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86 Cards in this Set
- Front
- Back
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eldely abuse difficult to quantitate ...
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-parent may be believe it to be a family affair
-fear of reprisals -guilt feeling -cause further tensions in the family -parent etc. may feel they are the culprit |
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Data on elderly abuse
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USA -.8and 1.9 million abused elders
NC- 33K older adults at a given time scandanavia 1-2% >65 yrs Canada - 2.2-3.9% Japanese <1% abuse not confined to a particular society/culture |
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Cost to society/family
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-50% of cases lead to physiclaly apparent trauma resulting in admission to hospital
-ultimately affects family life style -steady increase in reported cases |
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Abuse types
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-physical (14.6%)
-sexual (.3%) -emotional (7.7%) -Financial/Material - Explotiation (12.3%) -Neglect (55%) self, active, passiv -Abandonment (11%) |
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Population at risk
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- Women > Men
- Advanced Age (77.4) - > dependence on caregiver -ETOH/Drug abuse in elder/caregiver -History of intergenerational conflict -elders who internalize blame -excessive loyalty to caregiver |
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Caregiver Risks
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-ETOH/Drug Abuse
-Dementia -Inexperience -Economic stress - History of abuse as a child -Economic dependence on elderly |
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Family unit characteristics engendering abuse
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-lack of family support
-caregiver reluctance -overcrowding -isolation -marital conflict -violence |
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Perceptions/Help seeking behavior
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- koreans less apt to report abuse
-formal vs informal sources of help caucasians- informal sources -Varies across culture as well as from individual to individual |
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Orofacial sign of physical abuse
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-facial bruising
-lip trauma -fractured teeth/jaw -red swollen eyes -unkempt |
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DENTAL TEAM MEMBERS MUST...
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have a working knowledge of medical conditions that mimic accidental trauma (bleeding problems, atrophic signs, frequent falls etc)
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DDS Role in Abuse
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-complete hx with written description of inury
-photos, radiographs -Call Adult protective services -Mandatory reporting of abuse to social service (general statute 108A-102) -careful interviewing of caregivers suspected abuses who may "speak for the patient" -watching facial expression/body language of caregiver and patient |
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interviewing
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-have a second person there
-use open ended questions |
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Social work instruments
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-hwalek-sengstock elder abuse screening test
-care giver abuse screen -both aid in prevention/recognition of elder abuse |
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FACTS
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-all 50 states with legsilation to protect elderly victims of abuse
-42 states with mandatory reporting -some states have criminal charges against DDS/MD who does not report -elder abuse is a medical diagnosis and a crime -must have resources to follow through with reported cases - if not could exacerbate abuse situation |
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APS (adult protected service) suspected abuse
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-can be reported by anyone suspecting abuse
-self abuse/ neglect more common in orange county -reported most frequently by Home health agencies or health care professional (22.5%) -one only needs to suspect abuse -64.2% of reported abuse is substantiated |
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Process of reporting
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-if you suspect elder abuse/neglect call in a referral to the APS (social worker) on call (if after hours) call 911
-if you were wrong you will get a letter saying so -1-800-752-6200 |
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Required info
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-name/age of adult and caregiver
-age of adult -information that indicated disability -what was done to harm, mistreat, or exploit the adult in question |
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Screening criteria- MUST MEET ALL THREE
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-Are they disabled?
>18 years of age lives in NC physically or mentally handicapped -have they been abused neglected or exploited? -are they in need of APS |
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Abuse
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-willful infliction of pain, injury or mental anguish
-willful deprivation of needed services -unreasonable confinement -by caretaker generally! |
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Neglect
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Self neglect
-uanble to provide essential services to self -caretaker neglect: not receiving essential services from caretaker |
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Exploitation
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-illegal or improper use of disabled adult or his resources for another person's advantage
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Who needs APS?
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any adult unable to perform or obtain essential services and is without an able, responsible and willing person to obtain these services
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How quickly are reports followed up?
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-emergency: within 24 hours
-routine: within 72 hours -initiatied by contact with adult about which the report was mde -f there is reason to believe abuse has occurred law enforcment escort for social worker |
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What further steps are taken?
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-consultation with others who might have info aobut adult
-medical pschological, psychiatric evaluation when deemed necessary -by law all staff/ MD's at health depts mental helath and public or private facilities must cooperate -conservative investigation |
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detmination fo capacity or competence
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Capacity: DSS decision; temporary; decision used for services authorai
Competency: clerk of superior court decision; long-term decision used for guardianship |
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What determines if services are rendered or not?
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-must fufill 3 screening criteria and
-have capacity and consents to services -has capacity and refuses services -legal guardianship proceedings if suspected incompetence |
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If APS suspects abuse
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-report is filed with the district attorney
-a detective is hired to investigate -case is taken to court but.. -in practice- DA never folows through due to lack of concrete evidence -APS attempts to fulfill unmet needs of the abused person |
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Our role as DDS
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-be sensitive to prevalence of elder abuse/neglect
-carefully evaluate geriatric patients under the care of a caretaker -be able to notice signs of abuse/neglect -know how to notify the proper authorities (DSS-APS) -document the supsected case of abuse/neglect |
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Health
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- a state of bieng free of disease
-a state of being free of functional consequences of disease -WHO- a state of complete physical, mental and social well-being |
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Quality of life
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-encompasses all areas of everyday life
-individualistic and subjective -4 components: physical, psychological, social and spiritual well-being |
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Health related QOL
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Measured by:
-objective assessment of functioning of health -subjective perception of health Why is it important? -can detemrine the overall benefit of a treatment |
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Context for Chronic Illness
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-Ageing society: increasing life expectancy and proportion of elderly
-more than 12 million people about 1/2 <65 years and 1/2>65 years -long term care demands for people over 65 years will more than double in the next 30 years -increase in disability |
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Chronic Illness
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-largest expenditure of health care dollars
-system geared towards episodic management of health needs -separate systems for health services and social services -medicare- does not cover social services -medicaid - provides health and social services for those who meet income requirements |
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Total spending
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-2.6 trillion
on various services |
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Medicare
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-feral program for elders (over 65 years) and people with end stage renal disease
-covers acute medical care -long term care serices SNF (skille dnursing faciilty) 100 days following hospital stay of three days |
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Barriers to service
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-perceptions or fears of health care system
-access to care -43.4 million americans (36%) wthout health insurance -79% of uninsured are from families with 1 full time worker whose sector does not provide health insurance or whose co-pay for premiums are too expensive -largest group = children |
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Pattern of health care service use: prescription drugs
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-in 2009 there was a 5.1% growth in prescription drug spending, in 200 1.2% increase - $259.1 billion
-prices have increased -direct to sonsumer marketing- may increase drug use |
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Morbidity vs. Mortality
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Morbidity- the relative incidence of disease
Mortality- relatie incidence of death |
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Much of all health care devoted to care of older adults
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-57% of all visits to genralist physicians
-50% of hospital expenditures -80% of home care visits -90% of nursing home care |
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3 common chronic conditions
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-arthritis
-diabetes -cognitive impairment |
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Musculoskeletal system: main functions
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-support
-protection of vital organs -movement -blood cell production -mineral storage |
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Musculoskeletal age-related changes
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-subtle loss of height after maturity; significant shortening in old age
-thinning of intervertebral discs, shorteining or collapse of verterbral bodies due to osteoporosis -decreased bone mass (post memopause) -kyphosis of aging |
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Arthritis and Disability
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-arthritis is the leading cause of disability for adults in the US
-more than 7 million Americans are limited in their everyday activities -an estimated 12 million americans will have limitations in daily activities due to arthritis by 2020 |
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Osteoarthritis risk factors
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-age (>40 years) strongest factor
-obesity -family history -joint hypermobility |
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Functional assessment: purpose
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-detemine ones capacity for activy
-determine level of activity performance -determine any activity limitations and need for assistance -intervene to improve, maintain, or enhance one's ability to perform and actual performance of activity -basic activities of daily living (ADLS) |
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Functional assessment tools and instuments
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-Katz ADL index
-Barthel index for physical functioning -functional independence measure -the get up and go test |
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Katz index
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-assesses ADLs
-creates a common language about patient function |
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Physical Activity
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-sedentary lifestyle in america: 50% of adults in US do not do enough
-decrease risk for CHD, stroke, diabetes and HTN -helps to control weight -contributes to healthy bones, muscles and joints -reduces falls among older adults -helps to relieve arthritic pain -helps to maintain the functional independence of older adults enhances qualiy of life (all ages) |
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Diabetes Mellitus (DM)
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-hyperglycemia of diabetes
-disordered metabolism: carbs, fat and protein -structural abnormalities: organs and organ systems (espec. heart, kidneys, eyes) -complication of pregnancy -etiology linked to causes such as obesity and stress |
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Diabetes Statistics
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-24 million peple in the US have diabetes
-7 million adults over the age of 65 have diabetes -12-25% of all hopital discharges have a diagnosis of diabetes -about 6.2 million people with diabetes are unaware -57 million in US hae pre-diabetes |
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Risk factors for diabetes
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-age >45
-overweight (bmi >25) FH diabetes -sedentary lifestyle -IFT or IFG -ethnicities -history or GDM or deliverying infant > 9 lbs -hypertension -low HDL or high TG -PCOS -metabolic syndrome: high TG, low HDL, high HDL, insulin resistance, HTN |
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Classification of DM
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Type I : insulin production by beta cells are decreased or absent
Type II: a decrease in insulin sensitivity, insulin production may be normal but target cells are not receptive o insulin (most prevalent) |
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Type II DM
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-most common form of DM
-may not need insulin to survive -about 1/2 of cases are in people -prevalence varies by race |
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Social Support dimesions
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-Structural dimensions: living arrangement, # of close relatives and friends, frequency of contact with family and friends, satisfactions of social contact
-Functional Aspects: emotional, instrumental and financial support received from others -mutual exchange is high between older adults and their family, friends and neighbors -pattern of mutual exchange varies across culture |
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Changes of Social Support
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-changes with advancing age
-age-related changes in social support vary across different domains -studies suggest that contacts with friends and family tend to decline with age -emotional support is relatively stable with age -instrumental support increases as one gets older -better social support is associated with mental health, physical health, physical functioning, oral health, and health services use |
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Social Support Associations
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-better preventative health behaviors
-better compliance with preventative medical tx -greater opportunity to improve health literacy and knowledge of health care services -better communication with health problems -better access to health care -poor social support is associated with elevated stress hormones, heightened CV activity, and depressed immune function -the number of elderly is growing, however, the number of caregivers is declining |
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Cost of Informal Caregiving
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-significant time commitment from family members and a significant societal economic cost
-informal caregiving for dementia is largest share of caregiving time for older adults and largest societal economic cost |
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Informal Caregiving: Negative Health Effects
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-higher rates of depression and anxiety
-poorer physical health -increased mortality in strained caregivers -dementia caregivers have an extremely high risk of developing effective disorders such as major depression and anxiety -risk persists over many years of caregiving and even after caregiving ends with death of recipient |
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Negative Impact of Caregiving
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-financial impact (financial strain, women caregivers are more likely than men to give up work, chose to retire early, change to part-time employment,and forgo promotions or career development)
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Positive Impact of Informal Caregiving
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-providing more moderate levels of care may be beneficial to caregiver's health
-lower rates of depression/anxiety compared to non-caregivers -decreased mortality -can be rich and rewarding experience -can create feelings of efficacy and self worth -can have greater sense of meaning of life |
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Caregiving: Conclusion
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-likely lead to negative and positive effects
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Patient's Experience
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-70% of Americans die institutional settings
-41% receive Hospice -40% of pts experience severe pain in days prior to death -31% families report major financial hardship bc of terminal care costs |
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Factors important at End of Life
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-cleanliness
-alternate decision-maker -good nursing care -know what to expect -someone who will listen -maintain dignity -trusted physician -finances in order -free from pain -maintain sense of humor |
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Goals of Medical Care
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-to cure sometimes, to relieve often, and to comfort always
-curing disease and restoring health -prolonging survival -restoring of maintaining function -promoting comfort -facilitating pt goals (quality of life: staying home, maintaining awareness, living to see a grandchild born, reducing burdens on family) |
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Advance Directives
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-living will (notary, can be individualized) durable health care power of attorney (lawyer)
-Family communication: copy of advance directives, discuss values -Physician Communication: copy of advance directive, discuss goals, values, tx decisions, ACP note in WEBCIS, consider portable orders: DNR, MOST |
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Advance Care Planning
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-what makes life worth living?
-what health conditions seem worse than death? -What is most important to pt if diagnosed with a life-limiting illness? -Does pt have strong opinions about specific tx? |
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Limitations of living wills
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-Documents are not sufficient: 20%adults, 40% chronically ill older persons have them, use associated with educational attainment, ethnicity
-may not be available at the time of crisis; don't travel with pt -standard language is vague -muse be discussed and interpreted as health changes -should physician listen to living will or to family -documents dont replace communication |
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Life-prolonging measures
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-mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and similar tx
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Living Will specifications
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-incurable condition with relatively short life expectancy
-unconscious and unlikely to regain consciousness -advanced dementia -can prioritize preference or HCPOA |
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Portable DNR order
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-medical order
-issued by MD, NP or PA -not hypothetical; immediately in effect -no interpretation, immediately directs care in the event of a cardiac arrest |
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Tx decisions beyond DNR
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-DNR does not mean Do not tx
-resuscitation orders do not direct other txs -some pts desire DNR but would accept other tx -some patients desire CPR but want to limit other types of tx |
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MOST: Medical Orders for Scope of Treatment
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-CPR vs DNR
-scope of tx-full, limited additional tx, comfort -antibiotics-use, determine use, don't use -IVF/TF: use, use for trial period, don't use |
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MOST: Communicating decisions
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-portable medical order: travels with pt (hospital, home, nursing home), available when needed (pt of care) , re-assess annually, with transfers, with change in health
-Standardized and easily identified: bright color (find it among paperwork), same form for all settings -More than a DNR order: accept or reject other types of tx -Signed by patient (surrogate) and MD; also PA or NP: promotes discussion prognosis, risks, and benfits of tx, opportunity to answer questions and make recommendations |
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Patients that use MOST
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-seriously ill with advanced incurable disease
-patients whose life expectancy is months -generally not intended for healthy pts, pts with functionally disabling problems with many years of life expectancy or pts with stable medical conditions |
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Prognosis
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-prediction of possible future outcomes of a tx, tx options, or a disease course based on medical evidence and on clinical experience
-life expectancy or probability of survival -experience of illness-trajectory, function, symptoms |
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Informing prognosis
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-disease-specific information
-response to tx -nutritional status -functional status |
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Patients and prognosis
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-expectation of living correlated with tx choices
-patients are optimistic -chronically ill patients value their quality of life more highly than do their families of physicians |
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Physicians and prognosis
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-physicians overestimate survival in advanced cancer
-good discrimination poor calibration |
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Knowing survival rates
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-Helps practical and emotional preparation
-many want to know survival rates |
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Communicating prognosis
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-Discuss what to expect: trajectories
-Communicate time frames not times - listening improves communication |
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When to use shared decision-making?
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-high risk, high certainty : intermediate discussion
-high risk, low certainty: shared decision making -low risk, high certainty: simple consent, minimal discussion -low risk, low certainty: simple consent, some elements of shared decision making |
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Deciding on overall Tx plan
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-MD and pt, family share decision-making
-elicit goals and preferences, make recommendations -tx matched to primary goals -setting-ICU hospital, nursing facility, home |
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Palliative Care
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-interdisciplinary care to improve comfort and quality of life for pts and their families who face serious or life-limiting illness
-pain and symptom management -emotional and spiritual support -help with difficult tx decisions |
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Role of palliative care
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-palliative care not defined by terminal illness or DNR decision
-marked symptom distress -Diagnosis of progressive incurable disease -hospice: life expectancy 6 months of less if disease follows usual course |
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Palliative Care Improved Outcomes
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-improved pt and family satisfaction
-improved pt symptom control and quality of life -fewer ICU and hospital days -no change in mortality; may prolong survival for pts with advanced cancer or CHF |
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Hospice Improves quality
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-decreased hospital transfer
-increases use of pain management -improves family satisfaction with pain management, care for emotional needs -Hospice probably reduces Medicare costs-more so if cancer, younger pt, LOS 7wks but increases family caregiving costs -hospice doe not increase mortality |
