Aging in America

Challenges of Aging

"Grief takes many forms. But don't worry, we're here to help you fill them out." Mike Baldwin

A demographic and fiscal challenge: The U.S. is challenged by dramatic growth in the aged population. This is the result of the baby boom that took place between 1946 and 1964 following World War II. This population starts reaching the age of 65 from 2011 through 2029. This will place greater stress on families and care systems than any previous period.

The U. S. Administration on Aging provides the following statistics on this aging trend:



The U.S. Census Bureau provides a chart of projected growth of the older population. (**Image here "chart...jpg")

The elderly population has diverse needs for care. Approximately 10% of people over age 65 live in their communities and require some level of long-term care. An additional 5% are in nursing homes. After age 65, nearly half of Americans spend some time in a nursing home. Nearly 75% will require some form of home care. (Stone, 2000)

Grave concerns are being raised by analysts and policymakers regarding the capacity of nations affected by a projected severe imbalance between young and old. Demands on society include costs, service design and delivery, and recruitment and training of the needed labor force. Although these questions have been debated since the 1970's in the U.S., analysts state that there has not been sufficient sign of the political will necessary to prepare adequately, particularly regarding development of the labor force. (Stone, 2000)

One response to costs and psychological needs in long-term care is a trend away from institutional care in favor of community-based care. However, a 2000 estimate was that only 18.2% of long-term care expenditures for elderly persons was for community-based care. (Doty, P., 2000)

Physical Challenges: The biological impact of aging can involve many challenges to physical health and functioning. These challenges translate into stress upon family and caretakers as well as the aging individuals. These stresses can pose serious mental health challenges not only in tolerating stress and adjusting to loss and change, but also the triggering of latent or remitted mental illness, and the generation of new psychiatric symptoms and disorders such as delirium and Alzheimers disease.

Stress can translate into mental health issues: It is very important for the mental health professional to fully appreciate the impact of aging-related stress. Of course, this is difficult to do without experiencing such stresses. Specifically, the frustration, grief, and insecurity that seniors and family members experience in reaction to stress and loss can be profound. For the elderly, the diminishment of cognitive functions can multiply such reactions.

Another very common example is the effects of slowed and impaired processing of speech. With increasing age, individuals are likely to have difficulty processing speech and distinguishing speech and other important sounds from background noise. The earliest manifestation may be that the individual loses interest in socializing in crowded environments such as busy networking meetings or enjoyable social events because of the resulting difficulty in conversing. This language processing problem may be further compounded by the development of difficulty hearing sound itself.

These social activities become awkward and frustrating, forcing the individual to take a more passive role. Note that this limitation begins as the result of a single impairment. It requires little imagination to recognize the challenge of adjusting to limitations imposed by growing and multiplying disabilities.

To put this into perspective, imagine the extreme frustration of having great difficulty taking care of typical daily tasks while having trouble seeing, becoming fatigued by pain, and even finding eating to be challenging because of trouble with chewing and digestion. Compound that with difficulty thinking clearly, and you also have trouble getting cooperation from others, difficulty controlling one's affairs, losing things, and being taken advantage of by predatory con artists.

An abuse dynamic: Families and caretakers already stressed by the physical and emotional demands of caretaking are further stressed by the reactions of the elderly to their circumstances and by behavior that may be the result of mental illness or confusion. Much caregiver distress, conflict, and even abuse occurs when family members do not have adequate skills or impulse control to meet the increasing challenge of coping with an elderly dependent whose behavior exhibits signs of dementia. In particular, unsophisticated individuals may take the disorganized behavior of an elderly person personally, and this can create anger that the individual is not prepared to control. This disorganized behavior stemming from dementia can be difficult for most people to cope with, and may include perseveration, mishandling and misplacing important things, saying disturbing things, and even being threatening or violent.

This dynamic is perhaps the one most amenable to mental health intervention for both the caretaker and the aging individual. Of course, moving the elderly person to a higher level of care or simply to a safe setting may be the only acceptable alternative. Determining the best course of action requires not the clinician's mental health assessment, but also investigation by Adult Protective Services that includes input from other professionals, family members, or others involved with the situation. Factors that may be of importance in such an investigation include the wishes and competence of the elderly individual, the level and frequency of the abuse, indicators of whether the abuse is remediable, and whether the living situation would be appropriate were the abuse resolved.

Challenges to adapting: At first, creative adaptations are fairly accessible and easy to arrange. However, additional losses of functioning can make adaptation increasingly difficult. Individuals who are not very resourceful will have the greatest difficulty accommodating the demands of aging. While everyone may benefit from mental health services and consultation in coping with the issues of aging, less resourceful individuals may quickly develop a desperate need for mental health intervention and other accommodation and treatment. These individuals may be having difficulty adjusting because of early progression of Alzheimer's, or longer-term emotional or intellectual impairments that have resulted from problems such as trauma, mental illness, substance abuse, or brain injury. Multi-problem families stand to become all the more dysfunctional as they rely on inappropriate coping behaviors in reaction to issues of aging.

Stereotypes: It is important to distinguish between commonplace age-related changes in cognition and lower intelligence. The stereotype of the confused or doddering elderly person is based on individuals who are suffering from a more significant difficulty such as emerging Alzheimer's. While normal cognitive slowing can have some impact on functioning, it does not represent a significant decline in intelligence or judgment. A mild loss of cognitive efficiency can make it somewhat more difficult to be as organized because memory processing takes advantage of cognitive speed to make best use of short-term memory. But this is more of an inconvenience than a disability. Most people who were well-informed and perceptive as younger people continue to enjoy these traits and to make meaningful contributions well into their later years. It is usually not until serious health problems emerge toward the end of life that substantial losses of intelligence occur.

If anything, negative stereotypes and attitudes of others can create a self-fulfilling prophecy because of the effect of environment and expectations on our performance. (Mather & Carstensen, 2005) Staff and caretakers should be trained to bring out the best in elderly individuals. A growing body of research and practice tells us that humanized interaction and environments can produce significant changes in the well being of residents, and even improved behavior in individuals who have emotional or mental symptoms.

Optimal Aging: Despite the challenges and stereotypes, the majority of aging individuals have a substantial commitment to well being and take advantage of benefits of experience. For example, overall, older persons have better management of moods and have a more positive outlook. (Mather, & Carstensen, 2005) The concept of optimal aging has also been referred to as successful or healthy aging.

Optimal aging has been studied since the 1950s and gained popular interest in the 1980s.

The three primary areas indicative of optimal aging, according to Mather and Carstensen (2005) are:

1. Low probability of disease or disability;
2. High cognitive and physical function capacity;
3. Active engagement with life.

However, problems in any of these areas to not relegate a person depression or futility. People are remarkably adaptable in deriving satisfaction and making contributions within their capacities, despite issues in these areas. Optimal aging can be viewed in the same domains as those comprising a mental health and wellness assessment for the general population.

Aging and Psychiatric Symptoms

Introduction

Social service and mental health professionals may need to cope with challenges posed by elderly clients and their families and caretakers. Clients with cognitive impairments may ruminate about things that the clinician cannot do anything about. Some of these clients will not be very responsive to attempts at expanding the discussion to more valuable areas. Loss of impulse control or emotional stability may result in disturbing or insulting statements or lashing out by the client. Suspiciousness and accusations are very common. Add to that the client's poor memory and tendency to misplace things, and there may be ongoing accusations of sabotage or theft that are unsubstantiated.

The client's position of dependence on staff, family, and other resources can be disturbing to the client. Most people are very uncomfortable being relegated to a role that feels childlike. Of course, guidance by professionals to family and staff to respectfully emphasize choices and independence as much as possible will help the client from feeling that others are infantilizing them or being condescending or oppressive.

Also, clients who are highly dependent will have limitations in their ability to benefit from direct counseling. The clinician's role will often be more in consulting and working with family members or staff. This calls for care in defining roles and boundaries as well as in navigating issues of confidentiality. Many social workers and case managers will primarily be dealing with ensuring that all resources, including family members, are contributing as much as possible to good outcomes for the client. Therapists may need to define their role as doing family therapy, thus having multiple clients. Some therapists who are not used to functioning outside of a counseling role will need to expand their thinking and roles into psychosocial issues and very active case management. In some cases, the therapeutic relationship will be with one or more family members who are attempting to do their best with an elder member who has no interest in talking with the therapist, or a very limited ability to benefit.

Issues of death may be taxing to clinicians that must come to terms with losing their clients and seeing families and caretakers through intense grief. Grievous losses can be traumatic and lead to symptoms in all parties, including clinicians. Training in grief work is very important to ensure that the clinician feels confident and resourceful, as well as able to detect their own needs for assistance with these issues.

Much of grief work is a matter of facilitating expression and staying supportive, yet out of the way so that the process of grief can take place. An appreciation of the grief process as a part of life and a gateway to a new chapter of life is helpful.

Depression

Risk

There is a higher risk of depression in the elderly. The limitations and losses of aging can create situational depression. Clients with dissatisfaction regarding their lives, particularly those with characteristics of personality disorders, may experience intense or smoldering feelings about the lives and experiences that they feel they should have had, but didn't. The deaths of loved ones may leave clients with much unresolved grief and a lack of support that was there in the past. Those who were unable to create supportive, intimate relationships may have great regret. Any missed opportunities may loom large in their minds. This may include abortion, lack of children, business or career failures, loss of money to illness, any failures in life, rejections, having been misjudged, or having been betrayed in any way.

Disregulation of the brain can cause dark moods and inability to become free of rumination over negative experiences and circumstances. The diminished activity caused by depression is a risk factor for obesity and other health problems.

10% to 22% of the non-institutionalized elderly display depressive symptoms, with women being nearly twice as likely as men to have them. The following table from the Health and Retirement Study (AOA, 2005) provides figures for ages 65 to 85 and over:

Gender	65 and over	65-69	70-74	75-79	80-84	85 and over
Women	18	16	18	18	18	22
Men	11	10	10	10	15	15

Of individuals age 65 and over, 1% to 2% have major depression. Elderly persons are twice as likely to commit suicide as the general population, with white males in this age range having eight times the risk of the general population. Depression can compound difficulties with self-care by reducing motivation. The lack of physical movement that can lead to obesity can be made much worse by depression, increasing weight gain. Medications for depression or other symptoms may also contribute to weight gain. In turn, obesity may make activity more difficult, creating a vicious circle.

Assessment

Remember that depression can have behavioral and cognitive signs. Depression signs include cognitions of worthlessness, excessive guilt, self-loathing, hopelessness, or helplessness. There can be a pervasive despondency and despair. Behavior can include diminished activity, social withdrawal, tearfulness, and suicidality, including ideation or acting out.

Encourage family members, staff, and physicians to take depression seriously, rather than writing it off as a normal experience of aging or as something that cannot be helped. Educate them regarding the value of counseling, psychosocial interventions, activity, appropriate exercise, environmental factors such as the setting and light, and medication.

Depression can be more difficult to assess in the elderly because of it's complicated overlapping with pain, normal grief, and the process of dying and having health complications.

Standard screening tools for depression such as the Beck Depression Inventory or even the Geriatric Depression scale are not validated for dying populations. There is concern that they may generate false positives. The following questions are excellent examples for getting an initial sense of potential depression. Each question pertains to a different aspect of the depression experience: time, comparability, and introspection. The final question gets the client to slow down and think, rather than offer a superficial response:

The Quick Depression Screen

• Do you find yourself depressed most of the time?
• As compared to other people in your situation, do you feel that you are depressed?
• Inside yourself, how do you feel about yourself?

Also consider the risk factors for depression at the end of life:

• Poorly controlled pain
• Advanced illness
• Alcoholism or other substance abuse
• Pancreatic cancer, stroke, untreated hypothyroidism
• Medications
• Personal or family history of affective disorder
• Other pre-existing psychiatric diagnosis
• Multiple losses

Treatment

Psychosocial education of clients and their family members is an important aspect of depression treatment. (Alexopoulos, Katz, Reynolds, Ross, 2001) It fosters understanding of the roles of various professionals such as psychiatrists, understanding of the mechanisms of funding for care, costs and efforts to be anticipated, medication issues, and other matters related to treatment.

If it has not already taken place, a full medical evaluation for causes of depression is called for.

Cognitive behavioral treatment of depression has been shown to be effective in the elderly population.

Enhancing activity, intellectual stimulation, being valued, and being involved in social activities has proven helpful. Religious activities are a ready means of generating social involvement because of the ease of integration into such activities, and the structured means of involvement. Additionally, the religious beliefs of the individual can be leveraged for enhancing mood through such involvement. (Fentleman, Smith, & Peterson, 1990)

Medication for Depression: For the elderly population, consider the following medication issues for depression.

Tricyclics and atypical antidepressants: Pro: Co-analgesic effect, especially with neuropathic pain. Con: Time to onset is 14 to 28 days. Side effects.

SSRIs: Pro: Better speed of onset and are well tolerated. Con: Less co-analgesic effect.

Psychostimulants: Pro: There is sufficient experience to consider these quite safe. In addition to assisting with depression, they can counter disorganization in many patients by increasing short-term memory span and other factors. With low doses, cardiotoxicity is uncommon. Onset is rapid. Con: This is contraindicated in depression that is associated with delirium or anxiety. However, when anxiety is the result of difficulty with life management, the medication may reduce anxiety.

Anxiety

As discussed, anxiety is a common aging experience, and can be compounded at end of life. Dying can bring up emotions ranging from anxiety to outright fear and dread. Anxiety generally manifests in a manner similar to the non-dying population.

Factors associated with dying that can arouse anxiety include:

• History of anxiety, mood disorders, or psychological trauma
• Current, legitimate fears, including ongoing abuse; Unspoken fears about being moved to another setting, losing more independence, or painful medical procedures
• Fears for others' well being, not being there for them; Can include concerns about their finances or the effect of one's medical care costs on the family
• Delusional or unrealistic and obsessional fears
• Fearing losing control, health, independence
• Fear of death as a potentially agonizing experience, or as the termination of existence. Can include existential fears pertaining to meaninglessness or hopelessness
• Difficulty letting go of desires, plans, or personal connections
• Fear aroused by loneliness or isolation, not having caring people
• Fear of own impulses to self-harm in connection with depression. Anxiety and depression can coexist. Anxiety is often a precursor to depression
• Concern about finances

It is important to understand the circumstances or psychological factors that give rise to the anxiety in order to produce a relevant treatment plan.

Assessment

To assess for anxiety, start with the client's own assessment of sources of anxiety. Rule out the above factors in discussing the client's concerns. Sorting out normal reactions to anxiety-provoking situations from other factors is important.

Treatment

Treatment for normal fears may be as simple as making sure that the client has sufficient information or reassurances about situations that are of concern. The therapist should avoid being overly reassuring when it is premature or will lack credibility. Developing a plan to address the situation may be key. When there are psychological or psychiatric issues, the treatment plan should reflect a thorough assessment. Medication may include benzodiazepines. Stabilization of sleep may be a crucial element of treatment, as sleep problems may destabilize mood and cognition. Even people of very advanced ages can benefit from psychotherapy for anxiety and other problems. If there are concerns about therapy causing excessive arousal in a medically fragile individual, the treating therapist should have good skills in preventing or minimizing abreaction to material that is highly arousing. The incorporation of visualization and hypnotic modalities may be appropriate. Clients with unmet religious needs may derive a great deal of comfort when this is addressed in a manner that is sensitive to their beliefs.

Near-Death Delirium

Approximately half of individuals experience delirium when approaching end of life. This can be very emotionally disturbing to staff, family, and other patients. Because it is part of the dying process, it may be very different from non-terminal delirium. It is important that people in the patient's environment be prepared and understand that it is a medical phenomenon, and that steps be taken medically and emotionally to minimize the patient's distress.

The argument that medication will make the dying individual become a zombie must be countered with understanding about the experience of delirium. Many physicians are not skilled in responding to delirium, so discussion of this potential circumstance with treaters in advance may help to prevent suffering. For example, if the physician or others in the environment attempt to control the patient from a highly aroused state of mind, this can escalate the patient. This can result in injuries, including painful soft tissue injuries that are not reported by the patient or detected. They may be invisible to a medical assessment, unless there is sufficient inflammation, and they typically do not show in X-rays.

Delirium vs. Dementia: Delirium can be differentiated from dementia in that delirium is a disturbance in the level of consciousness with fluctuating symptoms and acute onset. Dementia, on the other hand, normally involves being fairly alert with little or no clouding of consciousness. It usually has a gradual onset. The two conditions share the features of impaired memory, thinking, orientation, and judgment.

Terminal delirium is, generally speaking, distinct from non-terminal delirium in that it is relatively refractory to clearing through medical intervention. This is because it is part of the dying process, exhibiting a more profoundly changing brain state. Non-terminal delirium usually has an underlying cause that is correctable. It can occur in any fragile patient, but is more likely to occur when the patient is very ill. Common but reversible causes of delirium at end of life include pain, constipation, and urinary retention.

Treatment

Sedation is the most common approach. This is because the condition is not usually correctable through any means. For example, withdrawal of opioids may exacerbate distress. Medications may include the following:

• Neuroleptics (List is arranged from least sedating to most sedating)
  • Haloperidol (Best for mild confusion or disorientation)
  • Thioridazine
  • Chlorpromazine (Ease of access and treats nausea as well)
• Benzodiazepines (Sedating but may worsen confusion)
• Barbiturates and Anesthetics (For severe delirium)
• Avoid opioids for sedation, the effect is too transient
• If response is poor, refer to a specialist

Be reassuring to the patient and family. Simple statements as to where the patient is and who they are with may be reassuring to many patients. It is important to maintain a peaceful environment.

When it is not distressing: Delirium may not be distressing, but merely confusing. Some patients experience pleasant visions or hallucinations. These may involve transpersonal themes such as deceased relatives, guardian angels, young children, or babies. In this case, no intervention is required. It is important to avoid medication that would increase confusion in this case, such as benzodiazepines. If the family is distressed by this, educate the family members and reframe the experience in a positive manner.

Grief

Grief is a specialty. You could say this about any condition, but many therapists are not trained specifically in grief treatment. This section is an overview of grief issues that may be applied to the grieving experience of the elderly individual or others who are experiencing losses. Of course, the elderly or dying person has a different perspective of grief because they are approaching the end of life and may be experiencing degenerative illnesses that are not common in other age groups.

Grief can be sharply painful, with mental suffering regarding loss or regrets. All losses potentially can cause grief, and there are many kinds of attachments. Grief can manifest in many ways. People may feel shame about expressing grief, but it is difficult to control. Although there are academic stages of grief, the process is not necessarily even, and can be like a roller coaster, move in what appears to be a forward and backward progression, and can come in waves, even after periods in which it appears to be resolved. While others may encourage a person to complete grief, this is probably more for their own comfort than that of the bereaved. Many people experience grief as something that never allows them to become fully detached. For them, something is permanently missing. Nonetheless, most people learn to live with their loss. Although people experiencing grief may tend to isolate, or others may believe that they need to be left alone, it is important for people in grief to have opportunities to share with others their memories and experience of grief, and to receive support. Others who are going through grief may be in the best position to share this support, and often want to take the time for this. For this reason, grief support groups can be very productive.

People may experience anticipatory or preparatory grief, as they see losses looming. There may be complications of grief that involve serious psychiatric manifestations, or mild symptoms. The cultural interpretation of these experiences may provide a safe frame for them, as occurs with perceived transpersonal phenomena such as seeing or hearing the deceased. However, complications may also include clinical depression or even psychosis. Some cases will not show signs of resolving, and this can indicate risk of long-term disability unless resolved.

High-level risk factors include unexpected, traumatic, or violent deaths, deaths of children, multiple or repeated losses, and a history of mental illness or grief reactions.

Life Transitions, Relationships, and Meaning

Relationships and Social Well Being

Trends: People are likely to live well beyond 65. For men, this is usually an additional 16.6 years, and for women, an additional 39.5 years. If anything, lifespans are likely to continue to increase. The result is that there are substantial numbers of elderly persons whose spouses have died. 71% of older men are married, but only 41% of older women. We are likely to see increasing numbers of non-institutionalized individuals living alone. (AOA, 2005)

Relationship and family issues: Even good relationships can become quite stressed by challenges of aging. These can include difficulties with adjustment to loss, cognitive changes, health issues, retirement, and financial difficulties.

Changes in roles are often a trigger for relationship difficulties. The treatment plan can include reducing anxiety levels and helping couples navigate their changing expectations and circumstances. A previously positive relationship is, of course, a positive prognostic indicator.

Some transitions are especially difficult to tolerate. This can include adjusting to financial problems or outright crises. Care for the child of a poorly functioning direct descendent may become increasingly difficult. According to the AOA (2005), 416,000 grandparents aged 65 or over were responsible for raising their grandchildren. Many such grandparents are not willing to see their grandchildren relegated to foster care or subjected to neglect or abuse by their child.

Poorly functioning adults with diagnoses such as downs syndrome may not be prepared for independent living. The parents must be helped to utilize resources for this transition. Disturbed adult children may be taking advantage of their parents' support, but pose so much of a risk, that the parents will require assistance in developing a plan for change.

Income challenges: The elderly are especially vulnerable to financial problems that amplify their risk of poorly treated health issues. Median income of the elderly in 2003 was only $20,363 for males, and $11,845 for females. Social security benefits comprise 90% of the income of those over 65, with 10.2% of the elderly living below the poverty line. Another 6.7% were the "near poor," those with incomes no more than 25% above the poverty level. (AOA 2005)

Employment issues: Older persons generally wish to retire. A minority of older persons continue to work. Most have hoped to use retirement to do other satisfying activities. Clients may need assistance in coming to terms with forced choices that result from economic necessity, health issues, or age discrimination. The expectations with which individuals enter their later years often have a great impact on the manner in which they respond to demands of life.

Physical activity: A shocking number of elderly persons do not maintain adequate levels of physical activity. (CDC, 2002) From age 45, physical levels of persons involved in regular physical activity go from 30% to lower levels. By ages 75 to 84, 20% are reported to have adequate levels. Because of the benefits to well being and mental clarity that physical exercise create, professionals should assist elderly clients to adopt appropriate levels of activity that are gratifying. Some physical activities have the added benefit of social involvement, such as walking groups and gym memberships. Social networking sites such as MeetUp.com can be helpful in finding or starting activity groups locally.

Identity, End-of-Life, and Dementia

Dementia as emblematic of end-of-life issues: There are many end-of-life issues that elders, family members, and professionals must grapple with, such as euthanasia, when to terminate life-sustaining treatment, and assisted suicide. These issues are intimately tied to matters of free will and identity. Dementia is a medical condition that brings these issues and more into the foreground. Growing old and experiencing decline pose challenges to our identity and closest human relationships. As old as these issues are, we are experiencing them in a new context, that of modern medicine and its effects in increasing the healthy and active lifespan, as well as the years of dependency and decline.

According to panelists on The President's Council on Bioethics (2004) quoting American Psychiatric Association publications, in 1900, people over 65 constituted only 4.1% of the U.S. population. In 2004, this climbed to 14%. Among these older Americans, roughly 15% suffer from dementia in some form. Of this group, 60% suffer from Alzheimer's disease. About 1 million of them have severe symptoms, with another 3 million being mild to moderately impaired.

Cognitive and memory loss affecting relationships: Memory loss and cognitive impairment can cause significant changes in the personality of the individual, and memory loss can blur or even eclipse life-long relationships in the sufferer's mind. Nonetheless, in some combination of obligation, attachment, and love, family members families generally maintain the bond and commitment to the affected individual and go to great lengths to support them in being as independent and comfortable as possible. The hardiness of family and marital relationships means that many people will want to utilize whatever help they can acquire in enduring the stresses involved in maintaining the well-being of their elderly family members. There will be a great need for therapists familiar with issues of aging, particularly the most stressful issues of caretaking and adjustment to profound transitions.

A source of various conflicts: Where there is severe cognitive impairment, such dynamics can create a collision between three factors in particular: The desires of the elderly individual as perceived by the family, the recommendations of medical clinicians, and any directives left by the elderly person. Two major sub-conflicts arise: Conflict between family members as well as the presumed or actual conflict between an advance directive and the elderly person's current life satisfaction.

A highly dependent and low-functioning individual whose "past self" would have elected die before becoming so dependent and impaired may now be taking satisfaction in simple tasks. It can be argued that the person as they are now cannot be affected by a directive made by a "past self" that should no longer be considered as a viable decision-maker when it comes to end-of-life decisions. The conflict that occurs within the family often centers around the interpretation of a dying and dependent person's preferences when decisions around treatment and withdrawal of life support must take place. Parents and siblings are more likely to desire heroic measures, while spouses are more likely to favor termination of life support sooner. Most likely there is a mix of selfish and altruistic motivations at play in these positions. These conflicts are compounded by the fact that many advance directives are too vague or do not adequately address the issue at hand. As society gains experience in these matters, advance directives are becoming more templated and sophisticated.

Loss as a fundamental: At the root of many such conflicts is grievous loss. The person is still physically there, but has so changed, that family members and fiends experience a loss of that person. They may not be able to express it because of shame. The therapist can help individuals and families deal with this as a grief issue by helping them to recognize it and develop a constructive interpretation of their own issues as being valid and constituting a gateway to a new chapter in their own lives. Such matters are influenced by our philosophies regarding what it means to be a person. Some of the most intense loss that we experience is that of what we think of as conscious experience, that is, the part of ourselves that can be conscious of ourselves and verbalize that consciousness. People who experience themselves beginning to lose this sense of self through early Alzheimer's may have great difficulty coming to terms with it. Those who lose this aspect of a loved one have a serious loss to grieve.

Relationship and consciousness: But the adjustment issue that this raises, is the maintenance of a relationship with what feels like a new or changed self. Sometimes the individual maintains much of their ability to personally connect with family members, such as after a left hemispheric stroke that eliminates speech. This makes it easier for family members to feel the presence of their loved one. More disabling strokes or neuro-degenerative illnesses are generally experienced much more as a loss and a more extreme adjustment.

Recognition of a broader meaning of self and the fact that consciousness largely exists outside of what we typically experience as consciousness can inform therapists in guiding people to connect with impaired individuals. A very articulate neurologist, Jill Bolte Taylor, recovered speech after a left hemispheric stroke. She describes her experience of nonverbal consciousness in very artful and compelling terms. In her book on the experience, she described her experience of losing left hemispheric function: "I felt like a genie liberated from its bottle. The energy of my spirit seemed to flow like a great whale gliding through a sea of silent euphoria." (Kaufman, 2008) In order to embrace the challenges posed by cognitive changes associated with aging, we need to recognize and legitimize the self that exists outside of the familiar narrative.

Palliative care: It is a myth that the elderly experience pain less than other age groups. It is also inappropriate to think of pain as a character-building experience, certainly not in the elderly population. For these reasons, palliative care is intended to enhance comfort rather than engage in life-saving medical procedures. However, palliative care does not necessarily obstruct the provision of other medical treatment.

Spirituality

Spiritual or religious questions may arise in patients, even those who have a history of firmly rooted beliefs. These reactions range from mild crises in faith, to manifestations of psychiatric illness that may be overlooked. Questions such as, "How could God let this happen this way?" and "Why would God's will create such suffering in the world?" may sound the same in a normally grieving person and a person experiencing a mood disorder.

Therapists should be prepared to embrace the diversity of religious and spiritual beliefs of clients and family members, as well as staff members, any of whom may express their beliefs and feelings in ways that may make the therapist uncomfortable. Therapists who can function seamlessly within the person's belief system may be able to provide some consoling words that are very easy for the client to take in. However, this can be a slippery slope, as it may imply to the patient that it is not okay for them to be having doubts. The therapist may seem more acceptable or safe to the client, or less so.

Specialized training in responding to spiritual concerns can help the therapist navigate this territory, regardless of their personal beliefs. Some therapists express neutrality in a way that is still supportive of the client's quest for meaning. For example, the therapist may say, "You have found meaning in scripture before, haven't you? Can you tell me more about that?" Or, "People want to know these answers right away, when they are in the middle of their pain, but you may do better by accepting the gift of time that you have now, as you heal from this, as countless people before you have healed." Or, "You can give God time to answer you, by taking the time to write a letter to God. You can get your thoughts and feelings out, and this can help you feel better."

A 1997 Gallup poll found that nearly 70% of people in the U.S. said that they would want their physician to address their spiritual issues if they were in distress. Most likely, this number would be higher for psychotherapy. Given the diversity of spiritual practices and beliefs, this requires that the therapist at least be prepared for various scenarios, and accept the profound feelings that others have about beliefs that may be quite different from those of the therapist.

One answer is so obvious, it's almost invisible. The therapist can ask simply, "How would you like me to address this (spiritual issues brought up) in our work?" There's no reason for the therapist to try to read the client's mind. Also, the therapist can use the client's beliefs as a gateway to interventions such as getting the client involved in their faith community in some way in order to create more support. Most likely, there is a range of options. Even home-bound individuals have options such as visits, phone calls, online support, and recorded media.

A quick assessment of spiritual issues take the form of the FICA Spiritual Assessment, and it has nothing to do with the client's credit score:

• Faith or beliefs: Tell me something about our faith or beliefs.
• Importance & influence: How does this influence your health or wel-being?
• Community: Are you par of a supportive community?
• Address or application: How would you like me to address these issues?

Non-religious clinicians may feel duplicitous in supporting clients' religious beliefs or may recognize that many people function better with their beliefs supported. Research shows that religious affiliation can be a good source of social support and engagement. Research has repeatedly failed to support the idea that prayer heals, distance prayer heals, visualization heals, or energy work heals. However, these processes can function as part of a stress management program. Clinicians are ethically restricted from imposing their beliefs on others, and are cautioned not to undermine others' beliefs, since people come to therapists during times of heightened stress when they are vulnerable.

Non-religious clients may elicit an urge to proselytize if only in a subtle way. Again, ethics dictate respect for alternative beliefs. Non-religious clients range from those who reject religion because of disappointment to those who have a very sophisticated and well-grounded belief system and humanistic value system. And, of course, there are levels of belief from atheism to agnosticism to faith to fanaticism.

Patients or their family members may have or rationalize various spiritual or superstitious beliefs that may interfere with medical decision-making, in so far as the professionals involved are concerned. This may involve keeping the patient on life support until God decides it's time for them to die. It may involve refusing treatment because what's happening is God's will or because they believe in and expect miracles. Sometimes, legal issues arise in regards to treatment being withheld from a senior.

Long-Term Care

A spectrum of options: As individuals age, they may begin to require some level of support in order to maintain their independent living arrangement. As their needs increase, they may need a supportive living arrangement of some kind. This section reviews some of the alternatives and related issues.

A broad range of arrangements: Arrangements are as organic as a family member providing regular assistance and as professional as living in a facility that provides ongoing care. Of course, there are arrangements across this spectrum. Social workers or other professionals with experience in this area can assist families in determining the appropriate level of assistance for a given individual.

Blurring boundaries: Long-term care takes many forms and can include acute care that is part of a long-term care setting. Generally, long-term care facilities are distinct from acute care because they are normally dedicated to the overall well being of their residents and management of chronic conditions. There is no universal definition of long-term care. It may be referred to as home and community-based care when it is non-institutional. Such arrangements range from home-based care to various group living arrangements that include specialized homes called residential care facilities (RCFs). These include assisted living facilities, board and care facilities, and adult foster homes. These facilities can blur the boundaries between non-institutional and institutional care when they provide relatively high levels of care or when they are larger.

Assisted living and residential care facilities range from smaller, home-like settings to larger arrangements that resemble hotels.

Adult day care: By providing supervision and services during the weekday, adult day care programs can fulfill the role of offering respite to family members who are caring for an elderly relative, and who need to work. This kind of program can also be a way of consolidating care among facilities during the day in order to reduce costs. Adult day care services may be provided at a larger care facility, or at a community setting. Such services may help a fairly broad population, but some are intended for more individuals with a higher relative level of need. A large percentage of individuals benefiting from such services have cognitive impairments from dimenting illnesses such as Alzheimer's disease. Many of them need supervision and assistance, but do not require a high level of specialized medical care on an ongoing basis.

Day health model: An emerging model related to adult day care is the day health model, in which adult day care is provided to elders with major disabilities and who often have multiple co-morbidities such as heart disease, diabetes, or stroke. And example program is the Program of All-Inclusive Care for the Elderly (PACE).

Responsibilities: Long-term care provides a wide range of assistance with typical activities that individuals with chronic disabilities require over an extended period of time. You could call these services low-tech in the sense that they are intended to accommodate or rehabilitate physical or mental functioning deficits. Such facilities or in-home arrangements provide ongoing assistance with basic activities of daily living (ADLs). These include eating, dressing, bathing, and other typical personal care activities. They also include household tasks such as laundry, cleaning, and meal preparation. Management of finances and medication are also included. To provide these services, assistance must be available on an ongoing basis. Depending on the level of need, this may be predominantly supervisory or may be more intensive. Equipment and devices are also provided that assist the resident, or provide alerts to staff. These range from walkers and medication reminders, to emergency alert systems. For persons residing at home, there may be modifications to the home such as ramps, grab bars, and special door handles.

Individuals require social, physical, and intellectual involvement and challenges in order to maintain or enhance their level of functioning at optimal levels. Thus, the setting in which the individual resides must afford as much activity and freedom as possible, within the capacities of the individual. Additionally, it must be designed to incorporate relevant programming in the form of social activities, the availability of appropriate equipment and transportation, and staff with the right training and temperament. Policies and arrangements of long-term care facilities contain details for such arrangements, and the laws and regulations affecting such facilities require this. Case managers, regulators, and auditors provide corrective feedback and actions to ensure that these facilities are compliant.

Family and other caretakers: Surveys of long-term care tell us that family members provide the lion's share of long-term care services. A smaller percentage of care is provided by informal, unpaid caregivers that have various types of relationships with the elderly individual. If such free care were paid for, it is estimated that it would amount to as much as $100 billion. Roughly 95% of non-institutionalized elders receive some level of support from family members. A good majority of them rely solely on this free help. The person providing the most support is referred to as the primary informal caregiver. Additional caregivers are called secondary informal caregivers. On the other hand, about half of the elderly who need long-term care, but who do not have family support available, live in nursing homes. Of those who do have such support, only 7% live in nursing homes. (National Academy on Aging, 1997)

Any number of emotional adjustment issues can arise in family members and the older individual in considering changes in living situation, even when it is nothing more than increased family involvement. People can be quite protective of their independence; particularly where there is not a strong history of open communication and collaboration between the elderly individual and the family members involved. Additionally, the elderly person is being pushed by circumstances to face limitations that may be difficult to accept or acknowledge to others.

It is very important to assist all family members in preparing for transitions as much as possible so that they are not wrenching experiences. Skills from the motivational interviewing techniques can be very helpful here. For example, helping an older individual to review the evidence regarding their current and emerging needs will prime them to seriously consider a needed change and to communicate about it effectively.

When changes involve greater family involvement, family therapy may be needed to iron out difficulties such as chronic conflict or boundary negotiations.

Examples of Long-Term Care Facilities

Skilled Nursing Facilities: Also known by their acronym as SNFs (pronounced "sniffs"), these establishments are highly regulated, and provide various levels of personal and medical care and supervision. They also provide supervised activity. These are funded privately and, where there is eligibility, through Medicare. They are often inadequate in any number of ways, which can include being unpleasant and invasive environments. Residents who should be receiving higher levels of supervision because of mental health needs can be particularly vexing to higher functioning residents because of their acting out or noise level. There can also be danger of assault. The threat of drug-resistant infections plagues the facilities that provide care to residents most in need of medical care and who are bedridden.

Of course, the move to a populous facility in which there is so much less independence is a very demanding adjustment. For example, it is not possible to simply go to the kitchen and make a sandwich.

Staff are placed under great demands by the most impaired residents, and they have extensive documentation requirements. This can result in the staff being stretched very thin and can create burnout. There is a high level of turnover in many of these facilities, resulting in an increased likelihood of error, neglect, or maltreatment.

There is funding for mental health services when it is deemed necessary. This may require advocacy or additional coordination. In some regions, appropriately trained mental health professionals, particularly psychiatrists, can be scarce. This may be because of poor funding levels that discourage many professionals from accepting Medicare patients or clients.

Hospice Care: This form of care is for individuals approaching the end of life, and for whom heroic medical efforts to prolong life are not desired or are not appropriate. One of the benefits of hospice care is that the emphasis is on emotional and physical comfort. The care provided is called palliative care. This is made possible by not emphasizing invasive medical treatment, and by cultivating a more pleasant environment.

Care is provided by a team of professionals such as nurses, nursing aides, social workers, counselors, chaplains, volunteers, and physicians. Each member of the team has various roles to play. Therapists and other professionals can gently and sensitively help older individuals and their families talk more comfortably about the realities of aging and end-of-life matters.

Because of their training and experience with end-of-life matters, staff at such facilities can provide very helpful consultation and medical care that is relevant to the needs and values of the elder. This includes bereavement support for family members.

Funding Issues

In the U.S., funding is fragmented and patchy. The challenge of gaining and managing funding can require extensive efforts and patience. Medicaid is the main payer for long-term care public funding, while Medicaid is primarily for acute care. The funding environment can fragment care because of its dominant role in defining and, in a sense, regulating care provision. Services are said to follow funding because of this. Service categories tend to be defined by the mechanism of reimbursement, rather than the goals of the care, the skills required, or even the characteristics of the patients or residents.

Reporting Abuse and Neglect of the Elderly

Psychotherapists are among the individuals that are lawfully mandated reporters of elder abuse for which there is at least reasonable suspicion. Many care facilities combine elders and non-elders. Abuse of non-elder dependent adults is also a mandated reporting situation.

Laws on elder abuse reporting vary from state to state, but they have a great deal in common. Generally, therapists are legally required to report abuse, neglect, or exploitation that they have come to suspect when they have acquired the information in connection with their professional responsibilities or employment. Elders are considered to be those aged 65 years or older. Laws do not require therapists to investigate beyond their obligation to conduct an appropriate clinical assessment, and they do not require that therapists have conclusive proof of abuse prior to reporting. The therapist is not required to determine whether or not the act to be reported is illegal, but the therapist must be adequately familiar with the reporting requirements in their state.

When there is uncertainty, the therapist can consult with legal advisors available through their national or state professional organization. The adult protective services agency can provide such advice as well. In fact, documenting consultation can help in defending a decision regarding reporting. However, such a consult is unlikely to be an adequate defense for actions that are clearly not in compliance with the law.

State laws generally do not require the therapist to report information gleaned outside of professional activity, that is, information such as about a neighbor. Reporting such information would be an ethical, rather than legal, matter.

Generally, the report must be made immediately by phone to an adult protective services agency or to the police. Of course, if danger is immediate, 911 is the first call to make in order to prevent injury or death. There is usually a written follow up requirement. This obligation cannot be delegated to another individual unless the therapist confirms that the report has been made immediately and takes immediate action if it has not taken place. No policy of the therapist's employer can insulate the therapist from any reporting laws. Supervisors may not impede timely reporting, although there may be policies for managing the reporting and follow up process. Therapists who are members of the clergy are not immune to reporting laws. Failure to report abuse carries penalties, lead to disciplinary action by the licensing board and professional membership organization, and can incur civil liability.

Because there are many false allegations of abuse or neglect by persons with severely compromised mental functioning, there are exceptions to reporting when there is a lack of credibility. For example, some clients make repeated or random allegations that are unsubstantiated. These situations are usually fairly easy to distinguish when the claims lack credibility. However it is certainly true that individuals who are compromised are often subject to abuse or neglect. Thus, an allegation should not be written off exclusively because the individual making the allegation is compromised. Risk of abuse increases with age.

Resources for additional information, prevention resources, and agency contacts for reporting include the National Center on Elder Abuse website hotline section (http://ncea.aoa.gov), and the Eldercare Locator website (http://www.eldercare.gov), or by calling 1-800-677-1116.

Suspicion of abuse in long-term care facilities is reported to the Long-Term Care Ombudsman, www.aoa.gov

The therapist should have information available when reporting. The disabilities and medical status of the person is relevant to the work of these agencies and should be shared. This includes factors such as confusion or memory loss. The agency needs to know what social support or other professional or agency involvement is available and its status. The therapist should review with the agency the observations noted, including when they occurred, who was involved, and what happened. This should include any observations such as bruises or neglectful or dangerous conditions. Individuals who are not mandated reporters may report anonymously.

Once the report is made, the agency determines what action to take and what priority to assign to the matter. When the report is deemed worthy of investigation, a case manager is assigned to conduct the investigation. From the investigation, the agency will provide additional services. This may include case management to link the elder and caretaker with additional support, or may include removal of the individual and even involvement of the police. In some cases, the elder or caretaker refuses services. Unless the elderly individual is legally declared incompetent, there may be an impasse. However, legal action against the caretaker may result in the elderly person requiring and agreeing to other arrangements.

Types of Abuse and Neglect

Laws and regulations define types of abuse that generally fall into the categories of physical, emotional, and sexual abuse. It can be difficult to determine if suspected emotional abuse is reportable, and so it is emotional abuse that is especially likely to require consultation and review of the wording of the law.

In addition to legal definitions of abuse and neglect, the therapist must be concerned with the clinical issues and definitions. Ideally, signs suggestive of abuse or neglect are recognized during the initial assessment. In the case of risk of harm or self-neglect, therapists are mandated reporters with similar obligations to abuse or neglect situations.

The following are the general categories of abuse:

Physical abuse: Inflicting pain or injury. Common means include slapping, hitting, or restraint. Deviation from medical orders for punishment or restraint constitutes physical abuse. It can take the form of providing excessive dosing of tranquilizing medication.

Neglect: Failing to provide appropriate levels of care for basic needs such as nutrition, hygiene, and health services. Care facilities are subject to regulations requiring specified levels of care, and this includes mental stimulation through means such as an interesting environment.

Sexual abuse: Inflicting sexual contact of any kind that is non-consensual or that takes advantage of impaired mental functioning.

Emotional and psychological abuse: Inflicting suffering through emotional or psychological dynamics. This commonly occurs through acts such as threats, humiliation, and screaming. Emotional abuse can lead to serious degeneration in an individual's mental condition and capacity for self-care and assertive behavior. It must be taken seriously as a form of abuse.

Fiduciary abuse or other exploitation: Using or appropriating the elder's resources through manipulation or other illegal means.

Since many elderly individuals are subject to abuse or neglect because of their level of dependence or disability, it is important to note that abuse and neglect are most likely to occur in facilities that do not provide the level of care that the individual requires. Level of care includes factors such as the staffing level, the level of training of staff, the level of access to medical care and monitoring, and safety features.

However, much abuse or neglect occurs from family members. This is not necessarily because of criminal intentions or a desire to dominate. The challenge of care may be beyond the capacity of the caretaker in their current condition. Many caretakers feel, understandably, that home is the best option for their elderly parent or other relative. Because of negative accounts of incidents in care facilities, the caretaker may be highly motivated to maintain the individual at home, despite the inadequacy of care or other dangerous dynamics. Therapists can perform an invaluable role in helping family members recognize the true level of need and to make appropriate plans.

The Scope and Nature of Elder Abuse

According to the Administration on Aging (AOA, 2006), hundreds of thousands of elderly individuals experience abuse, neglect, or exploitation each year. Many of these individuals are dependent upon others and unable to effectively defend themselves or recognize exploitation. All 50 states have laws intended to prevent the abuse of elders.

The AOA provides the following statistics from the 1998 National Elder Abuse Incidence Study (AOA, 1998):

• 551,011 persons, aged 60 and over, experienced abuse, neglect, and/or self-neglect in a one-year period;
• Almost four times as many new incidents of abuse, neglect, and/or self-neglect were not reported as those that were reported to and substantiated by adult protective services agencies;
• Persons, aged 80 years and older, suffered abuse and neglect two to three times their proportion of the older population; and
• Among known perpetrators of abuse and neglect, the perpetrator was a family member in 90 percent of cases. Two-thirds of the perpetrators were adult children or spouses.

Confidentiality Issues in Elder Abuse and Neglect

Confidentiality is treated in some detail in federal and state law, as well as in professional ethical standards such as the NASW Code of Ethics, The provision of information regarding confidentiality is an important part of informed consent. In family therapy, all competent parties must have informed consent. Ethical codes and federal HIPAA law specifically address informed consent.

Abuse and neglect, as discussed earlier, give rise to circumstances in which information about the client must be shared. The therapist must take care to share only the information that is necessary to fulfill the purposes of the report. State law and case law afford mandated reporters protection from civil liability so long as a report is made in good faith. The primary litmus test is that the information was truthful in the sense that the therapist factually reported what he or she actually observed or was told. This means that third-hand information must be attributed to the source. This protection exists because of the need to preserve the function of mandated reporting in protecting people from abuse and neglect.

Some of the more difficult confidentiality issues arise when the elder, or any client, is not competent to participate in the informed consent process, or when there is reasonable suspicion that the individual is unable to make decisions regarding their own safety. These situations often call for communicating information regarding the client without their consent. There is some uniformity in state laws, in that agencies and processes exist to cope with such situations in a fairly similar way overall. The initial breach of confidentiality created by a mandatory reporting condition does not remain open. Any additional needs to release information must either be the result of a true legal requirement or take place with permission of the client or appointed representative.

At some point in the process, a family member or an agency or court representative is appointed to make certain decisions for the client. This includes decisions about the release of health information. The therapist must know the laws of their state, the client's current legal status and additional professionals involved in such cases.

The therapist's duty to protect confidentiality persists after the death of the client, although the therapist has a duty to report information supporting a reasonable suspicion that the death resulted from a crime. The client's legal representative is responsible for making decisions regarding confidentiality after the client's death, with exceptions established in law.

Appendix: Resources

Resources for the Elderly and Caregivers

California State Website on Aging and Care

www.aging.state.ca.us

See the ombudsman program and other resources.

The Eldercare Locator

www.eldercare.gov

1-800-677-1116

Help Guide to Mental Health and Lifelong Wellness

www.helpguide.org/elder_care.htm

Milbank Memorial Fund

Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the Twenty-First Century

www.milbank.org/0008stone

The National Hospice and Palliative Care Organization

www.nhpco.org

National Center on Elder Abuse website (includes a hotline section for reporting)

http://ncea.aoa.gov

National Senior Citizens Law Center

www.nsclc.org/

Errold F. Moody

www.efmoody.com

This website provides information and links to a comprehensive array of information regarding care for the elderly and those that care for them.

Elder Abuse Resources

Age & Opportunity Older Victim Services and Support

http://www.ageopportunity.mb.ca/htmlfiles/VOLUNTEER_OPPORTUNITIES/older_victim_services_program_support.asp

The OVS Program Support Volunteer provides emotional support to older adults who have experienced some form of criminal victimization as well as providing information and assistance when required.

American Administration on Aging: Elder Rights/Elder Abuse

http://www.aoa.gov/eldfam/Elder_Rights/Elder_Rights.asp

A wealth of information on elder abuse research, prevention, education, victim support, resources and reporting. Highly recommended.

American Administration on Aging Elder Abuse Factsheet

http://www.aoa.dhhs.gov/press/fact/alpha/fact_elder_abuse.asp

This page explains exactly what elder abuse is, how to recognize and where to go for help.

Directory of Services and Programs Addressing the Needs of Older Adult Victims of Violence in Canada

http://www.phac-aspc.gc.ca/ncfv-cnivf/familyviolence/pdfs/2004Seniors_e.pdf

This document -- in Adobe Acrobat format -- supplies a national reference for older victims of violence to programs and services.

Elder Abuse

http://www.wordbridges.net/elderabuse/

Extensive information on elder abuse, training for professionals dealing with such abuse, research in the field, legislation (US), as well as a monthly online review of articles, news and other information on this subject.

Elder Abuse Prevention Unit

http://www.eapu.com.au/

(Queensland, Australia) The goals of the EAPU are to enhance the quality of life and safety of older people in Queensland.

International Network for the Prevention of Elder Abuse

http://www.inpea.net/

The International Network for the Prevention of Elder Abuse aims to increase society's ability, through international collaboration, to recognize and respond to the mistreatment of older people in whatever setting it occurs, so that the latter years of life will be free from abuse, neglect and exploitation.

National Center on Elder Abuse. An excellent resource on elder abuse, how to help, where to go for aid, research and documentation, conferences, newsletters and their http://www.cane.udel.edu/cane/IntroAll.jsp

Clearinghouse on Abuse and Neglect of the Elderly (CANE)

Ontario Network for the Prevention of Elder Abuse

http://www.onpea.org/

The ONPEA is dedicated to educating professionals and lay persons about elder abuse and neglect; promoting information sharing among professionals and advocates in the field of elder abuse; developing educational and training programs about elder abuse prevention and intervention for people working with the elderly; advocacy and support to victims of elder abuse and neglect.



Information Resources

Administration on Aging

www.aoa.gov

This government agency, which is part of the Department of Health and Human Services, provides a great deal of information about the economic and health status of older Americans.

AARP

www.aarp.org

AARP conducts and publishes a wide range of studies on aging, most of which is at their Online Research Center at http://research.aarp.org

Centers for Medicare and Medicaid Services

http://cms.hhs.gov/researchers/

A good source for data on the health status of older Americans.

Civic Ventures

www.civicventures.org

This non-profit organization, which is the parent of Experience Corps, conducts research and publishes studies on topics such as attitudes toward retirement and volunteering and civic engagement among older Americans. Most of this research is available online.

Federal Interagency Forum on Aging-Related Statistics

http://www.agingstats.gov/chartbook2000/

This site provides access to a comprehensive report, Older Americans 2000: Key Indicators of Well-Being.

End of Life Toolkit (Florida Hospital Association)

http://www.fha.org/endoflife/endoflifetoolkit.html

Numerous materials on various topics

Generations United (GU)

GU is a resource to educate policymakers as well as the public regarding the economic, personal, and social opportunities for intergenerational cooperation.

www.gu.org

Independent Sector

www.independentsector.org

An excellent source of information about the involvement of Americans as volunteers. Independent Sector has just published a new report, Experience at Work: Volunteering and Giving Among Americans 50 and Over.

International Longevity Center

www.ilcusa.org

An independent research organization that conducts and publishes research on many subjects related to the extension of the life span and its social and economic impacts. National Council on Aging (NCOA)

www.ncoa.org

NCOA is an association of organizations and professionals for promoting the welfare of older persons.

National Institute on Aging

http://www.nia.nih.gov/

Office of the Assistant Secretary for Planning and Evaluation

http://aspe.hhs.gov/_/index.cfm

Search on: Assisted Living/Residential Care

Various reports on policy, demographics, issues.

Office of Disability, Aging, and Long-Term Care Policy

http://aspe.hhs.gov/_/office_specific/daltcp.cfm

Papers on various issues. This office coordinates HHS policies and programs which support the independence, productivity, health, and long-term care needs of children, working age adults, and older persons with disabilities.

Senior Corps

Senior Corps is a network of programs that tap the experience, skills, and talents of older citizens to meet community challenges with Foster Grandparents, Senior Companions, and RSVP (Retired and Senior Volunteer Program).

U.S. Census Bureau

www.census.gov

Provides a wide range of statistics on demographics as well as economics of Americans of all ages.

Citations

Administration on Aging. (2006). Elder Abuse. Accessed from http://www.aoa.gov/

Administration on Aging. (2005). Older americans 2004: Key indicators of well being

Administration on Aging. (1998). National elder abuse incidence study.

Alexopoulos, G. S., Katz, I. R., Reynolds, C. F. III, Ross, R. (2001). Depression in older adults: A guide for patients and families. Expert Knowledge Systems, L.L.C., and Comprehensive NeuroScience, Inc. Accessed from http://www.psychguides.com/Geriatric%20Depression%20LP%20Guide.pdf

Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, National Health Interview Survey (2002) as found in Federal Interagency Forum on Aging-Related Statistics: Older Americans 2004: Key Indicators of Well Being from http://agingstats.gov/ (June 2005)

Doty, P. (2000). Cost-effectiveness of home and community-based long-term care services. Washington, DC: U.S. Department of Health and Human Services: Office of Disability, Aging and Long-Term Care Policy.

Fentleman, D. L., Smith, J. and Peterson, J. (1990). Successful aging in a postretirement society. In P.B. Baltes and M.M. Baltes (Eds.).Successful aging: Perspectives from the behavioral sciences.

Kaufman, L. (2008). A Superhighway to Bliss. The New York Times, 5/25.

Komisar, H. and Thompson, L. (2004). Who pays for long-term care? Fact Sheet, Long-Term Care Financing Project. Washington, DC: Georgetown University Press.

Mather, M., and Carstensen, L. L. (2005). Aging and motivated cognition: The positivity effect in attention and memory. Trends in Cognitive Sciences

National Academy on Aging. (1997). Facts on long-term care. Washington, D.C. Accessed from http://geron.org/NAA/ltc.html

President's Council on Bioethics. (2004). Bioethical Issues of Aging I: Dementia and Human Personhood. Accessed from http://bioethics.georgetown.edu/pcbe/transcripts/april04/session5.html

Stone, R. I. (2000). Long- term care for the elderly with disabilities: Current policy, emerging trends, and implications for the twenty-first century. Milbank Memorial Fund.

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