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Laboratory AssessmentCGP Bootcamp 2017

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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.


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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


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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


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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


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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


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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.


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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.


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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


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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


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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


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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


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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.


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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?


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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


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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


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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’


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QUESTIONS?

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