The Number

INTRODUCTION TO GERONTOLOGY
Gerontology: study of aging and of the aged.

Subfields:

Geriatrics: medical care of the aged - 1990: 2.7%

Social gerontology- social aspects of aging vs
biological and psychological of total world
Geropsychology- specialists in psychiatry whose
knowledge, expertise and practice are with the older
population.
population
Geropharmaceutics/ Geropharmacology- Pharmacists
obtain special training in geriatrics.
(5.38)
Financial gerontology- combines knowledge of
financial planning and services with special expertise
- 1996: 3.6%
in the needs of the older adults.

Gerontological rehabilitation nursing- combines

of total world
expertise in gerontological nursing with rehabilitation
concepts and practice. population
(5.78)
Gerontological nursing- aspect of gerontology
that falls within the discipline of nursing and
scope of nursing practice.

Scope- - 2025: est

7.7% of
Nurses advocating for the health of older
persons at all levels of prevention from the time of old
age until death.

DEMOGRAPHICS OF AGING

-according to healthy people 2010, individuals aged

total world
65 years can be expected to live an average of
18more years than they did 100 years ago, for a total
population
(est.88)
of 83 years.

-Those aged 75 years can be expected to live

- 2030: est
an average of 11 more years, for a total of 86 years.

-Older adults are expected to represent approximately

20% of total
20% of the population by the year 2030.

Division of the older age group

- Young old: 65-74 years old

- Middle old: 75-84 years old

world
- Old-old: very old and frail elderly: 85-94 years old

- Elite- chronologically gifted: 95 years old and older

population
THE NUMBER:
Features of women,
population resulting in
aging “feminization”
- The most of
rapid growth population
occurs in the aging
oldest (because of
age groups- lower
the oldest mortality
old (80+or rates among
85+ years) women)
and - Another
centenarians consequence
(100+ years) of lower
n particular. female
- Population mortality is
aging is the fact that
particularly almost half of
rapid among older
women
-Reversal of net intergenerational wealth flows from
older relatives to children.

(45%) in Ageism Myths and Facts

Myth 1: Older adults are of little benefit to society
Fact: Older adult disabilities are declining; older adults

2000 were are part of a family where they give and receive love,
support and care; function in professional role

windows, Myth 2: Older adults are a drain on society’s resources

Fact: older adults had already paid the system from

thus which they are now drawing; many older adults do

not retire; many retired older adults are engaged in
unpaid volunteer (custodial care and others) work

living without thus saving employer’s cost.

spousal
Myth 3: Older adults are cranky and disagreeable
Fact: equal number of cranky and disagreeable young
adults; continuity theory- - Maintain similar and the

suppor same personality and coping strategies; older adults

are sick thus become cranky; negative interaction
with nurses is symptom of the illness rather than of
- 1990: 2.7% of total world population (5.38) is old age
- 1996: 3.6% of total world population (5.78) aging.
- 2025: estimated 7.7% of total world population
(est.88) Myth 4: You can’t teach old dogs new tricks
- 2030: estimated 20% of total world population Fact: Older adults may still benefit from health
education activities.
Features of population aging
- The most rapid growth occurs in the oldest Myth 5: Older adults are all senile
age groups Fact: Senility refers to cognitive impairment
-the oldest old (80+or 85+ years) (dementia); dementia is not a normal process of aging
and centenarians (100+ years) n particular. but a pathological disease process.
- Population aging is particularly rapid among women,
resulting in “feminization” of Myth 6: Depression is a normal response to the many
population aging (because of lower mortality losses older adults experience with aging
rates among women) Fact: depression is an abnormal response to the many
- Another consequence of lower female physiological changes of aging, they are more
mortality is the fact that almost half of older susceptible to pathophysiology thus predisposing
women (45%) in 2000 were windows, thus them to depression
living without spousal support.
Myth 7: Older adults are no longer interested in sex
Key Issues for Older People Fact: sexuality continues throughout the life of older
- Traditional support systems being eroded adults
- Government resources to devote to growing
older population are limited Myth 8: Older adults smell
- Many older people unable to accumulate Fact: Sweat glands decrease with age: urinary
sufficient resources during their working lives and bowel incontinence are pathologic and are
highly treatable.
Impacts of Family Change
-Less residential extension of households
-More physical separation due to migration Myth 9: The secret to successful aging is to choose
-Less children available to support older persons your parent wisely
Fact: there is a lot that individuals can do to -Almost a quarter of Filipinos living in poverty
age gracefully are older adults who do not have the financial
means necessary to sustain an adequate quality of life
Myth 10: Because older adults are close to death and -Working-age Filipinos must often remain in the
are ready to die, they do not require special workforce longer to financially support younger
consideration at end of life dependents and other family members.
Fact: older adults require equal and specialized -A lack of institutional care in the Philippines means
attention to physical, social, psychological and spiritual that older Filipinos are often cared for by
task at the end of life. End of life seems to complete Family members at home.
an important developmental task of aging thus nurses
play a role to help older adults complete this task. WHAT ARE BEING DONE?
“With old age comes skill. It’s called “Multi Tasking! *Republic Act No. 344 or the Accessibility Law of
You can Laugh, cough, sneeze, fart and pee all at the 1982-
same time” provides for the minimum requirements and
standards to make buildings, facilities, and utilities for
THE AGING SCENARIO public use accessible to persons with disability
including older persons who are confined to
-The country consists of approximately 103 wheelchairs and those who have difficulty in walking
million inhabitants, with less than 5% of the or climbing stairs, among others.
population 65years and older
-The age structure of the Philippines resembles many *Republic Act No. 7876 entitled “An Act Establishing
other developing countries because there is a greater a Senior Citizens Center in all Cities and
proportion of younger Filipinos in comparison to older Municipalities of the Philippines and
Filipinos Appropriating Funds.
Therefore” provides for the establishment of Senior
-The 60 years and older population of the Philippines Citizens Centers to cater to older persons’ socialization
is expected to increase by 4.2% whereas the 80 years and interaction needs as well as to serve as a venue
and older population is expected to increase by 0.4% for the conduct of other meaningful activities.
from 2010 to 2030.
-Life expectancy of Filipinos is 57.4 years for males and *Republic Act No. 8425 provides for the
63.2 years for females. institutionalization and enhancement of the
-Females are projected to expect an increase of 4.0 social reform agenda by creating the National Anti-
years in life expectancy and males an increase of 4.7 Poverty Commission (NAPC). Through its multi-
years in life expectancy by 2030, dimensional and cross-sectoral approach, NAPC
-The improvement in life expectancy can be attributed provides a mechanism for older persons to
to advances in public health in the Philippines, which participate in policy formulation and decision-
have eradicated many of the diseases that making on matters concerning poverty alleviation.
once caused earlier mortality of Filipinos.
*Republic Act No. 10155, known as “The
THE CULTURE OF CARING General Appropriations Act of 2012”, under
-Filipinos value filial piety and caring for older family Section 28
members later in life. mandates that all government agencies and
-It is an obligation to care for family members instrumentalities should allocate one percent of their
-Families would opt to provide care themselves rather total agency budget to programs and projects for
than resort to any health or social services for older persons and persons with disabilities.
assistance in providing care
-Catholicism reinforces the concept that caregiving is *Republic Act No. 9994, known as “Expanded Seniors
expected of family member. Citizen Act of 2010 ,′′ an act granting additional
benefits and privileges to senior citizens, further
CULTURAL CONCERS amending Republic Act No. 7432 and otherwise
-Older Filipinos may have to sacrifice their financial known as “an act to maximize the contribution
assets to care for younger family members of senior citizens to nation building, grant benefits and
special
 the BSN Program provided for the inclusion of NCM
*Residential Proclamation No. 470, Series of 114 Care of the Older Person in the
1994, declaring the first week of October of every Professional Courses with 2 units lecture and 1 unit
year as “Elderly Filipino Week.” privileges and for laboratory.
other purposes”
WHAT NEEDS TO BE DONE?
*Executive Order No. 105, Series of 2003, approved -Family caregiver training
and directed the implementation of the program -Training on care of the older person across health
providing for group homes and foster allied professions
-Establishment of accessible programs and services for
*The Philippine Plan of Action for Senior older people
Citizens(2011-2016) aims to ensure active aging for -Health services for older people in geographically
senior citizens where preventive and promotive isolated areas
aspects of health are emphasized in communities -Preservation of cultural practices in the care of the
and where health services are accessible, affordable older person
and available at all times. Envisioning a -Awareness campaign and information dissemination
population of senior citizens who are self-sufficient on the existing laws and policies for the welfare of the
and self-reliant, this plan aims to promote financial older person
security and financial independence of senior citizens
by developing community based local delivery system LESSON 2:
to address their needs.
WHY THE POPULATION IS AGING?
*The Department of Social Welfare
Development •Population dynamics
(DSWD) has issued Administrative Order No. 4 series -Variations in birth and death role
of 2010, “Guidelines on the Home Care •Declining fertility rates
Support Services for Senior Citizens”, establishing -Declining share of young people in society, increases
community based health care services for older the older population automatically
persons. •Longevity increase
- Increase in life expectancy
*The RA 9994 provides health care services for poor - Advances in the field of medicine, medical
older persons such as free medical services on technology and biotechnology
government hospitals, discounted services on private
hospitals and clinics, free vaccines, discounted THEORIES OF AGING
medicines, and mandatory PhilHealth coverage. •A good gerontological theory integrates knowledge,
tells how and why phenomena are related, leads to
The Philippine Constitution supports the formation of prediction and provides process and understanding
community based organizations. The DSWD have •In addition, a good theory must be holistic and take
facilitated the formation of older people’s into account all that impacts on a person throughout a
associations in every city and municipality. They are lifetime of aging.
also tasked to provide technical assistance to support
and strengthen OPAs. •Population dynamics
-Variations in birth and death role
*Under the RA 9994, the Philippine •Declining fertility rates
Government provides a social pension of 12USD -Declining share of young people in society, increases
(Php500) per month to poor older persons aged 77 the older population automatically
and over who are not yet receiving any •Longevity increase
government or private pension. The Department - Increase in life expectancy
of Social Welfare and Development is the lead - Advances in the field of medicine, medical
agency tasked with identifying and reviewing social technology and biotechnology.
pension beneficiaries.
BIOLOGICAL THEORIES
CMO 15 s 2017 Policies, Standards and Guidelines for -explain information regarding the physiologic
processes that change with aging CONNECTIVE TISSUE OR CROSS-LINK THEROY
•Stochastic or statistical perspective Theoretical propositions
-Identifies episodic events that happen throughout - Over time, biochemical processes create
one’s life that cause random cell damage and connections between structures not normally
accumulate over time, thus causing aging. connected.
•Nonstochastic theories
- Series of predetermined events happening to PROGRAM OR FEATURE THEORY
all organisms in a timed framework Theoretical propositions
•Defect theory - Cells divide until they can no longer divide,
whereupon the cell’s infrastructure recognizes
PSYCHOLOGICAL THEORIES this inability to further divide and triggers the
- Explain aging in terms of mental processes, apoptosis sequence or death of the cell
emotions, attitudes, motivation and
personality development that is characterized GENE OR BIOLOGICAL CLOCK THEORY
by life stage transitions. Theoretical propositions
- Each cell or perhaps the entire organism has a
genetically programmed aging code that is
MORAL/SPIRITUAL THEORIES stored in the organism’s DNA
- Support the idea that once an older individual
finds spiritual wholeness, this transcends the NEUROENDOCRINE THEORY
need to inhabit a body, and they die. Theoretical propositions
- A change in hormone secretion have an
SOCIOLOGICAL THEORIES influence in the aging process.
- Changing roles, relationships, status, and
generational cohort impact the older adult’s
ability to adapt. IMMUNOLOGIC OR AUTOIMMUNE THEORY
Theoretical proposition
NURSING THEORIES OF AGING - Normal aging process of human and animals is
- Developed to guide nursing care of the elderly related to faulty immunological function

FREE RADICAL THEORY OF AGING DEFECT THEORY

Theoretical propositions Theoretical propositions
- Aging is due to oxidative metabolism and the - Breakdown and losses that occur with aging
effects of free radicals, which are the end are accidents or mistakes
products of oxidative metabolism
What are free radicals? HUMAN NEEDS THEORY
- Free radicals are like robbers which are Theoretical proposition
deficient in energy - Hierarchy of five needs motivates human
- Free radicals attack and snatch energy from behavior: physiologic, safety and security, love
the other cells to satisfy themselves. and belonging, self-esteem and self-
actualization
ORGER OR ERROR THEORY OF AGING
Theoretical proposition STAGES OF HUMAN DEVELOPMENT
- Aging would not occur if destructive factors Theoretical propositions
did not exist and cause “errors” such as - Older adults experience the developmental
mutations and regulatory disorders. stage known as “ego integrity versus despair,
characterized by evaluating one’s life and
WEAR AND TEAR THEORY accomplishment for meaning
Theoretical proposition
- Aged cells have lost the ability to counteract INDIVIDUALISM THEORY
mechanical, inflammatory, and other injuries Theoretical propositions
due to their senescence - Individual personalities tend to view life
primarily either through the self or through others.
 AGE STRATIFICATION THEORY
LIFE-COURSE OR LIFE SPAN DEVELOPMENT Theoretical proposition
PARADIGM - Aging and society are interrelated and cause
Theoretical propositions reciprocal changes to individuals, age group
- Life occurs in stages that are structured cohorts and society.
according to one’s roles, relationships, internal
values and goals. PERSON-ENVIRONMENT FIT THEORY
Theoretical proposition
SELECTIVE OPTIMIZATION WITH COMPENSATION - Functional competence in relations to the
THEORY environment
- Emerged from the life-course perspective
Theoretical proposition FUNCTIONAL CONSEQUENCES THEORY
- Individuals learn to cope with the functional Theoretical proposition
losses of aging through processes of selection, - Aging adults experience environmental and
optimization and compensation. biopsychosocial consequences that impact
their functioning
KOHLBERG’S STAGES OF MORAL DEVELOPMENT
Theoretical proposition THEORY OF THRIVING
- An individual goes through a series of moral Theoretical proposition
reasoning activities that become progressively - Thriving is achieved when there is harmony
more sophisticated throughout life. between a person and his or her physical
environment and personal relationships
TORNSTAM’S THEORY OF GEROTRANSCEDENCE
Theoretical proposition
- Aging individuals undergo a cognitive
transformation from a materialistic, rational SOCIOECONOMIC ASPECTS OF AGING
perspective toward oneness with the • Workers 55 and older account for 18.8 percent of
universe. the labor force today- up from 17.6 percent at
the start of the current economic recession and
DISENGAGEMENT THEORY higher than any time since 194.
theoretical proposition •Their share of the workforce has increased by 7.1
- Aging is characterized by gradual percent over the last 21 months.
disengagement from society and relationships •The lack of access to retirement savings,
coupled with a massive financial market crisis
ACTIVITY THEORY leaves older workers scrambling for other sources of
Theoretical proposition income.
- Remaining occupied and involved is a • Benefits for those retiring today are less than they
necessary ingredient to satisfying late-life were for previous generations due to benefit cut—a
higher normal retirement age—enacted in 1983. This
CONTINUITY THEORY OR DEVELOPMENT THEORY Leaves wage earnings as the primary pressure valve
Theoretical proposition for cash-strapped retirees.
- Personality is well-developed by the time one
reaches old age and tends to remain SOCIAL CHANGES WITH AGING
consistent across the lifespan • Gradual isolation
- Geographical sense: moving away from
SUBCULTURE THEORY friends
Theoretical proposition - Physical sense: difficulty with traveling,
- Older adults is a unique subculture within the difficulty in seeing and hearing
society that is formed as a defensive response •Senior adult role
to society’s negative attitudes and the loss of - Loss of prestige, status and self-esteem.
status that accompanies aging. Older adults
prefer to interact among themselves. PSYCHOLOGICAL CHANGES WITH AGING
•Information processing
- Reaction time: increase with age older person is dependent on influences beyond
- Intelligence: the same until late into the aging the manifestations of their medical conditions.
process Among these are social, psychological and mental
- Learning: constant, given enough time to health, and environmental factors
learn Geriatric assessment also places high value on
- Memory: difficulty with short term recall, long functional status, both as a dimension to be
term recall remains intact evaluation and as an outcome to be improved or
- Problem-solving: less use of trial and error; maintained,
prior to giving solutions most older people Although in the strictest sense geriatric
“think through” assessment is a diagnostic process, many use the
•Personality term to include both evaluation and management
- Remains constant as one ages; becomes more setting where the patient is being evaluated.
and more pronounced than when the person In the hospital setting, the initial assessment is
who was once young; individual differences usually directed at the acute medical problem
become more pronounced that precipitated the hospitalization.
•Myth of senility As the patient, begins to recover and plans are
- Ageism: discrimination based on age, initiated for discharge, other components (eg,
employment, attitude towards the aged social support, environment) assume
- Gerontophobia: fear of old age; product of increasing importance in the assessment
high value contemporary places on youth The inpatient setting can be problematic for
•Retirement geriatric assessment because of the rapidly
- Represents reward for participation in labor changing status of several key dimensions.
force Nursing home geriatric assessment requires
- Ensure turnover of the labor force that attention be directed to selected aspects
- Decreased income of assessment such as nutritional status and
- Leaves older adults a “Roleless role” self-care activities.
Geriatric assessment conducted in the
EMOTIONAL CHANGES IN AGING patient’s home provides an opportunity for an
- Aging is associated with gains in emotional life entirely different type of assessment;
- Older adults increased ability to regulate environmental factors (eg, home safety) and
emotion aids in the enhancement of positive insights into functional status (eg cleanliness
emotions and down-regulation of negative of the home) can be directly assessed.
ones
- Frequency and duration of positive emotions COMPONENTS OF THE GERIATRIC ASSESSMENT
increase, those of negative emotions decrease In addition to the standard medical history
with aging and physical examination, the clinician should
- Older adults prefer emotionally satisfying systematically search for specific conditions
relationships over ones that are related to that are common among older persons and
knowledge-acquisition (limited time) that might have considerable impact on
- Aging increases emotional control= positive function.
emotion In the course of the traditional medical
- Older adults are especially unlikely to conform evaluation, these problems may go unnoticed
to others judgments when the judgment is because older patients fail to report them
related to emotion, such as identifying an spontaneously.
emotional facial expression For example, they may not recognize that
falling is a treatable medical problem.
PRINCIPLES OF GERIATRIC ASSESSMENT They may also be embarrassed to mention
Geriatric assessment is a broad term used to problems with maintaining urinary continence
describe the health evaluation of older patients, or with sexual function.
which emphasizes components and outcomes Finally, they may believe that these symptoms
different from that of the standard medical such as hearing loss, are normal aspects of
evaluation aging that cannot be helped.
This approach recognizes that the health status of
VISUAL IMPAIREMENT underrecognized.
Visual impairment is a common and Patients may be embarrassed to raise the
often underreported problem in the older issue; they may also regard it as a normal
population aspect of aging.
The standard method of screening for Urinary incontinence has been associated
problems with visual acuity is the Snellen eye with depressive symptoms in older adults and
chart is a major factor in nursing home placement.

HEARING IMPAIREMENT Asking two questions can screen for

Hearing impairment is among the most incontinence:
common medical conditions reported by >“In the last year, have you ever lost
older persons, affecting approximately your urine and gotten wet?” and if so
one third of those 65 years or older >Have you lost urine on at least six
Hearing impairment is associated with separate days?
reduced cognitive, emotional, social and
physical function, as well as increased BALANCE AND GAIT IMPAIRMENTS AND FALLING
hospitalizations, and the use of Over one third of community dwelling persons
amplification devices has led to improved over age 65 fall every year.
functional status and quality of life of Falls are independently associated with
older persons. functional and mobility decline.
Screening for hearing loss can be Patients who have fallen or have a gait or
accomplished by several methods balance problem are at higher risk of another fall.
The most accurate of these is the Welch The risk of falling can be assessed by asking all
Allyn Audio Scope 3 a handheld otoscope older patients if they have fallen in the last
with a built-in audiometer year, and then performing a multifactorial falls
A simple alternative is to rely on patient’s assessment by testing balance, gait and lower
own subjective report of hearing loss. A extremity strength
self-reported hearing loss question Observing patients walking and performing
involves asking patients whether they feel balance maneuvers best assesses balance and
they have hearing impairment. gait disorders
Another alternative is the whispered
voice test POLYPHARMACY
Polypharmacy in older patients is associated
Malnutrition/Weight Loss with adverse drug reactions, reduced
Malnutrition is a global term that adherence and inappropriate medication
encompasses many different nutritional usage.
problems that are associated with diverse Older persons often receive care from
health consequences. multiple providers and may fill prescriptions at
Both extremes of body weight place older several pharmacies.
people at risk for subsequent functional Patients should be instructed, therefore to
impairment, morbidity and mortality. bring in all current medications- both
Among community-dwelling older persons, prescription and nonprescription medications-
the most common nutritional disorder is to each visit, for a through medication
obesity. reconciliation and to check for a potential
In addition, a small percentage of community drug-drug interactions.
dwelling older persons have energy or protein
energy under nutrition, which places them at COGNITIVE ASSESSMENT
higher risk for death and functional decline. Because the prevalence of Alzheimer disease,
other dementias and cognitive impairment
Urinary Incontinence rises considerably with advancing age, the
Urinary incontinence (UI) is common, yield of screening for cognitive impairment
estimated to affect 11% to 34% of older men increases with age.
and 17% to 55% of older women, and is There is insufficient evidence on the balance
of benefits and harms of screening for independent household such as shopping for
cognitive impairment, but clinicians should groceries, driving, or using public transportation
assess cognition when there is suspicion of using the telephone, meal preparation, housework,
impairment. home repair, laundry, taking medications and
Several screens are available for clinical use handling finances whereas AADLs refer to the
and some can be performed in 5 minutes or ability to fulfill societal, community and family roles
less. as well as participate in recreational or occupational
Among hospitalized patients, mental status tasks.
should be assessed at the time of hospital These advanced activities vary considerably
admission and then periodically because older from individual to individual but may be
persons are especially prone to develop valuable in monitoring functional status prior
delirium during the hospital stay. to the development of disability.

AFFECTIVE ASSESSMETNT ASSESSMENT OF SOCIAL SUPPORT

Major depression and other affective The composition of the older patient’s social
disorders are common among older adults support structure can be assessed by asking a
and are likely under diagnosed, as symptoms few questions about relationship such as
may be underreported, present atypically or family, friends, neighbors and caregivers when
be masked by cognitive impairment or other obtaining the social history.
neurologic diseases such as Parkinson disease.
Given their association with increased The quality of these relationships should also
disability, health care utilization, morbidity be determined.
and mortality and decreased quality of life, For very frail older persons, the availability of
clinical detection and treatment of affective assistance from family and friends is
disorders is paramount. frequently the determining factor of whether
A brief two-item screening inquiry asks about a functionally dependent older person
the frequency of depressed mood and remains at home or is institutionalized.
anhedonia over the past 2 weeks. If dependency is noted during functional
assessment, then the clinician should inquire
ASSESSMENT OF FUNCTION as to who provides help for specific BADL and
Measurement of functional status is an IADL functions and whether these persons are
essential component of the assessment of paid or voluntary help.
older person Even in healthier older persons, it is often
The patient’s ability to function can be viewed valuable to raise the question of who would
as a summary measure of the overall impact be available to help if the patient becomes ill.
of health condition in the context of his or her Early identification of problems with social
environment and social support system. support may prompt planning to develop
Moreover, in older persons, the ability to resources should the necessity arise.
function consistent with their personal For vulnerable older adults, clinicians should
lifestyle desires should be an important be mindful of signs of elder abuse, neglect, or
consideration in all-care planning. exploitation and if suspected are mandated to
Measurement of functional status is also report cases.
valuable in monitoring response to treatment
and may provide prognostic information that ECONOMIC ASSESSMENT
will help plan for long-term care. Although some clinicians feel uncomfortable
Functional status can be assessed at three assessing the economic status of their patients,
levels: basic activities of daily living (BADLs), inquiring about financial stress may
IADLs, and advanced activities of daily living prompt referral to social work or other
(AADLs) agencies and help prevent the associated poor
BADLs refers to self-care tasks such as bathing, health outcomes.
dressing, toileting, continence, grooming, Furthermore, insurance status is routinely
feeding and transferring
IADLs refers to the ability to maintain an
collected by office staff and a patient’s income can be used in clinical practice.
assessed and eligibility determined for state or local Simply asking older persons whether religion
benefits. or spirituality is important to them may
For the frail and functionally impaired older provide insights that may facilitate their care
adult, clinicians should partner with patients Especially in hospital settings, involvement of
and families to provide anticipatory guidance pastoral care may be valuable in supporting
regarding the resources that may be required the patient and in framing medical decisions
to pay for care at home or in a residential facility. in the context of the patients personal belief system.

ENVIRONMENTAL ASSESSMENT ADVANCE DIRECTIVES

Environmental assessment encompasses two An advance health care directive enables
dimensions, the safety of the home patients to make sure that their health care
environment and the adequacy of the wishes are known in advance and considered
patient’s access to needed personal and it for any reason they are unable to speak for
medical services. themselves. It allows a patient to appoint a
Particularly among frail individuals and those durable power of attorney, or health care
with mobility and balance problems, the proxy who will have legal authority to make
home environment should be assessed for health care decisions in the event that patient
safety. is incapacitated or whereupon the patient
For those receiving home health services, in- grants such authority.
home safety inspections can be performed, Discussions of advance directives are
including recommendations for installations of especially important for older patients and
adaptive devices such as shower bars and should be initiated early on, to discuss the
raised toilet seats. patients goals and preferences for care should
Older persons who begin to develop IADL they experience progressive cognitive
dependencies should be evaluated for the impairment of acute illness.
geographic proximity of necessary services Physicians can assist patients by focusing on
such as grocery shopping and banking, their patients overall goals of care, rather than
need for use of such services and their ability specific detailed interventions and
to use these services in their current living incorporating these goals into the patients
situations, current clinical situation
Increasingly some of these services are A particularly important time to discuss such
available online through many older persons, preferences is prior to surgery because of the
particularly those who are frail do not feel possivility of surgical complications of
comfortable using the internet to purchase postoperative delirium which may preclude
services. discussions following the procedure.
Older drivers are at increased risk for motor Such discussions should be revisited any time
vehicle accidents secondary to functional there are significant changes in a patients
impairments, medications and medical medical condition and a better understanding
conditions. about prognosis becomes available as patients
often revise their thoughts about the burdens
SPIRITUALITY Cultural differences regarding preferences for
Spirituality whether affiliated with a formal advance directives and end of life care should
religious denomination or nonreligious be recognized and respected
intangible elements, has increasingly been Overall patients are receptive and grateful for
recognized as an important influence on discussion of their goals and preferences for care and
health and quality of life. increasingly advanced directive counseling
Frequent attendance of religious services has discussions have been incentivized and recognized in
been associated with lower health care quality of care measures, with various tools being
utilization and mortality rates. developed to support advanced care planning in
Formal instruments for assessing spirituality practice.
have been developed such as the FICA tool for
spiritual assessment, but these are not widely