age-friendly health care and systems 4ms overview

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Age-Friendly Health Care and Systems

4Ms Overview

Marianne Smith, PhD, RNAssociate Professor & Director of the

Csomay Center for Gerontological Excellence, University of Iowa,

College of Nursing

Goals for Today . . .

What Age-Friendly health care is

Why it is important

Brief review of how to use the 4Ms

Acknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

An Age-Friendly Health System

Where every older adult:

Gets the best care possible

Experiences no healthcare-related harms

Is satisfied with the health care they receive

Value is optimized for everyone!

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Age-Friendly Health Care: 4Ms

What Matters most to the person

Medications

Mobility

Mentation: dementia, delirium, depression

A framework: not a program, but a shift in how we provide care to older adults

4Ms Guide Quality Care

Lots of good reasons to use 4M framework!

Best practice acrosshealthcare settings

Focus on the person,not the disease

Focus on quality of life, not “more treatment” or acute care transfers


Make care for older adults with multiple chronic conditions: Less fragmented

and burdensome

Better focused on What Matters most to older persons

Less frustrating for thehealthcare team

Source: Mary Tinnetti, 2016, AGS

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Critical Interactions Among 4Ms!

What Mattersis the “driver”!

Medications Mobility

Mentation• Dementia• Delirium• Depression

What Matters Most

Know and act on each older adult’s specific health outcome goals and care preferences across settings

Daily living and engagement

Outpatient care

Rehab/short stays

Transfers between settings

Acute care

End-of-life care

What Matters Most

Life & Living: What gives us joy, happiness,

meaning in living

Health:Our ongoing

health concerns

& conditions

Health Care:Treatment and

care of disease, illness, conditions

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What Matters: Life Outside Health

Explore life context, priorities, preferences . . .

What is important to you?

What brings you joy? Makes you happy? Makes life worth living?

What do you worry about?

What are some goals you hope to achieve before your next birthday?

What would make tomorrow a really great day?

What else would you like us to know about you?

What Matters: Anchor to Health

Consider health status and care needs New diagnosis, treatment decision

Change in health status

Change in residence or care location

Focus question on How treatment could facilitate or impede

abilities to do things enjoyed (everyday activities) or attain a goal (attend a meaningful event)

What Matters: Guiding Questions

Health OUTCOME goals

What is the one thing about your health care you most want to focus on so that you can do [desired activity] more often or more easily?

What are your most important goals now, and as you think about the future with your health?

What concerns you most when you think about your health and health care?

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What Matters: Varies with Needs

Hospitalization: What is the goal of acute care treatment? To do WHAT?

Post-Acute/Skilled care: To regain abilities to do WHAT?

Long-term stay: To maintain abilities to do WHAT?

End-of-life care: To best assure WHAT is achieved or avoided?

4Ms Key Actions

Focus on What Matters, then think about how Mobility, Medications, dementia, delirium, and depression may impact the person’s ability to do What Matters most!

Don’t make assumptions! Use 2 steps:

ASSESS each M: Screen & document

ACT ON each M: Manage, treat, intervene to promote wellness

Medications

ASSESS: Review high-risk Medications

Benzodiazepines

Opioids

Highly anticholinergic drugs

Sedatives and sleep medications

Muscle relaxants

Tricyclic antidepressants

Antipsychotics

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Medications

ACT ON: Use Age-Friendly Medicationthat does not interfere with

What Matters to the older person,

Mobility, or

Mentation

Medications

Deprescribe

Dose reductions

Discontinuation

Focus on person’s goals!

What Matters most

Desired health outcome

Mobility

ASSESS: Ensure that older adults move safely every day in order to maintain function and do What Matters

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Mobility

ACT ON

Ensure a safe environment

Set daily Mobility goals that support What Matters

Avoid high-risk Medications

Refer to PT

Regular exercise, no matter what level!

Mentation

Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care

Acute care: greater focus on delirium

Ambulatory care: greater focus on depression, dementia

Senior living: Pay attention to all 3Ds!

Mentation: Dementia

Check history related to cognitive function, diagnosis of dementia

ASSESS

Mini-Cog

SLUMS

MOCA

6-ItemScreener

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Mentation: Dementia

ACT ON Memory deficits do not rule

out making decisions aboutWhat Matters

Capacity to make MANY decisions endures

Ask about preferences

Focus on ABILITIES

Encourage person-FIRST approach, supported by family involvement

Mentation: Delirium

Consider common causes: infection, pain, hypoxia, dehydration, Medications

ASSESS

2-Item Ultra-Brief Delirium Screen (UB-2)

1 question confusion assessment

Delirium Observation Scale (DOS)

Confusion Assessment Method (CAM)

Mentation: Delirium

ACT ON

Treat/reverse underlying causes!

Assure safety

Gently re-orient

Promote hydration

Promote sleep

Increase ambulation Mobility

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Mentation: Depression

Anhedonia is common in late-life depression; sadness may not be prominent!

ASSESS

2-item Patient HealthQuestionnaire (PHQ-2)

9-item Patient HealthQuestionnaire (PHQ-9)

Geriatric Depression Scale


ACT ON

Behavioral activation: schedule pleasant activities

Talking therapy: brief problem-solving therapy

Physical activity/exercise

Self-care: nutrition, sleep, pain management

Antidepressant Medication: many choices based on symptoms

4Ms Is a “Package,” not Silos!

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4Ms Series

Please also see our additional programs:

What Matters

Medication

Mobility

Mentation, including dementia, delirium and depression

Goal: Understand and use the framework to guide care of older people!

Work as a team to deliver high-quality care!

Summary

Being Age-Friendly and using the 4Ms makes good sense in all settings!

Acute care, hospitals

Ambulatory care, clinics

Senior living, home health

FOCUS on What Matters!

Reduce unwanted/unneeded care and treatment

Promote quality of life and living!

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Age-Friendly Health Care and Systems What Matters



College of Nursing


Brief review of 4Ms Age-Friendly health care Common care challenges

What Matters to older persons Person-centered vs. disease-focused Aligning care to each person’s goals and preferences Conversations across settings


Acknowledgements

https://patientprioritiescare.org/http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

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https://www.acponline.org/clinical-information/clinical-resources-products/patient-priorities-care

Patient Priorities Care

An excellent resource for

learning how to have

conversations with older people

about WhatMatters and

aligning care to the person’s

priorities!









Medications

Mobility



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Lots of good reasons to use 4M framework!

Best practice acrosshealthcare settings

Focus on the person, not the disease

Focus on quality of life, not “more treatment” or acute care transfers

The Big Challenge

Needs of older adults with multiple chronic conditions vary!

One size does NOT fit all (or over time)

What made sense earlier may not make sense now

Priorities change

Where Is the Person NOW?


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What Matters

Patients identify their health priorities

Clinicians translate these priorities into care options

All care aligned with these priorities


What Matters

What Matters to older adults is the basis of Age-Friendly health care!

Change the conversation from

What is the matter?to

What matters to you?

What Matters to Older Adults

Know and align care with each person’s specific health outcome goals and care preferences across settings

Daily living and engagement

Outpatient care

Rehab/short stays

Transfers between settings

End-of-life care

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https://theconversationproject.org/

What Matters: Not Just End of Life

Discussing What Matters is critical to advance care planning

However, 4Msframework is not limited to end of life!

What Matters

Health outcome goals

Values & activities that motivate a person to sustain and improve health

Can help guide decision-making

E.g., babysitting grandchild, walking with friends, gardening, volunteering

Care preferences

Healthcare activities the person is willing and able (or NOT willing or able) to do or receive

Institute for Healthcare Improvement | ihi.org

I go for blood work every month. It’s not a bother.My medications

make me so tired I can hardly get out

of the chair, let alone get to

church.

I walk and do the exercises that my PT taught me every day.

Not helpful? Or helpful and doable?

Care Preferences

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What Matters Conversations

Ongoing communication and relationship building with older persons and caregivers Regular visits

Annual Wellness visits

New diagnosis

Life change

Ongoing management of chronic conditions

Inpatient visits

Advance care planning for end of life

What Matters Conversations

Team effort!

Nurses, nurse practitioners, nurse navigators

Physicians, physician assistants

Social workers, chaplains

Community health workers, trained volunteers

Identify, understand, and document WhatMatters so it can be acted on and updated across settings

Patient/Family Boards

Lots of creative ways to share What Matters

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What Matters Most


meaning in living

Health:Our ongoing

health concerns

& conditions



What Matters: Life Outside Health

Explore life context, priorities, preferences . . .

What is important to you?

What brings you joy? Makes you happy? Makes life worth living?

What do you worry about?

What are some goals you hope to achieve before your next birthday?

What would make tomorrow a really great day?

What else would you like us to know about you?

What Matters: Anchor to Health

Health status and care needs New diagnosis, treatment decision

Change in health status

Change in residence or care location

Focus question on How treatment could facilitate or impede

abilities to do things enjoyed (everyday activities) or attain a goal (attend a meaningful event)

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Health OUTCOME goals

What is the one thing about your health care you most want to focus on so that you can do [desired activity] more often or more easily?

If we could change one thing in your health or health care, what would it be? What would you be doing more of if we could accomplish this?

What concerns you most when you think about your health and health care?


What are your fears or concerns for your family?

What are your most important goals if your health situation worsens?

What things about your health care do you think aren’t helping you, and you find bothersome or difficult?

Is there anyone who should be part of this conversation?

What Matters: Plan Ahead!

Keep it comfortable

Invite the person to talk about “What Matters” ahead of time

Ask one or more “What Matters” questions

Listen carefully!

Affirm your understanding

Incorporate “What Matters” information into the care plan and share with the team

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What Matters: Example

“As you know, you have several diseases and health problems that your other clinicians and I are trying to help you with. We know that people differ in what matters most to them in terms of their health and healthcare. Knowing what is most important to you helps me, and your other doctors and nurses, work with you to recommend the best care and treatment for you. You would have 1-2 sessions of about ½ hour with one our healthcare team members to help you identify what is most important to you about your health, what you think is working well about your current healthcare, and what you find difficult or unhelpful. If you agree, which I hope you will, we can set up a time that works for you to get started. This will help us take the best possible care of you. Any questions about this?”

© Mary Tinetti, Caroline Blaum, 2018, Patient Priorities Care. https://www.acponline.org/clinical-information/clinical-resources-products/patient-priorities-care

What Matters Varies

Priorities often change based on the setting of care

Hospitalization

Post-Acute/Skilled care

Long-term stay

End-of-life care

What Matters most may vary from the health issue!

Feeling safe & calm

Managing pain in order to walk again

Time with family

Talking with the chaplain

What Matters: Example

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What Matters: Shared Decisions

Work to reconcile differences Agree on information to inform the decision Person’s priorities, life context, family concerns

Burden of treatment, co-existing conditions

Health trajectory

Present trade-offs (unbiased)

Be realistic about benefits If person understands alternatives, then

accept decision

4Ms Start with What Matters




Summary: What Matters Most

Ongoing conversations

Aligns care with each person’s health outcome goals and care preferences

Goals change over time

Team effort: identify, understand, document

Conversation skills are developed with practice!

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Mentation: Dementia



College of Nursing


Overview of dementia Why it is important in 4Ms Brief review of screening Brief review of interventions


Mentation





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Mentation: Dementia

Cognitive status is important to having conversations aboutWhat Matters

Memory deficits do not rule out making decisions about What Matters

Consider how cognitive status does, or does not, impact the person’s ability to engage in meaningful conversations about goals and preferences

Mentation: Dementia

Brief Overview Permanent loss of cognitive abilities

caused by damage to brain cells NOT a “normal” part of aging The common end result of many entities Diseases Traumas Infections Drugs

Dementia: Common Features

Impairments in . . .

Thinking Ability to reason Judgement Problem-solving Language Memory Perception Impulse control

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Dementia Due to . . .

Alzheimer’s disease Vascular disease Frontotemporal

lobar degeneration Lewy body disease Traumatic brain

injury

HIV disease Prion disease Parkinson’s disease Huntington’s

disease Substance/

Medication use Another medical

condition

Dementia: Progressive Course

Early Confused Ambulatory Late

Months to years (-)

Cog

nit

ive

& f

un

ctio

nal

ab

ilit

ies

(+

)

Dementia: Common Features

Progressive loss of abilities results in many changes . . . Personality Behavior Emotion Function: social and physical

Interferes with doing What Matters most! Identification is essential to quality care

and living!

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Age-Friendly: Key Actions

ASSESS Consider risk factors, presentation Check history related to cognitive function,

history of dementia Screen for dementia

ACT ON your findings Refer for further evaluationManage symptoms Engage additional resources/supports

Mentation: Dementia

Assessment Tips* Normalize cognitive screening for patients

“I’m going to assess your cognitive health, just like

we check your blood pressure, or heart or lungs…”

Remember: Cognitive screening is part of Welcome to Medicare and Medicare Annual Wellness Visits!

*Source: Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (April 2019). Institute for Healthcare Improvement. www.ihi.org

Mentation: Dementia

Assessment Tips* Emphasize the older person’s strengths

when screening

Document and share findings with the team Consider and rule out delirium if cognitive

change is sudden (days to weeks)*Source: Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (April 2019). Institute for Healthcare Improvement. www.ihi.org

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Mentation: Delirium

Delirium Delirium

Dementia

Remember that delirium is part of Mentation, and can occur alone, or overlap with dementia!

Dementia: ASSESS

Many brief tools to screen for dementia

Mini-Cog

SLUMS

MOCA

6-ItemScreener

Select a tool that best fits your setting/practice!

Three item recall (3 pts)

Clock Drawing (2 pts)

Scoring: 0 to 5• 0-2 = concern for

cognitive functioning*• 3-5 = less concern

for dementia

*Mini-Cog is a screening tool! Further evaluation is needed to

diagnose dementia

https://mini-cog.com

Mini-Cog

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St. Louis University Mental Status (SLUMS) Examination

Scoring: 0 to 30• 27-30 = Normal • 21-26 = Mild

Neurocognitive Disorder

• 1-20 = Dementia

https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/slums_form.pdf

Montreal Cognitive Assessment Tool (MoCA)

Scoring: 0-30• 26-30 = Normal• 18-25 = Mild Cognitive

Impairment (CI)• 10-17 = Moderate CI• <10 = Severe CI

Note: Research for these severity ranges has not been established

https://www.mocatest.org

Six-Item Screener (SIS)

Scoring: 0-6• 4-6 = Normal• 1-3 = Assess

further

SIS is designed for brief screening that directs further assessment – not diagnosis

Med Care. 2002, Sept; 40(9):771-81.doi: 10.1097/00005650-200209000-00007

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Dementia: ACT ON

Taking action is guided by:

Care setting: acute care, ambulatory clinic, residential/nursing facility care

Stage of dementia: early, middle, late

Identified needs of the person Further evaluation/diagnosis Symptom management Social support, education, community

services, family support

Dementia: ACT ON

Not all cognitive impairment is dementia! Further evaluation, diagnosis is criticalMedication side effects can impair thinking

Depression can impact concentration / look like memory impairment

Delirium can mimic dementia

Consider all 4Ms!

Ask: What Matters Most


meaning in living

Health:Our ongoing

health concerns

& conditions



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Dementia: ACT ON

What Matters most to the person?

Use the person’s priorities in communicating, decision-making, and planning! Consider: How does the person’s cognitive function

influence reaching his/her goals?

What support, assistance, or resources may be needed?

Who else may need to be involved?

Dementia: ACT ON

Encourage persons living with dementia to be engaged in discussions!

Dementia: ACT ON

Capacity to make many decisions endures Ask about preferences Focus on abilities

Family involvement re: goals of care is important, but person-FIRST is best!

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Dementia: ACT ON

Maximize function to do What Matters

Evaluate Medications Side effects, interactions Impact on function?

Maintain Mobility Ambulation, activity engagement Do What Matters most!

Encourage, support independence

Dementia: ACT ON

Emphasize the person – not the diagnosis Preserved abilities, not losses Individual tastes, interests, values Preferences for care & treatment Engagement in meaningful activities

What Matters!

Compensate for lost abilities Support, encourage Simplify, adapt

Dementia: ACT ON

Many online resources offer education and support for the person, family ADEAR: https://www.nia.nih.gov/health/alzheimers

National Institute on Aging: https://order.nia.nih.gov/view-all-alzhemer-pubs

Alzheimer’s Association: https://www.alz.org/

Alzheimer’s Society, Canada: https://alzheimer.ca/en/help-support/im-living-dementia

Alzheimer’s Society, UK: https://www.alzheimers.org.uk

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Dementia Friendly Communities

Another importantsocial movement Important overlap

with being Age-Friendly! Many resources for

being Dementia Friendly!

https://www.dfamerica.org/


https://dementiafriendsusa.org/

Summary: Dementia

Recognize cognitive decline/impairment

Apply screening tools

Discuss with team members

Refer for further evaluation

Assess interaction with all 4Ms

Support function: Doing What Matters!

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Mentation: Delirium



College of Nursing


Overview of delirium (a.k.a. acute confusion) Why it is important in 4Ms Brief review of screening Brief review of interventionsAcknowledgement: This program is one in a series of 8 programs about the 4Ms and is co-sponsored by the Csomay Center for Gerontological Excellence and the Geriatrics Workforce Enhancement Program at the University of Iowa Geriatric Education Center. The content is based on the Age-Friendly initiative of the J.A. Hartford Foundation and Institute for Healthcare Improvement. We invite users to explore options to join the social movement at their website: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

Mentation





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Mentation: Delirium

Brief Overview Rates are high among older adults 10%-30% in emergency departments 15%-53% post-operatively 70%-80% in intensive care units Up to 60% in nursing homes Up to 83% at end of life

Delirium is often NOT recognized!

APA, DSM-5, 2013

Mentation: Delirium

Too often mistaken for dementia! Problematic in acute care settings Providers don’t know what “baseline” is ASSUME older person has dementia Lack of identification triggers downward spiral No interventions to treat symptoms Inappropriate Medication use Failure to communicate at discharge Persisting confusion that leads to disability, death

Identification is the key!

Mentation: Delirium

Key Signs & Symptoms

Disturbance in ATTENTION Reduced ability to direct, focus, sustain, and

shift attention; reduced orientation

RAPID ONSET of symptoms Change from baseline level

Symptoms FLUCTUATE in severity during the course of the day

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Delirium: Fluctuating Course

Morning Afternoon Night

(-)

S

ymp

tom

s

(+) De Lira = Latin for “Off the track”

Mentation: Delirium

Disturbance in COGNITIONMemory deficit Disorientation Language disturbance Visuospatial disturbance Perception: hallucinations, delusions,

illusions/misperceptions

Disturbances aren’t due to another neurocognitive disorder (like dementia)

Mentation: Delirium

Disturbance is the direct physical consequence of A medical condition Substance intoxication or withdrawal Toxin exposureMultiple causes (common in late life!)

Main Point Physical health problems trigger delirium & are often reversible

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Mentation: Delirium

Common associated features Sleep-wake cycle disturbance Daytime sleepiness Nighttime agitation Difficulty falling asleepWakefulness throughout the night

Rapid shifts in emotions Anxiety, fear, depression, irritability, anger Screaming, cursing, muttering, moaning

Mentation: Delirium

Predisposing factors Cognitive impairment/Dementia Multiple health problems Advanced age Dehydration Malnutrition Vision/hearing impairment Immobilization Functional impairments

So on a “good day” many older adults are at risk for delirium!

Mentation: Delirium

Physical causes of deliriumMedications* Infections Pain Electrolyte imbalanceMetabolic disturbance Hypoxia Sensory deficits

And every new health problem or change can tip the balance!

*Visit IA-ADAPT at https://igec.uiowa.edu/ia-adapt

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Delirium and Dementia

Remember! Delirium can overlap on dementia

Dementia

Delirium


ASSESS Consider risk factors, presentation Check history for new Medications, medical

conditions that may be the trigger Screen for delirium

ACT ON your findings Treat underlying health problemsManage symptoms, support function Educate person and family!

Mentation: Delirium

Assessment Tips Select & use the assessment approach

that best fits your setting & team Adjust your approach to avoid the sense of

being “tested” Engage & educate family about delirium Enlist their help to identify changes Is their loved one more confused than usual?

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Delirium: ASSESS

Many options to screen for delirium

2-Item Ultra-Brief Delirium Screen (UB-2)

1 question confusion assessment



Select a scale that best fits your team and care culture!

2-Item Ultra-Brief (UB-2) Delirium Screen

Fick D, Inouye S, Guess J, Ngo LH, Jones RN,Saczynski JS, Marcantonio ER. Preliminary development of an ultra-brief two-item bedside test for delirium. Journal of Hospital Medicine. 2015;10:645-650. DOI 10.1002/jhm.2418

https://www.nursing.psu.edu/wp-content/uploads/2019/03/UB-2-with-disclaimer-fick_Delirium-Pocket-Card_052118.pdf


Scoring: Delirium indicated by1) Presence of acute onset &

fluctuating discourse, AND

2) Inattention, AND EITHER

3) Disorganized thinking OR

4) Altered level of consciousness

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948.

Items mirror diagnostic criteria for delirium

1. Acute onset

2. Inattention

3. Disorganized thinking (cognitive disturbance)

4. Altered consciousness

5. Disorientation

6. Memory impairment

7. Perceptual disturbance

8. Psychomotor disturbance

9. Altered sleep-wake

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Resources are available at the Iowa Geriatric Education Center website: https://igec.uiowa.edu/ia-adapt


Scoring: 0-13

• No = 0

• Yes = 1

• Score of three or more points indicates risk of delirium, need for further assessment

* Items 3, 8, and 9 are reverse-scored (Yes = 0, No = 1)

Gavinski K, Carnahan R, Weckmann M. Validation of the Delirium Observation Screening Scale (DOS) in a hospitalized older population. J Hosp Med. 2016;11(7): 494-497. doi: 10.1002/jhm.2580

13 items observed each of 3 shifts: day, evening, night

1) Dozes off during conversation or activities

2) Is easily distracted by stimuli from the environment

3) Maintains attention to conversation or action*

4) Does not finish question or answer

5) Gives answers that do not fit the question

6) Reacts slowly to instructions

7) Thinks he/she is somewhere else

8) Knows which part of the day it is*

9) Remembers recent events*

10) Is picking, disorderly, restless

11) Pulls IV tubes, feeding tubes, catheters, etc.

12) Is easily or suddenly emotional (frightened, angry, irritated)

13) Sees/hears things which are not there

Growing Evidence for 1 Question*

Is the person more confused today than

USUAL?If Yes, then assess further!

*Best used by family and direct care staff who know the person well and know what “baseline” is for the person

https://pubmed.ncbi.nlm.nih.gov/20837733/

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Delirium: ACT ON

Taking action is guided by the care setting

Hospital/Acute care: greater focus on discharge planning and communication with family and other providers Long-term care: greater focus on risk

factors and reoccurrence Home: greater focus on family

knowledge, involvement

Delirium: ACT ON

First and foremost . . . Identify & treat

reversible underlying causes! Infection Pain HypoxiaMedication side effects, interactions

Assure safety

Delirium: ACT ON

Increase ambulation Mobility Sit, stand, walk as soon as able Support, assist to be safe & successful

Promote hydration Dehydration both causes & contributes Encourage & monitor intake

Promote sleep (without Medications!)

Reassure emotional reactions

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Delirium: ACT ON

Re-orient with environmental cues Clocks, calendars, white boards

Promote sensory input Increase lighting, glasses, hearing aids

Document and communicate across levels of care! Include in discharge planning, transfers Reduce risk that confusion is “accepted” as

baseline and not addressed!

Delirium: ACT ON

Reduce risk of misperceptions Remove or disguise objects that are

misinterpreted Clutter Pictures Reflections

• E.g., insists someone is in the bathroom with them try covering the mirror

Reduce sounds that are misunderstood Voices, address systems, radio, television

Delirium: ACT ON

Adjust approaches Offer limited choices Provide “conversational” orientation “Would you like juice or milk with breakfast?” “Isn’t it a beautiful day for early November?

Thanksgiving will be here in no time!”

Provide guidance Educate: Family, patient, caregivers Explain: Reversible confusion related to

illness, stress; should resolve! Support: What to monitor, how to get help

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Delirium: ACT ON

Use Medication ONLY for severe agitation, fear, or psychotic symptoms that pose safety risks Behaviors that interfere with medical

treatment and recovery Psychotic symptoms/misbeliefs that are

troubling/upsetting to the person

Low dose, short-term, discontinue as soon as safety risk passes!

Summary: Delirium

Recognize changes from baseline Assess using standardized method Collaborate with team to identify and

treat underlying health problem(s) Assure person’s safety and comfort Assist person and family to understand

symptoms Monitor outcomes to assure full recovery

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College of Nursing


Overview of depression Why it is important in 4Ms Brief review of screening Brief review of interventions


Mentation





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Clinical depression changes thoughts and feelings that interfere with: Talking about What Matters Engaging in physical & social activitiesManaging other health conditions Enjoying friends, family, activities

Depression robs older people of their quality of life AND contributes to a downward spiral of disability


Brief Overview Clinical depression is more than a

passing mood! Significant cluster of specific symptoms Persists over time Impairs function Contributes to dysfunction & disability Increases risk of self-harm, suicide


Who wouldn’t feel that way?Being sad is understandable –

I mean, after all…Goodness, you have every RIGHT to be

depressed!

Too often UNrecognized and UNtreatedamong older people!

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Mentation: Major Depression

Two “hallmark” symptoms Depressed mood Sadness, discouragement, crying “Down in the dumps” – “Blues”

OR

Loss of ability to experience pleasure (a.k.a. anhedonia)Withdrawal, inactivity, isolation “Nothing is fun” – “Don’t care”

Mentation: Major Depression

Plus additional symptoms for 5 totalWeight loss or gain Sleep disturbance Insomnia or

hypersomnia Psychomotor agitation or retardation Fatigue, loss of energy Feelings of worthlessness, inappropriate guilt Loss of ability to think, concentrate, make

decisions Recurrent thoughts of death, suicidal ideation

Depression “Without Sadness”

Anhedonia present, but sadness is NOT Loss of ability to experience pleasure loss of interest, apathy, withdrawal, indifference, low motivation

Additional symptoms Physical: Sleep, appetite, energy, motor activity looks like PHYSICAL ILLNESS

Psychological: Problems thinking, concentrating looks like DEMENTIA

Often overlooked AS depression!

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Depressionand Dementia

Depression

Dementia

Remember, depression can occur alone, or may overlap with dementia!

Depression

30% with both!

Depression: Course

(+)

S

ymp

tom

s

(-)

Weeks to Months (up to 2 years)


ASSESS Consider risk factors, presentation Check history related to depression, history

of symptoms or treatment Screen for depression

ACT ON your findings Refer for further evaluation Treat symptoms Support function, refer to resources

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Assessment Tips* Normalize depression screening for

patients

“I’m going to assess your mood, just like we check

your blood pressure, or heart or lungs…”

Remember: Depression screening is part of Welcome to Medicare and Medicare Annual Wellness Visits!

*Source: Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults (April 2019). Institute for Healthcare Improvement. www.ihi.org

Depression: ASSESS

2-item Patient HealthQuestionnaire (PHQ-2) 9-item Patient Health

Questionnaire (PHQ-9) Geriatric Depression Scale GDS Short Form GDS Long Form

Don’t guess! Quantify symptoms using a standardized measure!

PHQ-9

Nine items mirror the diagnostic criteria for Major Depressive Disorder

PHQ-2 uses the first two (hallmark) symptoms required for diagnosis of MDD

PHQ-9 uses all nine symptoms

https://www.phqscreeners.com/

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PHQ-2: Rate Hallmark Symptoms

Screening: If unsure, just rate 2 symptoms1. Little interest or pleasure in doing things2. Feeling down, depressed, or hopeless

Score each item: 0=Not at all1=More than half the days2=Several days3=Nearly every day

Total Score: 0-6

Score of 3 or greater Complete the remaining items!

PHQ-9: Rate Remaining Symptoms

1.Little interest or pleasure in doing things

2.Feeling down, depressed or hopeless

3.Trouble falling or staying asleep, sleeping too much

4.Feeling tired or having little energy

5.Poor appetite or overeating

6.Feeling bad about yourself, feeling like a failure

7.Trouble concentrating on things, such as reading the newspaper or watching television

8.Moving or speaking slowly, or being restless and moving around more than usual

9.Thoughts that you would be better off dead or of hurting yourself in some way

PHQ-9: Scoring

Score items as before: 0=Not at all to 3=Nearly every day

Add scores for 9 items; Total score 0-27 Apply cut-points: 0-4 = depression is not significant 5-9 = mild depression 10-14 = moderate depression; any score over 10 is

considered clinically significant/worthy of treatment 15-19 = moderately severe depression 20-27 = severe depression

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Geriatric Depression Scale: Long Form

Scoring: 0-30• 0-9 = normal• 10-19 = mild• 20-30 = severe

GDS forms are considered public domain

Geriatric Depression Scale: Short Form

Scoring: 0-15

• >5 suggestive of depression

• >10 indicative of depression

• Scores of 5 or greater suggest need for further assessment

Depression: ACT ON

Taking action is guided by: Severity of depression symptoms Risk of self-harm Older person’s treatment preferencesMany older adults prefer non-drug treatments! Explore preferences Discuss options Focus on What Matters!

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Depression: ACT ON

Think about interactions among 4Ms Difficulty identifying What Matters due to

anhedonia? Sense that nothing is fun? Nothing matters?

Medication(s) triggering depression?

Mobility challenged due to fatigue, lack of energy?

Depression masked by dementia?

All of the above?

Depression: ACT ON

Two main treatment approaches: Behavioral/non-drug therapies Behavioral activation Talking therapy Physical activity/exercise Self-care Antidepressant Medication Many choices; selection based on symptoms Follow 4Ms advice! Only if preferred and safe!

“For mild to moderate depression, talking and behavioral therapies often works as well as medication. What would you like to try?”

Depression: ACT ON

Behavioral activation Schedule pleasant events Re-establish healthy routines Increase positive experiences Leads to improved mood and better

functioning

Individual, social, physical activities

Keep it simple! (Failure-free!)

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Depression: ACT ON

Physical exercise Engaging in physical activity for 20 minutes a day, 5x each week, decreases depression and improves health!

Break the cycle of “Do Less Feel Worse”

Depression: ACT ON

Counseling, talking therapy Often preferred as 1st line Don’t want more pills Don’t want “mind” pills in particular

May need to explain goals No couches, no talking about dreams or

“mother,” unless she is a current problem Usually problem-focused, brief, limited

number of visits

Depression: ACT ON

Antidepressant Medication Apply Age-Friendly practices! Select Medications based on their

side effect profile Avoid high-risk Medications: TCAs & MAOsMonitor side or adverse effects Start low, go slow, but keep going until

symptoms resolve! Educate the person to advance adherence!

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Depression: ACT ON

Promote adherence Antidepressants . . . Do NOT work immediately Are NOT addictingWill not make you “high” Need to be taken every dayMay take 12 weeks to get the full benefit Side effects may occur & should be reported

Just another “illness treatment”

Summary: Depression

Clinical depression is often masked and misunderstood Apply screening tools; assess severity Address causal/contributing factors Assess interactions with all 4MS Treat following person’s preferences Support function: Doing What Matters!

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Mobility



College of Nursing


Overview of Mobility in the 4Ms

Brief review of screening

Brief review of interventions


4Ms in Health Care & Systems

Lots of good reasons to use 4M framework! Best practice across

healthcare settings Focus on the person,

not the disease Focus on quality of

life, not “more treatment” or acute care transfers

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Mobility: Importance

Brief Overview Most health and life goals are activities

that require Mobility Central to What Matters most! Do what is important Get to get where you

want to go Contributes to quality

of life, living


Medications Benzodiazepines Other psychoactives Anticholinergics Anticonvulsants Antihypertensives

Not silos! All 4Msinteract!

Mentation Delirium Dementia

Impaired Mobility, increased risk of falls is associated with


Falls risks are largely preventable! Lower body weakness Vitamin D deficiency Difficulties with walking and balance Medication side effects Vision problems Foot pain or footwear choices Home hazards like uneven steps, clutter, or

rugs that can be tripped overhttps://www.ncoa.org/healthy-aging/falls-prevention/falls-prevention-programs-for-older-adults-2/

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Value beyond fall reduction! Physical activity is a key

prevention strategy Heart health, lung functionManage painMaintain Mobility Increase function Enhance mood: stress, anxiety,

depression Promote sleep quality, appetite

Mobility

Ensure that older adults move safely every day in order to maintain function and do What Matters


ASSESS Identify & treat contributing factors

Screen for Mobility limitations

ACT ON your findings Support movement every day

Support Mobility goals to do What Matters

Refer to physical +/or occupational therapy

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Mobility

Assessment Tips Identify: Older adults at risk for

functional decline Assess: Baseline function at home/on a

“good day” and at admission Ask: What is needed to maintain

function? To prevent or treat complications of frailty or immobility? Who and what needs to be involved?

Mobility

Assessment Tips Remember! Team approaches are

essential to high quality 4Ms careMedications: providers, pharmacistsMentation: family, daily care providersMobility: all team members

All team members contribute to Gathering information Supporting Mobility goals

Mobility: ASSESS

Many tools to assess Mobility Get Up and Go Test (GUG) Timed Up and Go Test (TUG) Performance Oriented Mobility

Assessment (POMA) Johns Hopkins Highest Level of Mobility

(JH-HLM) Scale

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Get Up and Go Test

Rise from sitting position Walk 10 feet, turn, return to the chair Sit back down

https://fpnotebook.com/geri/exam/GtUpAndGTst.htm

Even if you don’t administer the TUG yourself, it’s good to know what observations are made as part of the assessment!

View an example at https://www.youtube.com/watch?v=j77QUMPTnE0

Scale Source: https://www.cdc.gov/steadi/pdf/TUG_test-print.pdf

Performance Oriented Mobility Assessment (POMA)

https://www.leadingagemn.org/assets/docs/Tinetti-Balance-Gait--POMA.pdf

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Johns HopkinsHighest Level of Mobility Scale

Google: JH HLM Scale

Which One Should We Use?

It’s less about the tool and more about using it Select tool that best

fits your setting Train staff to use it Use consistently!

Also assess & monitorcontributing factors

Mobility: ACT ON

Ensure a safe environment Identify, set daily

Mobility goals thatsupport What Matters Avoid high-risk Medications Regular exercise, no

matter what level!

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Mobility: ACT ON

Address factors that interfere with Mobility Pain Strength, balance, gait impairments Deconditioning due to immobility, bed rest Treatment-related “tethers” Catheters IV lines Telemetry, others that reduce movement

Refer to physical therapy!

AFHS Change Package, 2018, IHI

Mobility: ACT ON

Support to set a daily Mobility goal to do What Matters Build on strengths and abilities

Remember that variation in older adults is the “norm,” not the exception

Start where the person is!

Revise Mobility goals as needed Goals change with transitions in care, health status Hospital goal likely quite different from goals at

home!

Daily “ACErcise”

Example from IHI about exercise on the hospital ACE unit!

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Hospital Mobility Checklist

Once daily Mobility screen Ambulate 3 times a day Out of bed or leave room for meals Refer to PT: balance, gait, strength, gait

training, exercise Restraint-free Remove catheters and other tethers No high-risk Medications

Source: P. Mulhausen (9-2-2020). Promoting Health Aging: Mobility and the Age-Friendly Health System. Telligen AFHS Learning Collaborative. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/

Mobility: ACT ON

MyMobility PlanMySelf: plan to stay independentMyHome: plan to stay safe at homeMyNeighborhood: plan to stay mobile

https://www.cdc.gov/injury/features/older-adults-mobility/index.html

Mobility: ACT ON

Get a physical checkup yearly Review Medications with your provider Get a medical eye exam yearly Follow a regular exercise program to increase

your strength and balance

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Mobility: ACT ON

All exercise is good, but strength and balance help reduce falls!

Go4Life is now at https://www.nia.nih.gov/health/exercise-physical-activity

Mobility: ACT ON

Many Options! Regular exercise

need not be strenuous or time-consuming

Exercising with Chronic Conditions offers many good choices!

Visit Exercise and Physical Activity: https://www.nia.nih.gov/health/exercise-physical-activity

Home Mobility Checklist

Safety assessment Items in easy reach Trip hazards removed: rugs, cords Bright lights, lamps within easy reach, more! PT and/or OT consultation Supportive & adaptive equipment Physical activity program Vision referral, assessment No high-risk Medications

Adapted from P. Mulhausen (9-2-2020). Promoting Health Aging: Mobility and the Age-Friendly Health System. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/

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Mobility: ACT ON

Many evidence-based fall prevention programs! STEADI A Matter of Balance Stepping On Community Aging in Place –

Advancing Better Living for Elders(CAPABLE)

Stay Active and Independent for Life (SAIL)

Tai Chi (various versions)https://www.ncoa.org/healthy-aging/falls-prevention/falls-prevention-programs-for-older-adults-2/

Summary: Mobility

Mobility is often essential to doing What Matters most! Identify and treat factors that impair

Mobility Support individualized Mobility goals

across care settings to promoteHealthWell-beingFunction and Enjoyment in living!

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Age-Friendly Health Care and Systems Medications



College of Nursing


Overview of Medications in the 4Ms

Brief review of screening

Brief review of interventions


Medications: Importance

Critical to health & well-being for many Treat acute and chronic illnesses Improve function, well-being Reduce suffering, distress Increase longevity

At the same time, risks are ever-present! Age-related changes in how drugs work Metabolism, distribution, excretion = drugs may

have a greater or different impact than expected Longer half-life = drugs are in the system longer

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Multiple chronic conditions lead to . . . Multiple specialty providersMultiple Medications that all have risks Drug-drug, drug-disease interactions Adverse side effects Unexpected effects

Over-the-counter drugs that are not reported Financial cost relative to other needs: What

Matters most!


Key Point Medications have both risks & benefits! 4Ms framework

emphasizes SAFEuse! Promote function,

well-being Do What Matters!


Medications impact other Ms! Mobility: increased risk of falling Mentation: directly cause depression,

delirium; increases confusion in dementia What Matters: may not be possible due to

drug burden Function Cost

All 4Ms interact! Not silos!

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Medications

If needed, use Age-Friendly Medicationthat does not interfere with

What Matters to the older person,

Mobility, or

Mentation across care settings


ASSESS Review for high-risk Medication use Annually or change of status Team approach using established criteria

ACT ON your findings Deprescribe, or do not prescribe high-

risk Medications Dose reduction, discontinuation Avoid in the first place!

Medications

Assessment Tips* Consider the setting or practice culture Resources that improve Medication reviews? High-risk Medications most often prescribed

in your setting? Best approach to championing deprescribing?

Goal: Don’t be overwhelmed with Medication reviews! Start where you are!

*Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. (2019). Institute for Healthcare Improvement. IHI.org

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Medications

Assessment Tips* Consider delirium and fall prevention

protocols already in use Guidance to avoid high-risk Medications Build on, extend drug review procedures

Incorporate drug reviews at discharge Not all Medications may be needed

(e.g., short-term uses for specific symptoms)

*Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. (2019). Institute for Healthcare Improvement. IHI.org

Medications: ASSESS

IHI: Review high-risk Medications Benzodiazepines Opioids Highly anticholinergic drugs Sedatives and sleep MedicationsMuscle relaxants Tricyclic antidepressants Antipsychotics

Engage, screen, assess current needsAge-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. (2019). Institute for Healthcare Improvement. IHI.org

Medications: ASSESS

IHI list is one of many Think about drug impact on function, quality

of life, risk to independence Sedation Cognitive impairment Unsteadiness Falls Injuries Unpleasant side effects, adverse reactions Drug-disease interactions

Explore resources for high-risk Medications

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Medications: ASSESS

High-Risk MedicationResources American Geriatrics

Society Beers Criteria® JAGS DOI: 10.1111/jgs.15767 GeriatricsCareOnline.org Pocket card: 8 pages

High-Risk Medications

Resources are available at the Iowa Geriatric Education Center website

See Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) for pocket cards like this

https://igec.uiowa.edu/ia-adapt

Medications: ASSESS

What Matters most to the person?

What is most important?

How do their Medications facilitate or impede doing What Matters?

How much is “enough”?

What is a burden? Sheer number, management? Cost?

Is it time to stop some?

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Medications: ACT ON

Focus on person’s goals Desired health outcome

Prescribe Age-FriendlyMedications Prevent problems

Avoid high-risk drugs

Deprescribe Dose reductions Discontinuation

Medications: ACT ON

Avoiding high-risk Medications is a top priority for ALL older adults Next most important: What Matters!What are the person’s health outcome goals?

Treatment preferences?

Does Medication burden interfere? If so, how? Too many pills to manage?

Too high a cost?

Too little benefit to justify?

Medications: ACT ON

Focus on PREVENTION Do not start a drug unless truly needed! Ask: Could a non-drug approach be

safer & as effective? Behavioral activation, physical activity,

talking therapy in depression? Promote sleep without drugs? Exercise or activity vs. opioids for pain?

Source: R Carnahan (Sept 2, 2020). Age-Friendly Medication Use in Older Adults. https://www.telligenqinqio.com/telligen-qi-connect-events-archive/

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Medications: ACT ON

Use a time-limited trial then gradualdose reductions Assess need for continued use Stop drugs that don’t work! Avoid “prescribing cascades” Treating

side effects of one drug with another

Especially important with psych drugs! Antipsychotics for delirium, behavioral

symptoms in dementia; sleep aids


Medications: ACT ON

Engage & educate older adults At discharge As part of ambulatory care

Keep it simple, understandable Comprehensive list Person & family understand what each is for How to take, why to take How to monitor: Helping? Causing adverse

effects?

Medications: ACT ON

Engage & educate older adults Include information on high-risk Medications Discuss opportunities to Reduce number, dose Explore alternatives: drug and non-drug Discontinue

Use educational materials, brochures to promote knowledge, understanding

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Medications: ACT ON

Many good resourcesfor education HealthinAging.org Ten Medications to

Avoid, Use with Caution (2 pages) Consistent with IHI Types & names Provides reasons

Medications: ACT ON

Deprescribing Triggers Need for continued use

is unclear

Side effects

Prescribing cascades

Mobility problems, falls, other accidents

New cognitive impairment

Deprescribing Barriers Real need for drug

Lack of attention, time

Trust issues: person & provider

Person’s beliefs: Medsneeded for health

Cost of non-drug treatment

Time needed to taper (dependence)


Medications: ACT ON

https://professionals.optumrx.com/content/dam/optum3/professional-optumrx/resources/High_Risk_Medications_Elderly.pdf

Identify Alternatives

NCQA list Category

High-risk Meds

Alternatives

Work to select Age-Friendly options

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Medications: ACT ON

Tools to Deprescribe: Canadian Deprescribing Network – www.deprescribingnetwork.ca Deprescribing algorithms, videos for clinicians Deprescribing pamphlets for patients EMPOWER brochures for patients: stories, examples Templates:

pharmacist to prescribers; prescribers to patients

Many excellent resources!

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More from deprescribing.org

Need help to deprescribe?Check out the recent lecture series on the topic!

Visit the University of Iowa Carver College of Medicine Continuing Education site: https://uiowa.cloud-cme.com/course/search?P=4000&search=Medications%20and%20Deprescribing%20Series

Medications: ACT ON

Summary: Medications

Identify, document high-risk Medications

Use a team approach, starting “where you are” and then expanding

Address What Matters to the person

Educate and engage in decision-making

Use Age-Friendly Medications

Avoid prescribing and deprescribe high-risk Medications

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Age-Friendly and Dementia Friendly

Social Movements



College of Nursing


Briefly describe Age-Friendly Health Systems and 4Ms Age-Friendly Communities Dementia Friendly Communities

Briefly review similarities and overlaps

Encourage participation at all levels


Age-Related Social Movements

Change societal attitudes & practices Encourage & advance best practices Make life easier & better quality for older

adults Two main themes: Age-Friendly: Health Systems that provide

care & treatment, and also Communities Dementia Friendly Communities

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Age-Friendly Health Systems

Co-sponsored by the John A. Hartford Foundation Institute for Healthcare Improvement (IHI) Health systems, hospitals, outpatient, and

long-term services across the county

http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

Age-FriendlyHealth Systems

Achieve better health outcomes for older adults

Reduce unwanted care & treatment, risk of harm

Reduce fragmented, burdensome care

Focus on What Matters most to older people!







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Medications

Mobility



The 4Ms Framework

Lots of good reasons to use 4M framework! Best practice across

healthcare settings Focus on the person,

not the disease Focus on quality of

life, not “more treatment” or acute care transfers

Start with What Matters Most

What Matters: Know and align care with each person’s specific health outcome goals & care preferences

Older persons identify their health priorities

Clinicians translate these priorities into care options

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What Matters Most


meaning in living

Health:Our ongoing

health concerns

& conditions



Critical Interactions Among 4Ms

Medications: Use Age-Friendly Medications that do not interfere with What Matters to the older person or their Mobility or Mentation Mobility: Ensure that older adults move

safely every day to maintain function and do What Matters Mentation: Prevent, identify, and treat

dementia, delirium, and depressionacross care settings

Critical Interactions Among 4Ms




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126 systems 357 sites in 37 states(as of May 2019)

Age-Friendly on the Rise

Age-Friendly Health Systems

4Ms work well across care settings Institution-based care: Hospital, subacute,

skilled care, nursing home, residential Ambulatory/primary care Community-based organizations

Age-Friendly Communities

World Health Organization (WHO) initiative started in 2006

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Age-FriendlyCommunities WHO defines an AFC as a place that

“encourages active aging by optimizing opportunities for health, participation, and security in order to enhance quality of life as people age.”

AARP notes that “Age-Friendly Communities adapt their structures and services to be accessible to, and inclusive of, older people with varying needs and capacities.”

Source: N. Turner & L. Morken. (March 2016). Better Together: A Comparative Analysis of Age-Friendly and Dementia Friendly Communities, p. 3. AARP Research Report.

Age-Friendly Communities

AARP is the U.S. affiliate https://www.aarp.org/livable-

communities/network-age-friendly-communities/

“The common thread among the enrolled communities and states is the belief that the places where we live are more livable, and better able to support people of all ages, when local leaders commit to improving the quality of life for the very young, the very old, and everyone in between.”

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AARP: Age-Friendly / Livable Communities

Age-Friendly refers to livability for people of ALL ages, including older adults

AARP: Rooted in “Active Aging”

AF Health System vs. Community

Age-Friendly Health Systems focus on the person and system: What Matters most Age-Friendly Communities focus on

population aging: Environmental support Both focus on Maintaining function, independenceMaximizing physical, social, mental well-being Doing What Matters, which is often linked to

the larger environment

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Dementia Action Alliance Dementia Friends, UK Alzheimer’s Society, UK and Canada Dementia Friendly America Based on ACT on Alzheimer’s Minnesota Sponsored by National Association of Area

Agencies on Aging: https://www.dfamerica.org Includes Dementia Friends USA

State‐based, National, and International!


Understands that dementia can affect a person’s cognition, behavior, emotions, and physical abilities

Embraces the belief that EVERYONE has a role in recognizing people with dementia as part of their community AND supporting their independence, value, and inclusion

Increases awareness, promotes social inclusion, challenges stigma, & improves care and service

Community Capability:Adoption of

dementia friendly practices within and across all community

sectors (e.g., faith, business,

government, health care)

System Capability:Adoption of optimal

dementia care and supports in health, long‐term care, and community services

Person with Dementia—Well‐Being

Care Partner Efficacy

Care Partner Support and

Family Health


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Dementia Friendly America

10 Sectors of Community Engagement1) Transportation, housing, public services2) Businesses & employers3) Legal & advance planning4) Banks & financial services5) Neighbors & community members6) Independent living & community engagement7) Communities of faith8) Care throughout the continuum9) Memory loss support and services10) Emergency planning and first responders



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Dementia Friendly vs. Age-Friendly Communities

Considerable overlap in goals and approach. Both focus on Maintaining function, independenceMaximizing physical, social, mental well-being Broad stakeholder engagement

“A dementia friendly community is age-friendly, but an age-friendly community is not necessarily dementia friendly.”1

1. N. Turner & L. Morken. (March 2016). Better Together: A Comparative Analysis of Age-Friendly and Dementia Friendly Communities, p. 3. AARP Research Report.

Dementia Friendly vs. Age-Friendly

Doing What Matters is a common theme Support to older people to be successful! Facilitative social environment Facilitative physical environment Acceptance, respect, assistance Using the person’s priorities to guide care Focusing on strengths, abilities

EVERYONE has a role!

Summary

Many opportunities exist to change societal attitudes, beliefs, and practices! Healthcare systems: acute to residential Community settings: villages to cities

Support older people to live WELL Reduce unwanted care, burden Promote function, independenceMake life easier, better quality

Everyone has a role; how about you?

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age-friendly health care and systems 4ms overview

Documents