#99354: Aging and Long-Term Care

There is no one agreed upon definition of aging. One approach defines aging according to four key dimensions [86]:

Researchers have compiled a list of definitions that have been used in the literature [8]. This list included [8]:

These definitions touch on chronologic, physiologic, or biological aging. Kyriazis argues that while these definitions are valid, they are not practically meaningful for practitioners working with older adults [8]. Instead, he advocates for the use of the term "time-related dysfunction," reflecting a functional perspective. With the passage of time, older adults experience damage that cannot be easily repaired, resulting in a failure of normal functioning. Therefore, when a practitioner assesses an older patient, the practitioner takes into context the patient's personalized environment and their ability to complete certain tasks [8].

It is important to distinguish chronologic aging from physiologic aging. All persons, without exception, grow old chronologically. However, physiologic aging is unique process and varies from person to person. It involves changes in how an individual responds to internal and external stressors as well as inalterable variables, such as genetic predisposition [7]. In addition, studies are now focusing on aging as a process and underscoring the concept of successful aging [89].

Several subtly different terms are commonly employed when exploring aging. Successful aging refers to the physical and biologic advantages of remaining engaged throughout life. Active aging describes being active and engaged and maximizing opportunities to promote a good quality of life. Productive aging emphasizes integrating older adults into society and recognizing their unique contributions [189]. The World Health Organization uses the term healthy aging to describe the process of maintaining one's functional abilities throughout life [190]. These terms imply multidimensional dimensions of aging, and they are dynamic versus static [20]. The more "traditional" definitions of aging are static and homogenous, while terms like active, successful, and healthy aging connote a diverse and dynamic element to aging.

The age at which one is considered "older" or "senior" is always evolving and is influenced by culture and societal life expectancy. In England in 1875, old age was defined as 50 years or older, as stated in the Friendly Societies Act [88]. Today, most developed countries in the world use the chronologic marker of 65 years as a definition of old age; in some cases, the age of 62 years is used as a chronologic marker because, in the United States, one could receive social security benefits starting at this age [87]. However, Mohanty notes that using the criterion of age at retirement or when one becomes eligible to receive retirement benefits is not universal, given the fact that there are so many in the world who live in areas in which there are no formal definitions of retirement [88]. Using these chronologic markers to define old age is arbitrary, but they can be useful when studying the group as a whole [2]. Older adults can be further divided into various segments: the young-old, defined as 65 to 74 years of age; middle-old, defined as 75 to 84 years of age; and the oldest-old, defined as those who are 85 years of age and older [3]. In 2021, 32.5 million Americans were 65 to 74 years of age, 16.5 million were 75 to 84 years of age, and 6.7 million were 85 years of age and older [31]. In 2010, there were 53,364 persons 100 years of age and older in the United States [94]. By 2020, there were 92,000 U.S. centenarians [32]. Worldwide, in 2015, there were more than 500,000 centenarians, and it is estimated by 2050, there will be 3.7 million, with the greatest growth in China [90]. In the United States, it is projected that there will be 9.7 centenarians per 10,000 people by 2050 [90].

According to the U.S. Census, there were 55.9 million Americans 65 years of age or older in 2022, which translates to 16.8% of the U.S. population [41]. In 2020, Maine, Florida, West Virginia, and Vermont had the highest percentage of population comprised of adults older than 65 years of age [31]. By 2060, it is estimated that nearly 94.7 million Americans will be 65 years of age or older [42]. This is due to the aging of the "baby boomer" generation (i.e., those born between 1946 and 1964).

For many years, the average life expectancy has continued to increase, and this trend is projected to continue. In 2017, the average life expectancy in the United States was 79.7 years of age. However, life expectancy decreased from 78.8 years in 2019 to 77 years in 2020, largely due to excess mortality during the COVID-19 pandemic [31]. In 2021, the life expectancy was 76.4 years, a further decline from 2020 [44].

As mentioned, society holds several myths about older adults. Many of these myths may be easily disputed based on data from the U.S. Census and other studies.

In industrialized countries, it is estimated that 10% to 15% of human immunodeficiency virus (HIV) infections occur in adults 50 years of age and older, and approximately one of every nine new HIV diagnoses in the United States occur in those 50 years of age or older [17,18,126]. In 2019, there were 3,100 new cases of HIV among adults 55 years of age and older [225]. Between 2015 and 2019, the rate of new HIV diagnoses remained stable among those 55 years of age and older [226]. This prevalence may be higher in developing countries [18]. In 2016, there were an estimated 6,812 newly diagnosed cases of HIV among adults 50 years of age and older, accounting for 17% of total diagnoses in the United States. Of these, 841 diagnoses occurred in persons 65 years of age and older. In 2015, approximately 47% of all individuals with living with HIV were 50 years of age and older, and 2,749 people 55 years of age and older died from HIV disease [97]. However, older adults are not generally considered an at-risk group. This has led to a lack of targeted education and screening among older adults. For example, only 32% of state departments of public health websites contained information about HIV/AIDS in older adults [167].

Older adults living with HIV experience a variety of other medical conditions that place them at even further risk for frailty and other diseases of aging. Among older persons with HIV, more than half are considered pre-frail and experience challenges with instrumental activities of daily living (e.g., cooking, cleaning, managing finances, doing laundry) [195].

Because the symptoms of HIV infection (i.e., fatigue, weight loss, memory loss) are similar to those of other age-related illnesses, such as dementia, and because many older adults harbor the misconception that they are not at risk, this population frequently goes untested for the virus [17]. When these individuals do seek medical help, symptoms are often attributed to other disorders, such as Alzheimer disease or a respiratory disorder [17]. It has been argued that women 50 years of age and older are more vulnerable to HIV infection during heterosexual encounters than men or younger women for several reasons [19]. Older women often do not insist on condom use because there is no longer the risk of pregnancy. Furthermore, male-to-female transmission of HIV is higher than female-to-male transmission [19]. Due to divorce or being widowed, increasing numbers of older people are becoming sexually active with multiple partners. This increase in sexual activity can also be partially attributed to older men more commonly using medication in order to maintain erections [21]. Vaginal drying and thinning associated with menopause and aging can result in small tears or cuts during sexual activity, which also raises women's risk for infection with HIV [22]. Lusti-Narasimhan and Beard note that older women are generally more vulnerable to sexually transmitted infections because menopause affects the lining of the vagina, making it less protective to infection [127]. Furthermore, as one ages, the immune system also declines.

Ultimately, practitioners should be vigilant when working with older adults with HIV due to age-related comorbidities. Perhaps due in part to the misconception that older adults are not sexual beings, practitioners often do not have conversations with their older adult clients about HIV/AIDS and other sexually transmitted infections [168]. In addition, polypharmacy is common in the older population, and drug interaction with HIV medications should be considered [128]. Generally, older adults metabolize antiretroviral medications slower, which could place them at risk for higher levels of toxicity [126]. Older adults who are diagnosed with HIV/AIDS are also at greater risks for being diagnosed with cancers [126].

Findings are mixed regarding the scope of depression among older adults. In one study, it was reported that 7% of the older adult population worldwide experiences depression [201]. However, in a meta-analysis of 48 studies involving 72,878 older adults, the reported global prevalence rate of depression was much higher, at 28.4% [232]. Depression can affect the older person and is more prevalent among those who have experienced the loss of friends and family members [29]. The death of a spouse is a stressful event that may precipitate depression and may predict the onset of illness and earlier death [3]. Older women tend to experience greater depression and, once depressed, tend to stay depressed for longer periods of time compared with their male counterparts [131]. Older women with long, stable marriages were more likely to experience depression compared with women who had been married for a short period of time or whose marital quality was not as good [131]. In one study, older adults who are socially isolated are more likely to experience depression, fatigue, and sleep disturbances [202]. Psychosocial stressors (e.g., financial concerns) are also risk factors [233].

Depression is a concern among older adults because it can place them at greater risk for developing medical illnesses. The converse is also true; those who have medical illnesses or disability are also at risk for depression [30; 203; 233]. For example, older adults with high blood pressure and depression are three times more likely to experience a stroke compared with older hypertensive individuals who are not depressed [29]. It is interesting to note that older persons with rheumatoid arthritis or osteoarthritis experience higher levels of depressive symptoms [30]. As individuals age, it is more likely they will experience some form of chronic pain. Adults between 45 and 64 years of age are more likely to report that they experience physical suffering lasting more than 24 hours [172].

The highest rates of depression in older adults occur in those who have had strokes, coronary artery disease, cancer, Parkinson disease, and Alzheimer disease [84]. Recurrence rates are also very high. Although it is a misconception that older persons are more depressed than the general public, they may still be at risk. It is important to assess each person individually.

It is also crucial to remember that older person may not necessarily display dysphoria and feelings of sadness. Instead, depressive symptoms may be manifested somatically. Older adults who experience sadness or loss of pleasure in the things they normally enjoy are more likely to attribute these symptoms to aging rather than depression [203].

Suicide is also a concern, as individuals 65 years of age and older account for 19% of all suicides in the United States [173]. Death by suicide is 6.2 times higher among older male adults compared with their female counterparts [99]. The male-to-female suicide ratio is 3:1 in Western countries. However, women are more likely than men to attempt suicide [233]. In a 2021 study, functional disability and frailty were predictors of suicide ideation among older adults, regardless of severity of depressive symptoms [234].

Practitioners should be mindful that older adults are less likely to express emotional pain compared with their younger counterparts and are also less likely to endorse suicidal ideations [132]. It is important to account for risk factors more common in an older population, such as chronic illness, pain, loneliness, and social isolation, some of which may not be part of suicide risk assessments [132].

Although the terms "grief," "mourning," and "bereavement" are often used interchangeably, they have specific and unique meanings. Grief is a normal reaction to a loss, while mourning is the expression of grief and the process by which individuals adjust to the loss. Bereavement is the period of time during which grief and mourning occur [35,133]. Psychosocial support is essential for individuals who have lost loved ones and can help to decrease the risks of morbidity, substance abuse, and mortality commonly found among widows/widowers and other persons who have lost a loved one [36].

Alcohol and substance abuse/dependence in the older adult population are generally hidden problems. However, between 2002 and 2006, substance use rates almost doubled among those 50 to 54 years of age. It is estimated that slightly more than 10% of the older adult population abuse prescription drugs, with up to 5 million older individuals projected to have drug use disorders and 4.4 million requiring substance abuse treatment by 2030 [101,135,176]. It is estimated that more than 80% of patients 57 to 85 years of age are taking at least one prescription medication daily. In addition, more than 50% are taking more than five medications daily [177]. Among adults 65 years of age and older, there was an increase in past-month cannabis use and binge drinking between 2015 and 2019 [237]. The opioid use disorder hospitalization rate increased 120% from 46 per one million population in 2007 to 101 per one million population in 2014 [238]. Several factors contribute to the invisibility of these disorders. First, many older individuals do not disclose alcohol or substance abuse because they are ashamed. This is compounded by healthcare professionals' reluctance to ask older adults about substance abuse, mostly due to the prevalent images of young people misusing substances [40]. Polypharmacy is also a concern, as many older adults are taking prescribed medications for medical comorbidities and/or chronic pain [239]. Additionally, the symptoms of alcohol and substance abuse can mimic or resemble conditions and chronic illnesses associated with aging, thereby masking an underlying drinking or substance disorder [40; 239]. Finally, some older adults may be isolated, with minimal social contacts or networks to intervene in cases in which alcohol or substance use has become a problem [239].

A study comparing the 12-month prevalence of alcohol use, high-risk drinking, and Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV alcohol use disorder from 2001–2002 to 2012–2013 showed significant increases in the number of individuals 65 years of age that met those criteria. Alcohol use among older adults increased from 45.1% to 55.2% (a 22.4% increase), high-risk drinking increased from 2.3% to 3.8% (a 65.2% increase), and alcohol use disorder according to the DSM-IV criteria rose from 1.5% to 3.1% (a 106.7% increase) [120]. Approximately 11% of older adults reported binge drinking in 2022, which appears to defy stereotypes of older adults [239].

Late-onset alcoholism is common in older adults, and several risk factors may contribute to the development of alcohol use disorders in older age. Some may use alcohol to self-medicate to mitigate physical symptoms, such as difficulty sleeping or chronic pain. Chronic illnesses and depression are also risk factors [205]. Mourning a loved one, loss of social supports, and loneliness can also instigate alcoholism later in life [102]. In general, late-onset alcoholism is more common among older women than older adult men [136]. It is also more prevalent among older adults in higher socioeconomic brackets. Compared with early-onset alcoholism, individuals with late-onset alcoholism tend to experience less psychosocial and legal consequences as a result of the substance abuse [136].

Rigler argues that the DSM criteria for alcohol use disorder may be difficult to apply to older adults [45]. For example, age-related physiologic changes may change the individual's response to alcohol, increasing their sensitivity and levels of tolerance. Because of this, they may not spend a lot of time or expend a great amount of energy in activities related to alcohol or substance consumption [46]. Thus, these persons would not meet the DSM criteria for alcohol use disorder as they require smaller amounts of alcohol to become intoxicated. In addition, the DSM criterion of giving up activities or responsibilities as a result of substance use may not be appropriate for older adults because they may have fewer regular activities resulting from diminished vocational or social responsibilities [46]. Unfortunately, there are few evidence-based substance use disorder treatment approaches that are targeted for older adults. Practitioners tend to simply adapt treatments created for younger populations for older adults [135].

The 2015 White House Conference on Aging identified elder abuse as a top priority in public health [178]. Elder abuse refers to "any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to an older adult" [47]. There are three general categories of elder abuse, which appeared for the first time in the 1987 Amendments to the Older Americans Act [48]. These three categories of elder abuse are: domestic elder abuse, institutional abuse, and self-neglect or self-abuse [48].

Definitions of elder abuse vary based upon state statutes. However, the National Center on Elder Abuse has identified seven types of behavior associated with elder abuse [47,206]:

Epidemiologic studies of the prevalence of elder abuse indicate a prevalence of between 2% and 10%, with 1.7% experiencing more than one type of abuse [48,137,207]. In a survey study with 3,005 adults between 57 and 85 years of age, 0.2% disclosed to physical abuse in the last year, 9% reported verbal abuse, and 3.5% indicated financial abuse [138]. In a national study of older Americans with a mean age 75.5 years, 40% of women and 22% of men reported at least one form of mistreatment [240]. These prevalence rates may be lower than the actual rate given the amount of under-reporting due to fear of reprisals, embarrassment/shame, and hopelessness [179]. A study of 441 Michigan individuals living in nursing homes found that 21% of family members reported some type of elder neglect in the last year [139]. More recent data show similar rates. A 2022 meta-analysis study found that the neglect rate was 64% in home care and verbal abuse was 21% in nursing homes [241]. The factor most predictive of neglect was limited ability to engage in activities of daily living. Cognitive impairment also appears to be predictive of elder abuse [179].

Typically, older adults do not think about parenting at their particular life stage; however, there has been an increase in grandparents parenting in the last decade. The U.S. Census approximated that, in 2019, 4% of children younger than 18 years of age did not reside with a parent; 53.2% (2.5 million children) lived with a grandparent [242,243]. The reasons for grandparents taking over parenting responsibilities of their grandchildren are numerous, ranging from parents' substance abuse, divorce, health and mental health concerns, reported child abuse, and death of a parental figure [180,208]. In a 2019 study, one of the main reasons Native American and White grandparents raised grandchildren was parental drugs and alcohol abuse [244]. Many grandparents assume these roles so their grandchildren do not enter the foster care system.

Often, grandparents are placed in these new roles without much preparation, making the task more difficult. Some older adults may feel uncomfortable addressing issues such as drugs, sexually transmitted infections, gangs, and school violence [54]. Some studies indicate that these new parenting roles, particularly if the grandchildren have physical or mental health problems, trigger anxiety and negative well-being for grandparents [55]. In one study, Ross studied 50 African American grandparents raising grandchildren, and a majority (94%) reported increased stress [56]. Those grandparents who were involved in counseling and special school programs reported less stress. In a separate study of African American custodial grandparents, sleep disorders were common, with most linking the lack of sleep or poor sleep quality on the stresses of parenting their grandchildren [16]. A separate survey of custodial grandparents showed that 95% of respondents had one or more concerns regarding finances, legal issues, and/or physical health. Respondents also indicated that they had limited social supports and community resources, compounding the stress experienced [145].

Stress also results from the financial constraints associated with raising grandchildren. It is estimated that 21% of grandparents who raise their grandchildren live in poverty [245]. The unanticipated costs of raising children in retirement years may severely impact financial independence, as these individuals may already be living on a tight budget. With additional medical costs and, at times, costs associated with other therapies, many grandparents may experience caregiving burden [57]. Inadequate or inappropriate housing for children may also be an issue [209]. Custodial grandparents who are unable to work may have difficulty applying for Temporary Assistance for Needy Families (TANF) [34]. The TANF family grant offers financial support based on the income of the entire family, but it also has a work requirement for the grandparent [34].

The additional stress in assuming primary care of grandchildren may also be a contributing factor to the poorer physical health of custodial grandparents. Grandparents who are caring for their grandchildren report worse self-reported health symptoms, such as more body pain and general health perception, compared with their counterparts not providing care to their grandchildren [51]. However, the evidence is not conclusive. In a 2020 study, biomarkers (e.g., cholesterol levels) were compared in custodial and non-custodial grandparents [246]. Custodial grandparents did not necessarily have worse biomarkers, but they self-reported less healthy compared with their counterparts. The researchers speculated that custodial grandparents rate energy levels lower and stress levels higher than non-custodial grandparents, which contributed to the higher rates of self-reported poor health. Although there are negative effects, there are also positive outcomes for custodial grandparents. Some view it as a second chance to rectify mistakes they feel they made as parents [141]. In a study of custodial grandmothers, some reported enjoying parenting the second time because they felt they had more experience, had learned from past mistakes, and could now offer wisdom. In many respects, this created a sense of freedom, relaxation, and confidence [142]. Some grandmothers felt they had more time and attention to give to their grandchildren compared with raising their own children, when they had additional demands such as work [142]. Some custodial grandparents took on the role because they wanted to be useful in a time of need for their children [210]. In a mixed-methods study, grandparents related having peace of mind knowing that their grandchildren's basic needs were met. Aside from the knowing that their grandchildren will be secure, they also described how they enjoyed the simple pleasures of partaking in activities with them [210].

The older adult population in the United States is far from homogeneous in terms of race and ethnicity. In 2020, 24% of older adults 65 years of age and older in the United States were from a racial/ethnic minority group. Aside from Hispanic/Latino, the largest group was Black/African Americans, at 9% [31]. Between 2018 and 2060, it is projected that the proportion of older adults who identify as non-Hispanic White will drop from 77% to 55% [247]. Given the discrimination and oppression that racial and ethnic minority older persons may have experienced over the years, they may be reluctant to seek mainstream health and mental health services. In addition, some may be limited in English proficiency, which is often another barrier to help-seeking and compliance with health and mental health services. Practitioners should be aware of the dynamics that stem from the result of cultural differences in values, belief systems, health beliefs, attributions of causation to illness and problems, and communication styles [104]. Not understanding cultural differences can lead practitioners to take on a deficit or pathology perspective when viewing their clients.

In examining historical trends, there are gender differences in longevity rates; women tend to live longer than men [5,92]. For example, women who reach 65 years of age are expected to have a life expectancy of an additional 20.6 years; men who reach 65 years of age have an average life expectancy of 18.1 years [92]. As such, there are significantly more older women (30.8 million) than men (24.8 million) [31]. This longer lifespan has social and economic ramifications. In general, older adult women are more likely to be widowed, living alone, and experience greater poverty than their male counterparts. For example, the poverty rate for women 80 years of age and older was 14.7% in 2021 [248]. In 2021, 10.1 million U.S. women 65 years of age and older lived alone, compared with 5.2 million men [31]. Despite some of these negative social trends, a qualitative study of 15 urban elderly women related stories of survival, strength, and resilience [106]. The themes that emerged in these narratives were that of being able to rebound from adversity and tapping into social network systems that stemmed from their churches, community, and family.

There are an estimated 2.4 million lesbian, gay, bisexual, and transgender (LGBT) individuals 50 years of age and older, a number that is expected to double by 2030 [183]. In 2018, only 0.7% and 0.2% of older adults in the U.S. self-identified as gay/lesbian or bisexual, respectively [31]. The overall predominant attitude about sexuality is that it is a private matter, and the general myth is that older individuals are sexless [107]. Therefore, the unique needs of gay, lesbian, and transgendered/transsexual older adults are often ignored or unacknowledged. Furthermore, in a heteronormative society, older adults may have experienced (and continue to experience) discrimination [184]. Older adult homosexuals experience intersecting oppression stemming from ageism as well as homophobia. Older gay men, for example, are stereotyped as "dirty," "lecherous," and "oversexed" [108]. These stereotypes lead to discrimination, marginalization, and oppression and affect health, mental health, and social services. In a survey with 613 adults 60 years of age and older, ageism and stigma related to sexuality predicted psychological distress and mental health [249]. The interaction of ageism and concerns of sexuality acceptance by others are important dimensions for practitioners to consider when caring for patients.

Chronic minority stress results in health disparities among older LGBT older individuals, including greater risk of cardiovascular disease, depression, and premature cognitive decline [211]. One of the major fears associated with aging in the gay community is decline in health status and not being able to access services that accommodate to gays' and lesbians' needs and concerns [107]. Lesbians tend to express concern about lack of recognition of same-sex partners and lack of services that are sensitive and relative to gays and lesbians. Gay men tend to fear being alone in later life. Discriminatory housing policies in assisted living facilities are also a concern [212]. It has been hypothesized that, due to the discriminatory policies affecting gay and lesbian individuals' access to different types of services, older gay and lesbian women are more vulnerable to needing long-term care than their same-age heterosexual counterparts [147,212]. After controlling for race, age, and education, researchers found that women living with female partners were more likely to need help with bathing or dressing compared with women living with or married to male partners. Similarly, men living with male partners were more likely than men living with or married to female partners to need help with errands.

It is important to use the lifespan perspective to understand the experiences of older gay and lesbian adults [148]. Their reality is shaped by a culture that has historically criminalized, medicalized, and pathologized same-sex relationships. Therefore, they have historically been socially isolated and ostracized by their families and friends [109]. In addition, access to care and social services have been adversely impacted, which then has led to health disparities [148].

The Institute for Clinical Systems Improvement asserts that clinicians should routinely screen all adults for depression using a standardized instrument.

(https://www.icsi.org/wp-content/uploads/2019/01/Depr.pdf Last Accessed: May 22, 2023)

Strength of Recommendation/Level of Evidence: Strong recommendation/low-quality evidence (The work group feels that the evidence consistently indicates the benefit of this action outweighs the harms. This recommendation might change when higher quality evidence becomes available.)

Structured instruments like the Center for Epidemiologic Studies Depression-Revised scale (CESD-R) and the Beck Depression Inventory are brief self-reports that measure signs and symptoms of depression [59,60,166]. These practical tools are easily accessed and administered by practitioners. However, they are self-reports and can be unreliable, particularly for those with impaired memory. The CESD-R is a 20-item instrument consisting of closed-ended questions; the Beck Depression Inventory is a 21-item rating inventory. These assessment tools were not developed specifically for older adults.

In addition to these tools, a specific assessment measure for older adults, the Geriatric Depression Scale (GDS), has been developed [85]. Available in both a short and long form, this scale consists of 15 to 30 closed-ended questions. The GDS is recommended when screening older adults who are functioning well cognitively or are only slightly cognitively impaired for depressive symptoms [84,203].

If a practitioner finds that an older individual scores positively for depression, the patient should be further evaluated in a clinical interview to determine whether the symptoms are of sufficient intensity, number, and duration to meet the criteria for major depression or dysthymia.

Older adults are more likely to experience cognitive decline, and presence of the early signs of impairment should prompt immediate intervention [83]. Patients who display symptoms of changes in psychological status may be evaluated for dementia or cognitive impairment using the Mini Mental State Examination (MMSE). The MMSE consists of 11 items that assess five areas of cognitive function: orientation, registration, attention and calculation, recall, and language. A maximum score is 30, and any score less than 24 indicates cognitive impairment [83]. Because the MMSE takes little time to administer, it may be integrated into practice relatively easily.

The Mini-Cog is also another quick screening tool used to assess for cognitive impairment. It involves a three-item recall and a clock drawing test and takes about three to five minutes to administer. The patient is given three unrelated words to remember, then is asked to draw the face of a clock, with the time of 10 minutes after 11 o'clock. After drawing the clock, the patient is asked to repeat the original three words. He or she receives one point for each recalled word [150]. A score of 0 indicates likelihood of cognitive impairment, and a score of 3 indicates no concern of cognitive impairment. If the score is 1 or 2, the results of the clock drawing test are taken into account; an abnormal drawing is suggestive of cognitive impairment. This test has a sensitivity rate of 99% and classified a group of subjects correctly 96% of the time [150]. In a study of older adult veterans, researchers found that the majority of participants with no documented diagnoses of dementia failed the Mini-Cog [151]. The authors concluded that this simple screening tool can easily be incorporated into standard assessments.

The Montreal Cognitive Assessment (MoCA) assesses for memory, orientation, language, abstraction, executive functioning (i.e., ability to remember instructions, focus, and handle and execute multiple tasks), and constructional praxis (i.e., skill to join parts to make a whole). Some prefer this assessment because it detects milder forms of cognitive impairment compared with the MMSE [214]. It consists of 30 items and takes approximately 10 minutes to administer. More information on the MoCA is available at https://mocacognition.com.

In addition, the Alzheimer's Association has published a cognitive assessment toolkit intended to allow practitioners to detect cognitive impairment quickly and efficiently during the Medicare annual wellness visits. The toolkit is available online at https://www.alz.org/media/documents/cognitive-assessment-toolkit.pdf.

Asking questions about thoughts and/or intent to harm oneself is often uncomfortable for practitioners [61]. However, it can be done in a non-confrontational manner that conveys caring and respect. It is also recommended that cultural sensitivity be at the forefront of practitioners' minds when assessing for risk of suicide. Individuals from certain cultural backgrounds may view suicide as sinful [61,152]. Taking this into consideration, questions include: With this much stress, have you thought of hurting yourself? Do you think life is worth living? Have you ever thought of killing yourself? How would you do it? Do you have the tools to carry out your plan? What would stop you or what has stopped you from carrying out your plan?

When suicidal ideation is known or suspected, a more direct approach, using forced choice questioning, may be helpful [62]. Shea recommends inquiring about specific symptoms with an emphasis on overestimation in order to prevent individuals from underestimating the symptoms [62]. For example, a clinician might ask: "Do you think about hurting yourself 20 hours a day?"

The Geriatric Suicide Ideation Scale (GSIS) is targeted to older adults to specifically measure for suicidal ideations. It consists of 31 items in four subscales: suicidal ideation, death ideation, loss of personal and social worth, and perceived meaning of life [215].

The Depression and Suicide Screen (DSS) may also be useful. It consists of five items, is simple to administer, and can be used in health and mental health settings. The DSS requires patients to answer yes or no to following questions [113]:

A score of 2 or greater is considered sensitive for depression and/or suicidality.

There are several screening tools available for assessing older adults with problem drinking. The Drug Abuse Screening Test (DAST) is a 28-item questionnaire consisting of yes or no responses. The Short Michigan Alcohol Screening Test (SMAST) is a 13-item questionnaire with a similar response format. These instruments are commonly used but may not be appropriate for the older adult population. However, a longer version of the SMAST, the Michigan Alcohol Screening Test-Geriatric (MAST-G) was specifically developed in order to accurately assess alcohol abuse and dependence in older adults [46]. The MAST-G consists of 24 items, which may limit its incorporation into regular screening procedures. As opposed to the standard MAST, this version focuses more on drinking in response to grief and changes in drinking patterns over time.

The CAGE Questionnaire for Alcohol Abuse is a brief, easy-to-administer screening device that is easily incorporated into a medical or psychosocial assessment; it is the most widely used instrument in clinical practice (Table 1) [63]. The CAGE Questionnaire consists of four closed-ended items that assess an individual's perception of their drinking habits. Affirmative responses to any one item indicate a potential problem with alcohol abuse [64]. However, this tool does not identify those who may be in the early stages of alcohol abuse [63].

In general, patients will be willing to answer questions if they perceive that the practitioner is caring and nonthreatening. Responses to the screening questions will be most accurate when patients believe their responses will be kept confidential and will help with their health diagnosis [136].

There is no one single tool that is considered the criterion standard to assess and measure elder abuse [179]. One tool, the Indicators of Abuse form, is available for practitioners to use when observing and interviewing the client and family members for elder abuse [65]. This tool is not dependent upon self-reporting but is based on observation and assessment. Researchers have been able to isolate caregiver characteristics that are strongly related to elder abuse [65]. These characteristics include the caregiver's personal and emotional problems, financial dependence of a caregiver on the older adult, and the caregiver's general lack of knowledge about the older adult health and psychological concerns. Furthermore, elder abuse was also correlated with family conflict, the older adult's lack of social support, and history of past abuse (though not by the caregiver) [65]. Using these findings, the Indicators of Abuse form was developed. Based on observations and lengthy interviews with both the elder and family members, it asks practitioners to estimate how large the problem is in two areas: dimensions related to the caregiver (e.g., behavior problems, financial status, alcohol/substance problem, or marital/family conflict) and dimensions related to the older adult (e.g., social isolation, unrealistic expectations, suspicious falls/injuries, or behavior problems) [65].

Another good assessment instrument is the Elder Abuse Suspicion Index (EASI). It is a five-item tool that provides practitioners a very quick sense whether there is suspicion about the potential presence of elder abuse [114]. It was originally developed for physicians, but it may be used by practitioners in diverse disciplines. The screening questions are:

The Brief Abuse Screen for the Elderly (BASE) is another instrument, consisting of only five questions, that takes less than one minute to complete [153]. This tool is designed for the practitioner to complete to determine level of suspicion—the patient is not questioned directly. It is ideally suited for practitioners to use in conjunction with a patient screening tool [153].

The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults.

(https://jamanetwork.com/journals/jama/fullarticle/2708121 Last Accessed: May 22, 2023)

Strength of Recommendation: I (Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.)

There is no shortage of elder abuse assessment tools. A systematic review of elder abuse assessment tools published since 2015 found a total of seven new tools [251]. It is beyond the scope of this curriculum to conduct a comprehensive review of all the various elder abuse assessment tool, but the National Center on Elder Abuse (NCEA) has compiled 46 assessment tools housed in their Tools Inventory. This inventory is available here online at https://ncea.acl.gov/Resources/Tools-Inventory.aspx.

Assessing for elder abuse does not only involve asking questions to the older adult client. It is also about asking oneself difficult self-evaluative questions, such as: "Do I hold ageist attitudes? How are these attitudes translated when I conduct an assessment? Do I believe that older adults can be abused, even sexually abused?" Pervasive ageist attitudes held by practitioners can result in a failure to acknowledge that elder abuse (particularly sexual abuse) can occur [154]. This can impact whether certain assessment questions are even asked.

Coping with loneliness can involve increasing the number of social contacts or intensifying certain specified relationships and lowering individuals' expectations about relationships [157]. Loneliness and social isolation impact older adults' mental and physical well-being. For example, living alone, loneliness, and social isolation are correlated with falls among older adults [219].

Increasing or intensifying social networks can involve various approaches. Cattan and White identified three key aspects of interventions for older adults that support active engagement: group activities that provide support (e.g., support for bereavement), interventions targeted to a specific subgroup (e.g., widowers), and activities or interventions emphasizing older adults' control [70]. Several interventions for older adults that focus on decreasing social isolation have been identified and may be classified into four general categories [71]. The first type of intervention to address isolation is one-on-one telephone support services, whereby a counselor checks in with older adults periodically. Second, teleconferencing, whereby a group of older individuals are brought together via a phone conference, has been found to be a cost-effective and useful intervention. Third, face-to-face support groups were found to be beneficial in reducing social isolation, particular groups that last for at least five months [71]. Lastly, with increasing Internet accessibility, e-mails and Internet support groups can also be beneficial for older individuals. Older adults who have access to and use computers have more social support and are less likely to experience loneliness [217]. A study exploring the use of videoconferencing with frail older adults in Australia found that the patients preferred videoconferencing with a pain specialist over a face-to-face consultation [116]. A systematic review found that social connectedness and support were increased in older adults who used Internet technologies, although the effects were short term [187]. As discussed, loneliness is often intertwined with other variables, such as shyness or limited resources. Therefore, interventions should not simply focus on providing venues for older adults to meet; interventions and programs that focus on people's expectations about friendships and relationships are equally important [157].

When discussing engagement, practitioners should take into account the subjective quality of engagement. Engagement is not merely about the quantity of activities or the number of hours placed into an activity. Rather, it is more about the amount of physical and cognitive investment one is engaged in the particular activity that might reinforce the individual's sense of role identity and purpose [255]. Practitioners can spend time exploring with older adults what they perceive their roles are and how these roles promote health and wellness [255]. It is important to help these individuals reflect on how they can reconnect to their past accomplishments. Reminiscence techniques can help older adults recall and honor these past activities and memories [255].

Autonomy is a quality valued by all, but it may be even more important for persons whose movements are restricted by physical limitations, which is often the case with older individuals. Autonomy refers to the freedom and ability to act on one's own behalf [72]. It is described as having two attributes: independence and control. Independence entails the physical ability to act as one wishes; control is defined as perception of one's ability to exert power [72]. Control also refers to self-determination, or the ability to choose for oneself or formulating and executing a plan for oneself [117]. When older adults perceive they are losing their sense of autonomy, they are more vulnerable to becoming apathetic, depressed, powerless, and indecisive [158]. Family members become more involved as well [181]. For those living in nursing home facilities, it is crucial to provide them with choices and to empower them to make those choices, even simple decisions such as which foods to eat, activities to engage in, and clothes to wear [158].

Autonomy is central in promoting a sense of empowerment. Empowerment is the process by which individuals or groups perceive they can make positive changes or impact within their own lives related to interpersonal relationships and an array of social, political, and economic arenas [73]. In one small study of older adult women, the participants expressed the importance of relationships in the feeling of empowerment, including the significance of mutuality, problem solving based on collectivism, and mutual support and action [73]. Cox and Parsons recommend small group interventions, particularly for older women, that emphasize self- and mutual-help, meaningful relationships, and problem-solving skills [73].

With these overall themes in mind, Silverstone offers several practice guidelines when caring for older individuals [74]:

Interprofessional collaboration and practice (ICP) is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for patients and their families to improve health, mental health, social, and/or family outcomes [256]. ICP traverses professional boundaries, allowing teams to harness the skills and knowledge of diverse professionals in order to achieve a common goal [257]. Studies on the benefits of implementing ICP have demonstrated that health outcomes improve for patients; errors and mortality decrease; patients and families express higher levels of satisfaction; and measures of quality of life increases [258,259,260].

Because many older adults have complicated, chronic, and multiple conditions, they may be managed by several providers and be prescribed multiple medications. Unfortunately, practitioners often do not discuss prescribed treatments and medications with each other. ICP can help to minimize polypharmacy [261]. For frail older adults who may be at risk for falls, practitioners from different disciplines who have expertise and knowledge in gait and balance assessments, orthostatic blood pressure, nutrient deficiency, environmental evaluations to promote safety, and occupation/physical therapy and exercise (e.g., tai chi) can collaborate to improve patient outcomes [262]. In the case of financial elder abuse, attorneys and forensic accountants, may be included in the care team [263]. Well-coordinated, collaborative, and comprehensive intervention(s) should be communicated among the involved providers.

The ethical principle of beneficence mandates the duty of practitioners to do good and avoid harm [76]. The balance of good and harm is continuously evaluated. All persons have the right to self-determination, and it should be assumed that all adults (with some exceptions) have the capability to make decisions. Practitioners are responsible for encouraging (but not pressuring) the client to be autonomous [77]. This includes respecting the older adult's views/beliefs and right to make choices and decisions without manipulation by family members or providers [264].

Family members and practitioners may pressure older adults to use certain devices (e.g., electronic pill dispensers, data-gathering devices, robotic pets) because they appear to be beneficial and life-improving [218]. However, if an individual does not want to use the device, it is important consider if the pressure compromises his or her autonomy. A four-step process to assist practitioners to promote beneficence and client autonomy has been developed [76]:

The violation of clients' autonomy and self-determination can be very subtle. Practitioners should consider the role of power dynamics between the two parties and how the practitioner's expert status inadvertently reinforces a hierarchical relationship [118]. In a study of 21 older adults receiving in-home nursing care, one of the main themes that emerged was older adults need to be treated as people—as unique individuals and not cases [159]. The participants reported wanting to be treated with respect and dignity and wanting to make decisions about their care. Furthermore, older adults with chronic conditions eventually learn to live with and have established competencies and routines to manage it. They are still active in their decision making and want to continue to be [160; 264].

Informed consent is the direct expression of the principle of autonomy. The three criteria for informed consent are competence, voluntariness, and being informed [182]. Practitioners should evaluate older adults' capacity to consent, and the consent process should be an ongoing process rather than a one-time event [265].

Decision-making capacity refers to an individual's ability to understand, appreciate, reason, and ultimately express choices. There are different categories of decision-making capacity, such as personal, medical, and financial [119]. It is important for practitioners not to assume that older adults cannot make their own decisions, as this would be based on the ageist assumption that with age comes a lack of mental capacity. However, practitioners should remember that some losses may be associated with the normal process of aging. Loss of hearing, for example, can lead to miscommunication and a sense of isolation, anxiety, or paranoia. Therefore, effective communication, regardless of client disabilities, is key in helping older adults make informed choices [78]. It is also important to remember that assessing an older adult's level of capacity should be continuous [161].

The issues of an older adult's mental capacity and self-determination come into play with informed consent, particularly if cognitive impairments are present. Informed consent involves three dimensions: the communication of the information, the opportunity to ask questions, and the process of making a decision [162]. As stated, an older adult's self-determination should be promoted. It must involve not only the communication of the information but also giving older adults the opportunity to ask questions about their care, the intervention, and/or services provided to them and empowering them to make the decision. However, there may be times when an older adult cannot give informed consent. One way to assess if the older adult understands the intervention is to have him/her reiterate what the intervention entails [6]. However, there are a few options when an older adult's capacity is compromised. First, a surrogate caregiver could provide consent. Second, double informed consent could occur, whereby the surrogate caregiver gives informed consent and the older adult gives assent. Finally, it is possible to obtain early informed consent from the older person via legally binding documentation of wishes prior to any cognitive impairment [6]. Practitioners may consider the following questions when assessing capacity [266]:

Several tools are available to assess capacity, including [161]:

These tools evaluate different dimensions of capacity, highlighting the lack of consensus on the criteria to determine capacity.

The ethical principle of confidentiality is defined as the preservation of client privacy. Older adults have the right to confidentiality regardless of how family members may feel. In some case, family members may attempt to pressure practitioners to disclose information about the health or well-being of the patient, but patients who have capacity to make informed decisions have the right to confidentiality [267].

When older individuals are at risk of harming themselves or being harmed by others, as in the case of elder abuse or cognitive impairment, the issue of confidentiality becomes a challenge [267]. Practitioners should assess patients' risk and safety, and if safety is compromised, confidentiality may need to be breached [267]. Surveillance devices offer the benefit of monitoring the whereabouts of an older adult with dementia at the cost of reduced privacy. The decision of whether or not to use these devices should consider the extent of the older person's cognitive deficits and his/her ability to make decisions [218]. In the case of elder abuse, the ethical intervention is dependent upon state and national laws. Therefore, practitioners should be well-versed in their state's laws regarding elder abuse, advance directives, and other relevant issues. In addition, practitioners should clearly present the limitations of confidentiality to the client [267].