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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. IntroductionII. Living Environments

A. HospitalsB. Skilled NursingC. Residential CareD. Assisted Living

III. Common Health IssuesA. Malnutrition B. Aspiration/ChokingC. FallsD. Memory disordersE. DepressionF. Sexual healthG. Alcohol Abuse

IV. Elder AbuseA. Risk factorsB. SignsC. Reporting

V. End of LifeA. HospiceB. Euthanasia

VI. Developing Treatment PlansA. Frequency of visitsB. Medication managementC. Geropsychology pharmacology/Cognitive ManagementD. New/future therapies

VII. Cultural IssuesA. CommunicationB. Adherence to treatmentC. End of Life DecisionsD. Family support

VIII. Family MembersA. Power of AttorneyB. DNR

IX. Conclusion


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 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.

Help with activities of daily living

Help with additional services

Help with care needs

Range of costs


Community-Based 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 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].


Temporary long term care (Required for short term care over few weeks or months)

Ongoing long term care (Required for care over several months or years)

Rehabilitation from a hospital stay

Recovery from illness Recovery from injury Recovery from surgery Terminal medical condition

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 CaregiversHome-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. In-home 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 CaregiversTrained 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 CareThese 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 ServicesHomemaker 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.


Friendly Visitor/Companion ServicesFriendly 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 SystemsThese 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 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 Residents

ElementStage of disease or frailtyEarly Middle Late Bereavement

Goals of care Discuss diagnosis and prognosis; likely course of disease; disease-modifying therapies; resident's goals, hopes, and expectations for treatment

Provide resident education materials regarding diagnosis, palliative care resources

Discuss resident's understanding of prognosis, benefit versus burden of therapies

Reevaluate goals of care and resident expectations Prepare resident for shift in goals Encourage focus on important tasks, relationships, financial and legal issues

Discuss resident's understanding of diagnosis, disease course, and prognosis; appropriateness of disease-modifying treatments; goals of care and any necessary shifts

Assist resident in planning for a peaceful deathEncourage completion of important tasks

Screen surviving loved ones for complicated bereavement

Review course of care

Address questions and concerns

Programmatic support

Recommend initiation of visiting nurse, home care, case management, applicable home modifications

Recommend initiation of visiting nurse, home care

Consider palliative care (home or hospital), hospice, subacute rehabilitation, case management,

Recommend initiation of palliative care (home or hospital), case management, hospice, PACE

Consider nursing home with

Discuss hospice post bereavement services, mental health referral, support groups


ElementStage of disease or frailtyEarly Middle Late BereavementReview prognostic factors for resident's condition(s), relevant clinical practice guidelines

PACE hospice/palliative care services if there is substantial caregiver burden

Financial and legal planning

Recommend professional assistance with financial planning, long-term care, future insurance needs; legal counsel with expertise in health care issues; protection or transfer of financial assets

Reassess adequacy of financial, medical, home care, and family support; long-term care planning

Consider hospice referral, Medicaid eligibility assessment

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

Family support

Inform resident and family about support groups; ask about practical support needs; listen to concerns; encourage home modifications to reduce caregiver burden

Provide resident education materials regarding diagnosis, as well as general caregiver tasks and

Recommend support/counseling for caregivers; respite care; caregiver visit with his or her personal physician; help from family and friends

Discuss role and benefits of hospice care

Provide dialogue for caregiver concerns and needs; information on practical resources, stress, depression, and adequacy of care

Advise remote family and friends to visit the resident

Address caregiver need for support groups, counseling, personal health care, respite services

Send bereavement card, contact family, attend funeral

Listen to concerns, maintain contact


ElementStage of disease or frailtyEarly Middle Late Bereavementsupport

Cultural support

Understand acculturation, traditions, health beliefs

Understand approaches to medical decision making, issues of disclosure and consent

Address advance directives, end-of-life care planning, care intensity

Recognize specific cultural practices of surviving family members and caregivers

Spiritual support

Observe for spiritual themes or life stories that are sources of distress or support

Explore spiritual issues to develop a deeper sense of healing

Assist resident with resolving conflicts, receiving forgiveness, and grieving

Assist surviving loved ones with finding meaning, hope, comfort, and inner peace

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 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

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 HospiceCommon 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


Patterns of development of home-based long-term care services at different stages of economic development

Lowest-income economies

Almost all care is informal

Direct care is informal

Largely voluntary community workers (payment in kind), some training

No personal care, or home-making, 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 home-making 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 home-making and less clinical care

Professional staff involved in more direct home care

Emergence of some social-system-based home care

Growing institutional care

High-income economies

More pressure on availability of informal care

Few community health workers

Specialized personal care and home-making workers with no clinical or community development roles

Varying professional training for these workers and concern for over-professionalization

Professional home care highly developed

Institutional care of major importance

Segregated social and health-based home-care systems


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 co-morbidities, 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 ElderlyAn 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 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 SarcopeniaAnorexia + ++ −Weight loss + ++ +/−Fat loss ++ ++ 0Muscle 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.

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 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 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.


Common single nutrient deficiency diseases

DiseaseDeficient nutrient Clinical presentations

PellagraNiacin (Vit B3) Dermatitis, diarrhea or constipation and dementia

BeriberiThiamine (Vit B1)

Dry: Parasthenia, footdrop, loss of reflexes Wet: Edema, dyspnea, heart failure

Wernicke’s syndrome

Thiamine (Vit B1) Confusion, sixth nerve palsy, coma

Scurvy Vitamin C Petechiae, bleedingXeropthalmia Vitamin A Keratitis, blindness

Effects of protein energy malnutritionDeathPressure ulcersHip fractureFallsWeaknessFatigueAnemiaEdemaCognitive abnormalitiesInfectionsImmune dysfunctionThymic atrophyDecreased delayed hypersensitivityDecreased helper T cells (CD4+)Decreased lymphocyte response to mitogensDecreased response to immunizations


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 IndexClassification BMI(kg/m2)Underweight <18.5Normal 18.5–24.9Overweight 25.0–29.9Obesity Class

IIIIII

30.0–34.935.0-39.9

>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 HeightAGE (years)

6–18 19–60 >60MENWhite S = 40.54 + (2.22

KH)S = 71.85 + (1.88

KH)S = 59.01 + (2.08

KH)Black S = 39.60 + (2.18

KH)X = 73.42 + (1.79

KH)S = 95.79 + (1.37

KH)WOMEN White S = 43.21 + (2.14

KH)S = 70.25 + (1.87

KH) – 0.06 A)S = 75.00 + (1.91

KH) – (0.17 A)Black S = 46.59 + (2.02

KH)S = 68.10 + (1.86

KH) – (0.06 A)S = 58.72 + (1.96

KH)

Undernutrition in older adultsThe simplified nutrition assessment questionnaire (SNAQ)


1. My appetite isA. very poor B. poor C. average D. good E. very good

2. When I eatA. 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 tastesA. very bad B. bad D. good E. very good 4. Normally I eatA. 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 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 greater12-14 points: Normal nutritional status 8-11 points: At risk of malnutrition0-7 points: Malnourished

Screening MNAA 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

Ask patient or caregiver or check themedical 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 thanbefore, or only a little less?”

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

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 overweightelderly 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.

C Mobility 0 = bed or chair bound 1 = able to get out of bed / chair but does not go out 2 = goes out

Ask patient / Patient’s medical record /Information from caregiver• “How would you describe your currentmobility?”• “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

D Has suffered psychological stress or acute disease in the past 3 months? 0 = yes 2 = no

Ask patient / Review medical record / Useprofessional judgment• “Have you been stressed recently?”• “Have you been severely ill recently?”

E Neuropsychological problems 0 = severe dementia or depression 1 = mild dementia 2 = no psychological problems

Review patient medical record / Useprofessional judgment / Ask patient,nursing staff or caregiver• “Do you have dementia?”• “Have you had prolonged or severe sadness?”The patient’s caregiver, nursing staff ormedical record can provide informationabout the severity of the patient’sneuropsychological problems (dementia).

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

Determining BMIBMI is used as an indicator of appropriateweight for height (Appendix 1)BMI Formula – US Units• BMI = ( Weight in Pounds / [Height ininches x Height in inches] ) x 703BMI Formula – Metric Units• BMI = ( Weight in Kilograms / [Height in Meters x Height in Meters] )1 Pound = 0.45 Kilograms1 Inch = 2.54 CentimetersBefore determining BMI, record the patient’sweight 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.5. To determine BMI for a patient with anamputation, see Appendix 3.Note: If the BMI cannot be obtained,discontinue use of the full MNA® and usethe MNA®-SF instead. Substitute calfcircumference for BMI on the MNA®-SF.

F2 Calf circumference (CC) in cm 0 = CC less than 31


3 = CC 31 or greaterAdditional InformationG Lives independently (not in a nursing home)?Score 1 = Yes 0 = No

Ask patientThis question refers to the normal livingconditions 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?”

H Takes more than 3 prescription drugs per day?Score 0 = Yes 1 = No

Ask patient / Review patient’s medical recordCheck the patient’s medication record /ask nursing staff / ask doctor / ask patient

I Pressure sores or skin ulcers?Score 0 = Yes 1 = No

Ask patient / Review patient’s medical record• “Do you have bed sores?”Check the patient’s medical record fordocumentation 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.

J How many full meals does the patient eat daily?Score 0 = One meal 1 = Two meals 2 = Three meals

Ask patient / Check food intake recordif 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

K Selected consumption markers for protein intake Select all that apply.• At least one serving of dairy products (milk, cheese, yogurt) per day?Yes No• Two or more servings of legumes or eggsper week?Yes No• Meat, fish or poultry every day?Yes No

Ask the patient or nursing staff, or checkthe completed food intake record• “Do you consume any dairy products (aglass of milk / cheese in a sandwich / cupof 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?”


Score 0.0 = if 0 or 1 Yes answer0.5 = if 2 Yes answers1.0 = if 3 Yes answersL Consumes two or more servings of fruits or vegetables per day?Score 0 = No 1 = Yes

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

M How much fluid (water, juice, coffee, tea, milk) is consumed per day?Score 0.0 = Less than 3 cups0.5 = 3 to 5 cups1.0 = More than 5 cups

Ask patient• “How many cups of tea or coffee do younormally 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 7-8oz.

N Mode of Feeding?Score 0 = Unable to eat without assistance 1 = Feeds self with some difficulty 2 = Feeds self without any problems

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 addressed to avoid malnutrition (e.g. dental problems, need for adaptive feeding devices to support eating).

O Self-View of Nutritional StatusScore 0 = Views self as being malnourished1 = Is uncertain of nutritional state2 = Views self as having nonutritional problems

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.

P In comparison with other people of the same age, how does the

Ask patient• “How would you describe your state of


patient consider his/her health status?Score 0.0 = Not as good0.5 = Does not know1.0 = As good2.0 = Better

health compared to others your age?”Then prompt ”Not as good as others ofyour age?”“Not sure?”“As good as others of your age?”“Better?”Again, the answer will depend upon thestate of mind of the person answering thequestion.QMid-arm circumference (MAC) in cmScore 0.0 = MAC less than 210.5 =

Q Mid-arm circumference (MAC) in cmScore 0.0 = MAC less than 210.5 = MAC 21 to 221.0 = MAC 22 or greater

Measure the mid-arm circumference in cm

R Calf circumference (CC) in cmScore 0 = CC less than 311 = CC 31 or greater

Calf circumference should be measured incm

24-30 points-Normal nutritional status17-23.5-At Risk of Malnutrition<17 Malnourished


Undernutrition in older adultsThe ‘Meals on Wheels’ mnemonic for treatable causes of weight loss MedicationsEmotional (depression)Alcoholism, anorexia tardive dyskinesia, abuse (elder)Late life paranoiaSwallowing problemsOral problemsNosocomial infections, no money (poverty)Wandering/dementiaHyperthyroidism, hypercalcemia, hypoadrenalismEnteric problems (malabsorption)Eating problems (e.g. Tremor)Low salt, low cholesterol dietShopping 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.


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 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 deficienciesSystem Sign or symptom Nutrient deficiencySkin Dry scaly skin Zinc/essential fatty acids

Follicular hyperkeratosis Vitamins A, CPetechiae Vitamins C, KPhotosensitive dermatitis NiacinPoor wound healing Zinc, vitamin CScrotal dermatitis Riboflavin

Hair Thin/depigmented ProteinEasily plucked, hair loss Protein, zinc

Nail Transverse depigmentation AlbuminSpooning Iron

Eyes Night blindness Vitamin A, zincConjunctival inflammation RiboflavinKeratomalacia Vitamin A


System Sign or symptom Nutrient deficiencyMouth Bleeding gums Vitamin C, riboflavin

Glositis Niacin, pyridoxine, riboflavinAtrophic papillae IronHypogeusia Zinc, vitamin A

Neck Thyroid gland enlargement IodineParotid gland enlargement Protein

Abdomen Diarrhea Niacin, folate, vitamin B12Hepatomegaly Protein

Extremities Bone tenderness Vitamin DJoint pain Vitamin CMuscle tenderness ThiamineMuscle wasting Protein, selenium vitamin DEdema Protein

Neurological Ataxia Vitamin B12Tetany Calcium, magnesiumParasthesia Thiamine, vitamin B12Ataxia Vitamin B12Dementia Vitamin B12, niacinHyporeflexia Thiamine


Dysphagia

IntroductionDysphagia 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 [109-111].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 functionAging 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 sequelaeThe 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.


Conditions that may contribute to dysphagiaNeurologic 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 strokeDysphagia 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 strokePost-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 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 dementiaDysphagia 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 adultsDysphagia 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 adultsRecent 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 PREVENTIONVideo 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: 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 managementThe 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.


Swallowing managementDysphagia 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 adjustmentsChanges 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 adjustmentsTechnique Performance Intended

outcomeReported benefit

Body posture changesLying down • Lie down/angled

• Reduce impact of gravity during swallow

• Increased hypopharyngeal pressure on bolus

• Increased UES opening

Side lying • Lie down on stronger side (lower)

• Slows bolus• Provides time to adjust/protect airway

• Reduced aspiration

Head posture changesHead extension/chin up

• Raise chin • Propels bolus to back of mouth• Widens oropharynx

• Reduced aspiration• Better bolus transport

Head flexion/chin tuck

• Tucking chin towards the chest

• Improves airway protection

• Reduced aspiration

Head rotation/head turn

• Turning head towards the weaker side

• Reduces residue after swallow• Reduces aspiration

• Less residue [62]• Reduced aspiration

Swallow maneuversSwallow 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 ascertain the potential effect of these maneuvers before initiation of these compensatory strategies.

TYPES OF SWALLOW MANEUVERS


Swallow maneuver

Performance Intended outcome

Reported benefit

Supraglottic swallow

Hold breath, swallow, and then gentle cough

Reduce aspiration and increase movement of the larynx

Reduces aspiration

Super supraglottic swallow

Hold breath, bear down, swallow, and then gentle cough

Effortful swallow. Also called ‘hard’ or ‘forceful’ swallow

Swallow ‘harder’ Increased lingual force on the bolus• Less aspiration and pharyngeal residue

Increased pharyngeal pressure and less residue [67,68]

Mendelssohn maneuver

‘Squeeze’ swallow at apex

Improve swallow coordination

Reduced residue and aspiration [69]

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 dietsSolid foods can be modified to promote safe swallowing and proper nutrition.

LEVELS OF MODIFIED DIETLevel Description Examples of recommended

foodsFour Levels in the National dysphagia dietLevel 1: dysphagia pureed

Homogeneous, cohesive, and pudding like. No chewing required, only bolus control

Smooth, homogenous cooked cerealsPureed: meats, starches (like mashed potatoes), and vegetables with smooth sauces without lumpsPureed/strained soupsPudding, soufflé, yogurt

Level 2: dysphagia mechanically altered

Moist, semi-solid foods, cohesive. Requires chewing ability

Cooked cereals with little textureMoistened ground or cooked meatMoistened, soft, easy to chew canned fruit and vegetables

Level 3: dysphagia advanced

Soft-solids. Require more chewing ability

Well moistened breads, rice, and other starchesCanned or cooked fruit and vegetablesThin sliced, tender meats/poultry

Level 4: regular No modifications, all foods allowed

No restrictions


Adapted from Groher ME, Crary MA. Dysphagia: Clinical management in adults and children. Maryland Heights, MO. Mosby, Elsevier; 2010.

Feeding dependence and targeted feedingThose 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 long-term 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 nutritionAlternate 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 rehabilitationThe 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 exercise-based approaches for swallow rehabilitation are discussed in the table below.

Exercise-based swallow rehabilitation approachesProgram Focus Intended

outcomeReported benefit

Lingual resistance • Strengthening tongue with progressively increasing intensity

• Increased tongue strength• Improved swallow function

• Increased tongue muscle mass• Increased swallow pressure• Reduced aspiration

Shaker/head-lift • Strengthening suprahyoid muscles• Improve elevation of larynx• Increasing upper esophageal sphincter opening

• Improve strength of muscles for greater upper esophageal sphincter opening

• Increased larynx elevation• Increased upper esophageal sphincter opening• Less post-swallow aspiration

EMST (expiratory muscle strength training)

• Strengthening submental muscle• Improve expiratory pressures for better airway protection

• Improve expiratory drive• Reduce penetration and aspiration

• Better penetration-aspiration scores in Parkinson’s disease• Increased maximum expiratory


pressure• Increased submental muscle electromyography activity during swallowing

MDTP (McNeill dysphagia therapy program)

• Swallow as exercise with progressive resistance

• Improve swallowing including strength and timing

• 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 elderlyFalls 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 community-dwelling 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 community-dwelling 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 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.


Risk Factors for Falls in Older PersonsNon-modifiable Risk Factors Modifiable Risk FactorsAge older than 80 yearsArthritisCognitive impairment/dementiaFemale sexHistory of cerebrovascular accident or transient ischemic attackHistory of fallsHistory of fracturesRecently discharged from hospital (within one month)7

Environmental hazardsMedications (especially psychoactive)Polypharmacy (four or more prescription medications)Metabolic factors

Dehydration Diabetes mellitus Low body mass index Vitamin D deficiency

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 ASSESSMENT1. 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 Examinationsa. Comprehensive assessment of gait, balance, and mobility levels and

lower extremity joint functionb. 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 statuse. Assessment of visual acuityf. Examination of the feet and footwear

Functional Assessmenta. Assessment of activities of daily living (ADL) skills b. Assessment of the individual's perceived functional ability and fear

related to fallingEnvironmental Assessment

a. Environmental assessment including home safety.

INTERVENTIONSElderly 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 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 FACILITES1. 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 ElderlyMemory 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 % 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:

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

Clinical FeaturesComments

Alzheimer disease

Insidious onset of losses in memory, language, andvisual, spatial and executive function with largely normal results on neurologic examination

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.

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

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.

Lewy body dementia

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)

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.

Mild cognitive impairment

Memory or other cognitive problems in the setting of mild deficits on cognitive testing and relative preservation of other cognitive functions

History will show no clinically meaningful functional impairment as a result of cognitive deficits.Patients may progress to dementia, especially Alzheimer disease.

Depression (major depression,dysthymia, or subsyndromaldepression

Depressed mood plus 2 weeks of at least four of the following: diminished interest in

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*

Impairments can be found in measures of cognition, but they are typically mild. These generally improve with 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.


Medications Cognitive impairment following a medication changeor addition

Common causes include medications with anticholinergics or sedative effects.

Cerebrovascular infarcts

Cognitive impairment following the onset of a stroke

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.

Medical illnesses that impair brain metabolism

Illnesses that cause hypoxia, hepatic disease, andendocrine disorders such as hypothyroidism andhyperparathyroidism

Thyroid testing is warranted as part of an initial work-up of a patient with documented memory loss.

* 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.

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 lifeCaring 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 careMemory 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 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 careAmong 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 ElderlyDepression 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].

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 PATIENTSMajor 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 symptomsDysthymia: Low-grade depression symptoms that are chronic for more than two yearsDepression in Alzheimer’s disease: Specific criteria proposed that require only 3 symptoms, with irritability as a qualifying symptom


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]


Depression: Risk and Protective Factors in ElderlyGeneral 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)


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


Jassin, 06/09/13,

Note: While there are no significant changes in symptoms, the DSM5 does include criteria that helps distinguish the severity of major depressive disorders.

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 *NO

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 *NO

6) Are you afraid that something bad is going to happen to you? *YES No

7) Do you feel happy most of the time? Yes *NO

8) Do you often feel helpless? *YES No

9) Do you prefer to stay at home, rather than going out and doing new things?*YES No

10) Do you feel you have more problems with memory than most people?*YES 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 No

13) Do you feel full of energy? Yes *NO

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

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.


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 appropriatePsychotic depression: SSRI + antipsychotic medication, or ECTPersistent minor depression or dysthymia: Either SSRI or psychotherapy aloneDepression 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 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 (DHEA-S), 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 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 ElderlyNormal changes in sexual function in Elderly Men

Normal changes in sexual function in Elderly Women

• 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

• Decreased clitoral engorgement • Decreased vaginal lubrication • Decreased breast swelling • Decreased vasovaginal congestion • Diminished pre-orgasmic sweating • Diminished orgasm intensity


Common Sexual Problems for ElderlyA. 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 • 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 SettingsTreat 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


Common Geriatric Syndromes in Older PeopleGeriatric

SyndromeDescription

DIFFICULTY SWALLOWING

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”).

MALNUTRITION 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.

BLADDER CONTROL PROBLEMS

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 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.

DELIRIUM 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.

DEMENTIA 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 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 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 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

PRESSURE ULCERS

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.

VISION PROBLEMS

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 PROBLEMS

Hearing loss is the most common sensory problem among older adults.

DIZZINESS 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 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.

DIFFICULTY WALKING OR “GAIT PROBLEMS”

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.

Alcohol abuse in this generation is complicated by the use of prescription and over-the-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 smoking-related 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 medicationLoss of coordination ( walking unsteadily, frequent falls)Changes in sleeping habitsUnexplained bruisesBeing unsure of yourselfIrritability, sadness, depressionUnexplained chronic painChanges in eating habitsWanting to stay alone much of the timeFailing to bathe or keep cleanHaving trouble concentratingDifficulty staying in touch with family or friendsLack 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]: 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.


http://en.wikipedia.org/wiki/Ridiculing

http://en.wikipedia.org/wiki/Blaming

http://en.wikipedia.org/wiki/Hypercriticism

http://en.wikipedia.org/wiki/Psychological_abuse

http://en.wikipedia.org/wiki/Physical_abuse

http://en.wikipedia.org/wiki/Abuse

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 SignsThe 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


http://en.wikipedia.org/wiki/Institutional_abuse

http://en.wikipedia.org/wiki/Self-neglect

http://en.wikipedia.org/w/index.php?title=Rights_abuse&action=edit&redlink=1

http://en.wikipedia.org/wiki/Abandonment

http://en.wikipedia.org/wiki/Neglect

http://en.wikipedia.org/wiki/Sexual_abuse

http://en.wikipedia.org/wiki/Lottery_scam

http://en.wikipedia.org/wiki/Coercion

http://en.wikipedia.org/wiki/Deception

http://en.wikipedia.org/wiki/Financial_abuse

Physical Abuse 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

Verbal/Emotional/Psychological Abuse

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

Sexual Abuse Unexplained vaginal or anal bleeding Torn or bloody underwear Bruised breasts or buttocks Venereal diseases or vaginal infections

Financial Abuse or Exploitation 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

Caregiver Neglect 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 factorsRisk 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.

RelationshipA 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.

CommunitySocial 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-culturalSocio-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: 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 FactorsIndividual (victim) Sex: women

Age: older than 74 yearsDependence: high levels of physical or intellectual disabilityDementia, including Alzheimer’s disease and other types of dementiaMental disorders: depressionAggression and challenging behavior by the victim

Individual (perpetrator)

Sex: men in cases of physical abuse and women in neglect casesMental disorders: depressionSubstance abuse: alcohol and drug misuseHostility and aggressionFinancial problemsStress: caregiver burnout

Relationship Financial dependence of the perpetrator on the victimDependence of the perpetrator on the victim (emotional and accommodation)Intergenerational transmission of violenceLong-term history of difficulty in the relationshipKinship: children or partnerLiving arrangement

Community Social isolation: victim lives alone with perpetrator and both have few social contactsLack of social support: absence of social support resources and systems

Societal Discrimination because of age: ageismOther forms of discrimination: sexism and racismSocial and economic factorsViolent culture: normalization of violence

Health ConsequencesCompared 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 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


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 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 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-of-life 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 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 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 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]. 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 CareThe 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 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 CAREMembers DutyPrimary Physician

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 case-by-

case basis with the hospice medical director

Hospice Physician

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-by-case basis

Nurse 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

Home Health Aide

Assists patient with activities of daily living such as bathing and dressing

Provides a variety of other services depending on assessment of need

Social Worker

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, 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

Chaplain 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

Volunteer 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


Services Offered by HospiceFor 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].

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, physician- assisted 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 BURDENAdvances 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 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 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 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 under-treatment 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.

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 Asian-Americans 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 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 HealthCare 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.

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 BurdenCaregiver 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.


THE ZARIT BURDEN INTERVIEW Please circle the response the best describes how you feel.

Never

Never Rarely Sometimes

Quite Frequently

Nearly Always

1. Do you feel that your relative asks for more help than he/she

needs?

0 1 2 3 4

2. Do you feel that because of the time you spend with your relative that you don’t have enough time for yourself?

0 1 2 3 4

3. Do you feel stressed between caring for your relative and

trying to meet other responsibilities for your family

or work?

0 1 2 3 4

4. Do you feel embarrassed over your relative’s behavior?

0 1 2 3 4

5. Do you feel angry when you are around your relative?

0 1 2 3 4

6. Do you feel that your relative currently affects our

relationships with other family members or friends in a

negative way?

0 1 2 3 4

7. Are you afraid what the future holds for your relative?

0 1 2 3 4

8. Do you feel your relative is dependent on you?

0 1 2 3 4

9. Do you feel strained when you are around your relative?

0 1 2 3 4

10. Do you feel your health has suffered because of your

involvement with your relative?

0 1 2 3 4

11. Do you feel that you don’t have as much privacy as you would like because of your

relative?

0 1 2 3 4

12. Do you feel that your social life has suffered because you are caring for your relative?

0 1 2 3 4

13. Do you feel uncomfortable about having friends over because of your relative?

0 1 2 3 4

14. Do you feel that your relative seems to expect you to take care of him/her as if you were the only one he/she could depend on?

0 1 2 3 4

15. Do you feel that you don’t have enough money to take

0 1 2 3 4


care of your relative in addition to the rest of your expenses?

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 burdenScore 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 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 givingAbout 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 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 physiciansIt 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.

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 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


1. Allow extra time for older patients.2. Minimize visual and auditory distractions.3. Sit face to face with the patient.4. Don’t underestimate the power of eye contact.5. Listen without interrupting the patient.6. Speak slowly, clearly and loudly.7. Use short, simple words and sentences.8. Stick to one topic at a time.9. Simplify and write down your instructions.10. Use charts, models and pictures to illustrate your message.11. Frequently summarize the most important points.12. Give the patient a chance to ask questions.13. Schedule older patients earlier in the day.14. Greet them as they arrive at the practice.15. Seat them in a quiet, comfortable area.16. Make signs, forms and brochures easy to read.17. Be prepared to escort elderly patients from room to room.18. Check on them if they’ve been waiting in the exam room.19. Use touch to keep the patient relaxed and focused.20. 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?

Ask simple, direct questions that require only a yes or no response.

Can the patient read simple instructions? Provide instructions in a place that is easily visible to the patient.

Can the patient understand simple verbal instructions?

Use short, simple sentences. Use one-step 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.

Can the patient understand instructions given with physical cues?

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.

Can the patient make a choice when presented with two objects or options?

Limit choices; too many options will cause confusion and frustration

ASSESS EXPRESSIVE ABILITIES FACILITATE COMMUNICATION BY:Does the patient have difficulty finding the correct word?

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.

Does the patient have difficulty creating Listen for meaningful words and ideas.


sentences or a logical flow of ideas? Try to identify the key thoughts and ideas. Do not dismiss person as “totally confused”.

Does the patient curse, use offensive or aggressive language, or exhibit aggressive or combative behaviors?

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.

Does the patient avoid verbalization altogether or mutter in various tones Read nonverbal communication that may seem meaningless to others?

Read nonverbal communication that may seem meaningless to others? Anticipate needs.

TREATMENTMedication 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 non-adherence 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 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 KnowledgeIt 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-adherenceOne 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.


Strategies for assisting aging patients with medication managementMedication 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 [418-

420]. 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 medication-specific 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 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-blockersiii. Calcium channel blockers iv. Diuretics v. Bronchodilators vi. Benzodiazepines

b. If the patient intentionally misses doses, assess the reason(s). 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.

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 effectsi. 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.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 problem-focused 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 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 Be flexible Consider using an outreach approach For each client consider the merits of group v. individual CBT

DNR (Do-Not-Resuscitate) OrdersDNR 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 Self-Determination 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 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 Elderly1. 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 EldersQuality 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 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. Long-term 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 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 long-term 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 community-based 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 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 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 self- determination 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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