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Sunday, August 29, 2010

Geriatric terms, acronyms and definitions… words to know when working with or on behalf of seniors.

- A physical or organic syndrome (meaning not a mental illness nor psychological) which affects a person’s cognitive ability, i.e. memory and reasoning. Dementia is an umbrella diagnoses which envelops several different syndromes, the most notable being Alzheimer’s disease. Others include vascular dementia (often caused from a stroke), dementia with Lewy Bodies, Creutzfeldt-Jakob Disease, and the frontal temporal dementias including Picks disease and alcohol induced dementia (often seen in alcoholics). Dementia is also a standard and expected side effect of Huntington’s disease and Parkinson’s disease. Overall, dementia is a permanent and progressive disease in which a person loses the ability to remember what they had for breakfast, the names of their loved ones, how to get home and limits their reasoning skills. Medications do exist to treat dementia; Namenda and Aricept are two of the most used in my practice. Medication will not cure dementia, but is speculated to slow down its progression. Here, early detection and diagnoses is vital!

Geriatrician- Physician specializing in the elderly care. I highly recommend anyone over the age of 60 (55 depending on the policy) to begin seeing a geriatric physician. This would take the place of one’s primary care physician, which, can be hard for those who have had a lifelong relationship with their doctors. But, from my experience, issues experienced by those who are aging are so very specific, medication doses change, diagnoses suddenly stop being cured and instead become chronic and multiple, and with this is the issue of and counter indications becomes significant. Just like a child sees a pediatrician, as a senior I would encourage finding a geriatrician for my care.

ADLs- Activities of Daily Living- These include the very basic functions of living which are necessary to get by on a daily basis. Dressing, bathing, grooming, eating, ambulating (walking or ability to use a mobility device, i.e. wheel chair) are considered ADLs. When a person is no longer able to manage 1 or more of these functions without assistance, their ability to remain independent may become questioned. Often times a spouse or caregiver may be present to assist a person to complete all of their ADLs, thus enabling them to maintain. However, if there is no assistance available on a regular basis, a higher level of care may be needed, i.e. an assisted living facility or a nursing home.

Nursing home-Often referred to as a Skilled Nursing Facility (skilled, meaning medical) is a residence for people with constant medical need. This kind of facility has 24/hour medical staff consisting of nurses, certified nursing assistants (CNA), dieticians, physical therapists, occupational therapists, speech therapists, recreation therapists, medical directors (physicians who oversee the facility’s residents and daily procedures, etc.) as well as kitchen and housekeeping staff. Here, and ideally, everything a person needs is provided: room and board, medications, etc. A person must qualify, medically or otherwise, for placement at a nursing home. There are 2 components to which a person can be admitted: rehab or long term placement. A patient who’s just had surgery, i.e. a hip replacement, may need several weeks of rehab with a physical therapist, before they are able to successfully walk on their own again, manage pain, or complete ADLs independently. Thus, before going back home, they may spend several weeks at a nursing home and then return to their home. Payment for this is covered under Medicare Part A. As well, someone who is deemed unable to live independently ever again, like our advanced medical conditions and those with significant memory loss, can live permanently at a nursing home. Payment for permanent placement is typically covered either through private pay, some long term care insurances or Medicaid. Often times people must privately pay until their funds reach those of Medicaid criteria, and then Medicaid will kick in and pay for the remainder of the person’s stay.

Assisted living facility- A residence for those in need of some assistance on a daily basis. This is a non-skilled facility (meaning does not provide constant medical care) with 24/hour staff, which typically caters to seniors who are still able to manage most of their ADLs. Assisted living facilities provide meals and often times housekeeping and medication management. To be considered an assisted living facility (versus a group home) a nurse is usually required to be on staff for at least 8 hours a day. Other staff includes CNAs (certified nursing assistants), med techs (people trained to dispense medications), administrative staff, housekeeping, and maintenance and kitchen staff. In some situations, recreational staff is also available to provide activities. Some assisted living facilities cater to those with dementia and may be considered a “secured facility” meaning access into and out of the building is restricted without a key or code; this ensures the safety of those who may wander. Like nursing homes, an assisted living facilitie will ideally be all-inclusive providing everything a person needs to sustain, while usually offering a higher quality of life and independent status of living than that of a nursing home. For example these facilities are usually very aesthetically pleasing and people may still be functional enough to have their own cars to come and go and come as they wish. An assisted living facility will likely be a better option than a nursing home. Payment for assisted living is more often than not all private pay. Some long term care insurances may provide coverage and some (very few), and some facilities have limited rooms for those receiving Medicaid. The cost of this kind of facility is anywhere from $2,500 a month on up to $7,000-+$8,000 per month.

Medicaid- A program providing health insurance coverage for those who are considered low-income; children, pregnant women, parents of eligible children, people with disabilities and elderly needing nursing home care. Most residents of permanent stature at nursing home are covered by Medicaid (in a recent blog I noted that there are a million and a half people who currently live in nursing homes). Medicaid is reserved for those with financial and/or physical need. Its policies differ from state to state as Medicaid is jointly funded by states and the federal government. As well, Medicaid policy is changing constantly so it can be difficult to understand what Medicaid covers and what it doesn’t, and how it interacts with Medicare and private insurances.

Medicare- A social insurance program for those 65 and older and have paid into Medicare taxes for 10 years, or being a legal resident of the U.S. for 5 continuous years. As well, there are several stipulations in which a person under the age of 65 may qualify for Medicare, i.e. a person receiving dialysis, or those who’ve been receiving social security disability benefits and are diagnosed with qualifying medical conditions such as Lou Gerihg’s disease or ALS. Medicare has 4 parts to it which a person may be eligible for: Part A- Hospital coverage; Part B- medical coverage (i.e. the doctor’s office), Part C- Medicare Advantage, where a person has the choice to opt for their Medicare benefit to be provided by a private insurance; and Part D- prescription coverage. Most parts of Medicare include a deductible, copayment and/or premium of some sort. Medicare does NOT cover long term care, sitter services, or non-skilled in-home care.

Long Term Care Insurance-Insurance separate from that of health insurance, Medicaid or Medicare providing for the costs of long term care needs; potentially for that of nursing home costs, assisted living costs, sitter services, in home care, respite care, and other needs not typically covered but may be of significant cost to an individual. Coverage policies and rates differ from company to company.

PACE- Program for All-inclusive Care for the Elderly- a Medicaid/Medicare program for seniors in most state providing a holistic approach to healthcare. Criteria for this program include Medicaid financial eligibility and functional limitations that would make a person eligible for nursing home placement.

Private Sitter service- This is a non-skilled (meaning not medical) service that provides oversight to a person who is in need of a “babysitter,” for lack of a better term. Grandpa, grandma or a patient who is unable to remain at home alone, this service will provide a caregiver who is hired on an hourly basis; this caregiver can typically provide light housekeeping, cooking, take walks with clients, and provide stimulation through appropriate conversation and games (i.e. dominoes, cards, etc.). Sometimes families will also hire a sitter service to provide companionship to loved ones who may live alone and may be at risk for social isolation, like those at assisted living facilities, nursing homes, or perhaps someone who lives very far away. The draw back with a service like this is the hourly rates usually start at about $25 and for many people hiring someone to sit with mom, dad, aunt or grandma for a significant period of time can be a financial burden or outside of one’s resources.

MMSE- Mini Mental Status Exam; An assessment tool used to asses one’s cognitive functioning, i.e. how well is their memory working and how intact are their reasoning skills. The goal of this assessment is to screen for early stages of dementia and then track any decline from then on. The assessment is on a 30 question scale, 30 being a perfect score. Missing any more than 2 questions/tasks would indicate memory loss, often times associate to dementia. This assessment tool is not an exact science and has some limitations, but overall, it gives professionals an idea of where a patient is at mentally. I use this assessment on a daily basis at work. Per my agency’s policy, I re-assess every client every 6 months utilizing the MMSE in order to compare from year to year how they are doing. Ultimately, a person, professional or family member can be given a clear understanding of a person’s ability to safely remain independent (i.e. live alone) or how much assistance they should acquire on a daily basis, per the MMSE score. Things that may impact one’s MMSE score adversely and should be taken into consideration are mood and thought disorders, such as depression (someone suffering from depression may not score well, but not necessarily due to cognitive ability but rather due to the impacts of depression one’s thought process; here depression can be treated stopping any effects on their cognitive functioning).

St. Louis University Mental Status examination- this is an assessment tool much like the MMSE, but considered, among some professionals, to be a bit more sensitive to ascertaining memory loss, especially in individuals who have learned to compensate, thus, hiding any memory loss (often only possible in early stage dementia). Compensation is often observed in individuals with greater levels of education and economic standing. The SLUMS serves the same purpose as the MMSE but was developed later. Please see the MMSE definition for more detail.

Geriatric Depression Scale- An assessment tool used to identify depression in the elderly. The assessment asks 30 questions in which a patient will answer either ‘yes’ or ‘no’… Questions may include “Are you basically satisfied with your life?” and “Are you in good spirits most of the time?” A score greater than 9 is indicative of depressive symptoms.

APS- Adult Protective Services- A social service developed to protect senior adults, and sometimes disabled individuals, from abuse, neglect, and exploitation. APS is managed state to state differently by state health regulatory bodies. In Colorado, APS is managed by county. If abuse, neglect or exploitation is suspected, one can call and make a report to APS. Proof is not necessary, and the one reporting may remain anonymous if desired. APS has legal pull and rights to make decisions to protect at risk adults. However, seniors who are competent, those without significant memory loss, dementia, etc., who are making a choice to remain in an abusive, neglectful or exploitive situation, APS cannot force out of such a situation; not without request for help from that senior.

DNR- Do Not Resuscitate-A form which medical professionals facilitate for patients who do not wish to receive CPR (Cardio Pulmonary Resuscitation) or other life saving measures should their heart stop. Signing this form does not indicate that a person should not receive other normative treatments, such as antibiotics, dialysis, necessary surgeries, etc. As well, it’s important to note that CPR on a healthy 30 year old adult is VERY different than CPR on a senior adult. CPR on the elderly is not always a positive thing, even if it works and the person is revived; it often causes broken ribs and brings a person back in worse shape than before undergoing the process.

MDPOA- Medical Durable Power of Attorney- Known by different terms depending on which state a person is in (also known as MPOA-Medical Power of Attorney)- this is a completed form or paperwork in which a person (any person) may designate a person to make medical decisions for them in the event they are unable to do so; either because they are not conscious, or lack decision making capacity (indicated and documented by a physician). An MDPOA must be completed while a person is still competent to do so. After memory loss or dementia has progressed to moderate and especially advanced stages, a person may be deemed NOT competent to designate an agent, or person identified to make their medical decision for them. Again, depending on the state of residence, policies differ affecting whether an MDPOA requires witnesses or a notary to make it official (in Colorado neither are needed).

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