Community Accessibility for the Geriatric Client

1. Community Accessibility for the Geriatric Client

2. Learning Objectives • Apply the general principles of designs to create a safe environment for geriatric clients. • Discuss the factors affecting driving safety and the decision to stop driving in geriatric clients. • To describe the commonly available public and private transportation resources available. • Identify public and private housing options for the geriatric client.

3. Reading assignments • Guccione: Ch 7 (pp. 113-120 only), Ch11 (pp. 222-227 only)

4. Environmental design principles • Environmental press • The extent to which an environment demands a behavioral response • Competence • The ability of the person to respond adaptively in health, social roles, sensory-motor, cognition • Problems with high environmental demand • Incompetent people will have maladaptive behavior • Solutions • change competence through rehab or modify the physical environment (easier)

5. Living space • Enhance lighting • Supplement task light by desk/chair • Avoid direct lighting in the corridor • Minimize flickering • Warm white bulbs • Provide good color contrast for visual cues, e.g. floor vs. wall, grab bars vs. floor • Minimize the effect of glare, e.g. use blinds/curtains

6. Living space • Avoid figure ground or repetitive patterns • Avoid escalator (repetitive patterns may cause optical illusion and impaired depth perception) • Consider ribbed vinyl or rubber stair nosing of a contrasting color • Light switches and night lights by the stairs • Clear visual cues to indicate the edge of each step

7. Living space • Low pile carpets, or vinyl or linoleum flooring with non-glare wax • Appropriate ceiling/drapes materials to absorb noise • Minimize background noise • Do not play music

8. Definitely not this!

9. Comment on the designs of this corridor

10. Problems with multifocal glasses • Multifocal glasses (bifocals, trifocals, progressive lenses) may increase fall risk in a challenging environment, e.g. stairs • Focal distance for viewing the environment • Normally = ~1.5 to 2 m • Lower lenses of multifocal glasses = 0.6 m • As a result, individuals wearing multifocal glasses may have blurred vision, impaired contrast sensitivity and depth perception, and thereby increasing fall risk

11. Problems with multifocal glasses • Wearers of multifocal lens had significantly greater odds of falling than non-multifocal lens wearers. The falls were more likely to occur outside the home and when walking up- or downstairs.

12. Consideration for older adults with dementia • Amount, type, and variety of environmental stimuli can affect function and QoL of individuals with dementia • Under- or overstimulation can lead to confusion, illusions, frustration, and agitation • Inadequate lighting levels can cause agitation • Visual misperceptions (difficulty differentiating reality from representation), e.g. photographs in room may be perceived as people watching them, TV is perceived as reality • Excessive noise and auditory hallucination

13. Working in late life http://www.workinglate.org/research/later-life-working/

14. Working in the later years • Stigma of the older worker is unproductive and lazy • 8 out of 10 boomers plan to continue to work after 65 • 72% of those 70 y.o. who are working are part time in ‘service based’ occupations • Problems of working in late life • Physical demands, traveling to work, use of communication technology, lack of promotion, care responsibilities

15. The continuation of ‘work’ after retirement • Volunteerism • Learning: tutoring, new skills, academic work • Mentorship • Retirement brings opportunities for vocational wellness • Matching core values with interest, hobbies, employment, and volunteer work • Provide a sense of purpose • Enrich mental health and overall wellness

16. DOL: Senior community services employment program (SCSEP) • Department of Labor www.doleta.gov/seniors • Job training and employment assistance • Authorized by the Older Americans Act • Eligibility • Unemployed people 55+ y.o. • Family income <25% over the federal poverty level • Priority for people >60 y.o., veterans, their spouses • Work on average 20 hours a week at • Non-profit and public community facilities, e.g. day care, senior centers, governmental agencies, schools • Receive the highest of federal, state, or local min wage

17. Age discrimination in employment act (ADEA) • www.eeoc.gov/laws/types/age.cfm • Age Discrimination • Treating someone (an applicant or employee) less favorably because of his or her age • Age Discrimination in Employment Act • Only forbids age discrimination against people who are 40+ y.o. • It is NOT illegal for an employer to favor an older worker over a younger one, even if both are age 40+ • Discrimination can occur when the victim and the person who inflicted the discrimination are both 40+

18. self-determination autonomy competence • independence Driving is the ultimate cognitive–motor multitasking activity!

19. Factors affecting driving performance in older adults • Chronological age alone is NOT a useful indicator of driving ability • Risk of accident increases with • Certain diagnoses, e.g. dementia, depression, and other psychological disorders, diabetes, sleep apnea, alcohol use/abuse, and cataracts • A fall in the previous year • Orthostatic hypotension • Any medication that affects efficacy of CNS or level of consciousness may impact attention, decision making, and ability to respond to challenges

20. Factors Affecting Driving Performance of Aging Adults (Box 11-3)

24. Considerations for visual changes in older drivers • Static and dynamic visual acuity • Correct vision • Modify driving behaviors in low light • Dynamic visual skill training (gaze, smooth pursuit) • Visual field • Turn heads or use mirrors for lateral visual field • Look upward to see signs • Depth perception • Difficulty judging distances • Should avoid driving if unable to compensate

25. Considerations for visual changes in older drivers • Repeated optical patterns can cause visual depth illusion • Dark adaptation/glaring • Avoid night driving • Avoid looking at oncoming headlights • Travel on divided highways or well-lit roads • Improve safety standards of highway designs, e.g. divided lanes, better delineation of on/off ramp

26. Considerations for cognitive changes in older drivers • Tests of cognition and memory (e.g. Mini-Mental) alone are NOTstrongly predictive of driving safely • Tests of visual spatial skills, attention, and reaction timeare more predictive of driving safety (e.g. Trail Making A & B to test executive function) • Drivers with early- to mid-stage dementia may overestimate their abilities and become confused with challenging road conditions • Periodic on-road testing is recommended • Family may have to take away the car key

27. Driving behaviors associated with cognitive decline • Getting lost, especially in surroundings that were previously familiar • Going through stop signs or red lights • Getting lost, especially in surroundings that were previously familiar • Going too fast or too slow for safety • Having problems making turns at intersections, especially left turns • Having trouble seeing or following traffic signals, road signs, and pavement markings

28. Driving behaviors associated with cognitive decline • Misjudging gaps in traffic at intersections and on highway entrance and exit ramps • Receiving traffic tickets or “warnings” from traffic or law enforcement officers • Responding more slowly to unexpected situations • Straying into other lanes

29. Resources about older adult driving safety for patient and family (Box11-4) • AARP Driver Safety Programs • 888 687-2277 or www.aarp.org • AARP “We need to talk” Guide • www.thehartford.com/talkwitholderdrivers • AARP “We need to talk” Seminars • 202 434-3919 or http://www.aarp.org/home-garden/transportation/we_need_to_talk/ • AAA Senior Drivers • http://discover.aaa.com/PGA/SeniorMobility • AAA self-test, Drivesharp calculator, 55+ driving ability, Carfit, Safe driving for mature operators • www.seniordrivers.org/home/

30. Resources about older adult driving safety for patient and family (Box11-4) • NHTSA Older Drivers • http://www.nhtsa.gov/Senior-Drivers • Caring.com Guide to Driving: assessing driver fitness, safe senior driving, taking the keys, life without a car • www.caring.com/older-drivers • State Driving Laws • www.caring.com/calculators/state-driving-laws • Association for Driving Rehabilitation Specialists • www.driver-ed.org or 866-672-9466

31. Resources about older drivers safety for health professionals (Box 11-5) • National Highway Traffic Safety Administration Driving fitness assessment and educational tools • http://www.nhtsa.gov/Driving+Safety/Older+Drivers • National Council on Safety • http://www.nsc.org/safety_road/Pages/safety_on_the_road.aspx

32. Discussion about driving with family and older adults (Box 11-6)

33. Indicators That Driving May No Longer Be Safe (BOX 11-7) • Almost crashing, with frequent “close calls” • Becoming distracted or having difficulty concentrating while driving • Changing lanes without signaling • Difficulty moving foot between gas and brake pedal; confusing gas and brake pedals • Difficulty turning around to check for cars or obstacles when backing up or changing lanes • Experiencing road rage • Finding dents and scrapes on the car, on fences, mailboxes, garage doors, curbs, etc. • Frequently being “honked at” by other drivers

34. Transportation Options • Volunteer driver programs • May be free, or minimal fee • Membership may be required • Reservation required • Para-transit Service • Curb to curb, or door to door service • Reservations required • Use minibus (less than 25 people) or other forms of transportation • Taxis seniortransportation.easterseals.com/site/PageServer?pagename=NCST2_homepage National Center on Senior Transportation

35. Transportation Options • Door through door escort service • private agencies assist with physical help of getting out of home and to destination, levels of assistance vary • Public transit • No reservation required, mass transit, reduced fares for elderly or disabled • Transportation vouchers program • qualified persons purchase vouchers at a reduced rate, require reservations, must apply for service • Mobility managers • available in some communities

36. Transportation Items to consider • Accessibility • service area • times of service, how long between stops • social or just medical rides • Eligibility • income requirement • w/c users assisted • can family members escort? • Affordability • costs, membership fee

38. Needs for community based services • Majority of older adults want to remain at home until they die (AARP, 2003) • In order to stay at home, help with services outside of the family is needed

39. Home modification • Adaptations to accommodate a person’s changing physical needs • Make it more accessible • Can use AT (Assistive Technology) • Ranges from simple (grab bar) to complex (ADA accessible home) • 83% of older adults want to age in place but the majority of the housing is not appropriate for the person (e.g. stairs, bi-level, home maintenance)

40. Paying for home modifications • Title III of the Older Americans Act  • Funds distributed by area agency on aging. (1-800-677-1116) • Rebuilding Together, Inc. • a national volunteer organization • assist some low-income seniors • Low-income home energy assistance program (LIHEAP) and the weatherization assistance program (WAP)  • Both programs are run by local energy and social services departments

41. Paying for home modifications • Medicare/Medicaid • usually only covers items that the physician prescribed • Community development block grants • Home equity conversion mortgage • borrow against the equity in your home • The National Directory of Home Modification and Repair Resources • List of home modification and repair providers • Not an endorsement - Use with caution! • http://www.homemods.org/directory/index.shtml

42. Other home management programs • Utility or energy assistance • Home equity conversion • Home maintenance and repair • Rental assistance

43. Government housing assistance • Low income, rental or own, local housing authorities. • Provides assistance to a majority of older renters who have excessive housing costs. • Provides low-income elderly with service-enriched options to live independently. • Other offices • USDA Rural development office, Dept of Housing and Community Development, State Housing Finance Agencies Administration on Aging 2009

44. Types of Government Housing • HOPE for Elderly Independence Program • Housing Choice Voucher / Section 8 Program • HOME Investment Partnership Program • Public Housing • Rural Housing Service (RHS) - Rental Assistance Program (Section 521)

45. HOPE for Elderly Independence Program • Homeownership and Opportunity for People Everywhere (HOPE) program • provides a combination of HUD Section 8 rental assistance with case management and supportive services to low-income elderly persons. • Purpose is to give housing to frail elderly to prevent going to nursing homes • Eligibility • over 62, difficulty with at least 3 ADLs or home management • HUD at (202)708-1112 Administration on Aging 2009

46. Housing Choice Voucher/Section 8 Program • Provides very low-income families, the elderly, and persons with disability affordable, decent, and sanitary housing in the private market. • Participants choose any housing that meets the requirements of the program • Eligibility is determined by the public housing agencies. • In general, not exceed 50% median household income, US citizens and some non-citizens • portal.hud.gov/hudportal/HUD?src=/topics/housing_choice_voucher_program_section_8

47. HOME Investment Partnership Program • HOME is authorized under Title II of the Cranston-Gonzalez National Affordable Housing Act • HOME provides grants to States and local communities to fund activities that build, buy, and/or rehabilitate affordable housing for rent or homeownership or provide direct rental assistance to low-income people • http://www.hud.gov/offices/cpd/affordablehousing/programs/home/ Administration on Aging 2009

48. Public Housing • Affordable, decent, safe housing for elderly or disabled • Pay no more than 30% of income for housing • Eligibility based on • low income, status (elderly & disabled 1st), citizenship • Through local PHAs • portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/programs/ph

49. Rural Housing Service (RHS) - Rental Assistance Program (Section 521) • Rural Americans, rent subsidies • Pay no more than 30% of income • Eligibility • People with very low (50% of area median income) and low incomes (50% and 80% of area median income), the elderly and persons with disabilities who are unable to pay the rent within 30% of monthly income • www.rurdev.usda.gov/rhs/mfh/brief_mfh_rra.htm . (202)720-4323.

50. Section 202 Supportive Housing for the Elderly Program • Provided by private, nonprofit housing and service-oriented organizations that have received capital advances from the government to finance the construction and rehabilitation of structures. • Supportive services include meals, cleaning, transportation etc. • Eligibility: 62 or older, income • http://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/mfh/progdesc/eld202