Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
1
SOCIOECONOMICS OF AGING
Keith A. Swanson, Pharm.D., BCGP
University of Oklahoma
College of Pharmacy
FACULTY DISCLOSURE
• Keith Swanson has no conflicts of interest to disclose.
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
2
LEARNING OBJECTIVES
At the conclusion of this application-based activity, participants should be able to:
1. Predict impact of societal and economic challenges on health status in the elderly
2. List major changes in support systems typically experienced during aging
3. Compare the impact of functional change on elders who have limited support systems
4. Contrast the goals and typical medical care interventions for palliative care against those of hospice care
5. Describe the components and effect on health care delivery for advanced planning tools including: living wills, do-not-resuscitate orders, powers of attorney, guardianships, surrogates/proxies, advanced directives, trusts, and wills
CHANGES IN SOCIETAL ROLES
• Employment to Retirement• Parent to Grandparent (and back to
parent/guardian)• Spouse to Caregiver• Spouse to Widow/Widower• Independent to Dependent• Higher Function to Lower Function• Financial Stability to Limited/Fixed Income
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
3
CHANGES IN ECONOMIC STATUS
• Retirement and net loss of income• Variations in income sources
– Retirement savings– Pensions– Annuities– Government programs – Equity in family home
• Fixed Income vs. Increasing Costs– Housing and food– Taxes– Medical insurance and co-payments– Medications– Transportation
BROAD VARIABILITY IN
FINANCIAL RESOURCES• Geographic variation• Urban vs. Rural• Educational status• Employment status• Gender and race• Marital status• Health status• Lifestyle expectations
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
4
CHANGES IN SOCIAL SUPPORT
• Family transitions– Mobility of grown children– Declining health/death of spouse– Loss of extended family
• Friends and neighbors• Religious affiliation and organizations• Civic organizations and clubs• Health facilities and family doctors• Support equated with positive emotions, greater
purpose of life, lowered mortality
CHANGES IN FUNCTION
• Often initiated by health decline
• Changes self-perception and expectations
• Produces stress (loss of control)
• Fear influences decisions and quality of life
• Influences living environment and care services decisions
• Elder Living Environments– Special Independent
Living Communities– Assisted Living– Memory Care– Long Term Nursing Care– Home Health Care– Respite Care– In-home care aides and
services
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
5
CHANGING SOCIETAL SUPPORT
SYSTEMS• National programs and financial assistance
– Lack of knowledge, stress, and confusion– Complicated requirements and application
processes– Burgeoning numbers influencing thresholds for
receiving assistance
• Health status – Indicator of well-being – Predictor of societal and personal expenditures– Influenced by health care actions and supports
CHANGES IN COPING
MECHANISMS• Generational Standards
– Greatest Generation– Boomers
• Self-reliance• Substance use and abuse• Reliance on medical, mental and cognitive care
services and alternate health practices• Expectations and respect for health providers
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
6
SOCIETAL EXPECTATIONS FOR CARING
FOR ELDERS - ETHICS OF CARE
• Autonomy: Respecting the rights of a person to make decisions regarding their care
• Beneficence: Responsibility of the caregiver to make good choices, “to do good”
• Nonmaleficence: Responsibility of the caregiver “to do no harm”
SOCIETAL EXPECTATIONS FOR CARING
FOR ELDERS - ETHICS OF CARE
• Justice: The responsibility of the caregiver to treat patients fairly, without prejudice, and founded on medical needs
• Self-determination: Responsibility of the caregiver to recognize the rights and needs of clients to be free to make their own choices and decisions.
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
7
IMPACT OF ELDER
ABUSE/NEGLECT• Abuse:
– Actions intended to cause harm or risk of harm to an older adult
– Done by person in a trusting relationship with that older adult
– Includes failure to supply needs or protect the older adult from harm
IMPACT OF ELDER
ABUSE/NEGLECT• Neglect:
– Failure by a caregiver or other responsible person to protect an elder from harm
– Failure to meet needs for essential medical care, nutrition, hydration, hygiene, clothing, basic activities of daily living or shelter
– Results in a serious risk of compromised health and safety.
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
8
SIGNS AND SYMPTOMS OF
ELDER ABUSE/NEGLECT• Physical: Unexplained bruising, fractures,
burns, abrasions or sores
• Sexual: Bruising around the breasts or genitalia, infections
• Emotional: Social withdrawal, depression, isolation, frequent arguments with caregiver, and behavior of caregiver toward the older adult
SIGNS AND SYMPTOMS OF
ELDER ABUSE/NEGLECT
• Financial: sudden change in finances, not able to afford food, heat, clothing
• Neglect: Pressure sores, dehydration, disheveled appearance, lack of hygiene, weight loss
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
9
ADDRESSING ABUSE & NEGLECT
• Reporting– Family
– Facility administration
– Law Enforcement
• Support systems– Protective Services
– Ombudsman
END OF LIFE ISSUES
• Hospice and Palliative Care
• Decision-making in advanced disease– Do-Not-Resuscitate (DNR) orders
– Living Wills and Advance Directives
– Designating Decision-makers• Power of Attorney
• Surrogate/Health Care Proxy
• Guardianship
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
10
HOSPICE CARE
• Increasing Comfort Care Focus - symptom and pain management
• Decreasing Curative Care Focus - withdrawing non-essential interventions
• Generally offered for terminal conditions (final 6 months) • Medicare Benefit since 1982• Hospital/ED admissions avoided except for easily corrected
acute conditions that affect patient comfort• Implementing support services for patient and caregivers
– Health– Social– Spiritual
PALLIATIVE CARE
• Patient goals direct all decisions – requires communication
• Focus on BOTH Comfort Care and Curative Care• Reducing negative impact and risk from overly-
intensive care at all points of terminal illness (no time constraints)
• Support services for patient, family, and caregivers
• Hospitalization/ED visits still an option
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
11
HEALTH ISSUES IN PALLIATIVE CARE
• Weight loss/decreased appetite
• Anxiety/Depression
• Constipation
• Delirium/Cognition changes
• Dyspnea
• Nausea
• Pain
ADVANCED CARE PLANNING
• Requires active discussions between patient, caregivers, clinicians
• Tools and talking points– Advanced Directives– Living Will– Durable Power of Attorney– Proxies and surrogates– Do Not Resuscitate Order– Guardianships– Financial issues: wills and trusts, cost of institutional
care
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
12
SOCIETAL PERCEPTIONS OF AGING
• Ageism: stereotypical discrimination against older individuals or groups
• Prejudicial attitudes
• Discriminatory practices
• Institutional policies and practices
• Statutes and regulations
CASE #1 SUMMARY
• A 93 year old WWII veteran is moved from his apartment attached to his daughter’s home into a veterans home after having suffered 4 falls over two months. He was living with his daughter’s family after depleting his savings over the first 20 years of his retirement. His wife died following a stroke 12 years ago at age 79. Following the last fall, his family had to call Emergency Services to provide assistance helping him up to his feet.
• He shares his semi-private room with a man 30 years younger than him who suffered a brain injury during the Vietnam War. His room mate is unable to speak and spends all his time in bed. Our patient attends several activities at the facility each week and is seen in the physical therapy department three times a week.
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
13
CASE #1 CLINICAL SITUATION
• His physician is considering starting an antidepressant due to complaints of insomnia and reduced levels of energy. When questioned, our patient says, “The folks here are nice enough, but I miss going to my church on Sundays and attending my Tuesday Morning Bible Breakfast with the guys on Tuesday mornings.”
• Over the past 2 months he’s lost approximately 13 lbs (5kg) and isnow using a wheel chair instead of the 4 leg walker he used at home. His medication list includes: metoprolol, furosemide, potassium chloride, and acetaminophen for arthritis.
REFLECTION
• Does this situation sound familiar?
• What other issues would you expect to find if we dig deeper?
• What additional information do you need?
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
14
QUESTION 1:
Which issue is primarily responsible for his recent change in living arrangements?
A. Change in economic status
B. Change in family support
C. Change in physical function
QUESTION 2:
Which socioeconomic issue is exerting the greatest influence on medical care decisions at this time?
A. Reduced financial resources
B. Reduced social interaction
C. Loss of social supports
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
15
QUESTION 3:Which end of life tool would be most helpful in guiding the medical team’s decisions regarding the initiation of additional therapies?
A. Advanced Directive for Health Care (Living Will)
B. Do-Not-Resuscitate OrderC. Durable Power of Attorney
QUESTION 4:
Our patient is refusing morning doses of his metoprolol because he feels lousy during the day after taking it. What ethical principles should guide the team’s decisions when addressing this issue?
A. Autonomy and Nonmaleficence
B. Beneficence and Justice
C. Justice and Self-determination
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
16
QUESTION 5:
Which model of advanced life care is most likely applicable in this situation at this time?
A. Hospice Care
B. Palliative Care
C. Respite Care
ROLE OF THE PHARMACIST IN
ASSURING OPTIMAL CARE
• Assessing socioeconomic influences impacting delivery of optimal health care
• Anticipate changes in condition and support systems that negatively impact patient function and increase risk and mortality
• Recommending interventions: Think ‘Must’ – ‘Should’ – ‘Could’ – ‘Might’
Laboratory AssessmentCGP Bootcamp 2017
SwansonApril 2017
17
QUESTIONS?