ONE FIRST BEGIN WITH Promotion of good health, HEALTHY-AGEING FOR THOMAS MACARTY BASED ON THE PERSON CENTERED CARE APPROACH AND ABOVE ARGUMENTS .
• DISCUSS FUNCTIONAL DECLINE IN OLDER ADULTS -
• MAYBE SUMMERISE BELOW AND FIND AN APPROPRIATE Q 3-4 references (PLZ REFER ABOVE ARGUMENTS AND INFORMTION BELOW FOR DETAILS)
Promotion of good health
There are a number of components associated with successful ageing and these include, but are not limited to the following considerations:
• Physical well-being- where health is fostered and positive steps are encouraged to maintain good health
• Emotional well-being - Includes having a positive outlook on life and coping well with stress
• Spiritual well-being - Being able to find meaning and purpose in life.
• Mental well-being - Fosters a growth in self understanding and fostering a healthy mind.
• Social well-being - Having good relationships with others and enjoying social opportunities;
• Vocational well-being - work life balance, whether the person is in paid work or a volunteer;
• Optimising opportunities for participation within society.
Successful ageing considers the needs and values of the older adult and can be promoted by developing an understanding of the many facets that are involved in a 'life well lived'.
The Australian government has built ageing policies around the concept of healthy ageing in recent years. It is just as important for us to support and promote healthy ageing as it is to provide health care for older people. By promoting healthy ageing we can help older people to enjoy a better quality of life; maintain their citizenship and realise their potential for physical, social and mental well-being through to the end of life. Having good quality of life also helps to reduce demand for health and aged care services. Clinicians can help promote healthy ageing in older persons by:
• Promotion of good nutrition
• Encouraging appropriate physical activity
• Encouraging regular medical checks
• Promoting mental fitness
• Supporting older persons to have positive relationships and to stay connected with their community
SUCCESSFUL / HEALTH / ACTIVE AGEING AND PERSON CENTRED CARE
Healthy ageing, successful ageing, or active ageing are often terms that are used interchangeably however, whatever term is used it is clear, that healthy ageing involves much more than just 'good health'. Healthy ageing also considers optimising opportunities for participation and for physical, social and mental wellbeing in a supportive and secure environment (World Health Organisation, 2015). We can promote healthy ageing by a model of care delivery that focuses on the person, that is, 'person centered'.
Person centered care is not a “model of care” but rather, it is the way in which care is provided through respectful interaction by health professionals who value the person first, knows him or her as an individual, and understands their role as a person of significant influence in the life of the person in their care. Personhood is an intrinsic part of person-centered care and places an emphasis on the positive effects of daily interaction with other people. The concept was developed in response to a predominantly biomedical view of dementia and ageing, which were said to downgrade the person to being only a carrier of disease (Kitwood 1997) and refers to the recognition of a sense of self, who we are and what place we hold in the world around us. However, for many years now it has been considered optimal for care delivery regardless of setting, age or disability. The poor understanding of person centred approaches has led to significant issues with practice, undermining the fundamental aspects of valuing people as unique and individualising care - this is no more apparent than in health care for older people.
If you consider what you have learned about the social determinants of health earlier in the topic, it is a natural progress to consider that clinical gerontology must consider a framework in which life experiences may play a role in health status in later life, and also health seeking behaviour, and what has come to be referred to as 'compliance' in treatment.
TWO VERY IMPORTATANT PART OF THIS CASE STUDY IS ASSESMEMNTS AS WRONG ASSESSMNETS CAN LEAD TO POOR INTERVENTIONS AND OUTCOMES.
WE NEED TO ASSESS THOMAS MCCARTY AND HIS CASE BASED ON PERSON CENTERED CARE BEFORE WE PROVIDE ANY INTERVENTION UISNG Comprehensive Geriatric Assessment THIS SHOULD INCLUDE 1. COSIDERATION PERSON CENTERED ASSESSMENTS 2. COMPREHENSIVE GERIATRIC ASESSMENTS , 3. TOOLS USED FOR ASSESSMENTS . IN SHORT HIS CASE SHOULD BE ASSESEES HOLISTICALLY, CONSIDERING HIS CONCERNS, HEALTH, SOCIAL STRUCTURES AND SUPPORT SYSTEMS, HIS CULTURE, SPIRITUA;ITY, PAIN LEVELS, CHOICE, CONTROL, INTERESTS AND AVAILABLE RESOURCES. ( REFER AND USE THE INFORMATION FROM OUR ARGUMENTS ABOVE AND ALSO INFORMTION I HAVE INCLUDED BELOW) PLZ QUOTE ATLEAST 5 QUOTES .
COMPREHENSIVE GERIATRIC ASSESSMENT
A geriatric or gerontological assessment is a diagnostic process; the term is often used to include both evaluation and management (Ward & Reuben 2016). An assessment often seeks to obtain information on the health and socioenvironmental circumstances of an individual older person. It may have several purposes. An initial evaluation may be done in order to determine the older persons’ status in a given area (dental, nutrition, legal etc.). Or, a multifunctional assessment may be conducted to develop an initial care plan or a care plan at the time of hospital or clinic discharge or aiming to prevent hospital admission from the community or residential setting. It is also important in providing continuity of care or for setting priorities of care.
The rationale for assessment is usually identified as being for one or more of the following:
• Matching of needs to correct care options
• Allocation of scarce resources on basis of demonstrated need
• Providing data base for:
- Planning individual programs of care
- Needs based planning
- Identification of gaps in service
- Evaluation
- Meeting reporting requirements of authorities
Assessment of older people may take place in different settings: the home, the hospital, residential care or the clinic. Each location has advantages and disadvantages for collection of particular types of information. An individual assessment in a clinical setting may be a brief or limited evaluation of a single problem. Often, only one health care provider is involved in this kind of evaluation, for people with more complex problems, however, a multidisciplinary evaluation is often necessary.
Multidisciplinary care has been a long held method of care of older people as well as throughout other life stages. Within this method, key obstacles have arisen as different health professionals provide specialised assessment with little co-ordination of overall care and impact on an individual's health and wellbeing. Health service provision and recognition of geriatric medicine as a speciality have contributed to increasing the profile of this speciality in other areas of clinical health care.
The concept of interdisciplinary care involvement fosters a more cohesive approach to care where communication processes are embedded within a system. An interdisciplinary approach specifically refers to integration through active coordination, which fits the criteria for sharing information across disciplines involved in the process of comprehensive assessment of the older person. As a result, a much higher level of collaboration , an assumed equality across the team fosters a shared responsibility for effectiveness and team functioning to maximise the care outcomes for the older individual being assessed (Zeiss and Thompson, 2003) . The assessment team can include an extended range of health care professionals such as: nurses, social worker, occupational therapist, speech pathologist, pharmacist, dietician, audiologist, podiatrist optician, geriatrician, and general practitioner. Many assessment teams are moving towards providing more virtual assessment and interactions with older people, placing an increased reliance on videoconference consultations, and the use of electronic health records. The evidence does show that interdisciplinary team approaches to assessment and care facilitate adherence to recommendations, prevent functional decline and decrease hospitalisations and nursing home placements (Davis, Dorevitch and Garratt, 2009).
Your required reading in this section also brings to light a little discussed issue: how do older people themselves recognise conditions and the implications for geriatric assessment?
PAIN AND OLDER PEOPLE
Pain is a particularly important consideration in the older population due to high prevalence rates and the influence of pain on physical, psychological, emotional, social and behavioural realms. As pain is subjective, with assessment often based upon self-reporting in the majority of instances, it is important that the health professional not only respect the persons view but also acts upon their report. In situations where self-reporting ability is limited due to communication difficulties it is common to use observational assessment tools to determine the persons pain status, such as the Abbey Pain Scale (an Australian developed tool), Pain Assessment in Advanced Dementia (PAINAD) and Facial Pain Scales (FPS).
There are many barriers to achieving adequate pain management in older people. Factors such as treatment cost, access to appropriate health services, lack of education on treatment purpose, reluctance to self-report pain, existing health status (e.g. co-morbidities), cognitive dysfunction, or linguistic or cultural influences all contribute to reduce pain identification and treatment efficacy. Prompt identification and management of pain can reduce the presence and frequency of delirium, falls, and behavioural symptoms of dementia while also potentially identify previously undiagnosed health issues such as infection, malignancy, or neurological disease.
A multidisciplinary systematic approach to pain assessment ensures that full consideration is given to the individual’s pain experience. Through identification, assessment, treatment, education and efficacy reviews, the cycle of quality pain management is achieved. This is particularly important in individuals with a diagnosis of dementia due to the influence pain has on symptoms. For example, aggressive responses may indicate a protective or guarding response by people who are unable to articulate their pain (Zwakhalen et al 2006, pg. 2). Increased responsive behaviours, such as wandering, verbal disruption, physical aggression, paranoia, agitation, and apathy are all heavily influenced by pain. These in turn impact on sleep, dietary intake, emotional status, socialisation, and depression often resulting in outcomes such as resistiveness at times of care assistance and reduced appetite. As behavioural and psychological symptoms of dementia remain a primary reason for hospitalisation and long term care admissions, it becomes all the more apparent that by reducing pain we can not only reduce these admissions but also provide better care overall.
The key to good management is early detection and treatment to ensure that we break the cycle of older people’s pain being under reported and frequently under treated (Murdock & Larsen 2004). The primary messages for you to take away from this section are: pain is not a normal part of ageing; and timely assessment and treatment cannot be overestimated.
TOOLS FOR ASSESSMENT
Conducting an assessment involves identifying the key assessment needs of the older person and tailoring the assessment to suit their individual requirements, while still broadly capturing a broad spectrum of general assessment data. Assessment processes generally involve data collection, team discussions (both with and without the older person present), treatment or care plan development and implementation, evaluation of the process put in place and a review.
Data collection is often supported by the use of validated assessment tools. “ Well-validated tools and survey instruments for evaluating activities of daily living, hearing, fecal and urinary continence, balance, and cognition are an important part of the geriatric assessment” (Elsawy & Higgins, p. 48). Literature is full of assessment tools which can be applied and have been used for assessment in the older population. Several examples include:
• Katz Index of Independence of Activities of Daily Living, Lawton Instrumental Activities of Daily Living Scale, Barthel Index of Activities of Daily Living
• Geriatric Depression Scale, Cornell Scale, Hamilton Depression Scale
• Malnutrition Screening Tool
• Tinetti Balance and Gait Index, Fall Risk Assessment Tool (FRAT), Falls Risk for Older People in the Community Screen (FROP-Com Screen)
• Mini Cognitive Assessment Instrument
• Pain Verbal Descriptor Scale (VDS), PAINAD, Abbey Pain Scale, Visual Analogue Scale (VAS)
• Physical Mobility Scale,
• Braden Scale, Waterlow Pressure Ulcer Risk Assessment Tool
Assessment of older people may take place in different settings: the home, the hospital, residential care or the clinic. Each location has advantages and disadvantages for collection of particular types of information. An individual assessment in a clinical setting may be a brief or limited evaluation of a single problem. Often, only one health care provider is involved in this kind of evaluation. For people with more complex problems, however, a multidisciplinary evaluation is often necessary.
CONSIDERATIONS FOR PERSON-CENTRED ASSESSMENT
Frail, older people with multiple problems and co-morbidities, particularly those not under the care of geriatric services, are at risk of adverse outcomes. Appropriate assessment is required to address the complexities of health needs in older people. Given that assessment sets the scene and the approach to an episode of care and the working relationship that follows (Dewing and Pritchard, 2000), person-centred comprehensive geriatric assessment would be a crucial to appropriate care provision to maximise positive outcomes. The older person should be the focal point of the assessment in a partnership that is both respectful and reciprocal, and that person should feel empowered by the process (Heath, 2000). It is the significance of the relationships between health care professionals and the older person, as well as the relationships between health care professionals themselves, that is often overlooked as a result of misconceptions about the concept of person-centredness.
All older people undergoing assessment should be treated with respect and dignity at all times. In general, giving consideration to the following can facilitate person-centred assessment (Davis, Dorevitch and Garratt, 2009):
• creating the right context by providing a quiet environment, affording privacy and minimal distractions, no feeling of time pressures and with the assessor taking a physical position that does not dominate the older person (eg seated facing each other at the same level);
• establishing rapport with the patient at the outset of the assessment by introducing oneself, asking how they would like to be addressed, explaining the purpose of the assessment, asking what they consider the main problem(s) to be and what their goals are (what they would like to see come from the assessment);
• being honest about the purpose of the assessment and the realities of what might be offered;
• taking a positive view by acknowledging personal abilities, strengths and resources;
• being attentive and open to what the older person is communicating;
• being non-judgemental and prepared to listen, making a concerted effort to understand the person's current perspectives, priorities and anxieties
• clarifying what is understood about the conclusions of the assessment and what will come next.
Keep in mind that if the person is acutely unwell or in physical discomfort, they may find it difficult to meaningfully participation the assessment process so medical considerations are important.
Communication considerations are equally as important. Hearing and vision impairments or mental health needs can be challenging to communication and require specific skills and considerations. "Where there are concerns about receptive communication abilities, this can be easily screened by asking them to follow a simple one stage command (eg close your eyes) followed by a two stage command (eg lift up your hand, then poke out your tongue). Expressive communication can be tested by asking the patient to repeat a simple phrase (eg, Opposite North Terrace) and to name several common objects (eg pen, watch, key)" (Davis, Dorevitch and Garratt, 2009: 182).
Such considerations sit alongside cultural competence in assessment as well. For example, where it might suit to sit across from an older person from many cultures, the protocol in Australia in assessing Aboriginal older people would be to sit shoulder to shoulder or on the diagonal as this is non-confrontational, allows for less direct eye contact to occur and will make the person feel more comfortable (Carrillo et al 1999). But by the same token, even Aboriginal and Torres Strait Islander communities are as diverse as any other community, and as such, there are different traditions and customs, different ways of communicating, different understandings, different sensitivities and different Elders (Hurley, 2003). Health professionals and those support older people from different cultural backgrounds cannot know it all but developing awareness of cultural considerations can be a starting point for developing cultural competence for those people you are working with or caring for regularly.
THREE - INTERVENTIONS AND CLINICAL DECISION MAKING – WHAT CAN WE DO IN RESIDENTIAL CARE TO MAKE THOMAS COMFORTABLE AND PROMOTE HEALTHY AGEING AND TAKE CARE OF HIS DECLINED FUNCTIONS AND FRAILITY WITHOUT MAKING HIM LOSE HIS RIGHTS, CHOICES AND DIGNITY ( PLZ REFER TO INFORMATION ABOVE AND BELOW INFORMTION AND CASE STUDY BELOW TO SUGGEST IDEAS AND INTERVENTIONS)
CLINICAL DECISION MAKING
Clinical decision-making is a continuous and evolving process in which data are gathered, interpreted, and evaluated in order to apply evidence to formulate a decision’ (Tiffin, Corbridge and Slimmer 2014, p. 400). Clinical decision-making often requires critical thinking in order to choose between potential alternatives and to predict future needs; it seeks to ensure that the individual receives the highest quality care with the resources available.
Collaborative partnerships involved in a person centred approach to clinical decision making, ensure that the older person is empowered to guide their decision making while ensuring the inclusion of other interested parties such as, family, carers and health care professionals. It is in later life that some significant decision need to be made in regards to health and treatment choices. Decisions such as: What happens if we are no longer in a position to make choices for ourselves competently? Will we agree to certain interventions or treatment choices, and who do we wish to make decisions for us if we need this type of support? The importance of Advanced Care Planning (ACP) to prepare for and answer these questions prior to need is very useful. To do so ensures that these type of issues do not cause any undue stress to family during potentially difficult times and clearly signifies your intent, however having said that it is only as useful as the preparation that has gone into it.
The Fried et al (2008) article that is part of your required reading explores how the views of older people play out in relation to clinical decision making. Their study that finds "the task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions" (Fried et al 2008:1839).
END OF LIFE CONSIDERATIONS
While ‘a primary goal of medical care is preservation of life…when life cannot be preserved, the task is to provide comfort and dignity to the dying person, and to support others in doing so’ (NSW Dept. Health 2005, p. 2). Dying is a normal part of life and something we need to consider when planning for the needs of people in our care, sometimes we need to accept that due to advancing illness or a lack of prospect of a cure that we may need to plan for palliative care.
Palliative care aims to:
• Affirms life and considers dying as a normal process
• Neither hasten or delays death
• Provides relief from pain and other distressing symptoms
• Integrates the physical, psychological, social, emotional and spiritual aspects fo care, with coordinated assessment and management of each person’s needs
• Offers support to help people live as actively as possible until death
• Offers support to help the carers during the person’s illness and in their own bereavement.
Palliative Care can be provided in hospitals, hospices, residential aged care facilities as well as in a person’s home. However it should be considered that ‘a person’s preference for where they wish to be cared for, and where they wish to die, can change over time. It can be influenced by what services and supports are available to them, the needs of others around them, their specific care needs’ as well as where they live (Caresearch 2017).
It is important that we encourage older people in our care to pre-plan their care preferences. Consideration should be given to the laws governing the legal requirements of each of the following types of documents in each state of Australia as they vary state to state:
• Enduring Guardianship
• Enduring Power of Attorney
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• Advanced Care Directives
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