].
5. A list of all the medications, prescribed and non-prescribed, as well as list of
corresponding medical diagnoses should be provided to the prescribing
provider(s) [416].
6. All the prescribed medications and related medical diagnoses should be verified
with the prescribing provider(s) [417].
7. The dose and frequency of all the currently prescribed medications should be
provided to the patient or caregiver. The patient should share this list with the
physician or other healthcare providers [416].
Medication Procurement
1. Patient’s or caregiver’s ability to procure medications should be assessed [418420].
2. If the elderly or caregiver has problems in refilling or obtaining prescriptions,
help the elderly to procure medications through:
a. Pharmacy delivery.
b. Refill reminders or automatic refill service.
c. Scheduling family or friends to pick up medications.
3. In case elderly has a financial problem in buying
a. Refer the patient to a social worker to obtain Medicare Part D coverage, other
insurance coverage, or participation in drug company programs
b. Consult with the pharmacist regarding use of generic drugs.
c. Consult the prescribing doctor about availability of free samples.
Medication Knowledge
1. Patient’s or caregiver’s knowledge of the following should be assessed:
a. Dose and frequency of medications taken.
b. Special instructions pertaining to prescribed drugs, such as “take with meals.”
c. If the elderly uses an inhaler, understanding of the correct inhaler technique.
d. Medication mode of action
e. Side effects to monitor and report.
2. In case the medication regimen is changed, review dosage, frequency, side
effects and medication purpose to monitor and report, and other medicationspecific instructions].
3. Interventions related to medication knowledge include:.
a. Provide written instructions related to prescribed medications in large letters
and bullet or list format.
b. Tailor instructions to how the elderly takes his or her medicine.
c. Group information starting with generalized information, followed by how to
take the medicine, and then the outcomes such as side effects to watch for
and when to call the doctor
d. Use medication schedules or charts to reinforce instructions
e. If the patient was unaware or did not know important medication
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information at a previous encounter, review dose, time, side effects to
monitor and report, and special instructions at the next visit.
Physical Ability
1. Assess for decreased manual dexterity or vision impairment and its affect on the
patient’s ability to identify the correct medication, open medication containers,
and prepare medications (e.g., breaking tablets) for administration.
a. Observe the patient opening medication containers.
b. If the patient uses an inhaler, observe the use of the inhaler.
c. If the patient is required to break tablets, assess his or her ability to do so.
d. If the patient is unable to open or see the label and contents of each
medication container, provide one of the following:
i. Pill box or other easy-open container. If the patient is unable to fill the pill
box, identify someone who can assist him or her.
ii. Medication calendar with pill box.
iii. Blister packs. Consult the pharmacy about the availability of the drug in
blister packs or non-childproof containers.
iv. If tablet breaking is required and the patient has difficulty doing it, consult
with the pharmacist about tablets that are easier to break or tablets that
are the correct dosages without requiring breaking.
Cognitive Capacity
1. Cognitive ability of patient’s or caregiver to organize and remember to
administer medication should be assessed.
2. Patient or caregiver should be taught the use of memory cues based on one
of the following methods:
1. Clock time. Ask if the patient or caregiver is usually aware of the time of
day or keeps track of time through a watch or clock.
2. Meal time. Ask if the patient eats meals at a regular time.
3. Daily ritual, such as using the bathroom in the morning, shaving, or hair
combing.
3. If needed, patient should be provided additional support,
a. Provide memory-enhancing methods or devices such as
i) Medication calendar or chart.
ii) Electronic reminder or alarm.
iii) Voice-message reminder.
iv) Telephone reminder.
v) Pill box. (If the patient is unable to fill a pill box, identify someone
who is willing to assist him or her.)
vi) Electronic medication dispensing device.
vii) Combine methods and devices when possible.
b. Discuss dose simplification with the prescribing provider.
Intentional Non-adherence
1. Assess if medication doses are missed intentionally.
a. Drugs at high risk for intentional noncompliance include the following:
i. ACE-inhibitors
ii. Beta-blockers
iii. Calcium channel blockers
iv. Diuretics
v. Bronchodilators
vi. Benzodiazepines
b. If the patient intentionally misses doses, assess the reason(s).
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i. Belief medication is not helping.
ii. Fear of adverse side effects.
iii. Side effects.
c. The following medications are most risky for patients to miss:
i. Coumadin
ii. Digoxin
iii. Beta-blockers
iv. Insulin
v. Prandinm® (repaglinide)
vi. Antibiotics
vii. ACE-inhibitors
2. If the patient misses medication doses for reasons related to health beliefs,
1. Explore with the patient his or her health concerns for not taking
medication.
2. Discuss the benefits of taking medication as prescribed.
3. Provide positive reinforcement for taking medication as prescribed.
3. For patients on high-risk medications, reinforce the danger of missing
medication doses.
4. If the patient misses medication doses for reasons related to medication
side effects,
a. Explore with the patient a plan to manage the side effects.
b. Modify the regimen to reduce the side effects.
i.
Ongoing Monitoring
1. For all patients on a prescribed medication regimen, monitor the patient
with each encounter for the following:
a. Medication adherence
i. Monitor both under- and over adherence. Over-consumption occurs
frequently in a once-daily dose schedule.
ii. For persons using inhalers, assess
a) Inhaler emptying rate.
b) Reported forgetfulness.
c) Use of short-acting inhaler.
b. Medication side effects
i. If medication side effects are present, notify the prescribing
provider, as appropriate.
c. Lab work, as appropriate, for prescribed medications
Cockcroft-Gault Formula or other creatinine clearance measure at least annually. If
creatinine clearance <50 ml/min, notify the prescribing provider.
d. Medication effectiveness
i. If signs and symptoms of the problem the medication is treating are
present, notify the prescribing provider, as appropriate
Geropsychology
Most of the 40 million elderly people in the US live independently in the community.
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Working with the elderly, particularly in long term care settings, requires specialized
competencies and skills. Working in such an environment poses a unique challenge
for mental health providers. Psychologists may be consulted for a number of issues,
such as health and behavioral concerns, depression, anxiety, other mood disorders,
end-of-life issues, etc. Regardless of the treatment or intervention needed,
collaborating with multiple professionals is important to provide better care to
elderly. Geropsychologists are trained specialists in the field of aging and mental
health who provide psychological services to the elderly, especially in nursing homes
and long-term care settings.
Clinical geropsychology has grown slowly but surely since its inception in 1981.
Geropsychologists provide consultation, assessment, intervention, and other
professional services to elderly people in a number of settings which includes
medical, mental health, residential, community, long term care and other care
settings.
Geropsychologists can be of immense help to elderly in managing medical conditions.
They provide essential psycho-educational information to the elderly about their
condition, its’ onset and contributing factors, and steps toward self-management.
Geropsychologist helps the patient better understand the emotional impact of the
illness that led to patient’s admission.
Geropsychologists help the elderly in many respects including:

Assessment of perceptions and values of the elderly regarding his or her
future outlook.

Identification of psychological barriers that prevent the elderly in taking part
in rehabilitation.

Assist the elderly to stay engaged in his or her physical therapy and other
interventions.

Promote effective transition back to the community when the patient is
discharged.
Cognitive Behavior Therapy for Elderly
With an ever-increasing population of elderly globally, a wide range of psychological
treatments and techniques are being used to treat elderly who have psychiatric
disorders. Certain illnesses such as depression have a poor prognosis in the elderly
and require effective psychiatric interventions. Cognitive–behavioral therapy or CBT
is the treatment of choice for several psychiatric disorders in elderly. Cognitive
therapy is now a popular intervention for the treatment of a number of psychiatric
disorders such as anxiety, depression, and eating disorders.
Cognitive therapy: Rationale
Psychiatric problems such as anxiety or depression develop from an individual's
specific and exaggerated viewpoints and beliefs about him or herself and the world
around them.
When these beliefs are activated, they lead to unpleasant emotions mediated by
negative thoughts or cognitions. Cognitive therapy trains the elderly with the skills
needed to modify those underlying beliefs mainly through techniques of identifying
and testing the validity of such biased thoughts. Cognitive therapy is problemfocused approach and requires an active collaboration between the elderly patient
and the psychotherapist. The most common cognitive problems seen in elderly
develop because of poor adaptation to losses such as physical disability, retirement,
loss and bereavement etc. Aging may also impact the ability to appropriately review
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life, end of life issues and anticipate death. In general, the treatment strategies are
identical for both young adults and elderly, although certain aspects of intervention
may differ in elderly patients due to their specific problems and circumstances;
therefore, some adaptations may be essential in such patients. Compared to young
adults, cognitive therapy in the elderly usually progresses at a much slower pace. In
addition, the therapy requires more frequent pauses and summaries for effective
treatment. Compared to young adults, elderly patients also tend to be less
independent and tend to depend more upon others for their care. Care givers can be
inducted into treatment to help in assessing and challenging of cognitive distortions.
The elderly have a greater likelihood of having underlying co-morbid diseases,
physical illness and disability which may play an important role in the development
of cognitive distortions. Therefore, the psychotherapist must also pay attention to
these factors. For example, disability in elderly will require modifications in the
planning of treatments.
Attitudes to cognitive therapy
Cognitive therapy can also be influenced by the attitude of the elderly patient. Some
elderly may attach a deep sense of shame to emotional problems or may believe that
they are incapable of new learning. Such attitudes need to be challenged in the
initial phase of the treatment.
Group therapy
Some elderly prefer cognitive therapy in group settings. Group therapy is also
preferred by elderly who are averse to psychological approaches.
Use of educational material
Education of elderly patients regarding different aspects of depression plays an
important role in the treatment of elderly patients. Use of a handbook and other
reading materials is usually more acceptable to elderly. Patient should be made
aware about the influence of negative attitude on mood.
Close collaboration between the therapist and the treating physician is essential to
ensure that patients with physical symptoms and psychological disorders are
provided optimal and appropriate treatment.
Cognitive therapy should be modified and adapted to other age-related problems.
Procedural modifications in Cognitive Therapy for Elderly
Tackling cognitive changes

Repeat and summarize information

Present information in multiple modalities

Use folders and notebooks

Consider offering memory training
Tackling sensory impairment

Help to correct it where possible

Prepare written materials in bold print

Use tape recorders
Physical health

Agree realistic goals

Tackle dysfunctional beliefs that limit activity

Input from a ‘medicine for the elderly’ team
Therapy setting and format
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


Be flexible
Consider using an outreach approach
For each client consider the merits of group v. individual CBT
DNR (Do-Not-Resuscitate) Orders
DNR is a request made by the patient or health care power of attorney to prevent
use of cardiopulmonary resuscitation (CPR) in case a patient’s heart ceases to
function. In the United States, CPR and advanced cardiac life support (ACLS) are not
performed if a DNR order is in place. The use of DNR, especially by the elderly, has
increased considerably over the last few decades [421-425]. In the US, most
patients, both hospitalized and institutionalized, request a DNR [422]. The use of
DNR orders has significantly increased after the enactment of “The US Patient SelfDetermination Act of 1991.” [426] Compared to young adults, elderly are more likely
to request DNR. A DNR does not alter any treatment or care management except use
of intubation or CPR. Patients who are DNR continue to receive their respective
treatments such as dialysis, chemotherapy, antibiotics, etc.
Many studies have observed that most patients are not made aware of DNRs, despite
a patient’s desire to be informed about their options. Elderly patients usually have a
poor understanding of CPR. Recent data from the SUPPORT project showed that
approximately 25% of the patients had discussed CPR with a physician [427]. The
decision for DNR is usually made by family members rather than the patients
themselves [428, 429] together with treating physicians. This usually happens
because of a failure to consider the use of DNR orders until the elderly are in a
condition where they can no longer participate in the decision making process [428].
Several US studies involving elderly patients have indicated that patients want to
talk about CPR with their doctors [430-432]. In general, the elderly want their
physician to discuss DNR [38 39] while they are still healthy [40]. Furthermore, it
was observed that majority of patients had not talked about CPR with their doctors
[432, 433]. It has been found that most of the elderly have CPR preferences and
want to participate in the decision making process [434]. In addition, it has been
observed that majority of elderly wish to be resuscitated. These include seriously ill
patients, outpatients, and nursing home residents [435]. The data from the
SUPPORT showed that around two thirds of patients who were 70 or older preferred
CPR. This trend is also seen in other countries. Several studies conducted in the UK,
Israel and other countries have observed that majority of elderly patients prefer CPR.
In Ireland, however, a large majority of patients did not prefer CPR. It has been
observed that certain sociodemographic variables are associated with the preference
of the elderly for CPR. In the US, younger age, better functional status, belief in
medical advancements, male sex, lesser education, and non-white ethnicity are
associated with preference for CPR [436, 437]. However, when the elderly were
asked to consider CPR in case of a terminal illness or persistent cognitive or
functional impairment, they preferred DNR instead of CPR [438]. Several studies
have observed that elderly would prefer quality of life than quantity of life [438].
Several studies have also observed that many elderly patients wish that family
members’ or physicians opinion be considered if the patient becomes incapable of
making proper decisions, even if it is conflict with the patient’s prior expressed
wishes [439 Some studies have also observed that family members of the elderly
often misinterpret the desires of elderly relatives [440].
HEALTH CARE PRACTIONER ATTITUDES TOWARD DNR ORDERS
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Physicians have an inclination to opt for their own personal preferences and
judgments regarding CPR. Several studies have reported that majority of doctors
would not opt for CPR themselves [441, 442] and prefer less end-of-life care than
their patients [84]. Two US studies have indicated that physicians consider age as
one of the key factor in their decision to aggressively treat patients or to use DNR
[85, 86]. US physicians also reported that they are more likely to use CPR in a
middle-aged than an elderly patient. In the US, physicians have often conflicting
attitudes toward DNR. Almost 50% of all physicians and nurses thought that they act
against their conscience when they resuscitate patients who are terminally ill. The
majority of doctors prefer patient participation in the decision making process, [443]
but many were uncomfortable discussing issues related to DNR and hardly ever
discussed the possibility of CPR with patients except rarely in cases such as
terminally ill cancer patients. Several surveys have reported that physicians withheld
CPR in more than one-third of the cases despite patient’s wishes. In another
research study, it was reported that 4 out of 10 US physicians believed they would
never provide CPR or override a DNR order they considered futile despite patient’s
request for it. Nurses have varying opinions with respect to DNR as well. US nurses
desire more participation in the decision making process [444]. In another study
conducted on US and British nurses, it was observed that unlike physicians, they
would never prefer to override patient wishes for a CPR or a DNR. Recent data have
shown that CPR should be considered in elderly patients who are reasonably healthy
and have no major cognitive impairments. Variations in attitudes also depend on the
kind of training imparted to the healthcare professionals and their personal cultural
religious beliefs [445, 446].
CPR Decision-Making Tips for Elderly
1. Make sure that elderly understand what really happens during CPR.
2. CPR will not change the underlying cause of patient’s condition, and it might
make you worse.
3. CPR doesn’t work like patients might see on television.
4. Think about the kind of death patient is choosing.
5. The decision about CPR is only one component of a good end-of-life plan.
DNR status, CPR, medical futility and self determination should always be discussed
with the elderly. A balance should be made in our quest to save patients lives as
long as possible while maintaining elderly patient’s self-esteem and dignity of life.
Quality of life Issues for Elders
Quality of life (QOL) is an important parameter for elders whether they are living in
the community, a LTC facility or a nursing home.
A recent study of nursing home residents determined that the most important
domains in achieving a high quality of life were retaining their dignity, their spiritual
well-being, and enjoyment of food [448]. Other studies have indicated that
loneliness and social isolation are important factors in QOL domains and
interventions designed to decrease loneliness and increase a variety of social
interactions can positively impact QOL for the elderly [449,450,451]. It is critical
that professional and non-professional caregivers recognize the importance of social
interactions for the elderly and take these into account when providing care. The
elderly express a need to be included in important decision making processes, in
community events, family functions and for social events and these relatively simple
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efforts can significantly impact the overall health and well-being of the elderly. LTC
facilities, nursing home facilities and communities are recognizing this and are
designing activities and events to include the elderly populations, their friends and
families [449].
Assessment of Neurological and Behavioral Functions in the Elderly
In the US, the National Institutes of Health (NIH) has developed a “toolbox” for the
assessment of neurological and behavioral functions across all age groups. Use of
this toolbox has found great utility among physicians and healthcare workers who
are caring for an elderly population. The toolbox consists of a “multidimensional set
of brief measures assessing cognitive, emotional, motor and sensory function”
including motor function tests for strength, endurance, balance and dexterity ( e.g.
Standing Balance Test, 4-Meter Walk Gait Speed Test, Grip Strength Test), cognitive
functions, including executive functions, memory, language, attention and processing
speeds (e.g. Flanker Inhibitory Control and Attention Test, Dimensional Change Card
Sort Test, Pattern Comparison Processing Speed Test), tests assessing sensory
function including hearing, vision, taste and smell (e.g. Words-in-Noise Test,
Regional Taste Intensity Test, Words-in-Noise Test), emotional states including anger
and hostility levels, fear, anxiety, sadness, loneliness and satisfaction levels (e.g.
Anger-Hostility Survey, Meaning and Purpose Survey, Loneliness Survey, Emotional
Support Survey). The assessments can be done in the home or in a LTC facility,
nursing home or hospice environment and are quick, portable and easy to perform.
Recent studies implementing the toolbox have indicated that it is a very useful tool,
particularly in the elderly population [452-455]. A recent article in a special issue of
the journal Neurology called the toolbox a “psychometrically sound, cutting-edge,
adaptable measures that enable uniformity of measurement, data sharing, and
integration of findings in the research setting.” [456]
Conclusion
The population in the United States is getting older and, in the coming decades, the
trend will only increase. Between 2010 and 2050, the U.S is expected to achieve
rapid growth in its older population. By 2050, it is expected that the total population
of US citizens aged 65 and older will reach 88.5 million, which is more than two fold
its population in 2010. Between 2010 and 2050, the 65+ population will rise rapidly.
This growth in the elderly population will far exceed the growth in younger age
groups or categories. As the United States ages, the demand for long term care for
elderly will increase dramatically and the need for health services to help the elderly
will grow exponentially. In the US, most long-term care for the elderly is provided by
families, relatives and friends. Another federal/state program called Medicaid
provides long-term care financing for low-income families. However, long-term care
continues to be a major challenge for the country and especially the elderly. It is
estimated that that the demand for long-term care among the elderly will increase to
more than double in the next three decades. Long-term care for the elderly
encompasses a wide variety of services that includes non-medical as well as medical
care. Long-term care also caters to the health or personal needs of elderly. Longterm care may be needed by people of younger age group, but is generally required
by the elderly. Long-term care assists the elderly with various types of support
services such as ADL or activities of daily living. Long-term care (LTC) can also be
provided at home, in the community, in nursing homes, or in assisted living. The
need for LTC is impacted by changes in the physical, mental, and/or cognitive
functional capacities of the elderly which in turn are greatly influenced by the
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environment. The type and duration of LTC are a complex issue and usually difficult
to predict. The goal of LTC is to make sure that an elderly individual who is not fully
capable of long-term self-care can maintain the highest possible quality of life, with a
high degree of independence, participation, autonomy, individual fulfillment, and
dignity.
Home-based LTC encompasses health, personal, and other types of support services
to help the elderly stay at home and live independently as much as possible. This
type of care is usually provided either in the home of the elderly person or at a
family member's home. Trained paid caregivers are also available for home-based
LTC services. Home healthcare may include nursing care to help an individual
recover from surgery, an injury, or illness. Homemaker services can be availed even
without a physician's recommendation. Nursing homes provide a comprehensive
range of medical services, which includes 24-hour supervision and nursing care.
Skilled nursing care is provided on a physician’s recommendation and requires
professional skills of a registered nurse or a licensed practical nurse. Intermediate
nursing care is provided under periodic medical supervision and encompasses
physical, psychological, social, and other restorative services. Personal or custodial
care can be offered by individuals without medical training. Community-based longterm care such as home health care, assisted living facility, adult day care, respite
care, and hospice care can be offered in many types of settings and by many kinds
of care providers. Assisted living facilities provide care to individuals in a residential
facility and include supportive services, personal care, and/or nursing services. Adult
day care is care provided in a nonresidential, community-based group program that
caters to the needs of functionally impaired elderly. Respite care offers personal
care, supervision, or other services to a debilitated individual to provide temporary
relief to patient’s care provider and family member. Hospice care primarily offers
symptom and pain management, and supportive services to terminally ill individuals
and their families. Hospice is a form of palliative care for terminally ill individuals.
Long-term care hospitals are acute care hospitals, but also focus on providing care to
patients who stay in the facility for more than 25 days.
In the older population, malnutrition is an important issue. Malnutrition is the state
of being poorly nourished due to under-nutrition i.e. lack of one or more nutrients, or
overnutrition i.e. an excess of nutrients. The causes of malnutrition among older
people are varied, and they can be categorized into three main types: medical,
social, and psychological. Management of malnutrition in the elderly focuses early on
offering ample food choices and high calorie food after which additional caloric
supplements can be considered. Dysphagia is a frequent health concern in our aging
population. Video fluoroscopy is considered to be the gold standard to study
dysphagia. Successful and optimal swallowing interventions/techniques can help in
the management of complication related to dysphagia malnutrition and pneumonia.
A number of dysphagia management techniques and tools can be used for the
treatment of dysphagia. Falls in elderly are caused by complex interactions among
various multiple risk factors, which may characterized as intrinsic or extrinsic.
Patients should be adequately educated about fall prevention. Memory disorders are
the most common cognitive change in the elderly which are generally caused by
Alzheimer disease, frontotemporal dementia, and dementia with Lewy bodies. The
majority of the elderly with AD and related conditions who live at home receive
unpaid help from friends and family, but some opt for paid home and communitybased services, such as personal care and adult day center care. Caring for the
elderly with memory issues also requires a multipronged approach. Depression is
very common in older patients. Depression is a mood disorder, but not essentially a
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psychiatric disorder. Depression in elderly is common and widespread globally. It is
also the most treatable disorder which affects approximately 15% of elderly, 20 % of
hospitalized elderly patients, and over 40 percent of elderly nursing home residents.
Elder abuse is "a single, or repeated act, or lack of appropriate action, occurring
within any relationship where there is an expectation of trust, which causes harm or
distress to an older person.” Elder abuse is predominantly a social hidden problem as
it is usually committed within confines of the elderly person's home, mostly by the
immediate family members. Any individual who suspects that elder abuse has
occurred should report the incidence because the abuse can continue and may
increase escalates if there is no intervention. All cases of elder abuse should be
reported to the Elder Abuse Provider Agency agencies in the area.
End-of-life care may be defined as health care for patients in the last few day or
hours of their lives, and for all individuals with a terminal condition or illness such as
cancer that is progressive, advanced, and incurable. End of life issues can be
medical, psychosocial, spiritual, legal, or existential in nature. The general approach
of healthcare givers and physicians is to preserve life; however, patients have the
right to choose the objectives and goals of their own medical care. The main role of
the healthcare providers near the end of life is to coordinate and administer optimal
medical and psychosocial care for the patient. The patient may wish an advance
directive. An advance directive is a legal document that allows patients to decide
that their treatment, or absence of treatment wishes be carried out in case they are
unable to make their preferences known. DNR orders, living wills and durable power
of attorney for health care are the most common forms of advance directives.
Communication is a very important aspect of end-of-life care. It is of the utmost
importance for patients and families near the end-of-life. Proper communication is a
key component of end of life care throughout the entire disease course because of
several factors. Euthanasia and physician-assisted suicide are highly emotive and
complex issues in American medicine. Euthanasia is the intentional ending of the life
of an individual who has an incurable or terminal illness. Physician-Assisted Suicide
can be described as a practice in which the physician provides a patient with a lethal
dose of a drug/medication, upon the patient's request, which the patient then
intends to use to end his or her own life.
The extended survival of individuals with severe chronic disease(s) has increased the
emotional burden of the patient as well as caregiver. Patients with chronic disease
conditions usually have to make an adjustment regarding their lifestyle, ambitions,
and employment. Not only patients, but treating physicians and caregivers can also
get overwhelmed by the emotional requirements of their patients. It is important for
the doctors and other healthcare professionals to equip themselves regarding the
challenges of understanding and responding adequately and appropriately to the
psychological, social, and cultural aspects of a patient’s illness and health. For the
elderly, especially those who live alone, it is important to adhere to a medication
regimen. Non-adherence to medication is an important determinant to place elderly
in the nursing home. It is important to adhere to strategies for assisting aging
patients with medication management. Geropsychologists have slowly become an
important part of elder care. They provide consultation, assessment, intervention,
and other professional services to elderly people in a number of settings which
includes medical, mental health, residential, community, long term care and other
care settings. In the last few decades, use of DNR, especially by the elderly, has
increased considerably. DNR is a request made by the patient or health care power
of attorney to prevent the use of cardiopulmonary resuscitation (CPR) in case the
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patient’s heart ceases to function. Compared to young adults, the elderly are more
likely to request DNR. A DNR does not alter any treatment or care management
except use of intubation or CPR. DNR status, CPR, medical futility and selfdetermination should always be discussed with elderly. A balance should be made in
our quest to save patients’ lives as long as possible while maintaining the elderly
patient’s self-esteem and dignity of life. As our life span increases, the need for
long-term care for the elderly will grow. We should prepare ourselves and the
society as a whole to better deal with this reality.
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References:
1. Y. Gorina and H. Lentzner, “Multiple causes of death in old age,” Aging
Trends, no. 9, pp. 1–9, 2008.
2. C. F. Dillon, Q. Gu, H. J. Hoffman, and C. W. Ko, “Vision, hearing, balance,
and sensory impairment in Americans aged 70 years and over: United States,
1999–2006,” NCHS Data Brief, no. 31, pp. 1–8, 2010.
3. Administration on Aging, “A profile of older americans: 2009, disability and
activity
limitations,”http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2009/16.as
px.
4. R. H. Lawrence, S. L. Tennstedt, L. E. Kasten, J. Shih, J. Howland, and A. M.
Jette, “Intensity and correlates of fear of falling and hurting oneself in the
next year: baseline findings from a roybal center fear of falling
intervention,” Journal of Aging and Health, vol. 10, no. 3, pp. 267–286,
1998.
5. B. J. Vellas, S. J. Wayne, L. J. Romero, R. N. Baumgartner, and P. J. Garry,
“Fear of falling and restriction of mobility in elderly fallers,” Age and Aging,
vol. 26, no. 3, pp. 189–193, 1997
6. Federal Interagency Forum on Aging-Related Statistics, “Older Americans
2010: key indicators of well-being,” Hyattsville, Md, USA
7. Kaye H, Harrington C, LaPlante M. Long-Term Care: Who Gets It, Who
Provides It, Who Pays, And How Much? Health Affairs. January 2010 2010;
29(1):11-21.
8. Administration on Aging (AoA). A Profile of Older Americans: 2009. 2010;
http://www.aoa.gov/ AoARoot/Aging_Statistics/Profile/2009/4.aspx.
9. PEW Research Center. 10,000 - Baby Boomers Retire.
http://pewresearch.org/databank/ dailynumber/?NumberID=1150.
10. U.S. Census Bureau, Population Division. Table 2. Projections of the
Population by Selected Age Groups and Sex for the United States: 2010 to
2050 (NP2008-T2) 2008; www.census.gov.
11. Murphy S, Xu J, Kochanek K. Deaths: Preliminary Data for 2010. National
Vital Statistics Reports 2012;
http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf..
12. Glover J. United States Life Tables: 1890,1901,1910, and 1901-1910. 1921;
http://www.cdc.gov/ nchs/data/lifetables/life1890-1910.pdf.
13. Anderson G. Chronic Care: Making the Case for Ongoing Care. 2010;
http://www.rwjf.org/files/ research/50968chronic.care.chartbook.pdf.
14. Medical Expenditure Panel Survey, 2006.
15. Alzheimer’s Association. 2012 Alzheimer’s Disease Facts and Figures,
Alzheimer’s & Dementia, Volume 8, Issue 2.
http://www.alz.org/downloads/Facts_Figures_2012.pdf
16. "Defusing the demographic "time-bomb" in Germany." Bull World Health
Organ 2012;90:6–7 | doi:10.2471/BLT.12.020112
17. Health Canada. Long-Term Facilities-Based Care.
18. Saltman, R.B., Dubois, H.F.W. and Chawla, M. (2006). The impact of aging on
long-term care in Europe and some potential policy responses, International
Journal of Health Services, 36(4): 719-746.
19. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing
Home Survey: 2004 overview. Vital Health Stat 13. 2009;(167):1–155.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 105
20. WHO. World Health Day–toolkit for organizers. Available
from:http://www.who.int/world.health.day/2012/toolkit/background/en/index
.html .
21. Office of National Statistics. Population trends. PT 118, table 1.4 (population
age and sex). London: ONS, 2004.
22. Office for National Statistics. Living in Britain: results from the 2002 General
Household Survey. London: ONS, 2004.
23. Kyle UG, Genton L, Hans D, et al. Total body mass, fat mass, fat-free mass,
and skeletal muscle in older people: cross-sectional differences in 60-year-old
persons. J Am Geriatr Soc 2001;49:1633–40.
24. Baumgartner RN, Stauber PM, McHugh D, et al. Cross-sectional age
differences in body composition in persons 60+ years of age. J Gerontol A Biol
Sci Med Sci 1995;50:M307–16.
25. Silver AJ, Guillen CP, Kahl MJ, et al. Effect of aging on body fat. J Am Geriatr
Soc 1993;41:211–13.
26. Enzi G, Gasparo M, Biondetti PR, et al. Subcutaneous and visceral fat
distribution according to sex, age, and overweight, evaluated by computed
tomography. Am J Clin Nutr 1986;44:739–46.
27. Kuczmarski RJ. Need for body composition information in elderly subjects. Am
J Clin Nutr 1989;50(suppl 5):1150–7.
28. Forbes GB, Reina JC. Adult lean body mass declines with age: some
longitudinal observations. Metabolism 1970;19:653–63.
29. Novak LP. Aging, total body potassium, fat-free mass, and cell mass in males
and females between ages 18 and 85 years. J Gerontol 1972;27:438–43.
30. Broadwin J, Goodman-Gruen D, Slymen D. Ability of fat and fat-free mass
percentages to predict functional disability in older men and women. J Am
Geriatr Soc 2001;49:1641–5.
31. Landers KA, Hunter GR, Wetzstein CJ, et al. The interrelationship among
muscle mass, strength, and the ability to perform physical tasks of daily living
in younger and older women. J Gerontol A Biol Sci Med Sci 2001;56:B443–8.
32. Yeh SS, Schuster MW. Geriatric cachexia: the role of cytokines. Am J Clin Nutr
1999;70:183–97.
33. Corish CA, Kennedy NP. Protein-energy undernutrition in hospital in-patients.
Br J Nutr 2000;83:575–91.
34. Finch S, Doyle W, Lowe C, et al. National Diet and Nutrition Survey: people
aged 65 years and over, Vol 1.Report of the diet and nutrition survey.
London: The Stationery Office, 1998.
35. Edington J, Kon P, Martyn CN. Prevalence of malnutrition in patients in
general practice. Clin Nutr 1996;15:60–3.
36. Landi F, Zuccala G, Gambassi G, et al. Body mass index and mortality among
older people living in the community. J Am Geriatr Soc 1999;47:1072–6.
37. Gariballa SE, Sinclair AJ. Nutrition, aging and ill health. Br J Nutr 1998;80:7–
23.
38. Delmi M, Rapin CH, Bengoa JM, et al. Dietary supplementation in elderly
patients with fractured neck of the femur. Lancet 1990;335:1013–16.
39. Robinson G, Goldstein M, Levine GM. Impact of nutritional status on DRG
length of stay. JPEN 1987;11:49–51.
40. Friedmann JM, Jensen GL, Smiciklas WH, et al. Predicting early nonelective
hospital readmission in nutritionally compromised older adults. Am J Clin Nutr
1997;65:1714–20.
41. de Groot CP, van Staveren WA, de Graaf C. Determinants of macronutrient
intake in elderly people. Eur J Clin Nutr 2000;54(suppl 3):S70–6.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 106
42. Wakimoto P, Block G. Dietary intake, dietary patterns, and changes with age:
an epidemiological perspective. J Gerontol A Biol Sci Med Sci 2001;56:65–80.
43. de Groot CP, van den BT, van Staveren W. Energy intake and micronutrient
intake in elderly Europeans: seeking the minimum requirement in the SENECA
study. Age Aging 1999;28:469–474.
44. Das SK, Moriguti JC, McCrory MA, et al. An underfeeding study in healthy men
and women provides further evidence of impaired regulation of energy
expenditure in old age. J Nutr 2001;131:1833–8.
45. Clarkston WK, Pantano MM, Morley JE, et al. Evidence for the anorexia of
aging: gastrointestinal transit and hunger in healthy elderly vs. young adults.
Am J Physiol 1997;272:R243–8.
46. Morley JE. Decreased food intake with aging. J Gerontol A Biol Sci Med Sci
2001;56:81–8.
47. De Castro JM. Age-related changes in spontaneous food intake and hunger in
humans. Appetite 1993;21:255–72.
48. Chapman IM, I. Endocrinology of anorexia of aging. Baillieres Clin Endocrinol
Metab 2004;18:437–52.
49. Hetherington MM. Taste and appetite regulation in the elderly. Proc Nutr Soc
1998;57:625–31.
50. Schiffman SS. Taste and smell losses in normal aging and disease. JAMA
1997;278:1357–62.
51. Duffy VB, Backstrand JR, Ferris AM. Olfactory dysfunction and related
nutritional risk in free-living, elderly women. J Am Diet Assoc 1995;95:879–
84.
52. Schiffman SS. Intensification of sensory properties of foods for the elderly. J
Nutr 2000;130(suppl 4):927–30S.
53. Mathey MF, Siebelink E, de Graaf C, et al. Flavor enhancement of food
improves dietary intake and nutritional status of elderly nursing home
residents. J Gerontol A Biol Sci Med Sci 2001;56:M200–5.
54. P. E. Petersen, “The World Oral Health Report 2003: Continuous improvement
of oral health in the 21st century—The approach of the WHO Global Oral
Health Programme,” Community Dentistry and Oral Epidemiology, vol. 31, no.
1, pp. 3–24, 2003.
55. J. G. Steele, A. E. Sanders, G. D. Slade et al., “How do age and tooth loss
affect oral health impacts and quality of life? a study comparing two national
samples,” Community Dentistry and Oral Epidemiology, vol. 32, no. 2, pp.
107–114, 2004.
56. E. Musacchio, E. Perissinotto, P. Binotto et al., “Tooth loss in the elderly and
its association with nutritional status, socio-economic and lifestyle
factors,” Acta Odontologica Scandinavica, vol. 65, no. 2, pp. 78–86, 2007
57. Keller HH. Malnutrition in institutionalized elderly: how and why? J Am Geriatr
Soc 1993;41:1212–18.
58. Payette H, Gray-Donald K, Cyr R, et al. Predictors of dietary intake in a
functionally dependent elderly population in the community. Am J Public
Health 1995;85:677–83.
59. Incalzi RA, Capparella O, Gemma A, et al. Inadequate caloric intake: a risk
factor for mortality of geriatric patients in the acute-care hospital. Age Aging
1998;27:303–10.
60. Claggett MS. Nutritional factors relevant to Alzheimer’s disease. J Am Diet
Assoc 1989;89:392–6.
61. Volicer L, Seltzer B, Rheaume Y, et al. Progression of Alzheimer-type
dementia in institutionalised patients: a cross sectional study. J Appl Gerontol
1987;6:83–94.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 107
62. Priefer BA, Robbins J. Eating changes in mild-stage Alzheimer’s disease: a
pilot study. Dysphagia 1997;12:212–21.
63. Berkhout AMM, Cools HJM, van Houwelingen HC. The relationship between
difficulties in feeding oneself and loss of weight in nursing home patients with
dementia. Age Aging 1998;27:637–41.
64. Blaum CS, Fries BE, Fiatarone MA. Factors associated with low body mass
index and weight loss in nursing home residents. J Gerontol A Biol Sci Med Sci
1995;50:M162–8.
65. Thompson MP, Morris LK. Unexplained weight loss in the ambulatory elderly. J
Am Geriatr Soc 1991;39:497–500.
66. Westin T, Jansson A, Zenckert C, et al. Mental depression is associated with
malnutrition in patients with head and neck cancer. Arch Otolaryngol Head
Neck Surg 1988;114:1449–53.
67. Rosenbloom CA, Whittington FJ. The effects of bereavement on eating
behaviors and nutrient intakes in elderly widowed persons. J Gerontol
1993;48:S223–9.
68. Feldblum I, et al. Characteristics of undernourished older medical patients and
the identification of predictors for undernutrition status. Nutr J. 2007;6:37.
69. Morley JE, et al. Nutritional deficiencies in long-term care: Part I. Detection
and diagnosis. Ann Long-Term Care. 2004;12(Suppl 2):S1-S7.
70. White H. Weight loss in advanced Alzheimer's disease, Part I. Contributing
factors and evaluation. Ann Long-Term Care: Clinical Care and
Aging. 2004;12(5):33-37.
71. DiMaria-Ghalili RA, Guenter PA. The mini nutritional assessment. Am J
Nurs. 2008;108(2):50-59.
72. Bagley B. Nutrition and health. Am Fam Physician. 1998;57(5):933-934.
73. Yesavage JA. Geriatric depression scale. Psychopharmacol
Bull. 1988;24(4):709-711.
74. Carolan Doerflinger DM. How to try this: the mini-cog. Am J
Nurs. 2007;107(12):62-71.
75. Borson S, et al. The Mini-Cog as a screen for dementia: validation in a
population-based sample. J Am Geriatr Soc. 2003;51(10):1451-1454.
76. Thomas DR. Introduction to Weight Loss in Older Persons. Malvern, Pa.: HMP
Communications; 2007.
77. Thomas DR, et al. Nutritional management in long-term care: development of
a clinical guideline. Council for Nutritional Strategies in Long-Term Care. J
Gerontol A Biol Sci Med Sci. 2000;55(12):725-734.
78. Wolfe RR. The Danger of Weight Loss in the Elderly. Malvern, Pa.: HMP
Communications; 2007.
79. Flood M, Newman AM. Obesity in older adults: synthesis of findings and
recommendations for clinical practice. J Gerontol Nurs. 2007;33(12):19-35.
80. Alpers DH, Klein S. Approach to the patient requiring nutritional
supplementation. In Yamada T, ed. Textbook of Gastroenterology, 4th edn.
Baltimore: Lippincott Williams & Wilkins, 2003
81. Jeejeebhoy KN, Baker JP, Wolman SL, et al. Critical evaluation of the role of
clinical assessment and body composition studies in patients with malnutrition
and after total parenteral nutrition. Am J Clin Nutr 1982;35:1117 -27
82. Gariballa SE, Sinclair AJ. Nutrition, aging and ill health. Br J Clin
Nutr1998;80:7 -23
83. Gariballa S. Nutrition and older people: special considerations relating to
nutrition and aging. Clin Med2004;4:411 -14
84. Wallace JI. Malnutrition and enteral/parenteral alimentation. In: Hazzard WR,
Blass JP, Ettinger WH Jr, Halter JB, Ouslander JG, editors. Principles of
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 108
geriatric medicine and gerontology. 4th ed. New York: McGraw-Hill; 1999. pp.
1455–69.
85. Endoy MP. Anorexia among older adults. American Journal for Nurse
Practitioners. 2005 May;9(5):31–8.
86. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation
in elderly people at risk from malnutrition. Cochrane Database Syst Rev
2009; 15 (2): CD003288.
87. Morley JE, Argiles JM, Evans WJ et al. Nutritional recommendations for the
management of sarcopenia. J Am Med Dir Assoc 2010; 11: 391–6.
88. Wilson MM, Purushothaman R, Morley JE. Am J Clin Nutr 2002; 75: 944–7.
89. Nijs K, de Graaf C, van Staveren WA, de Groot LC. Malnutrition and mealtime
ambiance in nursing homes. J AmMed Dir Assoc 2009; 10: 226–9.
90. Keller HH, Gibbs-Ward A, Randall-Simpson J et al. Meal rounds: an essential
aspect of quality nutrition services in long-term care. J Am Med Dir Assoc
2006; 7: 40–5.
91. Rahman AN, Simmons SF. Individualizing nutritional care with between-meal
snacks for nursing home residents. J Am Med Dir Assoc 2005; 6: 215–8.
92. Berenstein EG, Ortiz Z. Megestrol acetate for the treatment of anorexiacachexia syndrome. Cochrane Database Syst Rev 2005; 18 (2): CD004310.
93. Navari RM, Brenner MC. Treatment of cancer-related anorexia with olanzapine
and megestrol acetate: a randomized trial. Support Care Cancer 2010; 18:
951–6.
94. Chapman IM, Visvanathan R, Hammond AJ et al. Effect of testosterone and a
nutritional supplement, alone and in combination, on hospital admissions in
undernourished older men and women. Am J Clin Nutr 2009; 89: 880–9.
95. Perry HM 3rd, Horowitz M, Morley JE et al. Longitudinal changes in serum 25hydroxyvitamin D in older people. Metabolism 1999; 48: 1028–32.
96. Argento V, Roylance J, Skudlarska B et al. Anemia prevalence in a home visit
geriatric population. J Am Med Dir Assoc 2008; 9: 422–6.
97. Niewoehner CB, Allen JI, Boosalis M et al. Role of zinc supplementation in
type II diabetes mellitus. Am J Med 1986; 81:63–8.
98. Huffman GB. Evaluating and treating unintentional weight loss in the
elderly. Am Fam Physician. 2002 Feb 15;65(4):640–50.
99. US Department of Health and Human Services. Agency for Healthcare
Research and Quality. Diagnosis and treatment of swallowing disorders
(dysphagia) in acute-care stroke patients. Evidence report/technology
assessment (Summary). Archived EPC Evidence Reports. 1999:1–6.
100.
Barczi SR, Sullivan PA, Robbins J. How should dysphagia care of older
adults differ? Establishing optimal practice patterns. Semin Speech Lang.
2000;21:347–361.
101.
Leder SB, Suiter DM. An epidemiologic study on aging and dysphagia
in the acute care hospitalized population: 2000–2007. Gerontology.
2009;55:714–718.
102.
Crary MA, Groher ME. Introduction to Adult Swallowing Disorders.
Philadelphia, PA: Butterworth Heinemann; 2003.
103.
Logemann JA, Stewart C, Hurd J, Aschman D, Matthews N. Diagnosis
and Management of Dysphagia in Seniors. 2008. Available at:
http://americandysphagianetwork.org/physician_education_course.
104.
Fucile S, Wright PM, Chan I, Yee S, Langlais ME, Gisel EG. Functional
oral-motor skills: Do they change with age? Dysphagia. 1998;13:195–201.
105.
Steele CM, Greenwood C, Ens I, Robertson C, Seidman-Carlson R.
Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia.
1997;12:43–50, discussion 51.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 109
106.
Lee A, Sitoh YY, Lieu PK, Phua SY, Chin JJ. Swallowing impairment and
feeding dependency in the hospitalised elderly. Ann Acad Med Singapore.
1999;28:371–376.
107.
Mann G, Hankey GJ, Cameron D. Swallowing function after stroke:
prognosis and prognostic factors at 6 months. Stroke. 1999;30:744–748.
108.
Smithard DG, O’Neill PA, Parks C, Morris J. Complications and outcome
after acute stroke. Does dysphagia matter? Stroke. 1996;27:1200–1204.
109.
Kawashima K, Motohashi Y, Fujishima I. Prevalence of dysphagia
among community-dwelling elderly individuals as estimated using a
questionnaire for dysphagia screening. Dysphagia. 2004;19:266–271.
110.
Serra-Prat M, Hinojosa and impaired safety and efficacy of swallow in
independently living older persons. J Am Geriatr Soc. 2011;59:186–187.
111.
Roy N, Stemple J, Merrill RM G, López D, et al. Prevalence of
oropharyngeal dysphagia, Thomas L. Dysphagia in the elderly: preliminary
evidence of prevalence, risk factors, and socioemotional effects. Ann Otol
Rhinol Laryngol. 2007;116:858–865.
112.
Groher ME, Crary MA. Dysphagia: Clinical Management in Adults and
Children. Maryland Heights, MO: Mosby Elsevier; 2010.
113.
Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute
stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis. 2000;10:380–
386.
114.
Paciaroni M, Mazzotta G, Corea F, et al. Dysphagia following Stroke.
Eur Neurol. 2004;51:162–167.
115.
Carnaby-Mann G, Lenius K, Crary M. Update on Assessment and
Management of Dysphagia Post Stroke. Northeast Florida Medicine.
2007;58:31–34.
116.
Smithard DG, Smeeton NC, Wolfe CD. Long-term outcome after
stroke: does dysphagia matter? Age Aging. 2007;36:90–94.
117.
Altman KW, Yu GP, Schaefer SD. Consequence of dysphagia in the
hospitalized patient: impact on prognosis and hospital resources. Arch
Otolaryngol Head Neck Surg. 2010;136:784–789
118.
Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R.
Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.
Stroke. 2005;36:2756–2763.
119.
Martino R, Martin RE, Black S. Dysphagia after stroke and its
management. CMAJ. 2011.
120.
Maeshima S, Osawa A, Miyazaki Y, et al. Influence of dysphagia on
short-term outcome in patients with acute stroke. Am J Phys Med Rehabil.
2011;90:316–320.
121.
Guyomard V, Fulcher RA, Redmayne O, Metcalf AK, Potter JF, Myint
PK. Effect of dysphasia and dysphagia on inpatient mortality and hospital
length of stay: a database study. J Am Geriatr Soc. 2009;57:2101–2106.
122.
Foley NC, Martin RE, Salter KL, Teasell RW. A review of the
relationship between dysphagia and malnutrition following stroke. J Rehabil
Med. 2009;41:707–713.
123.
Axelsson K, Asplund K, Norberg A, Alafuzoff I. Nutritional status in
patients with acute stroke. Acta Med Scand. 1988;224:217–224.
124.
Davalos A, Ricart W, Gonzalez-Huix F, et al. Effect of malnutrition after
acute stroke on clinical outcome. Stroke. 1996;27:1028–1032.
125.
Gariballa SE, Parker SG, Taub N, Castleden CM. Influence of nutritional
status on clinical outcome after acute stroke. Am J Clin Nutr. 1998;68:275–
281.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 110
126.
Crary MA, Carnaby-Mann GD, Miller L, Antonios N, Silliman S.
Dysphagia and nutritional status at the time of hospital admission for
ischemic stroke. J Stroke Cerebrovasc Dis. 2006;15:164–171.
127.
Finestone HM, Foley NC, Woodbury MG, Greene-Finestone L.
Quantifying fluid intake in dysphagic stroke patients: a preliminary
comparison of oral and nonoral strategies. Arch Phys Med Rehabil.
2001;82:1744–1746.
128.
Sellars C, Bowie L, Bagg J, et al. Risk factors for chest infection in
acute stroke: a prospective cohort study. Stroke. 2007;38:2284–2291.
129.
Masiero S, Pierobon R, Previato C, Gomiero E. Pneumonia in stroke
patients with oropharyngeal dysphagia: a six-month follow-up study. Neurol
Sci. 2008;29:139–145.
130.
Pikus L, Levine MS, Yang YX, et al. Videofluoroscopic studies of
swallowing dysfunction and the relative risk of pneumonia. Am J Roentgenol.
2003;180:1613–1616.
131.
Ney DM, Weiss JM, Kind AJ, Robbins J. Senescent swallowing: impact,
strategies, and interventions. Nutr Clin Pract. 2009;24:395–413.
132.
Horner J, Alberts MJ, Dawson DV, Cook GM. Swallowing in Alzheimer’s
disease. Alzheimer Dis Assoc Disord. 1994;8:177–19.
133.
Morley JE. Nutrition in the elderly. Curr Opin Gastroenterol.
2002;18:240–245.
134.
Claggett MS. Nutritional factors relevant to Alzheimer’s disease. J Am
Diet Assoc. 1989;89:392–396.
135.
Makowska I, Kloszewska I, Grabowska A, Szatkowska I, ymarczyk K.
Olfactory deficits in normal aging and Alzheimer’s disease in the Polish elderly
population. Arch Clin Neuropsychol. 2011;26:270–279.
136.
Serby M, Larson P, Kalkstein D. The nature and course of olfactory
deficits in Alzheimer’s disease. Am J Psychiatry. 1991;148:357–360.
137.
Zuliani G, Galvani M, Sioulis F, et al. Discharge diagnosis and
comorbidity profile in hospitalized older patients with dementia. Int J Geriatr
Psychiatry. 2012;27:313–320.
138.
Serra-Prat M, Palomera M, Gomez C, et al. Oropharyngeal dysphagia
as a risk factor for malnutrition and lower respiratory tract infection in
independently living older persons: a population-based prospective study. Age
Aging. 2012;41:376–381.
139.
Kaplan V, Angus DC, Griffin MF, Clermont G, Scott Watson R, LindeZwirble WT. Hospitalized community-acquired pneumonia in the elderly: ageand sex-related patterns of care and outcome in the United States. Am J
Respir Crit Care Med. 2002;165:766–772.
140.
Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the
elderly. Chest. 2003;124:328–336.
141.
Ewig S, Birkner N, Strauss R, et al. New perspectives on communityacquired pneumonia in 388 406 patients. Results from a nationwide
mandatory performance measurement programme in healthcare quality.
Thorax. 2009;64:1062–1069.
142.
Murphy S, Xu J, Kochanek KD. Deaths: Preliminary Data for 2010.
National Vital Statistics Report: Center for Disease Control and Prevention;
January 11, 2012. Available at:
http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf.
143.
Almirall J, Bolibar I, Vidal J, et al. Epidemiology of community-acquired
pneumonia in adults: a population-based study. Eur Respir J. 2000;15:757–
763.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 111
144.
Loeb MB, Becker M, Eady A, Walker-Dilks C. Interventions to prevent
aspiration pneumonia in older adults: a systematic review. J Am Geriatr Soc.
2003;51:1018–1022.
145.
Rofes, L., Arreloa, V., Almirall, J., Cabre, M., Campins, L., GarciaPeris, P., Speyer, R., & Clave P. (2011). Diagnosis and management of
oropharyngeal dysphagia and its nutritional and respiratory complications in
the elderly. Gastroenterology Research and Practice. Volume 2011, 1-13.
oi:10.1155/2011/818979
146.
Leder, S.B., Suiter, D.M., Warner, H.L., Acton, L.M., & Swainson, B.A.
(2012). Success of recommending oral diets in acute stroke patients based on
passing a 90-cc water swallow challenge protocol. Topics in Stroke
Rehabilitation, 19(1), 40-44.
147.
Rasley A, Logemann JA, Kahrilas PJ, Rademaker AW, Pauloski BR,
Dodds WJ. Prevention of barium aspiration during videofluoroscopic
swallowing studies: value of change in posture. Am J Roentgenol.
1993;160:1005–1009.
148.
Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia
in acute stroke: a randomised controlled trial. Lancet Neurol. 2006;5:31–37.
149.
Kahrilas PJ, Logemann JA, Krugler C, Flanagan E. Volitional augmentation of upper esophageal sphincter opening during swallowing. AM J Physiol.
1991;260:G450–G456.
150.
Hind JA, Nicosia MA, Roecker EB, Carnes ML, Robbins J. Comparison of
effortful and noneffortful swallows in healthy middle-aged and older adults.
Arch Phys Med Rehabil. 2001;82:1661–1665.
151.
Huckabee ML, Butler SG, Barclay M, Jit S. Submental surface electromyographic measurement and pharyngeal pressures during normal and
effortful swallowing. Arch Phys Med Rehabil. 2005;86:2144–2149.
152.
Elmstahl S, Bulow M, Ekberg O, Petersson M, Tegner H. Treatment of
dysphagia improves nutritional conditions in stroke patients. Dysphagia.
1999;14:61–66.
153.
Neumann S, Bartolome G, Buchholz D, Prosiegel M. Swallowing
therapy of neurologic patients: correlation of outcome with pretreatment
variables and therapeutic methods. Dysphagia. 1995;10:1–5.
154.
Carnaby-Mann GD, Crary MA. Adjunctive neuromuscular electrical
stimulation for treatment-refractory dysphagia. Ann Otol Rhinol Laryngol.
2008;117:279–287.
155.
Chandra RK. Nutrition and the immune system: an introduction. Am J
Clin Nutr. 1997;66:460S–463S.
156.
Hengstermann S, Fischer A, Steinhagen-Thiessen E, Schulz RJ.
Nutrition status and pressure ulcer: what we need for nutrition screening. J
Parenter Enteral Nutr. 2007;31:288–294.
157.
Robbins J, Gangnon RE, Theis SM, Kays SA, Hewitt AL, Hind JA. The
effects of lingual exercise on swallowing in older adults. J Am Geriatr Soc.
2005;53:1483–1489.
158.
Carnaby-Mann G, Crary MA, Schmalfuss I, Amdur R. “Pharyngocise”:
Randomized Controlled Trial of Preventative Exercises to Maintain Muscle
Structure and Swallowing Function During Head-and-Neck
Chemoradiotherapy. Int J Radiat Oncol Biol Phys. 2011;83:210–219.
159.
Carnaby-Mann GD, Crary MA. McNeill dysphagia therapy program: a
case-control study. Arch Phys Med Rehabil. 2010;91:743–749.
160.
Crary MA, Carnaby GD, Lagorio LA, Carvajal PJ. Functional and
Physiological Outcomes from an Exercise-Based Dysphagia Therapy: A Pilot
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 112
Investigation of the McNeill Dysphagia Therapy Program. Arch Phys Med
Rehabil. 2012.
161.
Feder G, Cryer C, Donovan S, Carter Y. Guidelines for the prevention
of falls in people over 65. The Guidelines’ Development Group. BMJ.
2000;321(7267):1007–1011.
162.
Kannus P, Sievänen H, Palvanen M, Järvinen T, Parkkari J. Prevention
of falls and consequent injuries in elderly people. Lancet. 2005;366:1885-93.
[PMID: 16310556]
163.
Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl
J Med. 2003;348:42-9.
164.
Connell BR, Wolf SL. Environmental and behavioral circumstances
associated with falls at home among healthy elderly individuals. Atlanta
FICSIT Group. Arch Phys Med Rehabil. 1997;78:179-86.
165.
Centers for Disease Control and Prevention (CDC). Self-reported falls
and fall-related injuries among persons aged > or = 65 years—United States,
2006. MMWR Morb Mortal Wkly Rep. 2008;57:225-9.
166.
Rubenstein LZ, Josephson KR. The epidemiology of falls and
syncope. Clin Geriatr Med. 2002;18:141-58.
167.
Centers for Disease Control and Prevention (CDC). Fatalities and
injuries from falls among older adults-United States, 1993-2003 and 20012005. MMWR Morb Mortal Wkly Rep. 2006;55:1221-4.
168.
Public health surveillance of 1990 injury control objectives for the
nation. MMWR CDC Surveill Summ. 1988;37:1-68.
169.
Guideline for the prevention of falls in older persons. American
Geriatrics Society, British Geriatrics Society, and American Academy of
Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc.
2001;49:664-72.
170.
Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip
and fall injuries. J Forensic Sci. 1996;41:733-46.
171.
National Institute for Health and Clinical Excellence. Falls: The
Assessment and Prevention of Falls in Older People. London: National
Institute for Health and Clinical Excellence; 2004.
172.
Rubenstein L. Falls in older people: epidemiology, risk factors and
strategies for prevention. Age Aging. 2006;35:ii37–ii41. doi:
10.1093/aging/afl084.
173.
Rubenstein LZ, Josephson KR. The epidemiology of falls and
syncope. Clin Geriatr Med.2002;18:141–158. doi: 10.1016/S07490690(02)00002-2.
174.
Nurmi IS, Luthje PM, Kataja JM. Long-term survival after falls among
the elderly In institutional care. Arch Gerontol Geriatr. 2004;38:1–10.
175.
Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and
non-fatal falls among older adults. Inj Prev. 2006;12:290–295. doi:
10.1136/ip.2005.011015.
176.
Carroll N, Delafuente J, Cox F, Narayanan S. Fall-related
hospitalization and facility costs among residents of institutions providing
long-term care. Gerontologist. 2008;48:213–222. doi:
10.1093/geront/48.2.213.
177.
van den Berg M, Castellote J, Mahillo-Fernandez I, Pedro-Cuesta J.
Incidence of spinal cord injury worldwide: a systematic
review. Neuroepidemiology. 2010;34:184–192. doi: 10.1159/000279335.
178.
Cumming R, Salkeld G, Thomas M, Szonyi G. Prospective study of the
impact of fear of falling on activities of daily living, Sf-36 Scores, and nursing
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 113
home admission. J Gerontol A Biol Sci Med Sci. 2000;55:M299–M305. doi:
10.1093/gerona/55.5.M299.
179.
Tinetti M, Powell L. Fear of falling and low self-efficacy: a case of
dependence in elderly persons.J Gerontol. 1993;48:35–38. doi:
10.1093/geronj/48.Special_Issue.35.
180.
Becker C, Rapp K. Fall prevention in nursing homes. Clin Geriatr
Med. 2010;26:693–704. doi: 10.1016/j.cger.2010.07.004.
181.
Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing
home. Ann Intern Med.1994;121:442–451.
182.
McGlone J, Gupta S, Humphrey D, Oppenheimer S, Mirsen T, Evans
DR. Screening for early dementia using memory complaints from patients and
relatives. Arch Neurol. 1990;47:1189-93.
183.
Ha¨nninen T, Reinikainen KJ, Helkala EL, Koivisto K, Mykka¨nen L,
Laakso M, et al. Subjective memory complaints and personality traits in
normal elderly subjects. J Am Geriatr Soc. 1994;42:1-4.
184.
O’Hara MW, Hinrichs JV, Kohout FJ, Wallace RB, Lemke JH. Memory
complaint and memory performance in the depressed elderly. Psychol Aging.
1986;1:208-14.
185.
Tierney MC, Szalai JP, Snow WG, Fisher RH. The prediction of
Alzheimer disease. The role of patient and informant perceptions of cognitive
deficits. Arch Neurol. 1996;53:423-7
186.
Turvey CL, Schultz S, Arndt S, Wallace RB, Herzog R. Memory
complaint in a community sample aged 70 and older. J Am Geriatr Soc.
2000;48:1435-41.
187.
Federal Interagency Forum on Aging Related Statistics: Older
Americans 2004: Key Indicators of WellBeing.http://www.agingstats.gov/chartbook2004/population.html
188.
Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer
disease in the U.S. population: Prevalence estimates using the 2000 Census.
Archives of Neurology2003;60(8):1119–22.
189.
Seshadri S, Wolf PA, Beiser A, Au R, McNulty K, White R, et al. Lifetime
risk of dementia and Alzheimer’s disease. The impact of mortality on risk
estimates in the Framingham Study. Neurology 1997;49(6):1498–504.
190.
Hebert LE, Scherr PA, McCann JJ, Beckett LA, Evans DA. Is the risk of
developing Alzheimer’s disease greater for women than for men? American
Journal of Epidemiology 2001;153(2):132–6.
191.
Hebert LE, Beckett LA, Scherr PA, Evans DA. Annual incidence of
Alzheimer disease in the United States projected to the years 2000 through
2050. Alzheimer Disease & Associated Disorders 2001;15(4):169–73.
192.
U.S. Census Bureau. Current Population Reports, Special Studies, P23209, 65+ in the United States: 2005. U.S. Government Printing Office, ed.
Washington, D.C., 2005.
193.
Centers for Disease Control and Prevention and The Merck Company
Foundation. The State of Aging and Health in America, 2007. Whitehouse
Station, N.J.: The Merck Company Foundation; 2007.
194.
Miniño A, Murphy SL, Xu J, Kochanek K. Deaths: Final Data for 2008.
National Vital Statistics Reports, Hyattsville, Md.; National Center for Health
Statistics, 2011.
195.
Arrighi HM, Neumann PJ, Lieberburg IM, Townsend RJ. Lethality of
Alzheimer disease and its impact on nursing home placement. Alzheimer
Disease & Associated Disorders 2010;24(1):90–5.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 114
196.
Mitchell SL, Teno JM, Miller SC, Mor V. A national study of the location
of death for older persons with dementia. Journal of the American Geriatrics
Society 2005;53(2):299–305.
197.
Unpublished tabulations based on data from the Medicare Current
Beneficiary Survey for 2008. Prepared under contract by Julie Bynum, M.D.,
M.P.H., Dartmouth Institute for Health Policy and Clinical Care, Dartmouth
Medical School, November 2011.
198.
Prepared under contract by Julie Bynum, M.D., M.P.H., Dartmouth
Institute for Health Policy and Clinical Care, Dartmouth Medical School,
November 2011.
199.
MetLife Mature Market Institute. Market Survey of Long-Term Care
Costs: The 2011 MetLife Market Survey of Nursing Home, Assisted Living,
Adult Day Services, and Home Care Costs. New York, N.Y.: Metropolitan Life
Insurance Company, 2011.
200.
Fortinsky RH, Fenster JR, Judge JO. Medicare and Medicaid home
health and Medicaid waiver services for dually eligible older adults: Risk
factors for use and correlates of expenditures. Gerontologist 2004;44(6):739–
49.
201.
Hirdes JP, Fries BE, Morris JN, Ikegami N, Zimmerman D, Dalby DM, et
al. Home care quality indicators (HCQIs) based on the MDS-HC. Gerontologist
2004;44(5):665–79.
202.
Mitchell G, Salmon JR, Polivka L, Soberon-Ferrer H. The relative
benefits and cost of Medicaid home- and community based services in Florida.
Gerontologist 2006:46(4):483–94.
203.
Partners in Care giving. A National Study of Adult Day Services, 20012002. Winston-Salem, N.C.: Wake Forest University School of Medicine, 2002.
204.
O’Keeffe J, Siebenaler K. Adult Day Services: A Key Community
Service for Older Adults. U.S. Department of Health and Human Services,
Office of the Assistant Secretary for Planning and Evaluation, Washington,
D.C., July 2006.
205.
American Health Care Association. Nursing Facility Patient
Characteristics Report. Table 12: Medical Condition: Mental Status, June
2011.
206.
American Health Care Association. LTC Stats: Nursing Facility
Operational Characteristics Report. Table 5: Nursing Facility Beds in Dedicated
Special Care Units, June 2011.
207.
"Practical Tips for Daily Life | UCSF Memory and Aging Center".
Memory.ucsf.edu. Retrieved 2012-08-17.
208.
Salmans, Sandra (1997). Depression: Questions You Have – Answers
You Need. People's Medical Society.
209.
Alexopoulos G. Pharmacotherapy of depressive disorders in older
patients. Minneapolis: McGraw-Hill Healthcare Information, 2001
210.
Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major
depressive disorder: Results from the National Epidemiologic Survey on
Alcoholism and Related Conditions. Arch. Gen.Psychiatr 2005;62:1097–106.
211.
U.S. Department of Health and Human Services (1999). Older Adults
and Mental Health. In: Mental Health: A Report of the Surgeon General.
Available at:
http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec1.html
212.
Chapman DP, Perry GS, Strine TW (2005). The vital link between
chronic disease and depressive disorders. Prev Chronic Dis; 2(1):A14.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 115
213.
Teresi, J., Abrams, R., Holmes, D., Ramirez, M., & Eimicke, J. (2001).
Prevalence of depression and depression recognition in nursing homes. Social
Psychiatry and Psychiatric Epidemiology, 36(12), 613-620.
214.
Mazure CM, Maciejewski PK, Jacobs SC, Bruce ML. Stressful life events
interacting with cognitive/ personality styles to predict late-onset major
depression. Am. J. Geriatr. Psychiatry 2002;10:297– 304.
215.
Fiske A, Gatz M, Pedersen NL. Depressive symptoms and aging: The
effects of illness and non-health related events. J. Gerontol. B Psychol. Sci.
Soc. Sci 2003;58:P320–8.
216.
Prigerson HG, Frank E, Kasl SV, Reynolds CF, Anderson B, et al.
Complicated grief and bereavement related depression as distinct disorders:
Preliminary empirical validation in elderly bereaved spouses. Am. J. Psychiatry
1995;152:22–30.
217.
Zisook S, Kendler KS. Is bereavement-related depression different
than non-bereavement-related depression? Psychol. Med 2007;37:779–94.
218.
Cole MG, Dendukuri N. Risk factors for depression among elderly
community subjects: A systematic review and meta-analysis. Am. J.
Psychiatry 2003;160:1147–56.
219.
Torges CM, Stewart AJ, Nolen-Hoeksema S. Regret resolution, aging,
and adapting to loss. Psychol. Aging 2008;23:169–80.
220.
Umberson D, Wortman CB, Kessler RC. Widowhood and depression:
Explaining long-term gender differences in vulnerability. Journal of Health and
Social Behavior 1992;33:10–24.
221.
Knight BG, Flynn Longmire CV, Dave J, Kim JH, David S. Mental health
and physical health of family caregivers for persons with dementia: A
comparison of African American and white caregivers. Aging Ment. Health
2007;11:538–46.
222.
Schulz R, McGinnis KA, Zhang S, Martire LM, Hebert RS, Beach SR, et
al. Dementia patient suffering and caregiver depression. Alzheimer Disease
and Associated Disorders 2008;22:170–6.
223.
Williamson, GM.; Shaffer, DR. The activity restriction model of
depressed affect: Antecedents and consequences of restricted normal
activities. In: Williamson, GM.; Shaffer, DR.; Parmelee, PA., editors. Physical
illness and Depression in Older Adults: A Handbook of Theory, Research, and
Practice. Kluwer Academic/Plenum Publishers; New York: 2000. p. 173-200.
224.
Gallo JJ, Anthony JC, Muthén BO. Age differences in the symptoms of
depression: A latent trait analysis. J. Gerontol 1994;49:P251–64.
225.
Christensen H, Jorm AF, Mackinnon AJ, Korten AE, Jacomb PA, et al.
Age differences in depression and anxiety symptoms: A structural equation
modelling analysis of data from a general population sample. Psychol. Med
1999;29:325–39.
226.
Butters MA, Whyte EM, Nebes RD, Begley AE, Dew MA, et al. The
nature and determinants of neuropsychological functioning in late-life
depression. Arch. Gen. Psychiatry 2004;61:587–95.
227.
Kockler M, Heun R. Gender differences of depressive symptoms in
depressed and nondepressed elderly persons. Int. J. Geriatr. Psychiatry
2002;17:65–72.
228.
Paradiso S, Vaidya J, Tranel D, Kosier T, Robinson RG. Nondysphoric
depression following stroke. Neuropsychiatry. Clin. Neurosci 2008;20:52–61.
229.
Ehrt U, Brønnick K, Leentjens AF, Larsen JP, Aarsland D. Depressive
symptom profile in Parkinson's disease: A comparison with depression in
elderly patients without Parkinson's disease. Int. J. Geriatr. Psychiatry
2006;21:252–8.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 116
230.
Park JH, Lee SB, Lee TJ, Lee DY, Jhoo JH, et al. Depression in vascular
dementia is quantitatively and qualitatively different from depression in
Alzheimer's disease. Dement. Geriatr. Cogn. Disord 2007;23:67–73.
231.
L indau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh
CA, Waite LJ. A study of sexuality and health among older adults in the United
States. N Engl J Med 2007;357:762–74.
232.
Waite LJ, Laumann EO, Das A,Schumm LP. Sexuality: measures of
partnerships, practices, attitudes, and problems in the National Social Life,
Health and Aging Study. J Gerontol B Psychol Sci Soc Sci 2009;64(Suppl
1):156–66.
233.
L indau ST, Gavrilova N. Sex, health, and years of sexually active life
gained due to good health: evidence from two US population based cross
sectional surveys of aging. BMJ 2010;340:c810.
234.
Walsh KE, Berman JR. Sexual Dysfunction in the older woman: an
overview of the current understanding and management. Drugs Aging
2004;21:655–75.
235.
H oward JR, O’Neill S, Travers C. Factors affecting sexuality in older
Australian women: sexual interest, sexual arousal, relationships and sexual
distress in older Australian women. Climacteric 2006;9:355–67.
236.
Woloski–Wruble AC, Oliel Y, Leefsma M, Hochner-Ceinikier D. Sexual
activities, sexual and life satisfaction, and successful aging in women. J Sex
Med 2010 Apr 1
237.
DeLamater J, Hyde JS, Fong MC. Sexual satisfaction in the seventh
decade of life. J Sex Marital Ther 2008;34:439–54.
238.
Hartmann U, Phillippsohn S, Heiser K, Ruffer-Hesse C. Low sexual
desire in midlife and older women: personality factors, psychosocial
development, present sexuality. Menopause 2004;11(6 Pt 2):726–40.
239.
Wylie K, Kenney G. Sexual dysfunction and the aging male. Maturitas
2010;65:23–7.
240.
O ’Donnell A, Araujo A, McKinnlay J. The health of normally aging
men: The Massachussets Male Aging Study (1987-2004). Experimental
Gerontology 2004;39:975–84.
241.
Bhasin S, Enzlin P, Coviello A, et al. Sexual dysfunction in men and
women with endocrine disorders. Lancet 2007;369:597–611.
242.
Basson R, Schultz W. Sexual sequelae of general medical disorders.
Lancet 2007;369:409–24.
243.
elderabus.org.uk,
244.
Administration on Aging. (1998). The national elder abuse incidence
study: Final report.
245.
Acierno, R., Hernandex-Tejada, M., Muzzy, W., and Steve, K. (2009).
The national elder mistreatment study (NCJ Publication No. 2264560.
Washington, DC: U.S. Department of Justice
246.
Bulman, P., (April 2010). "Elder abuse emerges form the shadows of
public consciousness."NIJ Journal. 265, 4-7.
247.
Klein, A., Tobin, T., Salomon, A., and Dubois, J. (2008). A statewide
profile of abuse of older women and the criminal justice response (NCJ
Publication No. 222459). Washington, DC: U.S. Department of Justice.
248.
Choi, N.G., and Mayer, J. (2000). "Elder Abuse, Neglect, and
Exploitation." Journal of Gerontological Social Work, 33(4), 5-25.
doi:http://dx.doi.org/10.1300/J083v33n02_02
249.
Laumann, E.O., Leitsch, S.A., and Waite, L.J. (2008). "Elder
mistreatment in the United States: Prevalence estimate from a nationally
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 117
representative study." Journals of Gerontology: Series B, Psychological
Sciences and Social Sciences, 63 (4), S248-S254
250.
Rinkler, A.G., (2009). "Recognition and perception of elder abuse by
prehospital and hospital-based care providers." Archives of Gerontology and
Geriatrics. 48, 110-115.
251.
U.S. Department of Health and Human Services, Centers for Medicare
and Medicaid Services. (2009) Nursing Home Data Compendium. Washington,
D.C.: Author.
252.
National Center for Assisted Living. (2009). Assisted Living Resident
Profile. Washington DC: Author.
253.
Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of
Cornell University. & New York City Department for the Aging. (2011) Under
the Radar: New York State Elder Abuse Prevalence Study. New York: Author.
254.
Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy
W, et al. (2010). Prevalence and correlates of emotional, physical, sexual,
and financial abuse and potential neglect in the United States: The national
elder mistreatment study. American Journal of Public, 100(2), 292-297.
255.
Teaster PB, Dugar T, Mendiondo M, Abner EL, Cecil KA, & Otto JM.
(2004). The 2004 survey of adult protective services: Abuse of adults 60
years of age and older. Washington DC: National Center on Elder Abuse.
256.
National Research Council. (2003) Elder mistreatment: Abuse, neglect
and exploitation in an aging America. Washington, D.C.: The National
Academies Press.
257.
Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of
Cornell University. & New York City Department for the Aging. (2011) Under
the Radar: New York State Elder Abuse Prevalence Study. New York: Author.
258.
National Center on Elder Abuse, Westat, Inc. (1998). The national
elder abuse incidence study: Final report. Washington D.C.: Authors.
259.
Robinson, De Benedictis, Segal. "Elder Abuse and Neglect". Help
Guide. Retrieved 15 December 2012.
260.
"What is Elder Abuse?". Administration on Aging. Retrieved 17
December 2012.
261.
Shilling, D. (2008, November/December). "Improving the court
system's response to elder abuse," Victimization of the Elderly and Disabled,
11, 49, 51-52, 59, 62-63.
262.
Nursing Home Abuse Laws (NHAL)
263.
Oregon Revised Statutes.
264.
"Signs and symptoms of elder abuse and neglect in care". Advocare
Incorporated.
265.
Robinson, Lawrence; Tina De Benedictis, Jeanne Segal (November
2012). "Elder abuse and neglect: Warning signs, risk factors, prevention, and
help".
266.
Dong X, Simon M, Mendes de Leon C, Fulmer T, Beck T, Hebert L, et
al. (2009) Elder self-neglect and abuse and mortality risk in a communitydwelling population. Journal of the American Medical Association, 302(5),517526.
267.
Comijs, H.C., Penninx, B.W.J.H., Knipscheer, K.P.M., & van Tilburg, W.
(1999). Psychological distress in victims of elder mistreatment: The effects of
social support and coping. Journal of Gerontology, 54B(4), 240-245.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 118
268.
Bitondo Dyer C., Pavlik V. N., Murphy K. P., and Hyman D. J. (2000).
The high prevalence of depression and dementia in elder abuse or neglect.
Journal of the American Geriatrics Society. 48, 205-208.
269.
National Committee for the Prevention of Elder Abuse, Virginia Tech,
Metlife Mature Market Institute (2011). The metlife study of elder financial
abuse: Crimes of occasion, desperation and predation against america's
elders. Westport, CT: Authors
270.
Dong, X. (2005). "Medical Implications of Elder Abuse and Neglect."
Clinics in Geriatric Medicine. 21:293-313.
271.
Naila Francis - Dr. Lauren Jodi Van Scoy Poses Critical Questions About
Death in First Book - PhillyBlurbs.com - The Intelligencer, July 10/11, 2011.
272.
Julie Appleby. Debate surrounds end-of-life health care costs. USA
Today, July 10/11, 2011.
273.
Hoover, D. R.; Crystal, S.; Kumar, R.; Sambamoorthi, U.; Cantor, J. C.
(2002). "Medical Expenditures during the Last Year of Life: Findings from the
1992–1996 Medicare Current Beneficiary Survey". Health Services
Research 37 (6): 1625–1642. doi:10.1111/14756773.01113. PMC 1464043.PMID 12546289.
274.
Lo B: Overview of ethical guidelines. In Resolving ethical dilemmas: a
guide for clinicians 2nd edition. Lippincott Williams and Wilkins; 2000:11-18.
275.
Latimer EJ: Ethical care at the end-of-life. CMAJ 1998, 158(13):17411747.
276.
Simonds AK: Ethics and decision making in end stage lung disease.
Thorax 2003, 58(3):272-277.
277.
Yeolekar ME, Mehta S, Yeolekar A: End-of-life care: issues and
challenges. J Postgrad Med 2008, 54(3):173-175.
278.
Heyland DK, Cook DJ, Rocker GM, Dodek PM, Kutsogiannis DJ, Peters
S, Tranmer JE, O-Callaghan CJ: Decision-making in the ICU: perspectives of
the substitute decision-maker. Intensive Care Med 2003, 29:75-82.
279.
Heyland DK, Tranmer J, O'Callaghan CJ, Gafni A: The seriously ill
hospitalized patient: preferred role in end-of-life decision making? J Crit Care
2003, 18(1):3-10.
280.
Bomba PA: Enabling the transition to hospice through effective
palliative care. Case Manager 2005, 16(1):48-52.
281.
Ahern P: End-of-life- not end of story. Mod Healthcare 2007,
37(25):24.
282.
Herbst L: Hospice care at the end-of-life. Clin Geriatr Med 2004,
20(4):753-765.
283.
Wiese CHR, Vossen-Wellmann A, Morgenthal HC, Popov AF, Frag BM,
Hanekop GG: Emergency calls and need for emergency care in patients
looked after by a palliative care team: retrospective interview study with
bereaved relatives. BMC PalliatCare 2008, 7(11):
284.
Mercadante S, Intravaia G, Villari P, Ferrera P, Fabrizio D, Casuccio A:
Controlled sedation for refractory symptoms in dying patients. J Pain
Symptom Manage 2008 in press.
285.
Castellano G: The criminalization of treating end-of-life patients with
risky pain medication and the role of the extreme emergency situation.
Fordham Law Rev 2007, 76(1):203-34.
286.
Griffith R: Controlled drugs and the principle of double effect. Br J
Community Nurs 2006, 11(8):352-357.
287.
Gallagher A, Wainwright P: Terminal sedation: promoting ethical
nursing practice. Nurs Stand 2007, 21(34):42-6.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 119
288.
Boyle J: Medical ethics and double effect: the case of terminal
sedation. Theor Med Bioethic 2004, 25(1):51-60.
289.
Lo B, Rubenfeld G: Palliative sedation in dying patients: "we turn to it
when everything else hasn't worked". JAMA 2005, 294(14):1810-6.
290.
Kagawa-Singer M, Blackhall LJ: Negotiating cross-cultural issues at the
end-of-life: "You got to go where he lives". JAMA 2001, 286(23):2993-3001.
291.
Blackhall LH, Murphy ST, Frank G, Michel V, Azen S: Ethnicity and
attitudes toward patient autonomy. JAMA 1995, 274:820-825.
292.
Newman Giger J, Davidhizar RE, Fordham P: Multi-cultural and multiethnic considerations and advance directives: developing cultural
competency. Journal of Cultural Diversity 2006, 13(1):3-9.
293.
Andersen J: Cultural competence and health care: Japanese, Korean,
and Indian patients in the United States. Journal of Cultural Diversity 2001,
8(4):109-121.
294.
Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O: Defining
cultural competence: a practical framework for addressing racial/ethnic
disparities in health and health care. Public Health Reports 2003, 118:293302.
295.
Searight HR, Gafford J: Cultural diversity at the end-of-life: issues and
guidelines for family physicians. Am Fam Physician2005, 71(3):429-430
296.
Vachon M, Fillion L, Achille M: A conceptual analysis of spirituality at
the end-of-life. J Palliat Med 2009, 12:53-9.
297.
Hakim RB, Teno JM, Harrell FE, Knaus WA, Wenger N, Phillips RS,
Lavde P, Califf R, Connors AF, Lynn J: Factors associated with donotresuscitate orders: patients' preferences, prognoses, and physicians'
judgments. Ann Intern Med 1996, 125:284-293.
298.
Rosenfeld KE, Wenger NS, Phillips RS, Connors AF, Dawson NV, Layde
P, Califf RM, Liu H, Lynn J, Ove RK: Factors associated with change in
resuscitation preference of seriously ill patients. The SUPPORT Investigators.
Study to understand prognoses and preferences for outcomes and risks of
treatments. Arch Intern Med 1996, 156:1558-1564.
299.
Miller DL, Jahnigen DW, Gorbien MJ, Simbartl L: Cardiopulmonary
resuscitation: how useful? Attitudes and knowledge of an elderly population.
Arch Intern Med 1992, 152:578-582.
300.
Hamel MB, Lynn J, Teno JM, Covinsky KE, Wu AW, Galanos A,
Desbiens NA, Phillips RS: Age-related differences in care preferences,
treatment decisions, and clinical outcomes of seriously ill hospitalized adults:
lessons from SUPPORT. J Am Geriatr Soc 2000, 48:S176-S182.
301.
Marco CA, Schears RM: Societal Preferences regarding
cardiopulmonary resuscitation. Am J Emerg Med 2002, 20:207-211.
302.
Layde PM, Beam CA, Broste SK, Connors AF, Desbiens N, Lynn J,
Phillips RS, Reding D, Teno J, Vidaillet H: Surrogates' predictions of seriously
ill patients' resuscitation preferences. Arch Fam Med 1995, 4:518-523.
303.
Wenger NS, Phillips RS, Teno JM, Ove RK, Dawson NV, Liu H, Califf R,
Lavde P, Hakim R, Lynn J: Physician understanding of patient resuscitation
preferences: insights and clinical implications. J Am Geriatr Soc 2000,
48:S44-51.
304.
Golin CE, Wenger NS, Liu H, Dawson NV, Teno JM, Desbiens NA, Lynn
J, Oye RK, Phillips RS: A prospective study of patient-physician
communication about resuscitation. J Am Geriatr Soc 2000, 48:S52-60.
305.
Fischer GS, Tulsky JA, Rose MR, Siminoff LA, Arnold RM: Patient
knowledge and physician predictions of treatment preferences after discussion
of advance directives. J Gen Intern Med 1998, 13:447-454.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 120
306.
Beach MC, Morrison RS: The effect of do-not-resuscitate orders on
physician decision-making. J Am Geriatr Soc 2002, 50:2057-2061.
307.
Patient Self-Determination Act- Omnibus Budget Reconciliation Act of
1990. Pub L No. 101–508.
308.
Jacobson JA, White BE, Battin MP, Francis LP, Green DJ, Kasworm ES:
Patients' understanding and use of advance directives. West J Med 1994,
160:232-236.
309.
Silviera M, DiPiero A, Gerrity M, Feudtner C: Patients' knowledge of
options at the end-of-life: ignorance in the face of death. JAMA 2000,
284(19):2483-2488.
310.
Teno J, Lynn J, Wenger N, Phillips RS, Murphy DP, Connors AF,
Desbiens N, Fulkerson W, Bellamy P, Knaus WA: Advance directives for
seriously ill hospitalized patients: effectiveness with the patient selfdetermination act and the SUPPORT intervention. SUPPORT Investigators.
Study to Understand Prognoses and Preferences for Outcomes and Risks of
Treatment. J Am Geriatr Soc 1997, 45(4):500-507.
311.
Taylor DM, Ugoni AM, Cameron PA, McNeil JJ: Advance directives and
emergency department patients: ownership rates and perceptions of use.
Intern Med J 2003, 33(12):586-592.
312.
Upadya A, Visvanathan M, Thorevska N, Amoateng-Adjepong Y:
Patient, physician, and family member understanding of living wills. Am J
Respir Crit Care Med 2002, 166:1430-1435
313.
The SUPPORT Principle Investigators: A controlled trial to improve care
for seriously ill hospitalized patients. JAMA 1995, 274:1591-98.
314.
Llovera I, Mandel FS, Ryan JG, Ward MF, Sama A: Are emergency
department patients thinking about advance directives? Acad Emerg Med
1997, 4:976-980.
315.
Hanson LC, Tulsky J, Danis M: Can clinical interventions change care at
the end-of-life? Ann Intern Med 1997, 126:381-388.
316.
Robinson R, Eagen MK, Price TJ: Innovative solutions: taking advance
directives to the community. Dimens Crit Care Nurs 2008, 27:154-156.
317.
Llovera I, Ward MF, Ryan JG, Lesser M, Sama AE, Crough D, Mansfield
M, Lesser LI: Why don't emergency department patients have advance
directives? Acad Emerg Med 1999, 6:1054-1060.
318.
Iserson KV: Prehospital advance directives -a better way. J Emerg
Med 2002, 23:419-20.
319.
Morrison LJ, Morrison RS: Palliative care and pain management. Med
Clin N Am 2006, 90(5):983-1004.
320.
Von Gunten CF, Ferris FD, Emanuel LL: Ensuring competency in endof-life care: communication and relational skills. JAMA 2000, 284(23):30513057.
321.
O'Mara K: Communication and conflict resolution in emergency
medicine. Emerg Med Clin North Am 1999, 17(2):451-459.
322.
Buckman R: How to break bad news: a guide for health care
professions Baltimore, MD: Johns Hopkins University Press; 1992.
323.
Hobgood C, Harward D, Newton K, Davis W: The educational
intervention "GRIEV_ING" improves the death notification skills of residents.
Acad Emerg Med 2005, 12(4):296-301.
324.
Moskop JC: Informed consent and refusal of treatment: challenges for
emergency physicians. Emerg Med Clin N Am 2006, 24:605-618.
325.
Miller SS, Marin DB: Assessing capacity. Emerg Med Clin N Am 2000,
18(2):233-242.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 121
326.
Sorger BM, Rosenfeld B, Pessin H, Timm AK, Cimino J: Decision
making capacity in elderly, terminally ill patients with cancer. Behav Sci Law
2007, 25:393-404.
327.
Teno J, Clarridge B, et al. Family perspectives on end-of-life care at
the last place of care. JAMA. 2004;291:88–93.
328.
Casarett D, Quill T. “I’m not ready for hospice”: strategies for timely
and effective hospice discussions” Ann Intern Med. 2007;146:443–9.
329.
Connor S, Pyenson B, et al. Comparing hospice and non-hospice
patient survival among patients who die within a three-year window. J Pain
Symptom Manage.2007;33:238–46.
330.
Pyenson B, Connor S, et al. Medicare cost in matched hospice and
non-hospice cohorts. J Pain Symptom Manage. 2004;28:200–10.
331.
The University of Texas M. D. Anderson Cancer Center
[http://www.mdanderson.org/patients_public/about_cancer/dis
play.cfm?id=33540A76-72DF-11D4AEBD00508BDCCE3A&method=displayFull]. accessed 3/15/09
332.
University of Washington School of Medicine - Physician-Assisted
Suicide [http://depts.washington.edu/bioethx/topics/ pas.html].
333.
Steinbrook R: Physician-assisted death- from Oregon to Washington
state. N Engl J Med 2008, 359(24):2513-2515.
334.
Mayou R, Hawton K, Feldman E, et al. Psychiatric problems among
medical admissions. Int J Psychiatry Med 1991;21:71-84.
335.
Guthrie E. Emotional disorder in chronic illness: psychotherapeutic 4
Blazer DG, Kessler RC, McGonagle KA, et al. The prevalence and distribution
of major depression in a national community sample: the national comorbidity
survey. Am J Psychiatry 1994;151:979-986.
336.
McDaniel JS, Musselman DL, Porter MR, et al. Depression in patients
with cancer: diagnosis, biology and treatment. Arch Gen Psychiatry
1995;52:89-99.
337.
Blazer DG, Kessler RC, McGonagle KA, et al. The prevalence and
distribution of major depression in a national community sample: the national
comorbidity survey. Am J Psychiatry 1994;151:979-986.
338.
Powell T. Consultation-liaison psychiatry and clinical ethics.
Psychosomatics 1997;38:321-326.
339.
Breitbart W. Identifying patients at risk for and treatment of major
psychiatric complications of cancer. Support Care Cancer 1995;3:45-60.
340.
Draper B, Anstey K. Psychosocial stressors, physical illness and the
spectrum of depression in elderly inpatients. Aust N Z J Psychiatry
1996;30:567-572.
341.
Koenig HG, Kuchibhatla M. Use of health services by hospitalized
medically ill depressed elderly patients. Am J Psychiatry 1998;155:871-877.
342.
Harris EC, Barraclough BM. Suicide as an outcome for mental
disorders: a meta-analysis. Br J Psychiatry 1997;170:205-223.
343.
Saravay SM. Psychiatric interventions in the medically ill: outcomes
and effectiveness research. Psychiatr Clin North Am 1996;19:467-480.
344.
Morris PLP, Robinson RG, Samuels J. Depression, introversion and
mortality following stroke. Aust N Z J Psychiatry 1993;27:443-449.
345.
Parickh RM, Robinson RG, Lipsey JR, et al. The impact of post-stroke
depression on recovery in activities of daily living over two year follow-up.
Arch Neurol 1990;47:785-789.
346.
Glassman AH, Shapiro PA. Depression and the course of coronary
artery disease. Am J Psychiatry 1998;55:4-11.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 122
347.
Beliles K, Stoudemire A. Psychopharmacologic treatment of depression
in the medically ill. Psychosomatics 1998;39(suppl):2S-19S.
348.
Chaturvedi SK, Maguire P, Hopwood P. Antidepressant medications in
cancer patients. Psychooncology 1994;3:57-60.
349.
Schwartz CE, Steinmuller RI, Dubler N. The medical psychiatrist as
physician for the chronically mentally ill. Gen Hosp Psychiatry 1998;20:52-61.
350.
Pratt LA, Ford LE, Crum RM, et al. Depression, psychotropic
medication, and risk of myocardial infarction: prospective data from the
Baltimore ECA follow-up. Circulation 1996;94:3123-3129.
351.
Michelson D, Stratakis C, Hill L, et al. Bone mineral density in women
with depression. N Engl J Med 1996;335:1176-1181.
352.
Smith GC. From consultation-liaison psychiatry to psychosocial
advocacy: maintaining psychiatry’s scope. Aust N Z J Psychiatry
1998;32:753-761.
353.
Mayou R, Sharpe M. Patients whom doctors find difficult to help.
Psychosomatics 1995;36:323-325.
354.
Salmon P, Peters S, Stanley I. Patients’ perceptions of medical
explanations for somatisation disorders: qualitative analysis. BMJ
1999;318:372-376.
355.
Cope H, David A, Pelosi A, et al. Predictors of chronic “postviral”
fatigue. Lancet 1994;344:864-868.
356.
Rabkin JG, Remien R, Katoff L, et al. Resilience in adversity among
long-term survivors of AIDS. Hosp Community Psychiatry 1993;44:162-167.
357.
Dow KH, Ferrell BR, Leigh S, et al. An evaluation of the quality of life
among long-term survivors of breast cancer. Breast Cancer Res Treat
1996;39:261-273.
358.
Burstein HJ, Gelber S, Guadagnoli E, et al. Use of alternative medicine
by women with early stage breast cancer. N Engl J Med 1999;340:1733-1739.
359.
Holland J. Use of alternative medicine—a marker for distress
[editorial]? N Engl J Med 1999;340:1758-1759.
360.
Cohen LM, McCue JD, Germain M, et al. Denying the dying: advance
directives and dialysis discontinuation. Psychosomatics 1997;38:27-34.
361.
Slevin ML, Stubbs L, Plant HJ, et al. Attitudes to chemotherapy:
comparing views of patients with cancer with those of doctors, nurses, and
general public. BMJ 1990;300:1458-1460.
362.
Parker JC, Smarr KL, Buckelew SP, et al. Effects of stress management
on clinical outcomes in rheumatoid arthritis. Arthritis Rheum 1995;38:18071818.
363.
Smyth JM, Stone AA, Kael L. Effects of writing about stressful
experiences on symptom reduction in patients with asthma and rheumatoid
arthritis: a randomized trial. JAMA 1999;281:1304-1309.
364.
Kelly B, Varghese F. The emotional hazards of medical practice. In:
Sanders MR, Mitchell C, Byrne GJA, eds. Medical consultation skills.
Melbourne: Addison-Wesley, 1997:472-488.
365.
Committee on the Future Health Care Workforce for Older Americans,
Board on Health Care Services, INSTITUTE OF MEDICINE OF THE NATIONAL
ACADEMIES. "RETOOLING FOR AN AGING AMERICA: BUILDING THE HEALTH
CARE WORKFORCE". THE NATIONAL ACADEMIES PRESS.
366.
National Alliance for Care giving and the United Hospital Fund (2005),
(presentation), National Alliance for Care giving and the United Hospital Fund
367.
U.S. Department of Health and Human Services (2001),
(presentation), Rockville: Agency for Healthcare Research and Quality
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 123
368.
George LK, Gwyther LP. Caregiver well-being: a multidimensional
examination of family caregivers of demented adults. Gerontologist.
1986;26:253–9.
369.
Thompson TL, Robinson JD, Beisecker AE. The older patient-physician
interaction. In: Nussbaum JF, Coupland J, eds. Handbook of Communication
and Aging Research, 2nd ed. Mahwah, NJ: Lawrence Erlbaum Assoc; 2004.
370.
Halter JB. The challenge of communicating health information to
elderly patients: a view from geriatric medicine. In: Park DC, Morrell RW,
Shifren K, eds. Processing of Medical Information in Aging Patients: Cognitive
and Human Factors Perspectives. Mahwah, NJ: Lawrence Erlbaum Assoc;
1999.
371.
Ostuni E, Mohl GR. Communication with elderly patients. Dent Econ.
1994;84(3):27–32.
372.
Wiebe C. What did you say? Tips for talking more clearly to
patients. ACP Observer. December 1997.
373.
Baker SK. Thirty ways to make your practice more patient-friendly. In:
Woods D, ed.Communication for Doctors: How to Improve Patient Care and
Minimize Legal Risk. Oxford: Radcliffe; 2004.
374.
Dreher BB. Communication Skills for Working With Elders. New York:
Springer; 1987.
375.
Osborne H. Communicating with clients in person and over the
phone. Issue Brief Cent Medicare Educ. 2003;4(8):1–8.
376.
Breisch SL. Elderly patients need special connection. Am Acad
Orthop Surg Bull. February 2001;49(1).
377.
Nussbaum JF, Pecchioni LL, Robinson JD, Thompson T. Communication
and Aging. Mahwah, NJ: Lawrence Erlbaum Assoc; 2000.
378.
Meryn S. Improving doctor-patient communication: not an option but
a necessity. BMJ. 1998;316(7149):1922.
379.
Schopick JE. Hippocrates was right: treat people, not their disease. In:
Woods D, ed.Communication for Doctors: How to Improve Patient Care and
Minimize Legal Risk. Oxford: Radcliffe; 2004:12–13.
380.
National Council on Patient Information and Education. Eight easy
ways to make the medicine go down. In: Woods D, ed. Communication for
Doctors: How to Improve Patient Care and Minimize Legal Risk. Oxford:
Radcliffe; 2004:6–7.
381.
Woods D. Seven ways to build trust with your patients on their first
visit. In: Woods D, ed.Communication for Doctors: How to Improve Patient
Care and Minimize Legal Risk. Oxford: Radcliffe; 2004: 23–24.
382.
Lewis A. Non-compliance: a $100 billion problem. The Remington
Report 1997;5(4):14-5.
383.
Col N, Fanale JE, Kronholm P. The role of medication noncompliance
and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med
1990;150:841-5.
384.
Colt HG, Shapiro AP. Drug-induced illness as a cause for admission to
a community hospital. J Am Geriatr Soc 1989;37:323-6.
385.
Hallas J, Harvald B, Gram LF, et al. Drug related hospital admissions:
the role of definitions and intensity of data collection, and the possibility of
prevention. J Intern Med1990;228(2):83-90.
386.
Segal E, Tamir A, Ish-Shalom S. Compliance of osteoporotic patients
with different treatment regimens. Isr Med Assoc J 2003;5(12):859-62.
387.
Kuo YF, Raji MA, Markides KS, et al. Inconsistent use of diabetes
medications, diabetes complications, and mortality in older Mexican
Americans over a 7-year period: data from the Hispanic established
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 124
population for the epidemiologic study of the elderly. Diabetes Care
2003;26(11):3054-60.
388.
Raji MA, Kuo YF, Salazar JA, et al. Ethnic differences in
antihypertensive medication use in the elderly. Ann Pharmacother
2004;38(2):209-14. Epub 2003 Dec 15.
389.
Dunbar-Jacob J, Bohachick P, Mortimer MK, et al. Medication
adherence in persons with cardiovascular disease. J Cardiovasc Nurs
2003;18(3):209-18.
390.
DiMatteo MR. Social support and patient adherence to medical
treatment: a meta-analysis. Health Psychol 2004;23(2):207-18.
391.
Kilbourne AM, Reynolds CF, Good CB, et al. How does depression
influence diabetes medication adherence in older patients? Am J Geriatr
Psychiatry 2005;13(3):202-10.
392.
Maddigan SL, Farris KB, Keating N, et al. Predictors of older adults'
capacity for medication management in a self-medication program: a
retrospective chart review. J Aging Health 2003;15:332-52.
393.
McKellar JD, Humphreys K, Piette JD. Depression increases diabetes
symptoms by complicating patients' self-care adherence. Diabetes Educ
2004;30:485-92.
394.
Park H, Hong Y, Lee H, et al. Individuals with type 2 diabetes and
depressive symptoms exhibited lower adherence with self-care. J Clin
Epidemiol 2004;57:978-84.
395.
Thomas EJ, Brennan TA. Incidence and types of preventable adverse
events in elderly patients: population based review of medical records. BMJ
2000;320(7237):741-4.
396.
Spiers MV, Kutzik DM, Lamar M. Variation in medication understanding
among the elderly. Am J Health Syst Pharm 2004;61:373-80.
397.
Okuno J, Yanagi H, Tomura S. Is cognitive impairment a risk factor for
poor compliance among Japanese elderly in the community? Eur J Clin
Pharmacol 2001;57(8):589-94.
398.
Kiortsis DN, Giral P, Bruckert E, et al. Factors associated with low
compliance with lipid-lowering drugs in hyperlipidemic patients. J Clin Pharm
Ther 2000;25(6):445-51.
399.
Coleman EA, Smith JD, Raha D, et al. Posthospital medication
discrepancies: prevalence and contributing factors. Arch Intern Med
2005;165(16):1842-7.
400.
Gonski PN, Stathers GM, Freiman JS, et al. A critical review of
admission and discharge medications in an elderly Australian population.
Drugs Aging 1993;3:358-62. 51. McKinley BT, Mulhall BP, Jackson JL.
Perceived versus actual medication regimens among internal medicine
patients. Mil Med 2004;169(6):451-4.
401.
Moore C, Wisnivesky J, Williams S, et al. Medical errors related to
discontinuity of care from an inpatient to an outpatient setting. J Gen Intern
Med 2003;18(8):646-51.
402.
Meredith S, Feldman PH, Frey D, et al. Possible medication errors in
home healthcare patients. J Am Geriatr Soc 2001;49:719-24.
403.
Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate
medication use in the community-dwelling elderly: findings from the 1996
Medical Expenditure Panel Survey. JAMA 2001;286(22): 2823-9.
404.
Zhan C, Correa-de-Araujo R, Bierman AS, et al. Suboptimal prescribing
in elderly outpatients: potentially harmful drug-drug and drug-disease
combinations. J Am Geriatr Soc 2005;53(2):262-7.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 125
405.
Ellenbecker CH, Frazier SC, Verney S. Nurses' observations and
experiences of problems and adverse effects of medication management in
home care. Geriatric Nursing 2004;25(3):164-70.
406.
Hill-Briggs F, Gary TL, Bone LR, et al. Medication adherence and
diabetes control in urban African Americans with type 2 diabetes. Health
Psychol 2005;24(4):349-57.
407.
Ogedegbe G, Harrison M, Robbins L, et al. Barriers and facilitators of
medication adherence in hypertensive African Americans: a qualitative study.
Ethn Dis 2004;14(1):3-12.
408.
Jackson JE, Doescher MP, Saver BG, et al. Prescription drug coverage,
health, and medication acquisition among seniors with one or more chronic
conditions. Med Care 2004;42:1056-65.
409.
Yilmaz MB, Pinar M, Naharci I, et al. Being well-informed about statin
is associated with continuous adherence and reaching targets. Cardiovasc
Drugs Ther 2005;19(6):437-40.
410.
Atkin PA, Finnegan TP, Ogle SJ, et al. Functional ability of patients to
manage medication packaging: a survey of geriatric inpatients. Age Aging
1994;23(2):113-6.
411.
Jeste SD, Patterson TL, Palmer BW, et al. Cognitive predictors of
medication adherence among middle-aged and older outpatients with
schizophrenia. Schizophr Res 2003;63(1-2):49-58.
412.
Esposito L. The effects of medication education on adherence to
medication regimens in an elderly population. J Adv Nurs1995;21:935-43.
413.
168. Park D, Morrell RW, Frieske D, et al. Medication adherence
behaviors in older adults: effects of external cognitive supports. Psychol
Aging1992;7(2):252-6.
414.
Barber N, Parsons J, Clifford S, et al. Patients' problems with new
medication for chronic conditions. Qual Saf Health Care 2004;13(3):172-5.
415.
Beers MH, Baran RW, Frenia K. Drugs and the elderly, Part 1: The
problems facing managed care.Am J Manag Care 2000;6:1313-20.
416.
Bergman-Evans B. Improving medication management for older adult
clients. Iowa City, IA: University of Iowa Gerontological Nursing Interventions
Research Center;2004.
417.
Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for
potentially inappropriate medication use in older adults: results of a U.S.
consensus panel of experts. Arch Intern Med 2003;163(22):2716-24.
418.
Ellenbecker CH, Frazier SC, Verney S. Nurses' observations and
experiences of problems and adverse effects of medication management in
home care. Geriatric Nursing 2004;25(3):164-70.
419.
Hill-Briggs F, Gary TL, Bone LR, et al. Medication adherence and
diabetes control in urban African Americans with type 2 diabetes. Health
Psychol 2005;24(4):349-57.
420.
Ogedegbe G, Harrison M, Robbins L, et al. Barriers and facilitators of
medication adherence in hypertensive African Americans: a qualitative study.
Ethn Dis 2004;14(1):3-12.
421.
Jonsson P, McNamee M, Campion E. The “Do not resuscitate” order: a
profile of its changing use. Archives of Internal Medicine 1988;148:2373–5.
422.
Somogyi-Zalud E, Zhong Z, Lynn J, et al. Elderly persons’ last six
months of life: findings from the hospitalized elderly longitudinal project.
Journal of the American Geriatrics Society 2000;48(5 suppl);131–9S.
423.
Terry M, Sweig S. Prevalence of advance directives and do-not
resuscitate orders in community facilities. Archives of Family Medicine
1994;3:141–5.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 126
424.
Berlowitz D, Wilking S, Moskowitz M. Do-not-resuscitate orders at a
chronic care hospital. Journal of the American Geriatrics Society
1991;39:472–6.
425.
Meyers R, Lurie N, Breitbucher R, et al. Do-not-resuscitate orders in an
extended-care study group. Journal of the American Geriatrics Society
1990;38:1011–15.
426.
Teno J, Braco K, Mor V, et al. Changes in advance care planning in
nursing homes before and after the patient self-determination act: report of a
10-state survey. Journal of the American Geriatrics Society 1997;45:939–44.
427.
Krumholz H, Phillips R, Hamel M, et al. Resuscitation preferences
among patients with severe congestive heart failure. Circulation 1998;21:77–
81.
428.
Stolman C, Gregory J, Dunn D. Evaluation of the do not resuscitate
orders at a community hospital. Archives of Internal Medicine
1989;149:1851–6.
429.
Fader A, Gambert S, Nash M. Implementing a “do-not-resuscitate”
policy in a nursing home. Journal of the American Geriatrics Society
1989;37:544–8.
430.
Miller D, Jahnigen D, Gorbien M. Cardiopulmonary resuscitation: how
useful? Archives of Internal Medicine 1992;152:578–82.
431.
Godkin M, Toth E. Cardiopulmonary resuscitation and older adults’
expectations. Gerontologist 1994;34:797–802.
432.
Lo B, McLeod G, Saika G. Patient attitudes to discussing life-sustaining
treatment. Archives of Internal Medicine 1986;146:1613–15.
433.
Layton R, Adelman H, Wallach P, et al. Discussions about the use of
life-sustaining treatments: a literature review of physicians’ and patients’
attitudes and practices. Journal of Clinical Ethics 1994;5:195–203.
434.
Hamel MB, Lynn J, Teno JM, et al. Age-related differences in care
preferences, treatment decisions, and clinical outcomes of seriously ill
hospitalized adults: lessons from SUPPORT. Journal of the American Geriatrics
Society 2000;48:176-82S
435.
Schoenwetter R, Walker R, Solomon M, et al. Life values, resuscitation
preferences, and the applicability of living wills in an older population. Journal
of the American Geriatrics Society 1996;44:954–58.
436.
Romero L, Lindeman R, Koehler K, et al. Influence of ethnicity on
advance directives and end-of life decisions. Journal of the American Medical
Association 1997;277:298.
437.
Danis M, Mutran E, Fitzsimmons J, et al. Attitudes associated with the
desire for life-sustaining treatments in elderly patients. Clinical Research
1991;39:624A.
438.
Gunasekera N, Tiller D, Clements L, et al. Elderly patients’ views on
cardiopulmonary resuscitation. Age and Aging 1986;15:364–8.
439.
Pulchalski C, Zhong Z, Jacobs M, et al. Patients want their family and
physician to make resuscitation decisions for them: observations from
SUPPORT and HELP. Journal of the American Geriatrics Society 2000;48suppl
5):84–90S.
440.
Zweibel N, Cassel C. Treatment choices at the end of life: a
comparison of decisions by old patients and their physician-selected proxies.
Gerontologist 1989;29:615–21.
441.
MiIler D. Factors influencing physicians in recommending in-hospital
resuscitation. Archives of Internal Medicine 1993;153:199–203.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 127
442.
Schneidermann L, Kaplan R, Pearlman R, et al. Do physicians’ own
preferences for life-sustaining treatment influence their perceptions of
patients’ preferences? Journal of Clinical Ethics 1993;4:28–33.
443.
Ebell M, Doukas D, Smith M. The do-not-resuscitate order: a
comparison of physician and patient preferences and decision-making.
American Journal of Medicine 1991;91:255–60.
444.
Purvis R, Law E, Still J, et al. Nurses’ attitudes toward do-notresuscitate orders. Journal of Burn Care Rehabilitation 1998;19:538–41.
445.
Granja C, Teixeira-Pinto A, Costa-Pereira A. Attitudes toward do not
resuscitate decisions: differences among health care professionals in a
Portuguese Hospital. Intensive Care Medicine 2001;27:555–8.
446.
Dickenson D. Are medical ethics out of touch? Practitioner attitudes in
the US and UK towards decisions at the end of life. Journal of Clinical Ethics
2000;26:254–60.
447.
Seferian EG, Afessa B. Demographic and clinical variation of adult
intensive care unit utilization from a geographically defined population. Crit
Care Med. 2006; 34(8):2113-9.
448.
Burack OR, Weiner AS, Reinhardt JP, Annunziato RA., What matters
most to nursing home elders: quality of life in the nursing home. J Am Med
Dir Assoc. 2012;13(1):48-53.
449.
Dickens AP, Richards SH, Greaves CJ, Campbell JL., Interventions
targeting social isolation in older people: a systematic review. BMC Public
Health. 2011;11:647.
450.
Skingley A. Older people, isolation and loneliness: implications for
community nursing. 2013;18(2):84-90.
451.
Gopinath B, Rochtchina E, Anstey KJ, Mitchell P. Living alone and risk
of mortality in older, community-dwelling adults., JAMA Intern Med. 2013,
25;173(4):320-1.
452.
Salsman JM, Butt Z, Pilkonis PA, Cyranowski JM, Zill N, Hendrie HC,
Kupst MJ, Kelly MA, Bode RK, Choi SW, Lai JS, Griffith JW, Stoney CM,
Brouwers P, Knox SS, Cella D. Emotion assessment using the NIH Toolbox.,
Neurology. 2013;80(11 Suppl 3):S76-86.
453.
Reuben DB, Magasi S, McCreath HE, Bohannon RW, Wang YC, Bubela
DJ, Rymer WZ, Beaumont J, Rine RM, Lai JS, Gershon RC. Motor assessment
using the NIH Toolbox. Neurology. 2013;80(11 Suppl 3):S65-75.
454.
Weintraub S, Dikmen SS, Heaton RK, Tulsky DS, Zelazo PD, Bauer PJ,
Carlozzi NE, Slotkin J, Blitz D, Wallner-Allen K, Fox NA, Beaumont JL, Mungas
D, Nowinski CJ, Richler J, Deocampo JA, Anderson JE, Manly JJ, Borosh B,
Havlik R, Conway K, Edwards E, Freund L, King JW, Moy C, Witt E, Gershon
RC. Cognition assessment using the NIH Toolbox. Neurology. 2013 Mar
12;80(11 Suppl 3):S54-64.
455.
Dunn W, Griffith JW, Morrison MT, Tanquary J, Sabata D, Victorson D,
Carey LM, Gershon RC., Neurology. 2013;80(11 Suppl 3):S41-4.
456.
Hodes RJ, Insel TR, Landis SC; NIH Blueprint for Neuroscience
Research. e NIH toolbox: setting a standard for biomedical research.
Neurology. 2013 Mar 12;80 (11 Suppl 3):S1.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 128