Transcript Community based Services

Community Accessibility
for the Geriatric Client
Learning Objectives
• Apply the general principles of designs to
create a safe environment for geriatric clients.
• Discuss the factors affecting driving safety
and the decision to stop driving in geriatric
clients.
• To describe the commonly available public
and private transportation resources
available.
• Identify public and private housing options for
the geriatric client.
Reading assignments
• Guccione: Ch 7 (pp. 113-120 only), Ch11 (pp.
222-227 only)
Environmental design principles
• Environmental press
―The extent to which an environment demands a
behavioral response
• Competence
―The ability of the person to respond adaptively in
health, social roles, sensory-motor, cognition
• Problems with high environmental demand
―Incompetent people will have maladaptive behavior
• Solutions
―change competence through rehab or modify the
physical environment (easier)
Living space
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Enhance lighting
Supplement task light by desk/chair
Avoid direct lighting in the corridor
Minimize flickering
Warm white bulbs
Provide good color contrast for visual cues,
e.g. floor vs. wall, grab bars vs. floor
• Minimize the effect of glare, e.g. use
blinds/curtains
Living space
• Avoid figure ground or repetitive patterns
• Avoid escalator (repetitive patterns may
cause optical illusion and impaired depth
perception)
• Consider ribbed vinyl or rubber stair nosing of
a contrasting color
• Light switches and night lights by the stairs
• Clear visual cues to indicate the edge of each
step
Living space
• Low pile carpets, or vinyl or linoleum flooring
with non-glare wax
• Appropriate ceiling/drapes materials to
absorb noise
• Minimize background noise
• Do not play music
Definitely not this!
Comment on the designs of this
corridor
Problems with multifocal glasses
• Multifocal glasses (bifocals, trifocals,
progressive lenses) may increase fall risk in a
challenging environment, e.g. stairs
• Focal distance for viewing the environment
―Normally = ~1.5 to 2 m
―Lower lenses of multifocal glasses = 0.6 m
• As a result, individuals wearing multifocal
glasses may have blurred vision, impaired
contrast sensitivity and depth perception, and
thereby increasing fall risk
Problems with multifocal glasses
• Wearers of multifocal lens had significantly
greater odds of falling than non-multifocal
lens wearers. The falls were more likely to
occur outside the home and when walking
up- or downstairs.
Consideration for older adults with
dementia
• Amount, type, and variety of environmental
stimuli can affect function and QoL of
individuals with dementia
• Under- or overstimulation can lead to
confusion, illusions, frustration, and agitation
―Inadequate lighting levels can cause agitation
―Visual misperceptions (difficulty differentiating reality
from representation), e.g. photographs in room may
be perceived as people watching them, TV is
perceived as reality
―Excessive noise and auditory hallucination
WORKING IN LATE LIFE
http://www.workinglate.org/research/later-life-working/
Working in the later years
• Stigma of the older worker is unproductive
and lazy
• 8 out of 10 boomers plan to continue to work
after 65
• 72% of those 70 y.o. who are working are
part time in ‘service based’ occupations
• Problems of working in late life
―Physical demands, traveling to work, use of
communication technology, lack of promotion, care
responsibilities
The continuation of ‘work’ after
retirement
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Volunteerism
Learning: tutoring, new skills, academic work
Mentorship
Retirement brings opportunities for vocational
wellness
―Matching core values with interest, hobbies,
employment, and volunteer work
―Provide a sense of purpose
―Enrich mental health and overall wellness
DOL: Senior community services
employment program (SCSEP)
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Department of Labor www.doleta.gov/seniors
Job training and employment assistance
Authorized by the Older Americans Act
Eligibility
―Unemployed people 55+ y.o.
―Family income <25% over the federal poverty level
―Priority for people >60 y.o., veterans, their spouses
• Work on average 20 hours a week at
―Non-profit and public community facilities, e.g. day
care, senior centers, governmental agencies, schools
―Receive the highest of federal, state, or local min
wage
Age discrimination in employment act
(ADEA)
• www.eeoc.gov/laws/types/age.cfm
• Age Discrimination
―Treating someone (an applicant or employee) less
favorably because of his or her age
• Age Discrimination in Employment Act
―Only forbids age discrimination against people
who are 40+ y.o.
―It is NOT illegal for an employer to favor an older
worker over a younger one, even if both are age 40+
―Discrimination can occur when the victim and the
person who inflicted the discrimination are both 40+
DRIVING IS THE ULTIMATE
COGNITIVE–MOTOR MULTITASKING
ACTIVITY!
Factors affecting driving performance
in older adults
• Chronological age alone is NOT a useful
indicator of driving ability
• Risk of accident increases with
―Certain diagnoses, e.g. dementia, depression, and
other psychological disorders, diabetes, sleep apnea,
alcohol use/abuse, and cataracts
―A fall in the previous year
―Orthostatic hypotension
―Any medication that affects efficacy of CNS or level of
consciousness may impact attention, decision
making, and ability to respond to challenges
Factors Affecting Driving Performance of
Aging Adults (Box 11-3)
Considerations for visual changes in
older drivers
• Static and dynamic visual acuity
―Correct vision
―Modify driving behaviors in low light
―Dynamic visual skill training (gaze, smooth pursuit)
• Visual field
―Turn heads or use mirrors for lateral visual field
―Look upward to see signs
• Depth perception
―Difficulty judging distances
―Should avoid driving if unable to compensate
Considerations for visual changes in
older drivers
• Repeated optical
patterns can cause
visual depth illusion
• Dark adaptation/glaring
o Avoid night driving
o Avoid looking at
oncoming headlights
o Travel on divided
highways or well-lit
roads
o Improve safety
standards of highway
designs, e.g. divided
lanes, better delineation
of on/off ramp
Considerations for cognitive changes
in older drivers
• Tests of cognition and memory (e.g. MiniMental) alone are NOT strongly predictive of
driving safely
• Tests of visual spatial skills, attention, and
reaction time are more predictive of driving
safety (e.g. Trail Making A & B to test executive
function)
• Drivers with early- to mid-stage dementia may
overestimate their abilities and become
confused with challenging road conditions
• Periodic on-road testing is recommended
• Family may have to take away the car key
Driving behaviors associated with
cognitive decline
• Getting lost, especially in surroundings that
were previously familiar
• Going through stop signs or red lights
• Getting lost, especially in surroundings that
were previously familiar
• Going too fast or too slow for safety
• Having problems making turns at
intersections, especially left turns
• Having trouble seeing or following traffic
signals, road signs, and pavement markings
Driving behaviors associated with
cognitive decline
• Misjudging gaps in traffic at intersections and
on highway entrance and exit ramps
• Receiving traffic tickets or “warnings” from
traffic or law enforcement officers
• Responding more slowly to unexpected
situations
• Straying into other lanes
Resources about older adult driving
safety for patient and family (Box11-4)
• AARP Driver Safety Programs
― 888 687-2277 or www.aarp.org
• AARP “We need to talk” Guide
― www.thehartford.com/talkwitholderdrivers
• AARP “We need to talk” Seminars
― 202 434-3919 or http://www.aarp.org/homegarden/transportation/we_need_to_talk/
• AAA Senior Drivers
― http://discover.aaa.com/PGA/SeniorMobility
• AAA self-test, Drivesharp calculator, 55+ driving
ability, Carfit, Safe driving for mature operators
― www.seniordrivers.org/home/
Resources about older adult driving
safety for patient and family (Box11-4)
• NHTSA Older Drivers
―http://www.nhtsa.gov/Senior-Drivers
• Caring.com Guide to Driving: assessing
driver fitness, safe senior driving, taking the
keys, life without a car
―www.caring.com/older-drivers
• State Driving Laws
―www.caring.com/calculators/state-driving-laws
• Association for Driving Rehabilitation
Specialists
―www.driver-ed.org or 866-672-9466
Resources about older drivers safety
for health professionals (Box 11-5)
• National Highway Traffic Safety
Administration Driving fitness assessment
and educational tools
―http://www.nhtsa.gov/Driving+Safety/Older+Drivers
• National Council on Safety
―http://www.nsc.org/safety_road/Pages/safety_on_the
_road.aspx
Discussion about driving with family
and older adults (Box 11-6)
Indicators That Driving May No
Longer Be Safe (BOX 11-7)
• Almost crashing, with frequent “close calls”
• Becoming distracted or having difficulty concentrating
while driving
• Changing lanes without signaling
• Difficulty moving foot between gas and brake pedal;
confusing gas and brake pedals
• Difficulty turning around to check for cars or obstacles
when backing up or changing lanes
• Experiencing road rage
• Finding dents and scrapes on the car, on fences,
mailboxes, garage doors, curbs, etc.
• Frequently being “honked at” by other drivers
Transportation Options
• Volunteer driver programs
―May be free, or minimal fee
―Membership may be required
―Reservation required
• Para-transit Service
―Curb to curb, or door to door service
―Reservations required
―Use minibus (less than 25 people) or other forms of
transportation
• Taxis
seniortransportation.easterseals.com/site/PageServer?pagename=NCST2_homepage
National Center on Senior Transportation
Transportation Options
• Door through door escort service
―private agencies assist with physical help of getting
out of home and to destination, levels of assistance
vary
• Public transit
―No reservation required, mass transit, reduced fares
for elderly or disabled
• Transportation vouchers program
―qualified persons purchase vouchers at a reduced
rate, require reservations, must apply for service
• Mobility managers
―available in some communities
Transportation Items to consider
• Accessibility
―service area
―times of service, how long between stops
―social or just medical rides
• Eligibility
―income requirement
―w/c users assisted
―can family members escort?
• Affordability
―costs, membership fee
Needs for community based services
• Majority of older adults want to remain at
home until they die (AARP, 2003)
• In order to stay at home, help with services
outside of the family is needed
Home modification
• Adaptations to accommodate a person’s
changing physical needs
• Make it more accessible
• Can use AT (Assistive Technology)
• Ranges from simple (grab bar) to complex
(ADA accessible home)
• 83% of older adults want to age in place but
the majority of the housing is not appropriate
for the person (e.g. stairs, bi-level, home
maintenance)
Paying for home modifications
• Title III of the Older Americans Act
―Funds distributed by area agency on aging. (1-800677-1116)
• Rebuilding Together, Inc.
―a national volunteer organization
―assist some low-income seniors
• Low-income home energy assistance
program (LIHEAP) and the weatherization
assistance program (WAP)
―Both programs are run by local energy and social
services departments
Paying for home modifications
• Medicare/Medicaid
―usually only covers items that the physician
prescribed
• Community development block grants
• Home equity conversion mortgage
―borrow against the equity in your home
• The National Directory of Home Modification
and Repair Resources
―List of home modification and repair providers
―Not an endorsement - Use with caution!
―http://www.homemods.org/directory/index.shtml
Other home management programs
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Utility or energy assistance
Home equity conversion
Home maintenance and repair
Rental assistance
Government housing assistance
• Low income, rental or own, local housing
authorities.
• Provides assistance to a majority of older
renters who have excessive housing costs.
• Provides low-income elderly with serviceenriched options to live independently.
• Other offices
―USDA Rural development office, Dept of Housing and
Community Development, State Housing Finance
Agencies
Administration on Aging 2009
Types of Government Housing
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HOPE for Elderly Independence Program
Housing Choice Voucher / Section 8 Program
HOME Investment Partnership Program
Public Housing
Rural Housing Service (RHS) - Rental
Assistance Program (Section 521)
HOPE for Elderly Independence
Program
• Homeownership and Opportunity for People
Everywhere (HOPE) program
―provides a combination of HUD Section 8 rental
assistance with case management and supportive
services to low-income elderly persons.
• Purpose is to give housing to frail elderly to
prevent going to nursing homes
• Eligibility
―over 62, difficulty with at least 3 ADLs or home
management
• HUD at (202)708-1112
Administration on Aging 2009
Housing Choice Voucher/Section 8
Program
• Provides very low-income families, the elderly,
and persons with disability affordable, decent,
and sanitary housing in the private market.
• Participants choose any housing that meets the
requirements of the program
• Eligibility is determined by the public housing
agencies.
―In general, not exceed 50% median household
income, US citizens and some non-citizens
• portal.hud.gov/hudportal/HUD?src=/topics/housi
ng_choice_voucher_program_section_8
HOME Investment Partnership
Program
• HOME is authorized under Title II of the
Cranston-Gonzalez National Affordable
Housing Act
• HOME provides grants to States and local
communities to fund activities that build, buy,
and/or rehabilitate affordable housing for rent
or homeownership or provide direct rental
assistance to low-income people
• http://www.hud.gov/offices/cpd/affordablehou
Administration on Aging 2009
sing/programs/home/
Public Housing
• Affordable, decent, safe housing for elderly or
disabled
• Pay no more than 30% of income for housing
• Eligibility based on
―low income, status (elderly & disabled 1st), citizenship
• Through local PHAs
• portal.hud.gov/hudportal/HUD?src=/program
_offices/public_indian_housing/programs/ph
Rural Housing Service (RHS) - Rental
Assistance Program (Section 521)
• Rural Americans, rent subsidies
• Pay no more than 30% of income
• Eligibility
―People with very low (50% of area median income)
and low incomes (50% and 80% of area median
income), the elderly and persons with disabilities who
are unable to pay the rent within 30% of monthly
income
• www.rurdev.usda.gov/rhs/mfh/brief_mfh_rra.
htm . (202)720-4323.
Section 202 Supportive Housing for
the Elderly Program
• Provided by private, nonprofit housing and
service-oriented organizations that have
received capital advances from the
government to finance the construction and
rehabilitation of structures.
• Supportive services include meals, cleaning,
transportation etc.
• Eligibility: 62 or older, income
• http://portal.hud.gov/hudportal/HUD?src=/pro
gram_offices/housing/mfh/progdesc/eld202
Selection preferences
• People experiencing high rent burden (rent is
greater than 50% of income).
• Residents who live and/or work in the
jurisdiction.
• The homeless or those living in substandard
housing.
• Veterans and veterans’ families.
• Victims of reprisals or hate crimes.
• Working families and those unable to work
because of age or disability. Administration on Aging 2009
Home matching service
• Service connects those that need a home
with those that have available space
• Provides additional income, companionship
and help with chores
Homestead exemption
• Government programs that offer reduction in
property taxes for income eligible or disabled
homeowners
Supportive Services and Senior
Centers
• Grants are provided to states to fund
programs for those older than 60
• Access services such as transportation, case
management, and information and assistance
• In-home services such as personal care,
chore, and homemaker assistance; and
• Community services such as legal services,
mental health services, and adult day care.
Budget breakdown for Supportive
Services and Senior Centers in 2007
• Transportation: 27 million rides
• Personal care, homemaker, chore services:
28 million hours of assistance
• Adult day care: 8 million hours of care
• Case management: 4 million hours of
assistance
• Legal services: 968 thousand hours of
service
• Cost: $350 million/yr
How to get services
• Through information and referral from a
community organization or center
• Case management: health or social service
agency has a SW or nurse to assist
• Outreach: actions taken by social service
providers to reach older adults and
encourage their use of resources
Resources
• Eldercare Locator
www.eldercare.gov
800.677.1116
―The Eldercare Locator is first step to finding
resources for older adults in any U.S. community and
a free service of the U.S. Administration on Aging.
• American Bar Association Commission on
Law and Aging
202.662.8690
―www.abanet.org/aging/resources/statemap.shtml
―The Commission is dedicated to strengthening and
securing the legal rights, dignity, autonomy, quality of
life and quality of care of elders.