Debra Lacey, PhD, LCSW, MEd

March, 2013

Recognize political and cultural ramifications of a medical model approach v. a person-in-environment approach to assessment and intervention with older adults.

Recognize two or more dimensions of well-being relevant to inclusion in geriatric assessment and intervention.

Recognize two or more strategies to enhance patient/family and/or team roles in geriatric practice.

Team purpose/ organizational mission

Clarification of primary roles and responsibilities

Inclusive of patient/family member(s)

Non-hierarchical and characterized by mutual respect

Clarity of team processes:

Communication processes

Structure (assessment, interventions, evaluations)

Accountability – team and individually

Maintain a person-in-environment perspective in understanding human functioning and well-being.

Respect and promote older adults’ rights to dignity and self determination.

Attend to maintaining quality of life for older adults and family systems.

Promote social justice, including reducing barriers to wellbeing in later life.

Promote older adults’ coping and problem-solving capabilities.

20th century medical model: “health” as the absence of disease; aging=decline.

Typically focused on treating specific, physical diseases.

“Non-medical” dimensions of disease/illness (e.g., cognitive, psychosocial) considered ancillary to medical management.

Medical professional - expertise, do-er.

Patient –lacks expertise, is “done to” (passive).

“Biomedicalization of aging” (Estes & Binney, 1989)

Expansive understanding of health, e.g., epigenetics.

Right-to-die movement.

Baby boomers (+Gen-X + Gen-Y) – more proactive, less deferential to “authority”

Best practices 21st century: SDM Medical providers must share relevant medical

information, and clarify which information is evidence-based.

Patients participate in assessing risks and benefits, and choosing treatments consistent with their own preferences and values.

What value do frail, older adults provide in 21st century American society?

Clinicians – What do my older adult patients teach me about becoming a more effective, productive clinician?

“The more children knew about their family’s history, the stronger their sense of control over their lives, the higher their self-esteem and the more successfully they believed their families functioned. The “Do You Know” scale turned out to be the best single predictor of children’s emotional health and happiness.”

(Feiler, 2013)

History Entire lives in Atlanta until 2012

Self-employed – “successful” insurance business

Death of adult child two years ago

Major health issues (heart attack, stroke; cancer)

Currently Live in Delray Beach for 1 year - independently

Daughter and family in Boynton

Medical issues (poorly managed) – diabetes, medications

Behavioral health issues

Mr. and Mrs. P.

daughter

Insurance business

Daughter/Son

church

Civic group

(rotary)

friends

Extended family Medical

care

Professional organization

neighbors

Mr. and Mrs. P.

daughter

Medical care

Autonomy To what degree am I in charge of the things that are

important to me? (NOT equal to independence)

Relatedness How much do I matter to others, and how much do

others matter to me?

Competence Can I still find ways of achieving my own goals?

(Ryan & Deci, 2000)

Self acceptance

Positive relations with others

Autonomy

Environmental mastery

Purpose in life

Personal growth (Ryff; Keyes & Ryff)

Preliminary Primary care physician

Preferred language

Referral source and reason for referral

Social history

Current family network

Advance directives

Functional health

Health literacy

Behavioral health

Residence - how long at current residence; where he/she lived before and/or spent most of his/her life. (Parezas - place attachment; identity; grief and loss; well-

being)

Family history and current family network (Parezas - identity; values & culture; sources of meaning and

stress; grief and loss)

Work history – career/vocation; educational attainment. (Parezas – skills; identity; perceived social status)

Social engagement history – social/voluntary organizations? (Parezas – social roles/identity; skills)

Church/synagogue/mosque/other membership and/or degree of participation. (Parezas – religiosity/spirituality; identity; community;

coping)

At this point in time, what do you (patient) value most about your life?

Assessment:

Strengths

Challenges

Why would a social worker (or any helping professional) postpone completion of an advance directive (e.g., living will, DPAHC) in an initial assessment with the Pareza family?

How do you spend your day, or What did you do yesterday, or What’s a typical day like for you?

IADLs

ADLs

Who else provides help to you and what do they provide?

What types of tasks/issues are hard for you? What type of help would make it easier for you to manage more easily?

When was the last time you lost your balance?

Health literacy and self-rated health What medical conditions do you receive treatment for?

What medications (prescription and OTC) are you taking today and what are they for? Make sure patient/family member is providing information.

Do you take your medications as prescribed?

Do you have other prescribed medications that you do not take regularly? Explain?

How would you rate your health? (Excellent, good, fair, poor)

Assessment: Functional

Strengths

Challenges

How is your memory?

Or, What kinds of things do you have trouble remembering? (TRIGGER for SPMSE if identified as problematic by patient/caregiver or SW)

During the past month, have you often been bothered by feeling down, depressed, hopeless, irritable, or empty? q Yes q No

During the past month, have you often been bothered by having little interest or pleasure in doing activities you once enjoyed? q Yes q No

In past 6 months, have you often been bothered by feeling anxious, worried, restless, on edge, or nervous? q Yes q No

In the past 6 months, have you been bothered by feeling lonely or isolated, lacking social support, or having conflict with loved ones or friends? q Yes q No

In the past year, have you been so distressed that you have thought of harming yourself or someone else, or have had recurrent thoughts of death or suicide? q Yes q No

In the past year, have you tried to cut down on the medications or drugs that you use, including prescription medication, tobacco and alcohol? q Yes q No

In the past year, have you used prescription medication or other drugs more than you meant to or more than was prescribed by your doctor? q Yes q No

Are you depressed? (TRIGGER for GDS in appendix if any self-report of depression) ___________

Assessment: Cognitive/Behavioral

Strengths

Challenges

Caregivers – issues/concerns

Home condition – falls risk; sanitation issues: SW observation:

Safety issues: Caregiving and/or patient self-care indicators for referral: (SW observation):

Assessment: Safety Strengths Challenges

Goal #1:

Timeframe for implementation:

Participants and roles:

Goal #2

Timeframe for implementation:

Participants and roles:

Goal #3

Timeframe for implementation:

Participants and roles:

“We suggest that a new kind of ethical knowledge is emerging through “routine” clinical care …This new ethical knowledge is characterized by the difficulty of saying “no” to life-extending interventions, regardless of age. We explore the intensification of the biomedicalization of old age through a discussion of three features of the new ethical field: (a) the ways in which routine medical care overshadows choice; (b) the transformation of the technological imperative to a moral imperative; and (c) the coupling of hope with the normalization and routinization of life-extending interventions. We argue that societal expectations about longevity and standard medical care come together today in a shifting ethics of normalcy, with unexplored socio-cultural ramifications. “

(Kaufman, Shim, & Russ, 2004)