OCT1271 - Older Adults

Personal beliefs and values related to occupation and older adults

• older adults are both their past and present

• older adults’ lives and choices are linked to others’ lives and choices

• old age is a time of continuing development and adaptation amidst very real bodily changes

• older adults are an integral part of our communities

• older adults express who they are through their current and aspired occupations

Life stage subgroups

• young-old: 65-74

• “old”: 75-84

• “oldest-old”: 85+

Intersectionality of Canadian older adults

• diverse nature of older people is underrepresented

• life experiences and environment significantly impact and jeopardize the health and ability of older people

• marginalized groups at higher risk of being impacted by inequalities

Demographics of Canadian Older adults: race & ethnicity

• ~28% of OA are immigrants

• ~5% of the Indigenous population is over 65

Demographics of Canadian OA: Gender

• women > men, due to longer life expectancy among women

• gap is narrowing, as men catching up with life expectancy

• 1/700 transgender or non-binary

Demographics of Canadian OA: SES

• 238,00 (3.9%) OA living in poverty in 2017

• single OA/women are particularly vulnerable

Demographics of Canadian OA: Rural dwellers

• 23% live in rural areas

Contextual factors: ageism

• stereotyping on the basis of age —> discrimination

• includes two concepts

  • socially constructed way of thinking about OA based on negative attitudes and stereotypes about aging

  • a tendency to structure society based on an assumption that everyone is young, thereby failing to response appropriately to the real needs of older persons

Bodily changes associated with aging

• arthritis

• cardiovascular disease

• decreased hearing & vision

• depression

• diabetes

• frailty

• osteoporosis and fractures

Social changes associated with aging

• ageism

• isolation

• loss of social capital

• bereavement

• poverty

• poor mental health

Occupational approach for OA

• enable individual agency through occupation to navigate constraints and take advantage of opportunities

• create inclusive environments that enable occupational behaviour (performance, participation, engagement)

Perspectives of aging

• micro

  • disengagement theory, activity theory, continuity theory, successful aging

• micro-macro

  • life course theory

• macro

  • critical gerontology

Disengagement theory

• older adults typically withdraw from previous activities in preparation for death

• disengagement is mutual —> involves OA and society

• disengagement is necessary for society to remain stable and ordered

Activity theory

• OA maintain activity with aging

• OA do best (i.e. the aging process is delayed) when they are active and engaged

Continuity theory

• OA sustain previous beliefs, values and characteristics

• OA use adaptive strategies tied to past experiences of themselves and their social world

Successful aging

• realistic but optimistic expectations for later life

• three goals for living life with a sense of satisfaction and well-being

  • avoiding disease and disability

  • maintaining high cognitive and physical function

  • staying involved with life and living

Life course perspective: overview

• used to understand social pathways, their developmental effects, and their relation to personal and socio-historical conditions

• trajectories: sequences of roles and experiences

• transitions: changes in states or roles

Life course perspective: principle of life-span development

• human development and aging are a lifelong processes

• adults can and do experience changes that are developmentally meaningful

• studying lives over substantial periods of time allows for the analysis of the interplay between individual development and social change

Life course perspective: principle of agency

• individuals construct their own life course through the choices and actions they take within the opportunities and constraints of history and social circumstance

• individuals’ planning and choice- making have consequences for life trajectories

• planning and choice-making are dependent on context

Life course perspective: time and place

• life course of individuals is embedded and shaped by the historical times and places they experience over their lifetime

• same historical event may differ in meaning across regions or countries

Life course perspective: principle of timing

• the developmental antecedents and consequences of life transitions, events and behavioral patterns vary according to their timing in a person’s life

• same events or experiences may affect individuals in different ways depending on when they occur in life course

Life course perspective: linked lives

• lives are lived interdependently and socio-historical influences are expressed through this network of shared relationships

• larger social changes can affect individuals’ interpersonal contexts

• turning points fostered by new relationships can shape lives

• transitions in one person’s life often ential transitions for others

Critical gerontology

• broad spectrum of theoretical interests

  • feminist theories, political economy of aging

• common focus on critiquing the process of power and traditional approaches to knowledge

• emancipatory aims

Meaning-making

• need to understand how people create meaning in their lives through occupations in which they choose to engage

• construct meaning in life by engaging in occupations or roles that provide a sense of mastery and control participations in meaningful occupations influence a sense of good health and wellbeing

Common challenges in communication with OA

• cognitive changes

• hearing loss

• sensory changes

• cultural difference

• generational difference

• technology use

• language barriers

• scenario (ex. talking to younger family member rather than client)

Why think about communication

• expression of wants and needs

• exchange of information

• development and maintenance of social connection

Effects of ageism

• implicit and explicit social messaging

  • performance

  • risk taking

• youth-centric language and expressions

• elderspeak

Elderspeak: purpose and domains

• purpose

  • care

  • control

  • comprehension

• Domains and attributes

  • linguistic

  • para-linguistic

  • nonverbal

  • semantic

  • syntax

  • discourse

  • prosody

Elderspeak: Care Domains

• linguistics

  • diminutivies: terms of endearment

  • plural pronouns

  • juvenile terms

  • exaggerated praise

• prosody

  • raised pitch

  • excessive pitch range, sing-song intonation

  • excessively soft voice

• nonverbal

  • patting

  • exaggerated expressions

Elderspeak: Comprehension domains

• linguistics

  • simple vocabulary

  • short words

  • sentence fragments

  • long pauses

• prosody

  • overly loud voice

  • excessively slowed speech rate

  • overly exaggerated pronunciation

Elderspeak: control domains

• linguistics

  • tag questions: try to exert control, “you wouldn’t want to wear that would you?”

  • directives and imperatives

  • reflectives

  • interruptions

• nonverbal

  • eye-rolling

  • standing over

  • talking over

  • laughing at

Effects of elderspeak

• perceived as demeaning by many

  • lowered self-esteem

  • withdrawal

• reinforces dependent behaviours and internalized stereotypical ageist expectations

• contributes to decline

Ageism: strategies for resistance

• communication enhancement model

  • use an affirming emotional tone

  • balance care and control

  • communicate that the listener is competent, can comprehend the message, and can act independently

  • begin by assessing need for communication changes

  • be aware of non-verbal communication and its effects

Ageism & elderspeak: what about bodily changes?

• environmental considerations

  • eg. loud room, masks

• alternate methods of communication

• organization of information

Hearing loss and communication: possible solutions

• hearing aid

• minimize background noise

• face OA with lips at same level

• increase volume slightly, speak a bit more slowly

• visual aids

• clear written instructions

Vision loss and communication: possible solutions

• glasses

• increased lighting

• increased contrast

• enlarged print

• tactile cues

Dementia and cognitive decline: possible solutions

• allow ample time

• avoid distractions

• one topic at a time

• frequently summarize important points: provide written summary

• introduce yourself (more than once)

• avoid speaking slowly to OA

• ask closed-ended or yes and no questions

• simplify speech

• limit amount of information

Depression and communication: possible solutions

• acknowledge the pain

• be supportive and avoid suggesting client is not trying

• limit amount of information

• keep messages simple and repeat them frequently

Trans-cultural and intergenerational issues

• should consider

  • fluency and literacy

  • meanings attributed to aging

  • cohort effects

  • historical relationships

Intervention through communication: adult learning principles

• attribution theory

  • disposition vs situation

• social cognitive theory

• transtheoretical model of change

  • pre-contemplation

  • contemplation

  • preparation

  • action

  • maintenance

Adult learning principles examples

• self-monitoring

• errorless learning

• chaining

• start with what is already known

• engage client in collaborative planning and problem solving

• check client understanding and expectation

• grade levels of difficulty

• make task relevant to client

• build upon and relate to experiences of client

• use peer models

• establish a positive learning climate

• support client to establish own objectives and goals

• scaffolding

Disability at a population level

• disability =\ poor health

• most persons with disability

  • are older

  • have had the problem only a few years

  • difficulties with ADLs and IADLs more recently

• aging into disability: opportunities to accumulate resources and supports over a lifetime

Aging with disability

• delayed acquisition of life skills

• secondary health problems arise earlier: premature aging

• limited access to health care services and programs

• environmental influences on self-identity and health behaviours can be enabling or disabling

Precarity

• risk and insecurity due to disadvantages becoming magnified into greater inequalities

How might precarity look for someone aging with disability?

• what if…

  • employment opportunities are limited?

  • stigma around disability

• more likely to age successfully with more financial resources

Frailty

• decrease physiological systems (e.g. endocrine, immune)

• increased vulnerability to environmental stressors

• increased likelihood of adverse events (falls, delirium, infection)

• increased de-conditioning during hospitalization

Results of precarity and frailty

• disproportionate change in health status

• symptoms: extreme fatigue, unexplained weight loss, infections, fluctuating disability

Frailty should be addressed

• can lead to increased disability, early mortality

• 7 point clinical frailty scale (CFS)

  • 1: very fit

  • 7: severely frail

• UK Cohort study on adult admissions to surgical units

  • each CFS point was associated with 80% increase in mortality at day 90

• comprehensive geriatric assessment recommended

• recognizing and managing frailty in OA with multiple conditions is among top 10 research priorities

  • as identified by OA, their careers, health and social care professionals

What is reactive care?

• patient contacts the system when they have noticeable symptoms

• patients are passive recipients of treatments or other interventions

• clinical visits are symptom and treatment-focused

Current dilemma: healthcare and OA

• way in which cities, communities and healthcare system are designed, resourced, organized and delivered often disadvantages OA with chronic health issues

Primary health care

• point of contact where patient first goes when health problem occurs

• traditionally family doctor or hospital

• serves a dual function in system

  • direct provision of first-contact services

  • coordination to ensure continuity and ease of movement across the system

Primary health care: challenges

• lack of emphasis on health promotion and disease prevention

• lack of continuity and integration

• problems with access (rural areas, limited hours)

Healthcare system reform: Family health teams

• primary health care organizations that include physician, NP, RN, social work, dieticians and others

• programs and services geared to the population groups they serve

Healthcare system reform: home visits

• house calls team

• services provided: chronic and acute disease management, falls prevention, in-home interdisciplinary assessments, linkages to community supports, medication management, palliative care

• offer comprehensive and ongoing primary care with an emphasis on providing continuity of care for clients

Alternative care option

• proactive care

  • solutions to stratify at-risk individuals based on known algorithms to ensure preventive action is taken to intervene well before onset of symptoms, let alone illness

4 risk factors that lead to >90% of chronic disease

• tobacco use

• alcohol consumption

• physical inactivity

• unhealthy eating

Proactive care

• chronic disease is ongoing and warrants proactive, integrated care

• patients are active partners in managing their condition

• a multi-faceted approach needs to be taken

• chronic disease requires health promotion and disease prevention strategies

Health promotion

• health is a resource for living

• health is state of complete physical, mental and social well-being and not merely absence of disease

• health is a positive concept emphasizing social and personal resources, as well as physical capacities

• process of enabling people to increase control over and to improve health

• individual must be able to identify and realize their aspirations, satisfy their needs and change or cope with their environment

Disease prevention model

• primary prevention

  • help general population maintain health by protecting from risk factors

• secondary prevention

  • identify early stages of illness to limit effects

• tertiary prevention

  • maximize function, minimize dysfunction of people living with illness and disability

Components of population health promotion model

• what

  • health determinants

• with whom

  • level of actor

• how

  • strategies for health promotion

Operationalizing PHP model

• parents can create family environments that help children learn to develop positive social relationships

• community clinics can make appropriate primary care services accessible to young families

Chronic disease management

• individual focus

  • chronic disease self-management programs

• self management models

  • focus on providing people with the skills and knowledge they need to manage chronic illness and disability

  • developed with an understanding of social learning, self-efficacy, readiness for change

  • involve the delivery of structured, pre-determined content

Social learning theory

• factors that influence whether one learns from “models” in the social environment

  • attention

  • motor replication

  • reinforcement or motivation

  • retention

Self-efficacy

• belief in ones ability to use a certain skill

  • vicarious experience or peer modelling or peer support group

    • observing “someone like me” who has appealing consequences from an effor

  • verbal persuasion or social persuasion

    • can increase one’s sense of capability

  • attempted actual performance or skill mastery

    • if successful, nothing succeeds like success

  • physiological cues

    • internal state can be interpreted as signs of success or movement towards goal

Techniques to enhance self-efficacy

• contracts

  • listing behaviour and criterion for success

• reinterpretation of symptoms or physiological cues

Transtheoretical model

• Precontemplation

  • client is uninterested or un aware

  • OT can listen and provide info

• Contemplation

  • client: considering change

  • OT: barriers + provide info

• Preparation

  • client: decision to act

  • OT: strategies + grading

• Action

  • client: behavioural change

  • OT: reinforce +resolve barriers

• Maintenance

Health promotion + OT examples

• collaborate with interprofessional teams to provide holistic assessment of needs

• promote health and prevent illness through promotion and health literacy

• teach and support family members and caregivvers to help minimize risk of injury, stress and find balance in life

• address current gaps and challenges in health care and provide solutions for changing health service needs

• develop and advocate for transformative change in current health care model to meet current needs of Canadian population

Do-Live-Well Framework

• dimension of experience

  • range of experiences are needed

• activity patterns

  • nature of the experience matters

• health and wellness outcomes

  • everyday activities have important impact on health and well-being

• personal and social forces

  • many forces can affect experiences, activity patterns and outcomes

Do-Live-Well Framework: Dimensions of experience

• activating body, mind and senses

• connecting with others

• contributing to community and society

• taking care of self

• building prosperity and security

• developing and expressing identity

• developing capabilities and potential

• experiencing pleasure and joy

Do-Live-Well Framework: activity patterns

• engagement

• meaning

• balance

• choice

• routine

• what you do and how you do it, matters!

Do-Live-Well Framework: health and well-being outcomes

• physical, mental health, social, emotional and spiritual well-being

Do-Live-Well Framework: forces influencing activity engagement

• personal forces

  • interests, abilities, beliefs, cultural expectations

  • changes in health, work or family can disrupt activity patterns

• social forces

  • physical, institutional and sociocultural environments effect what people do everyday

Health promotion application: lifestyle redesign

• improve health and wellness by preventing and managing chronic conditions through building healthier lifestyles

• based on occupational science insights

  • power of occupation to transform and impact health

  • themes of meaning within occupational patterns

  • dynamic systems theory

    • change in one component impacts rest of the system

Social participation

• social isolation

  • structural

  • functional

• social isolation vs loneliness

Social isolation adversely related to wellness, QOL & health status

• loneliness and social isolation are associated with reduced health and wellbeing in OA

• they increase likelihood of heart disease, stroke and depression

• OA with functional limitations: greater risk of becoming lonely

Targeting social isolation

• IADLs

• leisure participation and exploration

• education

• volunteerism

Age-related physical changes

• universal

• intrinsic

  • aging and genetics, not environment

• progressive

• irreversible

• deleterious

  • decrease in function

Sarcopenia

• all OA eventually experience it

• age associated loss of skeletal muscle function and mass

• can impact ability to life objects and stair clibm

OA sensory system changes

• Vision

  • decreased acuity

  • thickening, yellowing and clouding of lens

  • difficulties with near vision

• hearing

  • decreased volume and pitch perceptions

  • ½ over 85

Cognitive aging

• slower processing and reaction time

• worse STM

• better or equal with semantic memory

• increase in crystallized intelligence

COPD and Occupational participation

• occasional breathlessness

• difficulties with occupations requiring physical exertion

• decreased occupational participation if feeling embarrassed by chronic coughing

Osteoarthritis and occupational participation

• impacts on occupations due to joint pain and stiffness

  • household management

  • mobility

  • personal care

  • active recreation

• use of hands might be very difficult

Osteoporosis and occupational participation

• impact on occupations requiring prolonged upright standing or sitting

• may withdraw from occupations due to fear of falling

• modify occupations to reduce amount of body stress from loads

Recent changes to Ontarios healthcare system

• surgeries at private clinics to reduce surgery backlogs

• expanding non-emergency paramedic services

• nurses working in multiple hospitals

• rural and northern EDs launch peer to peer physicians to provide real time support and coaching

OT role in ED

• assessment of function, performance, environmental factors to inform D/C decision

• type of client

  • high rate of frailty amongst patients referred to OT in ED (>60% score 5 or higher on clinical frailty scale)

  • frequently have return visits to ED

• OT

  • prevent unnecessary admission

  • addresses unmet functional support or performance needs

• interventions

  • equipment prescription

  • education

  • referral to community services

  • splinting

  • ADL retraining or transfers

  • discharge planning

OT role in ED: Challenges

• medically oriented

• fast paced

• problematic physical environment for assessment

• lack of time for intervention

• lack of coordination between services

• lack of knowledge about OT roel

OT role in acute care

• treatment for a disease or severe episode of illness for a short period of time

• goal: D/C client as soon as they are healthy and stable

• assessment

  • must be quick, standardized & nonstandardized used

  • ex. occupational profile

    • baseline level of fxn

    • assessment of UE, LE, trunk control and ADL

    • barriers to d/c

OT role in acute care: interventions

• education

  • e.g hip precautions

• rehabilitator

  • first phase of rehab

• consultant

• address decondition syndrome

  • physical, psychological and functional decline due to prolonged bedrest and associated loss of muscle strength

OT role: inpatient rehab

• goal

  • assist to achieve/restore highest level of functioning according to individual abilities

    • decrease risk of needing permanent residential care

    • increase likelihood of returning to independent living post-hospitalization

• Have strict eligibility criteria

• moderately intensive rehab program

  • tolerate minimum of 60 mins of therapeutic activity

• typical length of stay is 4-12 weeks

• OT main role

  • optimize functioning for often pre-morbidly frail individuals who have experienced a loss of independence due to acute illness/injury

  • improve functional abilities and increase rate of returning home

Innovate geriatric practice contexts

• interprofessional service delivery with paramedics responding to OA that have fallen

• collaborating with clients and caregivers to develop creative solutions to problems

• Legacy Work provides consultation on how to have important care conversations and honour or memorialize important relationships

OT role: home care

• support people who require care in home or in community to

  • stay at home

  • return home from hospital quick

  • delay/avoid hospital or LTC admission

  • sustain and improve QOL

  • reduce use of less appropriate and more expensive health services

• roles are numerous

  • home safety

  • restorative interventions

  • prescription of adaptive devices

  • teach new or modified ways for doing ADLs

  • education

  • caregiver skill training

OT role: health care, benefits and challenges

• Benefits

  • fully evaluate persons functioning in their own, familiar context

  • able to teach skills and new techniques within context in which they will be used

  • able to observe environment for clues as to how best to relate to and work with client

  • easily form therapeutic relationship

• challenges

  • wide variation in homes

    • solutions suitable for one client in their home environment may not work in another

  • differing knowledge/willingness of OA and family engagement

  • homes may adversely affect health of client

  • distinct challenges as a work environment

    • require strong clinical and time management skills

    • presence of hazards

OT role: LTC

• regulated by province

• government agencies determine eligibility for LTC and manage waitlist

• personal and nursing care funded by government; residents pay portion of LTC

• OT role

  • falls prevention

  • restorative feeding

  • ADL training

  • wound management

  • assistive devices

  • assess seating/mobility

  • cognitive restoration

Connecting care act, 2019

• guides home and community care in ontario

• defines scope and services/programs that can be provided as well as eligibility

What does home and community care support services do?

• home care services

• specialized nursing care

• family managed home care

• palliative care

• telehomecare

• complex pediatric care

• long term care home placement

• community behavioural supports

• school mental health and addictions nursing

HCCSS Service model

• direct care services

  • rapid response nursing

  • NPs

  • pharmacy

  • mental health and addiction nurses

  • telehome care nurses

• contracted services

  • nursing

  • PSW

  • OT

  • PT

  • Diet/nutrition counselling

  • SW

  • SLP

LTC Placement Waitlist Categories

• 4B

  • People with care needs but are currently managing at home with supports

• 4A

  • people who have high care needs but can still be supported at home until a bed becomes available

• 3B

  • waiting for LTC home serving a particular religion, ethinic or cultural origin; who have needs but are managing at home with support

• 3A

  • waiting for LTC serving particular religion, ethnic or cultural origin; have high care needs but still supported at home or people in LTC waiting for transfer to home of choice

• 2

  • need to be reunified with spouse/partner who is currently in LTC and who meet eligibility requirements

• 1

  • immediate admission to LTC, cannot have needs met at home

  • those in hospital when hospital is in crisis

  • residents in an LTC that is closing within 12 weeks

Short term stay in LTC

• convalescent care

  • short stay rehab

  • up to 90 days

  • provides time needed to regain strength, build endurance and resume normal activity level

• short-stay respite

  • allows caregivers a break from daily responsibilities

  • also available to patients who live alone and need short period of 24-hour care

  • up to 60 days at a time, max 90 days a year

LTC challenges

• home closures

• limited vacancies

• resident complexity

  • responsive behaviours, bariatric needs, medical complexity, mental health

• health human resource challenges

  • system wide

Who are family caregivers?

• 1/8 adults

• 66-100% are women

• person primarily responsible for providing or coordinating patients post-hospital care and not paid to do so