ANTICIPATORY GUIDANCE:

OLDER ADULT
NGR 5638 Health Promotion
Fall 2016
University of Central Florida

Mary Baertlein
Xxxxxx Xxxxx
Xxxxxxx Xxxx
Anticipatory Guidance Presentation

Health Mental Health; Functional Limitations; Physical Activity

Promotion

Health Falls Prevention; Prevention of Elder Abuse, and,

Protection Exploitation

USPSTF Recommendations; Management of Chronic

Disease
Prevention Conditions; Life Expectancy; Vaccinations

Mental & Physical Health / Decline; USPSTF; Advance

Anticipatory Directive Planning; Telehealth & Healthcare Literacy
Guidance

Copyright 2010 2
 Older Adult Population
 Age 65 and older

 Between 2015 and 2050 – World’s population over 60 years will

nearly double from 12% to 22%

 By 2020 – Number of people 60 years and older will be greater than

number younger than 5 years

 2050 – 80% of older people will live in low- and middle-income

countries

 All countries face the challenge of safeguarding social and health care
systems of this demographic shift

(World Health Organization [WHO], 2016c)

Anticipatory Guidance
 Health Promotion
Wellness Office Visits:
 60% of older adults must manage 2 or more chronic
conditions at the same time.
 Chronic illness can:
• Impair quality of life
• Increase hospitalizations
• Contribute to patient mortality
 Regular wellness visits and improvements in access to
primary care are important in chronic illness
management
 Early diagnosis and effective management can:
• Improve patient prognosis
• Extend life

(Department of Health and Human Services, 2014)

Copyright 2010 5
 Health Promotion
Mental Health – According to the World Health Organization (WHO), more than
20% of adults age 60 and older suffer from mental or neurological disorder.
 Risk factors influencing older adults’ mental health
include: loss of independence (decrease in physical
ability), drop in socioeconomic status (retirement),
bereavement (loss of loved one), and chronic disease.

 Early identification and treatment of mental,

neurological and substance use disorders in older adults
is key in ensuring optimal management (psychosocial
and medication interventions are recommended).

 Promoting mental health in older adults largely involves

strategies to guarantee that basic needs are met
(security [i.e. safe housing], freedom, social support,
physical activity etc.).

(WHO, 2016b)

Copyright 2010 6
 Health Promotion
Functional Limitations
 Healthy People 2020 Objective: “Reduce the proportion of older adults who
have moderate to severe functional limitations”.
(Department of Health and Human Services, 2014)

 According to Colon-Emeric et al., greater disability than anticipated is found in

those with multiple health conditions present (this is due to a lack of ability to
compensate for one problem because of the presence of other competing
problems). (2013)

 Older adults who are physically active have higher levels of functional health,
lower risk of falling, and have decreased risk of moderate / severe functional
and role limitations. (WHO, 2016c)
 Anticipatory Guidance

 Primary health care providers should integrate

mental health assessments utilizing a standardized
evidence-based evaluation tool into each office
visit, beginning with the initial wellness visit.

 Information obtained during the evaluation should

be documented into the electronic medical record
(EMR) to provide a baseline for future comparison
by all health care providers.

(CDC, 2013)
 Anticipatory Guidance

 The older adult exhibiting mental health changes

such as depression, memory loss, or diminished
cognitive function should be referred for
appropriate testing, therapy, and counseling based
on clinical findings.

 Consider inclusion of family members or care givers

in referrals to provide support for the patient.

(Edelman, C. L., Kudzma, E. C., & Mandle, C. L., 2014)

 Health Promotion
Physical Activity – World Health Organization (WHO) has specific
recommendations for older adults with goals to improve cardiorespiratory
and muscular fitness, bone and functional health, and reduce the risk for
non-communicable disease, depression, and cognitive decline

1. Perform either 150 minutes of moderate-intensity aerobic

activity or 75 minutes of vigorous activity each week

2. Aerobic activity should last at least 10 minutes

(WHO, 2016c)
 Health Promotion
Physical Activity - continued

3. Individuals with poor mobility should perform balance-enhancing,

falls-preventing exercises at least 3 times per week.

4. Muscle strengthening activities should be done at least 2 times per

week.

5. If unable to perform recommended amounts of activity due to health

condition, they should be as physically active as possible within their
individual ability.

(WHO, 2016c)
 Health Promotion
Sensory Changes:
United States Preventive Services Task Force (USPSTF) has
identified sensory changes and cognitive impairment as
important considerations to the health an well being of senior
citizens and thereby developed the following screening
recommendations.

Impaired Visual Acuity in Older Adults: Screening

Hearing Loss in Older Adults: Screening
Cognitive Impairment in Older Adults: Screening

While these recommendations have only garnered an "I" or

inconclusive rating, research links each of these issues to safety
concerns in the senior population.

(United States Preventive Services Task Force, 2016)

 Health Promotion

Impairment in cognition, vision and hearing present a documented risk to

the health of older adults with direct links to:

• Falls
• Automobile Accidents
• Household Accidents
• Dysphagia including choking and aspiration

Elderly individuals with cognitive and sensory impairments are noted to

have an increased mortality rate.

(Mitoku, Masaki, Ogata, Okamoto, 2016)

 Health Protection
 Falls are Serious and Costly
• One out of five falls causes a serious injury such as broken bones or a
head injury.
• 2.8 million older people are treated in emergency departments for fall
related injuries
• Over 800,000 patients are hospitalized annually due to a fall injury,
most often because of a head injury or hip fracture.
• At least 300,000 older people are hospitalized annually for hip fractures.
• More than 95% of hip fractures are caused by falling, usually by falling
sideways.
• Falls are the most common cause of traumatic brain injuries (TBI).
• Direct medical costs for fall injuries are $31 billion annually.

(CDC, 2015)
 Health Protection - Falls
STEADI Interventions: Start preventing falls with these 3 steps:
Screen for fall risk using these 3 questions:
1. Have you fallen in the past year?

2. Do you feel unsteady when standing or walking?

3. Do you worry about falling?

REVIEW
Review and manage medications linked to falls.

RECOMMEND
Recommend vitamin D for improved bone, muscle, and
nerve health.

(CDC, 2016d)
 Anticipatory Guidance
 Primary health care providers should assess for
osteoporosis, vision and hearing loss, and cognitive
decline and provide resources to patients and their
support systems to cope with functional limitations
affecting their ability to perform activities of daily living,
decrease quality of life, miscommunication, and loss of
self-esteem.

 Assess functional loss at each office visit and incorporate

information and educational tools related to physical
limitations.

 Provide resources including: public and governmental

agencies, community organizations to assist with
potential mobility barriers within the home,
transportation to medical visits and shopping, ability to
safely obtain and administer medications, and
socialization.

(Edelman, C. L., Kudzma, E. C., & Mandle, C. L., 2014)

 Anticipatory Guidance
 Assess for risks of falls, review medication with
potential to increase dizziness or sleepiness
including prescription and over-the-counter
medications.

 Assess for drug interactions during each office

visit or admission to an acute care setting.

 Educate patient and family or care givers

regarding environmental factors leading to or
prevention of falls.

 Provide information regarding exercise options

for the older adult within the community to
enhance balance, muscle strength, increase
bone density, and increase socialization (i.e.
Silver Sneakers Program)

(CDC, 2016a)
 Health Promotion
Diabetes Self-Management Benefits
 It is estimated that 25.9 % of individuals 65 years and older
suffer from diabetes (diagnosed and undiagnosed)
 Unmanaged, undiagnosed or poorly managed diagnosed
diabetes can lead to complications including:

• Heart disease • Non-alcoholic fatty liver disease

• Stroke • Periodontal disease
• Blindness • Hearing loss
• Kidney failure • Erectile dysfunction
• Depression
• Lower-limb amputation
• Nerve disease and damage

(Department of Health and Human Services, 2014)

 Anticipatory Guidance

 Diabetes Self-Management Benefits

• Offered through Medicare

• Provides 10 hours of diabetes self-management training during

the calendar year of diagnosis

• Underutilized – 2008 baseline utilization = 2.0%

2013 utilization = 0.6%

(Office of Disease Prevention and Health Promotion, 2016)

 USPSTF Recommendations:
The United States Preventive Services Task Force (USPSTF) has developed
a variety of recommendations focused on promoting the health and
welfare of the older adult population.

 As of 2016 the USPSTF has published 23 recommendations that are inclusive of or

specifically directed at what they identify as the senior population, individuals 65
years and older.

 Listed within this presentation are USPSTF recommendations which received

ratings of:
 A (high certainty of substantial benefit)

 B (high certainty of moderate to substantial benefit) with significance to the

senior population)

(USPSTF, 2016)
 USPSTF Recommendations:
1. High Blood Pressure Screening (A)
• Recommended for all adults 18 and over.
2. Type II Diabetes Mellitus Screening (B)
• Recommended for all overweight and obese adults
age 40-70
3. Tobacco Cessation (A)
• Recommended for all adults 18 and over who use
tobacco
4. Colorectal Cancer Screening (A)
• Recommended for all adults ages 50-75
a. Stool test annually
b. Sigmoidoscopy every 5 years
c. Colonoscopy every 10 years

(USPSTF, 2016)
 USPSTF Recommendations:

5. Biennial Breast Cancer Screening via Mammogram (B)

Recommended for women age 50-74

6. Abdominal Aortic Aneurysm (AAA) Screening (B)

• Recommended for men age 65-75 with any history of smoking

7. Osteoporosis Screening (B)

• Recommended for women age 65 and older

8. Statin Use for the Prevention of Cardiovascular Disease (B)

• Recommended for at risk patients age 40-75

(USPSTF, 2016)
 USPSTF Recommendations:

9. Depression Screening (B)

• Recommended for all adults age 18 and over

10. Alcohol Misuse Screening (B)

• Recommended for all adults age 18 and over

11. Latent Tuberculosis (TB) Screening (B)

• Recommended for at risk individuals of all ages

12. Fall Prevention Assessment, Counseling, and Preventive

Medication (B)
• Recommended for all community living adults age 65 and
over

(USPSTF, 2016)
The USPSTF is also in the process of
researching and publishing recommendations
of concern to older adults in the following area:

1. Cardiovascular disease risk assessment

2. Prostate cancer screening
3. Skin cancer prevention
4. Gynecological condition screening
5. Elder abuse screening
6. Osteoporotic fracture screening
7. Vitamin D and Calcium to prevent fractures

(USPSTF, 2016)
Due to the increase in life expectancy coupled with the advent
of virility and sexual enhancement medications, the importance
of STD screening and counseling is of greater importance in the
older adult population.

 Studies have shown an increase incidence in sexually transmitted

diseases inclusive of syphilis, herpes, and HIV in persons 60 years
and older.

 People 55 and over make up 26% of the individuals living with

diagnosed and undiagnosed HIV infection in the U.S.

 These statistics justify an increase in STD screening and safe sex

education in the older adult population.

(CDC, 2016b; Nunes, S., Azevedo, F., & Lisboa, C., 2016)
 Vaccinations
The Centers for Disease Control and Prevention
recommend the following vaccines for all
individuals 65 and older:

1. Influenza (annually)
2. Tdap booster every 10 years
3. Varicella (2 doses)
4. Shingles Zoster (1 dose)
5. Pneumococcal 13 (1 dose)
6. Pneumococcal 23 (1 dose)

(CDC, 2016e; USPSTF, 2016)

 Anticipatory Guidance
 Provide comprehensive coordinated care across all
health care settings including: primary care office,
acute care facility, rehabilitation facility, home care,
and skilled nursing facility.
• Offer vaccines as appropriate
• Assist with access to stroke and cardiac
rehabilitation with a goal to return individuals to
pre-event functional status

 Inform and educate older adult population regarding

normal changes related to aging versus stereotypes or
myths of aging.

 Health care providers need to seek out current

information regarding care for the elderly and directly
address issues related to abuse or neglect.

(Office of Disease Prevention and Health Promotion, 2014; CDC, 2016a)

 Anticipatory Guidance
 USPSTF recommendations include:
• Exercise or physical therapy – group classes / at-home therapy

• Benefit of vitamin D supplementation for 12 months - 600IU for

adults 50 to 70 years of age; 800 IU for adults older than 70 years
of age – improve bone, muscle, and nerve health

• Falls assessment - included on the welcome to Medicare exam and

annual Medicare exam – requires practices to use a valid or reliable
evaluation tool

(CDC, 2016a)
 Anticipatory Guidance
 Medicare benefits for screenings are underutilized by new
beneficiaries due to:
• Numerous screenings recommended for the older adult –
health care providers need to prioritize assessments based
on history and physical examination (i.e. colorectal or
breast cancer, AAA, diabetes, and Alzheimer’s disease).

• Some screenings (i.e. AAA ultrasonography) only provided

at no cost to the patient during the initial 6 to 12 months
following Medicare enrollment; Less than 1 % of eligible
patients receive this screening.

• If abnormal finding is discovered, patient is now in

surveillance program requiring co-payments for screenings.

(Chun et al., 2013; Kostun & Malik, 2016; USPSTF, 2016)

 Anticipatory Guidance

 Medicare benefits for screenings:

• Health care providers need to assess individuals based on

associated risk factors due to asymptomatic nature of
many cancers and chronic diseases in their early stages.

• Provide resources for emergency preparedness of the

older adult

• Consider health literacy of older adult patient when

developing plan of care

(Chun et al., 2013; Kostun & Malik, 2016; USPSTF, 2016)

Telehealth – Older Adult – Health Literacy
Telehealth for Chronic Care Management :

 Provides continuous interaction between patient

and health care provider
 Designed to promote positive outcomes
 Manage health issues including:
• Diabetes
• COPD (Chronic Obstructive Pulmonary Disease)
• Anticoagulation
• Atrial Fibrillation
• Heart Failure
• Hypertension
• Hyperlipidemia
• Pain

(American Geriatrics Society, 2016)

Copyright 2010 31
 Anticipatory Guidance - Telehealth
 Need to develop and maintain therapeutic
relationships with patients (i.e. face-to-face visits
in office and / or online)

 Patient-centered – avoid “one size fits all”

approach; assess needs and health care literacy
(i.e. cultural, socioeconomic, ethnic, gender)

 Create technology that can be used on numerous

devices (i.e. computer, tablet, smart phone)

 Obtain older adult patient input on the

development of telehealth tool (usability, content,
therapeutic device management, screen size)

 Provide ongoing training on use of telehealth tools

(Edelman, C. L., Kudzma, E. C., & Mandle, C. L., 2014)

 Anticipatory Guidance: End-of-life Planning
 Five Wishes
• Used in all 50 states – meets legal requirements for
an advanced directive in 42 states and the District of
Columbia

• Available in 28 languages – ability to use in any part

of the world as a document for medical wishes

• Meets legal requirement as an advanced directive in

the state of Florida

• Ability to customize to meet cultural, religious, and

ethnic values of the individual

(Aging with Dignity, 2015)

Anticipatory Guidance: End-of-life Planning
 U.S. Living Will Registry
• On-line database to store a Living Will

• Sent electronically to any health care

provider (primary care providers, hospitals,
ambulatory surgical centers, skilled nursing
facilities, home health agencies, and hospice)

• Reviewed annually, fees associated with

registry

 Durable Power of Attorney

(CDC, 2013; U.S. Living Will Registry, 2016)

Aging with Dignity. (2015). Five wishes. Retrieved November 23, 2016 from
https://www.agingwithdignity.org/five-wishes/about-five-wishes

American Geriatrics Society [AGS]. (2016). AGS guidelines & recommendations. Retrieved December 4,
2016 from http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical
_guidelines_recommendations/

Centers for Disease Control and Prevention [CDC]. (2013). The state of aging and health in America 2013.
Retrieved November 28, 2016 from
http://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf

Centers for Disease Control and Prevention (2015). Take a stand on falls. Retrieved November 29, 2016
from http://www.cdc.gov/features/older-adult-falls/index.html

Centers for Disease Control and Prevention [CDC]. (2016a). Enhancing use of clinical preventive services
among older adults: Closing the gap. Retrieved November 4, 2016 from
http://www.cdc.gov/aging/pdf/clinical_preventive_services_closing_the_gap_report.pdf

Centers for Disease Control and Prevention [CDC]. (2016b). HIV among people aged 50 and over. Retrieved
November 29, 2016 from http://www.cdc.gov/hiv/group/age/olderamericans/
Centers for Disease Control and Prevention [CDC]. (2016c). Home and recreational safety: Important facts
about falls. Retrieved November 4, 2016 from
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

Centers for Disease Control and Prevention [CDC]. (2016d). STEADI. Retrieved November 24, 2016 from
https://www.cdc.gov/steadi/

Centers for Disease Control and Prevention [CDC]. (2016e). What vaccines are recommended for you.
Vaccine Information for Adults. Retrieved November 29, 2016 from
http://www.cdc.gov/vaccines/adults/rec-vac/

Chun, K. C., Teng, K. Y., Van Spyk, E. N., Carson, J. G., & Lee, E. S. (2013). Outcomes of an abdominal
aortic aneurysm screening program. Journal of Vascular Surgery, 57(2), 376-381.
http://dx.doi.org/10.1016/j.jvs.2012.08.038

Colon-Emeric, C., Whitson, H., Pavon, J., & Hoenig, H. (2013). Functional Decline in Older Adults. American
Family Physician, 88(6), 388-394.

Department of Health and Human Services (2014). Older adults. Healthy People 2020. Retrieved November
29, 2016 from https://www.healthypeople.gov/2020/topics-objectives/topic/older-adults/objectives
Edelman, C. L., Kudzma, E. C., & Mandle, C. L. (2014). Health promotion throughout the life span (8th
ed.). St. Louis, MO: Elsevier.

Kostun, Z. W., & Malik, R. K. (2016). Screening for abdominal aortic aneurysms. Clinical Imaging, 40(2),
321-324. http://dx.doi.org/10.1016/j.clinimag.2015.12.009

Mitoku, K., Masaki, N., Ogata, Y., & Okamoto, K. (2016). Vision and hearing impairments, cognitive
impairment and mortality among long-term care recipients: A population-based cohort study. BMC
Geriatrics, (112) doi:10.1186/s12877-016-0286-2

Nunes, S., Azevedo, F., & Lisboa, C. (2016). Sexually transmitted infections in older adults – raising
awareness for better screening and prevention strategies. Journal of the European Academy of
Dermatology & Venereology, 30(7), 1202-1204. doi:10.1111/jdv.13124

Office of Disease Prevention and Health Promotion [ODPHP]. (2014). Older adults. Healthy People 2020.
Retrieved November 29, 2016 from https://www.healthypeople.gov/2020/topics-objectives/topic/older
-adults/objectives

Office of Disease Prevention and Health Promotion [ODPHP]. (2016). Healthy People 2020: Older adults.
Retrieved November 29, 2016 from: https://www.healthypeople.gov/2020/topics-objectives/topic/older
-adults
U.S. Living Will Registry. (2016). Protecting your choice and peace of mind. Retrieved November 26, 2016
from http://www.uslivingwillregistry.com/

U.S. Preventive Services Task Force [USPSTF]. (2016). Published recommendations. Retrieved November
29, 2016 from https://www.uspreventiveservicestaskforce.org/BrowseRec/Index

World Health Organization [WHO]. (2016a). Elder abuse: Fact sheet. Retrieved November 29, 2016 from
http://www.who.int/mediacentre/factsheets/fs357/en/

World Health Organization [WHO]. (2016b). Mental health and older adults: Fact sheet. Retrieved
November 29, 2016 from http://www.who.int/mediacentre/factsheets/fs381/en/

World Health Organization [WHO]. (2016c). Physical activity and older adults. Global Strategy on Diet,
Physical Activity and Health. Retrieved November 29, 2016 from
http://www.who.int/dietphysicalactivity/factsheet_olderadults/en/
 Contributions
 Mary Baertlein
• Created / provided content for slides: 1, 2, 3, 4, 8, 9, 15, 16, 17, 19, 27, 29, 30,
31, 32, 33, 34
• Formatted and edited PP and references for consistency
• Provided clip art and animations
 Xxxxxx Xxxxxxx
• Created / provided content for slides: : 5, 12, 13, 18, 20, 21, 22, 23, 24, 25, 26,
28
• Reviewed and edited PP
 Xxxxxxx Xxxx
• Provided content for slides: 6, 7, 10, 11, 14

 Each group member provided references for content contributed to PP

Clip Art obtained from:

https://www.google.com/search?q=images+of+active+older+adults&espv=2&biw=1920&
bih=950&tbm=isch&tbo=u&source=univ&sa=X&ved=0ahUKEwigqY70nNvQAhUB1CYKHc6
GCQYQsAQIGQ&dpr=1
Animations obtained from: http://www.presentermedia.com/powerpoint-
templates/science-technology.html