Long Term Care, Geriatrics and Gerontology

OverviewLong  Term Care - Health Architecture

Long Term Care (LTC) is medical and support services provided to someone who may have lost some or all capability to function on their own due to illness or a condition, and who are expected to need these services over an extended period of time. Many times this service is used for the aging but is not limited to it. Long term care can be care given at home or employed help, adult day health care, or care in assisted living or skilled nursing facilities. The American Health Care Association is one of the largest associations of long term care providers and advocates for the quality of care for the frail elderly and disabled Americans. The American Association of Homes and services for the Aging (AAHSA) helps individuals and their families by providing services that people need and when they need them in there home.

Who Pays for Long Term Care?
Medicaid: 42%

Medicare: 25%
Out of Pocket: 22%
Private Insurance and Other Sources: 11%

Types of long term care facilities include:There are 16,100 certified nursing home in the United States. There are more then 1.7 million nursing home residents in the the US. The average age when an individual enters a nursing home is 79. By 2020 12 million Americans will need long-term services and support.

History

12th Century Long term care has been in England from the 12th century and these facilities provided care for the elderly and the disabled.
<1450's long term care was associated with monasteries and the overseer was someone appointed by the king and bishop.
1536King Henry VIII closed the monasteries and the long term care facilities
1546A law similar to our current Medicaid law, the Poor Law was initiated by Kind Henry VIII stated that the sick and poor elderly could bee cared for better in a long term care facility in England
1722: institution established in Philadelphia, Pennsylvania, US ,
1734institution established in New York City, New York, US
1735:Institution established in Charleston, South Carolina, US
18th and 19th century: Homes in most American cities were prominent and flourished
1930'sNew Deal in America promotes the idea that elderly citizens should receive federal benefits. Social Security is now universal.
1933Adult day care started in Moscow to solve a psychiatric bed shortage
1935 Social Security Act
1943Great Britain adopts a similar program as Moscow to maximize health-care resources for war veterans.
1950's:subsidies were offered to anyone who erected a nursing home, and therefore there was a building boom that produced many nursing homes
1950'sAmendments to Social Security Act which included requirements that require licensing for nursing homes.
1950's: adult day care centers were set up throughout the UK. Canada and South Africa soon followed
1960's: the first adult day care program started in US, The Older Americans Act was established and supported the development of programs that provide social and recreation services for seniors
1965:Medicare and Medicaid were added to the Social Security Act.
1967Congress authorizes the first set of standards that were to be met by nursing facilities and created classifications for skilled nursing and intermediate care facilities.
1977: 200 Adult day care programs were listed in the directory of adult day care programs by the National Council of Aging
1980's:Special Care Units start appearing
1980: 600 Adult day care programs were listed in the directory of adult day care programs
19861,200 adult day care programs under the National Institute of Adult Day Care Centers.
1987Omnibus Budget Reconciliation Act of 1987 requires that that facility provides each patient with care that will allow the patient "to attain or maintain the highest practicable physical, mental and psychosocial well-being."

20 Most important Design Issues and Considerations according to Victor Regnier

  1. residential appearance
  2. stimulate social Interaction
  3. develop outdoor spaces as rooms
  4. make certain that the bathroom is safe
  5. respect the privacy of residents
  6. create a friendly, comfortable interior
  7. invite family and friends
  8. provide variety and control of lighting
  9. provide ventilation that eliminates odors
  10. create an accommodating Environment
  11. facility should be open and connected to the community
  12. provide a barrier free environment for everyone
  13. provide a place for people with dementia
  14. design a compact building plan
  15. provide a realm between the inside and outside
  16. facilitate staff behaviors that benefit residents
  17. focus on sensuous activity and beauty
  18. provide passive and active entertainment
  19. ensure safety and security
  20. encourage choice, control, autonomy and independence

Terms


Assisted Living is housing that provides individual spaces to a paying consumer. These facilities offer 24 hour on site staff, dining, and programs.Nursing services may be available and provided but with an additional fee. Assisted Living is defined as "a senior living option that combines housing, support services and health care, as needed. Assisted living is designed for individuals who require assistance with everyday activities such as meals, medication management or assistance, bathing, dressing and transportation. Some residents may have memory disorders including Alzheimer's, or they may need help with mobility, incontinence or other challenges. Residents are assessed upon move in, or any time there is a change in condition. The assessment is used to develop an Individualized Service Plan," according to the Assisted Living Federation of America.

Continuing Care Retirement Center is a facility that you can live at for the rest of one's life and move from independent, assisted and nursing care based on what the needs are. They are also known as Life care facilities

Hospice is care given to a person in their last stage of life. Care is very often provided at home by a professional, but care is also giving at many nursing facilities. Hospice is usually offered for the last 6 months of ones life, to help comfort and counsel.


Naturally occurring retirement communities (NORC's) are communities like an an apartment building that have become senior housing. These residents have choosen to live in a community but may need more services.

Nursing Facility (NF) can give custodial care, rehab care including physical, occupational or speech therapy. They may also proved specialized care for Alzheimer's. The facility provides nursing staff 24 hours, dinning and programs.

Alzheimer's/dementia care is given during the mid to late stages and high levels of skilled professionals are needed for care and treatment

Rehabilitation: Some nursing homes have rehab centers for temporary use for those recovering from and injury, operation or illness

Sources:
AAHSA: American Association of Homes and Services for the Aging. 2010. Web. 03 May 2010. <http://www.aahsa.org/facts/>.
"Continuing Care Retirement Communities (CCRCs)." Helpguide.org: Understand, Prevent and Resolve Life's Challenges. Helpguide, 2009. Web. 08 Mar. 2010. <http://www.helpguide.org/elder/continuing_care_retirement_communities.htm>.
"Nursing Home Abuse Resource - History of Nursing Homes!" Nursing Home Abuse Resource - Nursing Home Abuse Lawyer - Elder Abuse in Nursing Homes! Nursing Home Abuse Resource, 2002. Web. 03 May 2010. <http://www.nursing-home-abuse-resource.com/nursing_home_abuse/history.html>.

Perkins, Braford, J. David Hoglund, Douglas King, and Eric Cohen. Building Type Basics for senior living. Ed. Stephen A. Kilment. Hoboken: John Wiley & Sons Inc, 2004. Print.
Regnier, Victor. Design for Assisted Living. New York: John Wiley & Sons, 2002. Print.
"What is Assisted Living? Assisted Living Information:." ALFA. Assisted Living Federation of America, 2009. Web. 23 Feb. 2010.

Gerontology and Geriatrics

Although somewhat similar in the object of study, there is a large different between Gerontology and Geriatrics. Gerontology is the study of the aging process, while Geriatrics is the study of health and disease later in life.
Geriatrics consists of the comprehensive health care of older persons and their overall well-being. Geriatricians are doctors that see patients, usually in a clinical setting, and deal with the diagnostics and treatment of diseases specific to elderly patients.
Gerontology studies the physical, mental and social changes occurring as people age. It includes the effects of aging on society, different policies and programs for the aging population, as well as the interface between normal aging and age-related diseases. Occupations involved in gerontology can include: biology, medicine, nursing, dentistry, social work, physical therapy, psychology, psychiatry, architecture, pharmacy, sociology, housing and many others. Gerontology is more all encompassing than geriatrics, as it does not only rely on the medical aspects to treat the elderly.
Both of these studies, however, are critical to knowing about the geriatric community. In order to fully understand the elderly and how to improve their healthcare, you need to know not only the process of aging and issues related to it, but also the diagnostics and treatment model.

Common Geriatric Conditions

Often times elderly patients have more than one chronic condition affecting their health. The most common conditions that affect elderly patients include: cancer, hypertension, cardiovascular disease, congestive heart failure, cataracts, pneumonia, back pain, lack of strength, osteoarthritis, osteoporosis, dementia, prostate problems, depression, diabetes, stroke and urinary incontinence. Not only are these conditions part of geriatric care, but elderly patients must also deal with their bodies deteriorating due to old age and the risks that accompany that. As you get older, you are more prone to falling due to a loss of postural control, gait and visual ability, and the presence of acute and chronic diseases.
There are many parts of the body that get worse as you get older. For example, your vision, hearing, continence and mental status all decrease in patients over 65. The prevalence of visual impairment is very high in elder patients, some are due to cataracts, glaucoma, diabetic retinopathy or age related macular degeneration. Hearing loss occurs in 14-46% of the elderly, and a little less than half of those with hearing loss actually use hearing aids. Up to 34% of men and 55% of women experience incontinence, which have extreme social and emotional consequences in elderly patients. Often times these patients are too ashamed to tell their primary care physicians about these issue and therefore are rarely cured. Mental status is often times one of the most difficult issues of decline in the elderly. People often decline cognitively or experience depression. Cognition issues often involve dementia, which is chronic and progressive. Dementia impairs memory and causes deficits in cognition. Depression is a very serious issue in older patients. It not only can onset rapidly, but also increases morbidity and mortality. If treated it can be limited in duration, and greatly improve quality of life.
Lack of physical exercise is also a common condition in the elderly. Their bodies are weaker, and their joints hurt more often than not. By exercising, although sometimes hard to believe, these daily pains and problems can be relieved. Not only is exercise great for the body, joints and all, but is increases one’s life span by about 6 years. Obesity is one of the worst issues facing older people, even more so than younger people, because it leads to joint degeneration, heart problems, stroke, congestive heart failure, and diabetes. Although these are all conditions a younger person can attain, older people are more prone to these diseases, and by being obese; their chance at one of these conditions being fatal is more likely. Another aspect that exercise can help is depression. By exercising, people feel more in control of their lives, which at an old age can be lost. Being able to feel in control often helps with reducing depression.
Depression is one of the biggest issue that the elderly face. People 65 and up have 4 times the national suicide rate as a result of depression. Although being sad or depressed seems like more of a common issue in older adults, it can be treated just as effectively as in younger patients. Older adults aren’t a lost cause, and they want help with their depression as much as anyone. Over 70% of elderly suicide victims saw their health practitioner within one month of committing suicide.

Aging Community and Healthcare

The demand for geriatric care is greatly increasing. Not only are Americans living longer, but the population of geriatric aged patients is about to be at an all time high. By 2030, people of 65 years and older are expected to account for nearly 20% of the population. Also, as adults age, they account for a larger share of healthcare services. Elderly adults account for about 26% of all physician visits, 35% of all hospital stays, 34% of prescriptions, 38% of emergency medical responses and 90% of nursing home use.
Many times people underestimate the elderly in this country. Sometimes people give up on the elderly because they think they can’t learn anymore, or change at a certain point in their lives. Doctors often attribute illnesses or discomfort to the fact that a person is old and that their bodies and minds are failing. While these opinions aren’t always the case, it is discerning to know that in America, the elderly are perceived as useless, when in fact this is not the case. Older people can still learn, retain memory and be actively involved in a community. It is when people lack exercise, and mental stimulation that they begin to actually loose their minds and bodies.
While the percentage of geriatric specialized doctors is decreasing, their usefulness and need is greatly increasing. Often times doctors who do not have this specialty, underestimate the fragility and ability of the elderly. Not all discomfort is caused by aging bodies, and not all mental deterioration is caused by aging minds. The elderly can easily be misdiagnosed, because this healthcare system tries to find one issue wrong with people, and with the elderly that is very rarely the case. Christine T. Cigolla, MD, and MPH at the University of Michigan said, “The disease management model is directed toward individuals with a single disease that dominates their health care utilization; this model is less able to address older adults whose health care use is related to multiple diseases, conditions, and disabilities that affect one another.”


Medications

Currently, the elderly population comprises 13% of Americans and yet they consume over 30% of prescription drugs. Around 30% of those patients have adverse drug reactions; this is due to the fact that on average an elderly person takes 4.5 prescription drugs.
Adverse drug reactions account for 20% of all hospital admissions, and over 50% of the deaths attributed to this are for those over the age of 60. Drug reactions also can cause falls in older people which often cause larger issues. Elderly patients absorb the pharmaceuticals differently than younger patients. Sometimes they absorb drugs faster, and other times slower due to blockages in diseased cells. This is why it is so difficult to prepare proper dosages for elderly patients, but it is also a very important part of their overall health care. Elderly patients are more susceptible to adverse drug effects, and medication errors are even more potentially fatal for these older patients.

Case Studies

This case study shows the effects of age discrimination. Although most times, old age is a reason for some discomfort, both physical and emotional, but sometimes looking deeper into a situation is necessary.
A 71-year-old woman has surgery on her shoulder for a bone spur that is causing her considerable pain. The surgery is successful and she goes through several months of physical therapy to help her recover. But she is not recovering as expected. She continues to experience pain that radiates through her entire back. Her physical therapist does not know how to help her and attributes her failure to recover to old age. She visits her family care doctor at least twice over the next six months complaining of extreme tiredness and lack of energy. Her skin color is gray and she does not look healthy. Finally she visits her doctor and insists he check her for some problem since she is not recovering from the surgery and she feels awful. After her insistence he does a CBC blood lab and discovers she is severely anemic. He puts her in outpatient care and gives her four units of red blood cells and puts her on iron supplementation. Within two weeks the pain has disappeared and within a month she has recovered fully from the surgery. Numerous tests are done but there is no explanation for the anemia. Six months later she is healthy and active and her cheeks are ruddy. When she asks her doctor why he did not suspect anemia he tells her that she has never had anemia and based on her history he would never expect her to develop it. (He obviously has no training in geriatric care.) He then tells her, in an obvious contradiction of his previous position, that older people sometimes fail to absorb iron. Ironically, she defends the action of her doctor and does not feel he acted inappropriately.


Senior Housing Options

There are many different housing options for aging people. Many of those options depend on the activity level of the elderly person. There are many more options for more active people, and as the level of care increases the options tend to decrease. The different options of housing and level of care needs to be discussed in length with physicians as well as the family and elderly person or persons living there. The options for senior living include:
-Age restricted “retirement communities” which are similar to other neighborhoods or communities but restrict the ages from 55 and up to 62 and up. The 55 year restricted communities allow children and families, but require one member to be above the 55-year limit. The 62 year and up communities require each individual to be above the given age.
- Seniors only apartments, which allows seniors independent living with less maintenance and chores, as well as a better sense of security than they would at home. It also helps free up equity, which can then be supplemental income.
- Modular home communities allow full time or part time residents. The lots or mobile units are either leased or owned.
- ECHO housing, or Elder Cottage Housing Opportunity, allows seniors to occupy a second family living unit or apartment with a separate entrance. These houses or apartments are located on a single-family lot and there is another family living in the other unit. These units are permitted to foster affordable housing.
- Shared housing is when two or more people who share a home. Usually all roommates are seniors but technically the roommate could be of any age. With this type of living, there are many professional organizations that specialize in these arrangements in order to get the best combination of roommates possible.
- Continuing Care Retirement Communities (CCRC’s) offer life care. These communities offer active seniors the ability to stay independent in a private home, but also provide multiple levels of care. As a senior decreases in ability, this community is able to continue to care for him/her without the need to move.
- Congregate Housing offers independent living in separate apartments with the opportunity to share activities of daily living with other residents. With these units, the housing can be rented or owned.
- Assisted Living is a living option that offers help with non-medical aspects of the daily lives of the residents. Each resident lives in a separate private living unit, usually an apartment, but is less able to function independently.
- Board and Care (Residential Care or Foster Care) is usually offered as a converted home. It is similar to assisted living but offers a little more independence. It provides a more homelike setting but allows supervision and care for 4-10 residents.
- Skilled Nursing Facilities are facilities that specialize in many types of nursing care, often including: short term, acute, intermediate or long term care. Sometimes these facilities can be part of a senior community or can be freestanding.
- Alzheimer’s Facilities differ depending on the stage of care needed. During the early stages of Alzheimer’s, people can be accommodated in assisted living facilities. As this disease progresses, and patients develop argumentative behavior and wandering habits. These stages are best equipped for Alzheimer’s communities.
-Senior Day Care provides “custodial care” with programs for stimulation and rehab. These facilities are also able to provide medical care and do un-invasive medical procedures.
- Senior Short Term Housing allows seniors to take advantage of a senior community in a distant location. It gives seniors the opportunity to try a housing unit before buying it, or the opportunity to vacation in a senior community for months at a time.
Overall, there are many different types of housing, and most depend on your activity or ability as a senior, it is up to the family or elderly person to decide which would work best for him or her. ("Housing Choices.")


Designing for the Elderly

Overall, in order to design for the aging population you need to understand the different changes occurring and the aging process. You must understand the physiological and psychological changes occurring with age.
People want to remain as independent as possible for as long as they can. Sometimes this means someone with live in their home until their death, but other times a person needs to move elsewhere to get the care that they need. Throughout his transition, it is important to make sure that a person feels independent and respected. To design for these situations, you must think about privacy, making a place fee like home, while also taking into considerations the physiological complications occurring as one ages. For example, stairs are difficult after a certain age, low and high cabinets are difficult to reach. Sitting on a low (or normal height) toilet becomes difficult without grab bars. Getting up from a chair or bed is a challenge. Lighting needs to be at a proper level, not too dim, but also not too bright to cause glare on certain surfaces.
Another aspect to consider when designing is the difficulty of socializing. As you get older leaving your house or apartment gets more difficult, and the motivation declines. You must make sure everything is easily accessible, and plan easy transportation or access to other places. Socializing is very key with elderly people, this can help with depression and over activity levels.
Design for yourself and take into account that moving and socializing will get harder. Architecture, urbanism, and products and services need to compensate for that. I believe that sustainability (saving the planet) and designing for an aging society are the two biggest topics we as designers have to tackle in our lifetime” Matthias Hollwich. Overall, the most important aspect to design for is you. What or how would you want to live when you get older? Once you figure that out, alter certain pieces for mobility and vision constraints.

Sources
"Can Architecture Help the Elderly Age Gracefully?" Co.Design. Co. Design. Web. 9 May 2012. <http://www.fastcodesign.com/1662258/can-architecture-help-the- elderly-age-gracefully>.
Day, Thomas. "About Medical Care for The Elderly." Medical Care for The Elderly. National Care Planning Council. Web. 8 May 2012. <http://www.longtermcarelink.net/eldercare/medical_care_issues.htm>.
"The Demand For Geriatric Care and the Evident Shortage of Geriatrics Healthcare Providers." The American Geriatrics Society. July 2011. Web. 8 May 2012. <http://www.americangeriatrics.org/files/documents/Adv_Resources/PayReform_fact5.pdf>.
"Elderly People and Design." Lund Institute of Technology. Web. 8 May 2012. <http://www1.design.lth.se/aldreochdesign/elderlypeopleanddesign_screen.pdf>.
"Housing Choices." Senior Resource Housing Choices for Seniors. Senior Resource. Web.8 May 2012. <http://www.seniorresource.com/house.htm>.
Miller, Karl E., Robert G. Zylstra, and John B. Standridge. "The Geriatric Patient: A Systematic Approach to Maintaining Health." American Family Physician. AAFP, 15 Feb. 2000. Web. 8 May 2012.<http://www.aafp.org/afp/2000/0215/p1089.html>.
Tye, Alan. ""Design and Elderly People"" "Design and Elderly People" - RSA Commentary. RSA Journal, 1991. Web. 10 May 2012. <http://www.alantyedesignstudio.co.uk/rsacomm.htm>.
Warner, Jennifer. "Common Geriatric Conditions Overlooked." WebMD. WebMD, 6 Aug. 2007. Web. 9 May 2012. <http://www.webmd.com/healthy-aging/news/20070806/common-geriatric-conditions-overlooked>.
"What Is Gerontology? Geriatrics?" Careers in Aging. Andrus Foundation, 2001. Web. 9 May 2012. <http://www.careersinaging.com/careersinaging/what.html>.
Zwicker, DeAnne, and Terry Fulmer. "Medication: Nursing Standard of Practice Protocol: Reducing Adverse Drug Events." Geriatric Nursing Resources for Care of Older Adults. Hartford Institute for Geriatric Nursing, Apr. 2008. Web. 10 May 2012. <http://consultgerirn.org/topics/medication/want_to_know_more>.
Also see Used Sources and Websites of Interest