LONG-TERM CARE DECISION MAKING

Arden L Aylor, MDGeriatrics

Objectives: Primary Care

Health Maintenance Quick office screening tools Advance Directives

Driving issues Care types Placement

Health Maintenance

Primary and secondary disease prevention screening

Control chronic medical problems Bi-annual medication review Optimize function: cognitive, auditory, vision,

fall screening Assess for adequate support system Discuss and document Advanced Directives

Optimize Function

Auditory - annual Vision - annual Fall risk Cognitive screen

Fall Risk

Vital Signs/ Orthostatic Neurologic assessment Musculoskeletal assessment Medications Footwear Cognitive assessment Functional Reach Test

Falls in past year?

No falls No Intervention

Recurrent falls

Single fall

Fall Evaluation

Gait & balance problem

Yes No

Functional Reach Test

Single item test: quick screen for balance problems in older adults

Interpretation:Score of 6 or less indicates a significant increased risk for falls

>70% fall in 3 monthsScore between 6-10 inches indicates a moderate risk for falls

Cognitive screen

MMSE MoCA (Montreal Cognitive Assessment) Clock

Score (4-1)

Clock

4 3

21

Driving Myths

Specific rules for older driversRenewal is every 2 years for those 85 and older Mail, phone, and electronic renewal are not available for those 79 and older

Renewal conditions: In person

Vision test: At in-person renewals

Written test: No

Road test: No, unless there is a concern (mental or physical) regarding the driver's ability to safely operate a motor vehicle TxDOT

Quick Test

Support & Advance Directives

Adequate support system Legal Directives

Wills Financial

Medical Directive DNR/DNI

Home Health

Home Health Care is skilled nursing need All Medicare beneficiaries can receive home

health Physical Therapy Skilled Nursing Respiratory Care Medical Equipment Infusion Therapy Nursing aid - ADLs

No 24/7 care coverage

Assisted Living

Level A: Resident may require minimal assistance with ADL, must be mobile, may receive home health services

Level B: Resident may receive full assistance with ADL Resident may be semi-independent and may

require the assistance for transfers or to evacuate the facility

Resident may receive assistance with medication Level C: Resident receive full assistance with ADL

Caregiver 24hrs on sight

Nursing Home Myth

Patients need to go to hospital for nursing home placement

Placement: Nursing Home Types

Skilled Nursing Facility (short-stay): 1-6 months Terminally ill Short term rehabilitation Debilitated post-acute care hospitalization

Nursing Home (long-stay): 6 months to years Primarily cognitively impaired Significant impairments of both cognitive and

physical functioning Primarily physically impaired

Palliative Care

Focuses on improving the quality of life of people facing serious illness

Emphasis is placed on pain and symptom management

Goal is to improve the patients ability to tolerate medical treatments

Hospice

Hospice care is end-of-life care Terminal diagnosis with life expectancy <6 months Offering medical, psychological and spiritual

support No invasive treatment or PT/OT Goal to help people who are dying have peace,

comfort and dignity Where: Home, Nursing Home, Hospital, Hospice

respite center

Key Points

Advance Directive should be assessed and updated annually

Quick screen tools and be helpful in evaluating function

Patients need not go to hospital for nursing home placement

Palliative offers some degree of therapy Hospice comfort care

References

• Texas Department of Aging and Disability Services Revision: 08-5.07• American Geriatric Society, 2011

americangeriatrics.org• Center for Medicaid and Medicare Services, 2011

cms.gov• Trailblazers CMS Texas, 2010

trailblazerhealth.com• Federal Government Publication and statistics, 2010

gov/employees/govpubs/Pages/FederalGovernmentPublications.aspx• TxDOT, 2011

txdot.gov

Thank You!