Overview: This lesson provides basic information about the aging process.
Learning Objectives: At the conclusion of this lesson, participants will be able to:
- Identify common illnesses and conditions associated with aging,
- Demystify the myths about the aging process and resident care,
- Explain the basic characteristics of Alzheimer's disease and other forms of dementia that ombudsmen encounter among residents, and
- Identify the primary characteristics of facilities that implement culture change.
Duration: 1.5 hours (approximate)
What is Aging?
Aging is a continuous process from birth to death, which encompasses physical, social, psychological, and spiritual changes.
Although aging is an ongoing process, the value of aging is seen differently at different points in the process. Some of the changes are anticipated with joy, such as a baby's first tooth or first step. Other changes are greeted with a less positive response, such as pulling out the first gray hairs that appear.
These prevailing attitudes lead to a denial of the signs of aging. Some individuals quit celebrating birthdays after a certain age. The stereotypical perceptions of aging as a period of deterioration and decline are therefore perpetuated. The positive aspects of aging are ignored. Each stage of life has its own pluses and minuses. Sometimes in old age, the balance may seem to tip to more negatives than positives, but this is not due to the natural aging process.
Aging
There are many positive aspects of aging. After 70 or 80 years of living, individuals tend to have a clear sense of their values and priorities. Older persons can make definite choices about how to use their time and energy. Their priorities may be very different from what caregivers, family, or friends want them to be. Older people have learned ways to adapt to changes; they have managed to survive. Advanced age can bring a freedom to speak one's opinion. Because of retirement, many older individuals have greater freedom to pursue interests, to use time to think and to reflect. To paraphrase Jung, as we age, we become more ourselves.
The advanced stages of aging are a normal, natural part of physical maturation. Instead of placing such a high value on youthfulness, it may be more productive to accept the changes throughout life without fear or denial.
Profile of Elders
As a long-term care Ombudsman (LTCO), you will be working with older adults, their families, and their caregivers. To better understand the population of long-term care residents who are your primary focus, you need to understand the "big picture" of the senior population, defined here as persons 65 years of age or older.
So who are aged people? At what age does a person become old? When a 64-year-old goes to bed and wakes up the next morning as a 65 year old, has that person changed? Chronological age does not always correspond to a person's feelings. Although a person may be eighty years old, the person may feel like he/she is forty. The age a person feels may vary with the time of day, the day of the week, and/or activities or stresses present in that person's life. A person may be very energetic on Saturday, but very tired and slow moving on Monday morning. Knowing a person's chronological age tells you almost nothing about that individual's feelings or abilities
What causes Depression in Elders?
Our society's preoccupation with youthfulness and an often-dismissive attitude towards its older citizens can take a toll on the mental health of our older generation. Add to that, the fact that with age often comes illness. Elders have to deal with the loss of their friends and family members; they may have to face moving into an assisted living situation. They may feel isolated and lonely. Many medications can cause depression. And of course, genetics play a big role. An individual's risk factor increases if a relative has suffered from depression at any time.
Alive Inside Video:
Depression in Older Adults Video:
Types of Dementia Video:
Aspects of Aging
Memory:
- Short-term memory seems to decrease as we age. It becomes more difficult to remember events in the immediate past, like what a person ate for breakfast, who came to visit yesterday, or the date and time of an appointment. There are ways to compensate for any decreases in short-term memory function. A person may write notes to serve as reminders.
- Freedom from distractions or too much stimulation may also help with remembering immediate events or information. Long-term memory seems to improve with increasing age. Events, which occurred forty or fifty years ago, may become easier to remember. As events are remembered and retold, they become more vivid and detailed.
Adaptation to Change:
- Everyone experiences change throughout life. When a person reaches 60 years of age, he/she has lived through numerous changes. Individuals who have witnessed those changes have established patterns of adjusting to change. They know better what they can and can’t tolerate and what is important to them.
- Reactions to change vary from person to person. Change, whether positive or negative can be stressful. All individuals need time to adjust. Sometimes elders are seen as resistant to change, or “set in their ways.” It may be that their refusal to accept change is a way of maintaining control. To say, “No,” is to keep one area of their lives stable. At other times, change may be refused because it may not be understood. An individual may need more information or a clearer explanation, even if it is about a service being offered.
- Elders may need more time to consider the proposed change—to think it through and decide. There may be a very good reason for saying, “No.” They need to be listened to in order to understand their needs. Sometimes it is tough to find a balance between trusting their own priorities and understanding the enabling supports that they may need.
Aspects of Aging
The time needed to adjust to change and the stressful nature of change are related to “transfer trauma.” Transfer trauma is the result of the “physiologic and psychosocial disturbances that happen when elders are suddenly uprooted from routines and familiar surroundings.” Transfer trauma may be evident by confusion, agitation, increased falls, skin tears, and the exacerbation of medical conditions.
Reminiscence
One method of coping with change is through reminiscence. There are several positive benefits of engaging in reminiscence. The present may be depressing or unsatisfactory. By recalling a happier time, an elder may derive some contentment. The strength to adjust to change may be derived from remembering previous successful adjustments.
Furthermore, reminiscence may provide an emotional outlet. Everyone reminisces. When something good happens, most people share the event with friends. When friends meet, they sometimes recall previous shared experiences and relive them at that moment. Some elders may not have many people with whom to share an experience. If only one or two people are around the elder, those individuals may hear the same story several times.
Some of the common psychological purposes that reminiscing may serve are listed below:
Identity
Through story telling, an older person can reveal personal achievements and characteristics. Indirectly, they may be saying, “This is how I was before I aged.” It serves as an introduction to that person prior to any limitations on energy or functioning. Personal characteristics are often revealed; a new acquaintance can begin to understand what the older person has been throughout his/her life by listening to these memories.
Self-Assessment
In recalling the past, an older person may engage in self-assessment, deciding what kind of life one has lived. A review of the totality of one’s life imparts a sense of integration of self. Allowing an older person to give advice, wisdom, or history to others through reminiscence can reinforce self-esteem. It may reinforce a person’s feeling that his/her life has been worthwhile.
Grieving
Reminiscence can be a productive method of dealing with loss and grief. In verbally sharing the loss, an individual may come to accept it. In grief, there is a need to remember and to relive past experiences. Reminiscence provides that opportunity. There may be conflicts in the past that are unresolved or need to be re-evaluated. By remembering past events, a person may decide to make amends with someone; to forgive someone or to seek forgiveness. Losses, which were suppressed, may surface. Grieving may need to be completed.
Intelligence
Intelligence does not decline with normal aging. When tested, elders score lower on timed tests than younger individuals. On tests without time limits, elders score better than the young.
Aspects of Aging
Sociological
As with individuals of any age, familiar relationships are important to elders. With increasing age, family composition often undergoes some changes. Older men are much more likely to be married than older women. Almost half of all older women are widows. Divorced and separated older persons represent only 10% of all older persons. However, this percentage has increased since 1980. Family connections extend into later life as reflected by living arrangements. Almost 60% of older women and 78% of older men live with a spouse or with another relative. Relationship patterns established in earlier years prevail into later life. If a parent and child have always had personality clashes, they will most likely continue to do so unless they learn new ways of interacting with each other. The parent who listened primarily to one child or turned to a child for advice will continue that pattern unless something intervenes.
Role Reversal
While it is true that an elder may become more dependent on others in some capacities as they age, the person is still an adult. Sometimes individuals may appear to act like children because they feel they are being treated as children especially when living in a different setting.
An individual may need transportation or assistance in completing forms. That does not mean that person needs someone to make financial decisions for him/her. An aged individual may require temporary assistance in managing personal affairs until that person recovers from an illness or stress and is able to resume total responsibility. Sometimes families decide that an elder is incapable of independence because the person makes a decision that disregards their advice.
Elders need to be encouraged to do as much for themselves as possible to maintain their independence. Caregivers need to patiently allow sufficient time for persons to respond to questions or accomplish tasks. The emphasis should not be on perfection but on personal accomplishment. Ombudsman representatives should reinforce the decision-making ability of elders, supporting as much independence in as many areas as possible.
Alzheimer's Disease
- A disorder that destroys cells in the brain.
- A degenerative, irreversible disease that usually begins gradually, causing a person to forget recent events or familiar tasks.
- Variable in the rate with which it progresses from person to person.
- Diagnosed as “probable Alzheimer’s” based on a variety of tests. The diagnosis has an accuracy rate of 90%. Exact diagnosis can only be determined via a sample of brain tissues after death.
Residents with Alzheimer’s disease may have:
- Memory loss
- Confusion
- Personality and behavior changes
- Impaired judgment
- Difficulty communicating as the affected person struggles to find words, finish thoughts, or follow directions
- Inability to care for themselves as the disease progresses
Progression of Alzheimer's
- Alzheimer’s disease causes the formation of abnormal structures in the brain called plaques and tangles. As they accumulate in affected individuals, nerve cell connections are reduced. Areas of the brain that influence short-term memory tend to be affected first. Later, the disease works its way into sections of the brain that control other intellectual and physical functions.
- Alzheimer’s disease affects people in different ways, making it difficult for medical professionals to predict how an individual’s disease will progress. Some experts classify the disease by stage (early, middle, and late), but specific behaviors and how long they last vary greatly, even within each stage of the disease.
- As more is learned about the progression of the disease, new assessment scales are being developed to help physicians track, predict, and treat symptoms of Alzheimer’s disease. New medications can slow the progression of memory loss in its early stages.
Medications and Side Effects
Most nursing home residents are on five or more medications at any time. Ombudsman representatives, in visiting in nursing homes, may notice the side effects these medications can have on residents. Ombudsmen should be familiar with basic medication terminology so that when resident or family complaints involve medications, ombudsman representatives recognize the terms. Ombudsmen can thus refer or investigate the complaint thoroughly.
Over a four year period, two-thirds of nursing facility residents have adverse medication events (ADEs). One out of seven of these results in hospitalization.
Remember: your role is not to second guess a medical decision regarding medications. You are to listen, observe, ask appropriate questions, and suggest that an individual ask his/her physician for additional review or more information. Ombudsmen should know that all medications given to elders should be started at a low dose and raised slowly. This is especially true for individuals who have dementia.
Care & Medication of Residents with Alzheimer's Disease
How is Alzheimer's disease treated?
A doctor will determine the best treatment for an Alzheimer's case based on various factors, including:
- The patient’s age, overall health, and medical history;
- Extent of the disease;
- The patient’s tolerance for specific medicines and therapies;
- Expectations for the course of the disease;
- And the patient and his or her caregiver’s opinions or preferences.
Alzheimer's disease medications
- Several different types of medications are used to treat memory loss, behavior changes, sleep problems, and other symptoms of Alzheimer's disease.
- These medications won't stop the disease, but they can slow down the progression of symptoms for a few months or even years. All of these medications can have side effects, which can be even more pronounced in elders.
Communication
- Trying to communicate with a person who has Alzheimer's disease can be a challenge. Both understanding and being understood may be difficult.
- Choose simple words and short sentences and use a gentle, calm tone of voice.
- Avoid talking to the person with Alzheimer's disease like a baby or talking about the person as if he or she weren't there.
- Minimize distractions and noise—such as the television or radio—to help the person focus on what you are saying.
- Call the person by name, making sure you have his or her attention before speaking. Allow enough time for a response. Be careful not to interrupt.
- If the person with Alzheimer's disease is struggling to find a word or communicate a thought, gently try to provide the word he or she is looking for.
- Try to frame questions and instructions in a positive way.
Prevalence of Abuse
Abuse, Neglect and Exploitation (ANE)
- Estimated that 1 in 10 elders experience ANE
- Only 1 in every 23 cases are reported
- As many as 1out of 2 individuals with dementia are victims of ANE
- Family, friends and caregivers are the perpetrators in 70-90% of all ANE
Financial Exploitation
- Illegal or improper use of an older adult’s money or belongings
- The fastest growing form of elder abuse
- Grossly underreported
Responding to Allegations of Abuse: Role & Responsibilities of Long-Term Care Ombudsmen
- Provisions in the Older Americans Act (OAA) state that long-term care ombudsmen (LTCO) shall “identify, investigate, and resolve complaints” regarding “action, inaction, or decisions that may adversely affect the health, safety, welfare, or rights of the residents” made by, or on behalf of, residents. Complaints may include, but are not limited to, allegations of abuse, gross neglect, and exploitation.
- Long-term care ombudsmen are resident-centered advocates, directed by resident goals for complaint resolution and federal disclosure requirements; therefore, the LTCO role in investigating allegations of abuse is unique and differs from other entities such as, adult protective services and state licensing and certification agencies.
Referrals to Other Agencies
There are difficult cases other than complaints of abuse, neglect, and/or exploitation for which the LTCOP may refer a complaint to another agency. Referrals made should be included in the plan of action and for the purposes of complaint resolution.
When working on a case, referrals are made with consent of the resident and when:
- another agency has resources that benefit the resident;
- actions to be taken are outside of the expertise or scope of the LTCOP; or
- the representative needs outside assistance for complaint resolution.
When a representative makes a referral to another agency, it does not necessarily mean there is no further work to be done. LTCOP actions will depend upon the direction of the resident, the plan of action, and the resident’s desired outcome.
There are other times when individuals contact the LTCOP with a concern that is outside of the scope of the program’s work. The LTCOP provides information and contact information to the individual about other agencies or entities based on the problem shared and the services provided.
For example, a ombudsman receives a complaint about a facility type to which the LTCOP does not have access. In this situation, the Ombudsman program gives applicable information to the caller to address their situation and would have no further involvement.
APS accepts and investigates reports of abuse, neglect, and exploitation of elders and dependent adults. Ombudsman representatives should contact APS in the following situations:
- When an ombudsman has received a report of abuse (consent of the resident is required to refer to APS).
- A resident of a long-term care facility is going to return to the community and is at risk for abuse in the community;
- APS has worked with the resident in the past or is likely to work with him in the future and has information that is essential to the successful resolution of the case;
- The Ombudsman is working with a resident of a long-term care facility whose perpetrator is in the community and may abuse others.
Elder Financial Exploitation
- Definition: Illegal or improper use of an older adult’s funds, property, or assets.
- The most common form of elder abuse, but only a small fraction of incidents are reported.
- Perpetrators include family members, caregivers, scam artists, financial advisors, home repair contractors, fiduciaries, and others.
- Attractive targets: significant assets or home equity.
- Vulnerable due to: isolation, cognitive decline, physical disability, health problems, or recent loss of partner/family member/friend.
Common Signs of Financial Exploitation
- Money or property seems to be missing.
- Sudden changes in spending or savings, e.g.
- Large withdrawals without explanation,
- Excessive use of ATM,
- Can’t pay bills,
- Makes new or unusual gifts to family or others, e.g. “new best friend,” or
- Changes beneficiaries.
- Fear of relative, caregiver, or friend
- Relative, caregiver or friend keeps older adult from having visitors or phone calls; doesn’t let them speak for themselves.
Financial Exploitation in Long-Term Care Facilities
- In nursing homes (NHs), 8% of the complaints against facilities regarding abuse were about financial exploitation (FE), and the FE complaints involving a family member or other individual not associated with the facility were more than twice the number of any other type of abuse by family members or others not associated with the facility.
- In assisted living facilities (ALFs), 16% of the complaints against facilities regarding abuse were about FE, and the FE complaints involving a family member or other individual not associated with the facility were nearly three times the number of any other type of abuse by family members or others not associated with the facility.
Cultural Sensitivity & Cultural Diversity
MAJOR ISSUES
Alleged incidents of abuse, neglect, and mistreatment among different races, classes, and religious groups in long-term care facilities has been reported. Being aware of cultural differences and knowing that they can impact care delivery is important. The development of culturally sensitive programs can help bridge differences, positively impact care and lead to increased resident, family, and employee satisfaction.
Incorporating cultural themes, traditions, and customs into daily programming allow residents and staff to experience both their own and other cultures thereby contributing to a sense of community in the facility.
What is Culture Change?
"Culture change" is the common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working with them are considered and respected. Core person-directed values are choice, dignity, respect, self-determination and purposeful living.
Learning Summary
This module provided basic information about the aging process. Now you should know how to:
- Identify common illnesses and conditions associated with aging;
- Demystify the myths about the aging process and resident care;
- Explain the basic characteristics of Alzheimer's disease and other forms of dementia that ombudsmen encounter among residents; and
- Identify the primary characteristics of facilities that implement culture change.
Credits:
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