Case Managing Elderly Clients Kendra Peters, LMSW & Joyce - - PowerPoint PPT Presentation

Case Managing Elderly Clients

Kendra Peters, LMSW & Joyce Hefner, LMSW Family Eldercare Austin, TX TACAA Annual Conference, May 2019

Learning Objectives

Objectives:

• 1. Learn about normal aging process.
• 2. Learn about problem issues or abnormal changes and how to

address them when working with clients who are elderly.

• 3. Identify and learn about how to address critical issues:

a) Basic Needs b) Social Isolation and Depression c) Substance Misuse

• 4. Resources and tips for navigating the system of services.

Aging in America

• The demographics of aging: population

boom

• People are living longer.
• Many older adults live with chronic but

not life-threatening illness that contribute to disability and can diminish quality of life.

The sun shines different ways in summer and winter. We shine different ways in the seasons of our lives. Terri Guillemets

Aging is part of the Life Cycle

• A Physical Process
• A Psychological process
• A Social- Emotional Process
• Older adults are an extremely unique group. They bring a lifetime
• f diverse experiences, behaviors, and health status.

Emotional Changes

• Sadness and Grief over loss
• Physical
• Personal
• Resiliency, humor, internal locus of control
• Depression is common but not normal part
• f aging
• Under diagnosed
• Consequences of lack of treatment

Psychological/Brain Changes

Change: Brain and spinal cord lose nerve cells. Things slow down, including production of neuro-transmitters.

Normal

Short-term memory loss More difficulty handling change Slower memory retrieval

Problem/Abnormal

Confusion Dementia (includes Alzheimer’s) Significant short-term and long-term memory loss Delusions

Brain Changes Cont’d

Dementia is the general term for loss of memory and other intellectual abilities serious enough to interfere with daily life.

• Dementia occurs in 6%-10% of adults 65+. Rises to 30% in those 85+.
• Other things that cause memory problems: Depression, side effects of drugs, strokes, head injury,

sodium imbalances, and alcoholism Most common types: Alzheimer’s: Key symptom: memory loss, includes inability to do familiar tasks, time/place confusion, misplace things, poor judgment, mood/personality change. Gradual onset. Lewy-Body Dementia: Generally requires an ongoing decline in thinking skills, along with two of the following: visual hallucinations, Parkinsonism, or fluctuating alertness. May include sleep disorder, effect blood pressure, heart rate, cause sweating. About half of these patients also have Alzheimer’s dementia. Vascular Dementia: Lack of blood flow & oxygen to brain. Linked to strokes, heart attacks, high blood

• pressure. Symptoms can be fairly sudden and depend on what part of brain affected. Can be memory loss,

confusion, trouble with daily activities. Most treatable form. Korsakoffs (Alcohol related dementia): Memory problems, difficulty with daily tasks, psychiatric problems (depressed, irritable, resistant).

Physical Changes

Changes in Hearing Changes in Vision Changes in Smell and Taste Changes in Mobility Changes in Fine Motor Skills

Hearing Loss

Change: High pitched hearing and low pitched frequency reduced.

Stats for those age 65 and above

• 28% will experience some hearing loss
• 8% will lose hearing in 1 ear
• 5% will lose hearing in both ears
• Rates increase with age- 48% of those over 85 will have some hearing loss.
• The ear is connected to balance. Changes in the ear can impact balance.

Presbycusis, or “old ear” is the 3rd most common health problem of older adults and involves inability to hear high-pitched frequencies (it sounds like hands are cupped over both ears). Loss is gradual and impacts both ears.

Changes in Vision

Change: Elasticity decreases, lens thicken, prone to disease, produce less tears

Stats for those age 65 and above:

• 95% wear glasses
• 31% have difficulty seeing even with glasses
• Total vision loss is seldom a problem

Other factors:

• May have an increase of problems with glare (includes indoor glare), adjusting to

darkness or bright light.

• Muscles less able to fully rotate eye.
• Ability to distinguish blues and greens worsens.
• Reduced peripheral (side) vision is common.

Vision Loss Cont’d

Common Vision Problems: Presbyopia- most common, unable to clearly see or read things held close to the face. Cataracts- Causes fuzzy vision. Usually not significant problem, affects peripheral vision. Experienced by 90% of older adults. Macular Degeneration- decreases ability to see things in front of you. Does not impact side vision. Experienced to some degree by 30% of older adults. Retinopathy-Dark areas of vision. Diabetes common cause. Glaucoma: Glaucoma is an eye condition that develops when too much fluid pressure builds up

inside of the eye.

Vision Problems

CATARACTS GLAUCOMA DIABETIC RETINOPATHY MACULAR DEGENERATION

Smell and Taste

Change: Number of taste buds and sense of smell decrease

• Less satisfied with food, decreased appetite
• By age 80, over half of taste buds are lost. Loss of salty and sweet most significant. Lead

to over-salting food, using too much sugar.

• Olfactory (smell) nerve endings affected-changes with age and by disease.
• Illness and medications can affect taste and smell.

Other factors: A person with reduced ability to smell may not notice body odor. A person may be less likely to detect danger from gas leaks, smoke, etc.

Mobility

Change: decreased bone & muscle mass, sensory changes, heart and lung changes

Stats for those age 65 and above:

• 25% have difficulty walking 10 steps
• 19% have difficulty walking ¼ of a mile
• Increases with age. At age 85+, 48% have difficulty walking 10 steps and 36% have

difficulty walking ¼ of a mile Other factors:

• Common diseases such as arthritis & osteoporosis.
• Heart enlarges and pumping capacity decreases.
• Ability to take in oxygen decreases 40% between ages 20 and 70.

Fine Motor Skills

Change: related to common diseases found in elderly

Stats for those age 65 and above:

• 8% need help with bathing, 7% need help with dressing, 6% with phoning, 5% with

cooking

• Need increases with age. Of those age 85+, 23% need help with bathing, 18% with

dressing, 18% with phoning, 8% with cooking, and 10% with toileting. Other factors:

• The impact is not significant unless disease condition is present.
• Common diseases include Arthritis, Diabetes, Parkinson’s, Alzheimer’s or an
• ccurrence of a stroke.

Identifying Needs

Financial Plans Transportation Medicare Health Care Food Social Security Housing Safety Veterans Affairs Counseling Medication Medicaid

Geriatric Assessment

• Designed to address common issues faced by older

adults.

• Multi-dimensional-need to address complex needs.
• Emphasizes Functioning and Quality of Life.

Elements of Assessment

Physical Health Mental & Emotional Well- Being Cognitive Abilities Functional Abilities Environment Social Well-Being

Financial Status

What do we learn?

Physical Health

Risks Age Related Changes Chronic Conditions

Mental & Emotional Well- Being

Resiliency Life Changes Depression, Anxiety, Substance Abuse

Cognitive Function

Memory Adapt & Respond to Change Competency

What do we learn?

Functional Ability

ADLs IADLs Safety

Environment

Accessibility of Housing Accessibility of Services Safety

Social Well- Being

Choice and Values Self- Determination Support Network

Financial Resources

Resources Ability to Manage Exploitation

Critical Issues: Poverty and Limited Resources

• Older adults are the only population group to experience an

increase in the number of people in poverty (US Census Bureau Data).

• There are more older adults who work full time but live in

poverty than there are older adults who are unemployed. More than 13.2 million older adults who are still working are classified as low-income Americans. (AARP Foundation)

• The average monthly Social Security benefit for retired

workers is just over $1,300/month. About 46 percent of unmarried people over age 65 and nearly 25 percent of married older adults rely on Social Security for 90 percent or more of their income. (AARP)

Poverty and Limited Resources

For every unit of Section 202 housing (a federal-assisted housing program targeted to seniors) that becomes available, ten seniors are waiting. Almost half of the poorest seniors (those earning less than 50 percent

• f the area median income) pay

more than half of their income for housing 16% (10,000,000) of

• lder adults face hunger

each year. Of low income elders living in poverty, 63% choose to pay for food instead of medical care.

Critical Issues: Social Isolation & Loneliness

• Holt-Lunstad, Smith, & Layton (2010) found

a strong association has been shown between objective/subjective isolation and morbidity.

• Isolated individuals have been shown to

have greater rates of re-hospitalization (Mistry et al., 2001; Curtis et al, 2006).

• Tomaka et al. (2006) found both subjective

and objective isolation connected to negative health outcomes for:

• Diabetes
• Hypertension
• Arthritis
• Emphysema

What is Social Isolation?

Objective Isolation: Is a quantifiable measure that can be ascertained outside of a person’s judgment Subjective Isolation: Related to how a person views their experience and if they feel isolated. AARP Foundation Unifying Definition: Includes statement that “lack of social connectedness is measured by the quality, type, frequency, and emotional satisfaction

• f social ties. “

Elder, K., & Retrum, J. (2012).

Risk Factors For Social Isolation

• Living Alone
• Having impaired mobility , hearing, vision
• Experiencing a major life transition
• Having low income
• Being a caregiver
• Having psychological and/or cognitive vulnerabilities
• Living in a rural location
• Neighborhood/community limitations
• Small social network and/or inadequate social support
• Non-English speaker
• Belonging to a minority group (Ethnic, Racial, LGBTQ, Religious,

Other)

Elder, K., & Retrum, J. (2012)

Critical Issue: Depression

• Depression is not a “normal” part of aging.
• Depression is often under-recognized and under-treated in older

adults.

• Without treatment, depression can impair an older adult’s ability to

function and enjoy life, and can contribute to poorer overall health

• Symptoms: Depressed mood, loss of interest/pleasure in activities,

disturbed sleep, weigh loss/gain, lack of energy, feeling worthless/extreme guilt, difficulty concentrating or making decisions, restlessness or slow movement, frequent thoughts of death or suicide, attempt of suicide.

Risk Factors Depression

• Medical illness (particularly chronic

health conditions associated with disability or decline)

• Overall feelings of poor health,

disability, or chronic pain.

• Progressive sensory loss (i.e.

deteriorating eye sight or hearing loss).

• Sleep disturbances.
• Mental impairment or dementia
• Medication side effects (in

particular from benzodiazepines, narcotics, beta blockers, corticosteroids, and hormones)

• A history of falling repeatedly
• Alcohol or prescription medication

misuse or abuse.

• Prior depressive episode, or family

history of depression.

• Extended mourning due to death of

a friend, family member, or other loss.

• Any type of stressful life events (i.e.

financial difficulties, new illness/disability, change in living situation, etc.)

• Dissatisfaction with one’s social

network.

Depression: Ways to Help

• Therapy and/or medication.
• Make Transportation Available
• Promote Sense of Purpose /

Volunteer

• Encourage Religious Seniors to

Maintain Attendance at their Places

• f Worship
• Give a Senior Something to Take Care

Of

• Encourage a Positive Body Image
• Notify Neighbors
• Encourage Dining with Others
• Encourage Hearing and Vision Tests
• Make Adaptive Technologies

Available

• Address Incontinence Issues
• Give a Hug
• Give Extra Support to Seniors Who

Have Recently Lost a Spouse

• Help Out a Caregiver
• Phone Based Socialization Program

Critical Issues: Substance Misuse

Number of adults aged 65 or older who used alcohol, marijuana, or cocaine on an average day: annual averages, 2007 to 2014 NSDUHs

Alcohol Misuse

• Alcohol misuse is a significant, more than 15 million people struggle with alcohol

misuse disorder; an estimated 3 million are over 60 years of age.

• We are seeing an increase in people that drink, and increase in binge drinking, and

an increase in dependence.

• Less than 7% of those with the disorder receive treatment each year. It is estimated

that 88,000 Americans die from alcohol related deaths each year. It is the 3rd leading cause of preventable death.

Prescription Drug use

• Older adults use more medications than any other age group.

Medicare beneficiaries (aged and disabled) have among the highest and fastest-growing rates of diagnosed opioid use disorder.

• Nationally, one-third of Medicare Part D beneficiaries or 14.4 million

people had at least one opioid prescription in 2016, with over 500,000 beneficiaries using very high amounts of the medication.

Marijuana/Cannabis

• Most common illicit drug used by older adults.
• Fewer age 50+ using as compared to younger population (<5%) but greatest increase

in use is in this population =71% increase.

• Legal use is expanding: 33 states and DC have medical; 10 states and DC have

recreational.

• Baby Boomers using marijuana perceived marijuana as having less adverse effects, a

lower risk for addiction, and better effectiveness for treating symptoms of medical

• conditions. There is a lack of research demonstrating risks and benefits.
• Ingestion: smoking, vaping, tinctures, edibles, topical creams or patches.
• No uniform dosing. Use linked to higher injury rates and ED visits.

Substance Misuse

Signs of possible substance misuse among older adults may include physical symptoms such as injuries, increased tolerance to medication, blackouts, and cognitive impairment. Psychiatric symptoms that may suggest a problem with substance misuse include sleep disturbances, anxiety, depression, and mood swings.

• Screening, Brief Intervention, and Referral to Treatment (SBIRT) during physician visit

covered by Medicare.

• Treatment is covered by Medicare:
• Part A helps with payment for inpatient treatment at a hospital or inpatient rehab

center.

• Part B helps with payment for outpatient treatment services through a clinic or a

hospital outpatient center.

• Part D can be used to help pay for drugs that are medically necessary.
• Use of opioids monitored for Part D beneficiaries by CMS. May restrict pharmacy and

physician use for “at-risk” beneficiaries.

What Next?: A System Overview Most Common Financial and Health Resources

Resource Type Federal State Involvement Income or Asset limit?

Medicare Health Benefit Yes HHS-CMS No No Medicaid Health Benefit Yes HHS-CMS Yes TX-HHS Yes Veteran’s Benefits Financial and Health Benefit Yes VA No Some Social Security Retirement Financial Benefit Yes SSA No No Social Security Disability Financial Benefit Yes SSA Yes TX-HHS No Supplemental Security Income Financial Benefit Yes SSA Yes TX-HHS Yes

Older Americans Act

Administration for Community Living State Unit on Aging

Core Services Other Activities

Information & Referral Advocacy (SHIP) Legal Services Employment Long Term Care Ombudsman Elder Abuse (NCEA) Fund Community Based programs Training Caregiver Support Demonstration Projects

TX Health and Human Services AAA/ADRC (By Counties)

Fund Information & Referral Information & Referral Fund Nutrition Programs Benefits Counseling LTC Ombudsman Program Caregiver Support Aging Texas Well Care Coordination Texercise LTC Ombudsman Money Follows Person, CBA and HCS programs* Caregiver Tele-Connection LTC Regulatory* Health Promotion: Matter of Balance Medication Screening

* Not OAA, Medicaid

Eligibility Basics

Common Requirements Examples Age-Definition of Elderly varies Age 60+, Age 55+, Age 62+ Geographic Location Zip Code, City Limits, County Specific Disabling Condition Alzheimer’s Disease, End Stage Renal Disease Level of Care Assessment Help with 3 or more ADLs Homebound Income/Assets Federal Poverty Guidelines Median Family Income Guidelines Limits on account balances, savings, etc. Member of Group Veteran Religious Fraternal Organization Homeless

Community Based Services

Service Description

Information and Referral 211; Area Agency on Aging, ADRC Case Management Family, Private pay; provided if receiving other services; short term provided by AAA, special projects. Emergency Alert Private pay; VA benefit; AAA service; Medicaid funded; Safe Return (Alz. Assoc.) End of Life Care Hospice & Palliative Care (Medicare benefit); in home, facility based, support groups. Private pay, private insurance. Food and Nutrition Home Delivered (MOW); meal site (senior center); SNAP, Food Bank: food pantries, HOPE, and education programs. Home Care & Personal Care Private pay; Medicare (short term skilled); Medicaid (personal care); VA benefit; long term care insurance. Homemaker/Home Support Private pay; home repair/modifications (VA benefit, AAA help, private pay).

Community Based Services

Service Description

Housing Subsidized (public housing, HUD programs, tax credit); supportive (foster care, assisted living, personal care home, nursing facility). Medicare (limited nursing care), Medicaid (foster care, long term facility), Veterans benefit, private pay. Legal/Financial Private pay; legal forms on HHS website; Attorney General; programs for low income. Medical Programs for uninsured (City/County); Prescription Assistance; Preventive/Education programs. Durable Medical (Medicare, AAA, VA, Medicaid). Mental Health Private pay; Medicare funded counseling; Medicare funded inpatient services; programs for low income; Mental Health Authority; Mental Health Deputies; Mobile Crisis Outreach team. Social Senior Activity programs (Parks Dept.); Adult Day Program (Medicaid); Alzheimer’s Day program (private pay, no cost through volunteer network). Transportation Private pay; through home care services; Paratransit (specialized); volunteer groups; Veterans Benefit; some Medicare Advantage plans; some Medicaid supported. Discounts Utility and phone discounts, bus pass discounts, local businesses. Abuse Adult Protective Services; Long Term Care Ombudsman; Long Term Care Regulatory Program.

Navigation Tips

Questions

“Aging is not lost youth but a new stage of opportunity and strength.” ~Betty Friedan, writer/activist

Contact Kendra Peters, LMSW 512.628.1696 kpeters@familyeldercare.org Joyce Hefner, LMSW 512.483.3553 jhefner@familyeldercare.org