Geriatric Care Management Journal Care Management ... Nursing in its many locations and emphasis of...

Geriatric Care Management

Assessment ToolsWorkshop or How to GetAll Possible InformationWhen They Don’t Want toGive It!By Debra Sorensen, MSW, LISW

page ...................................�

Long-Term Care for DeafElders: ExploringResidential Optionsby Laura Iversen, MSG, MPA

page ...................................�

Loss in the Lives ofSoutheast Asian Eldersby Marcie Parker, Ph.D.

page ................................ ��

��2000

�� 4

�� 10

Alzheimer’s Disease:Help Is Available ThroughTriAD TM, an Innovativeand ComprehensiveDisease ManagementProgramby Gayle K. Sobel, CDMS/R, CCM

page ................................ ��

Oral Health Considerationfor Geriatric Clientsby Judith C. Corbin, RDH, BSDH,FADPD

page ................................ ��

Published by the

NationalAssociation ofProfessionalGeriatric CareManagers1604 North CountryClub Road

Tucson, Arizona85716-3102

520.881.8008 / phone

520.325.7925 / fax

www.caremanager.org

��2

GCM

fall 2000

(continued on page 3)

Assessment ToolsWorkshop or How to

Get All PossibleInformation When TheyDon’t Want to Give It!

by Debra Sorensen, MSW, LISW

assessment tool is twofold: 1) toprovide a means of recording thenecessary information to create aprofessional plan of care; and 2) toprovide the client with a “flexible,professionaldocument whichreflects the statedrecommendations,goals, andappropriateinterventions toattain the highestlevel of health andquality of life thatis possible”(rephrased fromStandard 5 of theStandards ofPractice forProfessional CareManagers).

Havingupdated andedited my ownassessment tooleight times in asmany months, Iwas interested inlearning frommore seasoned veterans as well asinnovative newcomers. We comparedand contrasted the tools received fromother GCMs and had a lively discus-sion, enlightening one another aboutour various disciplines, philosophies,and expertise.

Much has been written anddiscussed in workshops, inservices,and professional journals regardinghow to do a Mini-Mental Status Exam,for example, or the Geriatric Depres-sion Scale. The purpose of myworkshop was to participate in adiscussion of the actual process ofgathering comprehensive data,analyzing that data, and creating afunctional plan of care from thatprocess. Some of the questions thatwere posed to the group for discus-sion included:

● What works?

● What doesn’t?

● Do some people use differenttools for different clients?

● Are some tools better for specificsituations?

● Dialogue about philosophiesregarding the term “comprehen-sive.”

● What strategies are used tocomplete assessments?

● What’s anaverage assess-ment turnaroundtime?

��

ElderCareAdvocatesassesses a clientin six categories:environmental,financial, legal,medical, psycho-logical, and social.These categorieswere gleaned fromthe seminar givenby Gregory J.Paveza, MSW,Ph.D., ACSW(School of SocialWork, Universityof South Florida),

who espouses that “six elements seenas essential to a comprehensivegeriatric assessment are mental status,functioning on activities of dailyliving (ADL)/instrumental activities of

One of the most challengingaspects of the creation of an appropri-ate plan of care can be the diversity ofthe individual needs of the peoplewho come to us for help. In trying todevelop a comprehensive assessmenttool, one needs to take into accountall possible scenarios of problems andstrengths. We need to emphasize theneed for balance in people’s lives bylooking at as many compartments aspossible and then putting the partstogether into an ideal whole.

The wonderfully diverse back-grounds of our newly developingprofession gives us a unique multi-disciplinary approach to serving ourcare management clientele. LastOctober in San Diego, we put ourheads together in an experientialworkshop of idea sharing. We havesuccessfully combined our familiartools, with emphasis on what wefound most helpful in our former lives:

● Home Health Social Work.

● Hospital Discharge Planning.

● Nursing in its many locations andemphasis of service (e.g. hospital,extended care, hospice, homehealth, office...).

● Financial Planner.

● Counselor/Therapist.

● Occupational and PhysicalTherapy.

The purpose of a professional

We need to

emphasize the

need for balance

in people’s lives

by looking at as

many

compartments as

possible and then

putting the parts

together into an

ideal whole.

��3

GCM

fall 2000

�� (continued from page 2)

Published by the: �� !��

�� !�"��#��$��1604 North Country Club RoadTucson, Arizona 85716-3102

www.caremanager.orgPublished quarterly for members of GCM

Non-member subscriptions: $75.00 per year

© Copyright 2000

The GCM Journal is published as a membership benefit to membersof the National Association of Professional Geratric Care Managers.Non-members may subscribe to GCM Journal for $75.00 per year.Send a check for your one-year subscription to: Subscription Depart-ment, GCM, 1604 N. Country Club Road, Tucson, AZ 85716-3102.

EDITORIAL BOARD�� Boston, MA

�� Los Angeles, CA

�� Bryn Mawr, PA

��Charlotte, NC

�� Golden Valley, MN

EDITOR IN CHIEF�� Santa Monica, CA.

COMMUNICATIONSDIRECTOR�� Tucson, AZ

COMMUNICATIONSCOORDINATOR��! ��"�� Tucson, AZ

GRAPHICDESIGNER�� #��Redmond, WA

daily living (IADL), medical condi-tions, social well-being, nutritionalwell-being and health behaviors, andpsychiatric symptoms and behavioralproblems.” ElderCare Advocates, Inc.,founder and president, Chris Cooper,combined the ADL functioning andcognitive/mental status into themedical and psychological categories,respectively; and added the financialand legal categories as other importantcomponents to long-term caremanagement and planning. Other caremanagers may have other categorieswhich all basically fit into these moldsor reflect their own philosophiesregarding assessments.

��"�%&!��

The assessment should beginwith signed release of informationforms, and include interviews with the

client, significant friends/neighbors,relatives, physicians’ offices, psychia-trists, and perusal of documentationreceived from hospitals, physicians,home health agencies, and therapists.It is often interesting and significantto compare what is self-reported withwhat is objectively reported. A fewfollow-up phone calls, or personalvisits, to medical records departmentscan usually result in a timely receipt ofrequested materials. Most GCMsrecommend sending a letter ofintroduction to the recipients ofreleases, offering to share the resultsof the assessment (if appropriate) withthe client’s permission, and establish-ing the reality of the team approach.

Gather as much information aspossible in face-to-face interviews,being sensitive to the limitations (bothphysically and psychologically) of theinterviewee. Not all information mustnecessarily be gathered by the GCM;some information is already in theclient’s record and it may be inappro-priate to put the client through theprocess again. For example, the mini-mental status exam can often be veryinsulting to a client unless performed

with expert finesse and the ADL scalemay already be a part of a home healthagency’s record. The results of theGeriatric Depression Scale (GDS) canbe very helpful information for thephysician, whether or not she/he hasalready diagnosed the patient as beingdepressed. However, I usually wouldnot recommend a GDS without firstengaging the client and having built afavorable rapport. Also, use of theGDS has not been found effective withpersons with dementia. (The originalscale is in the public domain due to itbeing partly the result of federalsupport.)

Make follow-up appointments tofinish the assessment information-gathering process. Spread them outover a reasonable amount of time(given the circumstances, nature ofthe problem, and immediate needs).Most of the time, care managementand/or advocacy must be a part of theassessment process:

● Setting up safety nets such asemergency response systems.

● Ordering home health services.

● Arranging and attending doctorappointments.

● Intervening when long-term carefacilities are prematurely cuttingoff skilled care.

�� '�(�"��$��

�� When performing an assessment

of the client’s current physicalenvironment, many safety factors canbe overlooked. ElderCare Advocatesdecided to use a checklist format, andseveral good checklists were sent inby fellow GCMs. We chose oneprovided by Shelly Parkin of GoldenYears Consultants, Inc. With achecklist, one has less chance ofmissing an important piece of theassessment. For those of us who werenot trained as emergency medicaltechnicians or fire fighters, thischecklist can bring attention to littleknown hazards such as frayed cords,carpeting and throw rugs, sturdinessof furniture used for support in



��4

GCM

fall 2000



walking, and firerisks. It alsospeaks to crimeand injuryprevention,communicationdevices (tele-phone locationand type), andsocial supportsystems in theneighborhood,including pets.

Don’t forget,in assessing thetelephone and/orany emergencycall buttonlocations, tophysically handthe telephone tothe client and askthem what theywould do in anemergency; i.e.ask them tophysically dial 911for you (with yourfinger over thereceiver button ofcourse so as notto incur the wrathof the localemergencyfacilities).

�!�� Social factors

need to include anassessment of aperson’s spiritualbeliefs and needs. Many elderly ceaseattending their church due to trans-portation problems and embarrass-ment at their disabilities. A spiritualassessment was sent to me by myfriend, Ann Voorhees, MSW, ofHorizon Mental Health Managementin Venice, FL. This two-page assess-ment form contains questions for theclient which explore their value

systems, their coping methods, andtheir belief systems regarding deathand dying. It also touches on aperson’s ethnic heritage and howimportant that is to the person.

Golden Years reminds us to askquestions about aperson’s dailyroutine, hours ofsleep and hob-bies. Recentchanges in theabove can beindicative of anunderlyingcognitive orphysical deficit.

"�#� In long term

care assessments,it is important toassess a person’slegal documents.Even if the clientsays that theyhave a living will,durable power ofattorney, andeven a will, ask tosee the docu-ments. All toooften we find thatthese documentsare sorely out ofdate, inadequatefor their purpose,or completelyinappropriate.Most POAdocuments do notinclude the abilityto sign tax returns,make gifts ofproperty orassets, and/or arenot accepted byinsurance

companies for a variety of reasons.Before you get to a point where yourclient is unable to pay your bill, youwill want these documents reviewedby an elderlaw attorney who can thenprotect your client’s, and your, futureinterests.

Also, under legal, we address theissue of capacity/competency of theelderly person. Is this client safe? If

capacity does not exist, manychanges to the above-mentioneddocuments will be impossible tomake without establishing guardian-ship/conservatorship.

$�%�!� Medical records should be

requested from all professionalsinvolved, including psychiatrists,psychologists, social workers,hospitals, primary care physicians,specialists, and hospitals where theclient has recently received care.Obtaining releases from the respon-sible party to speak to theseprofessionals will enable you tofollow up with questions notanswered by the documentationsent, and will also allow you toattend appointments and/or hospi-talizations during the assessmentphase as well as during ongoing caremanagement.

ADLs and IADLs can beincluded in the medical diagnosis, aswell as a person’s ambulatory status,strength, etc. Many good checklistsfor assessing ADLs and IADLs weresent in by our colleagues. We choseone sent in by Golden Years asbeing the most concise yet inclusive.Linda Zale, from Arizona, also sent avery nice ADL tool called the“Living Skills Assessment,” whichgives a numerical score that is niceto show to family and physicians asa visual outline of the client’scapabilities.

Take special note of the client’sand family’s reported, versusprofessionally documented, diag-noses, the order of these diagnoses,and the prescribed treatment. Aneasy-to-read and conveniently-located list of client’s physicians,phone and fax numbers, andmedications prescribed will makeyour job easier. For medications besure to list amount, dosage, route(by mouth, injected, etc.), andprescription number, as listed in theform sent to us by Golden Years.Also, be sure to list the preferredpharmacy’s phone number, location,and hours of business so that caremanagement can be facilitated.

In long-term care

assessments, it is

important to

assess a person’s

legal documents.

Even if the client

says that they

have a living will,

durable power of

attorney, and even

a will, ask to see

the documents.

All too often we

find that these

documents are

sorely out of date,

inadequate for

their purpose, or

completely

inappropriate.

��5

GCM

fall 2000



A nutritional assessment issometimes overlooked by the non-medical care manager. Again, GoldenYears Consulting provided us withan easy tool which we incorporatedinto ElderCare Advocates’ assess-ment. It is a 10-question, weightedquestionnaire resulting in a numericalrisk factor which can be very helpfulto the physician for intervention.

Ultimately, it isthe medical diag-noses that guideyour plan of care;all other items in theassessment arecontingent uponthe diagnoses andprognosis of yourclient.

�� !� � A person’s

current cognitiveabilities as well asrecent changes areessential to arealistic assessmentand plan of care. Observationsduring the assessment process areoften enough information, combinedwith documentation from physicianand/or psychiatrist. I prefer not toput a person through cognitivetesting if it has already been done, orafter a reasonable period of familiarity.

Suicidal ideation needs to beaddressed in our fragile and volatilepopulation, and Gretchen Alkema,Senior Care Solutions, Claremont,CA, sent us a user-friendly suiciderisk questionnaire.

If a formal cognitive evaluationis in order, the Mini-Mental StatusExam is relatively simple to performand is in the public domain, availablein libraries or on the Internet. Thereare several versions of the GDSavailable in various informationalsettings and this tool is also veryeasy to perform. The clock drawing

test is a tool used to measure thelevel of a person’s dementia as wellas its progression on repetition of thetest at regular intervals. Basically,one draws a circle on a sheet of paperand asks the client to fill in the circlewith the face of a clock reading acertain time of day. This test, doneover a period of time, can indicate theprogression of dementia.

"�� Undoubtedly the most contro-

versial of our topics at the workshopwas the question of whether aperson’s financial resources are thebusiness of a professional geriatric

care manager. I would argue that,unless we know the answer to thesequestions, our plan of care could beglaringly inappropriate and couldpossibly constitute malpractice. Notknowing a person’s financial status ispossibly setting up the client forfailure in his or her choice of long-term care. If we are to remain aperson’s care manager for life, whichis ElderCare Advocates’ ideal, wemust be trusted enough by the clientfor them to share this intimateinformation with us. More impor-tantly, we must educate ourselves asto the issues underlying howfinancial status relates to long termcare.

That said, ElderCare Advocatesrequests copies of a person’sfinancial records, including bankstatements, stock certificates, bonds,annuities, life insurance policies, and

sources of income. A person’s lastwill and testament can revealinformation that they forgot to sharesuch as other real property owned, aswell as give insight into familydynamics. We ascertain whether aperson is eligible for entitlementprograms and when applicationshould be anticipated. This informa-tion helps determine what a personcan afford for long-term care andwhether they need to seek the adviceof a certified financial planner.

#��The “Family Questionnaire”

provided by Erica Karp andNorthshoreEldercare Man-agement, Inc., inEvanston, IL is awonderful way ofgathering informa-tion before theassessment, orprior to intake. Italso offers muchinsight into thefamily’s viewpointof the problemsand gives them anopportunity to tellthings they mightnot be forthcom-ing in telling (i.e.

alcohol problems).

The Genogram is a wonderfultool familiar to most social workers,and easy to learn how to perform.With the Genogram, one can map aperson’s family history and trackinformation relevant to medical andpsychosocial patterns, and isespecially useful for charting andrecognizing family dynamics andformer coping mechanisms.

$��!�� $��%�&��

The “Summary of Risk Factors”by Golden Years is a good justifica-tion for your plan of care because itlays out the problems in a numericalformat.

Writing your observations andgathered facts in summary sectionswith the headings as above, makes it

If we are to remain a person’s care manager

for life, which is ElderCare Advocates’ ideal,

we must be trusted enough by the client for

them to share this intimate information with

us. More importantly, we must educate

ourselves as to the issues underlying how

financial status relates to long term care.

��6

GCM

fall 2000


easy to pull out problems, goals, andproposed solutions for a chart styleplan of care. Keeping in mind thegoals of the client, it is also the caremanager’s role to propose alternativesolutions based on the assessment.

If extended care is in order, a

review of recommended facilities canalso be done in a table format, givingpros and cons of each so that theclient and family have a clearer ideahow to decide.

!��The dynamic process and purpose

of the GCM assessment is to engagethe client in discussions of their livesand history. We help them to prioritizetheir needs, and to create measurable,observable strategies for reachingtheir goals. The best way to help themto help themselves is to focus onstrengths, problem-solving skills, andlife successes they have had.

We sometimes must reframe ourown, and our clients’ thinking tocelebrate small accomplishments. Ourclients can become empowered whengiven choices that are goal-attaining.Using the appropriate assessmenttools can help us to utilize the client’sown strengths to reach their goals ofmaintaining independence and dignity.

Debra J. Sorensen, MSW, LISW, isthe clinical director of ElderCareAdvocates, Inc., a private geriatriccare management company in Toledo,OH. Previous experience as a homehealth social worker created in Debraan awareness of the complexity ofMedicare and Medicaid regulations,the issues of long term care for theelderly and the financial costs with

which families are faced. Debraprovides public and professionaleducation seminars regarding longterm care costs and options,caregiving and other issues relatedto aging. She obtained herbachelor’s degree in psychologyfrom Wichita State University and amaster’s degree in social work fromthe University of Kansas. Debra is aLicensed Independent SocialWorker in the State of Ohio and aCertified Social Worker in the Stateof Michigan.

"��#��

Folstein, M.F., Folstein, S.E., andMcHugh, P.R. (1975). “Mini-mentalState: A Practical Method for Gradingthe Cognitive State of Patients for theClinician.” Journal of PsychiatricResearch, 12, 189-198.

Gerontological Society of America.Katz, S., Down, T.D., Cash, H.R, et al.(1970). "Progress in the developmentof the index of ADL." Gerontologist10:20-30.

Hedlung and Vieweg, “The HamiltonRating Scale for Depression,” Journalof Operational Psychiatry, 1979;10(2):149-165.

Karp, Erica, LCSW, Director. “TheFamily Questionnaire,” NorthshoreEldercare Management, Inc., 701Sheridan Road, Evanston, IL 60202-2501; 847-866-7466.

McGoldrick, Monica; Gerson, Randy;Shellenberger, Sylvia. GenogramsAssessment and Intervention, SecondEdition. February / ISBN 0-393-70286-3 / 240 pages

Parkin, Shelly. “EnvironmentalChecklist, ADL Checklist, NutritionalAssessment,” Golden Years Consult-ants, Inc., 1939 S. 300 W. Suite 104-44, Salt Lake City, UT 84115; 801-481-9480.

Paveza, Gregory J., MSW, Ph.D.,Chair, Faculty Committee.“Comprehensive GeriatricAssessment: Moving PeopleDown the Road to ContinuedIndependence.” School of SocialWork, University of SouthFlorida, Tampa, FL.

Voorhees, Ann, MSW,“Spiritual and Social Factors,”Horizon Mental HealthManagement, Venice, Florida.

Zale, Linda J., MA, “LivingSkills Assessment,” 8312 N.53rd St., Paradise Valley, AZ85253.

Zung, “A Self-Rating Depres-sion Scale,” Arch Gen Psychia-try, 1965; 12:63-70.

We sometimes must

reframe our own, and our

clients’ thinking to

celebrate small

accomplishments. Our

clients can become

empowered when given

choices that are goal-

attaining.

��

Electronic copies of theassessment tool and the familyquestionnaire can be obtainedby e-mailing Kimberly Hess atthe GCM office at:[email protected].

The MMSE and the depres-sion scales mentioned in thisarticle can be obtained by aweb search and/or by manypharmaceutical companiesthat offer these tools toprofessionals. GlaxoWellcome,Inc., at Research Triangle Park,NC 27709

��6

GCM

fall 2000


easy to pull out problems, goals, andproposed solutions for a chart styleplan of care. Keeping in mind thegoals of the client, it is also the caremanager’s role to propose alternativesolutions based on the assessment.

If extended care is in order, a

review of recommended facilities canalso be done in a table format, givingpros and cons of each so that theclient and family have a clearer ideahow to decide.

!��The dynamic process and purpose

of the GCM assessment is to engagethe client in discussions of their livesand history. We help them to prioritizetheir needs, and to create measurable,observable strategies for reachingtheir goals. The best way to help themto help themselves is to focus onstrengths, problem-solving skills, andlife successes they have had.

We sometimes must reframe ourown, and our clients’ thinking tocelebrate small accomplishments. Ourclients can become empowered whengiven choices that are goal-attaining.Using the appropriate assessmenttools can help us to utilize the client’sown strengths to reach their goals ofmaintaining independence and dignity.

Debra J. Sorensen, MSW, LISW, isthe clinical director of ElderCareAdvocates, Inc., a private geriatriccare management company in Toledo,OH. Previous experience as a homehealth social worker created in Debraan awareness of the complexity ofMedicare and Medicaid regulations,the issues of long term care for theelderly and the financial costs with

which families are faced. Debraprovides public and professionaleducation seminars regarding longterm care costs and options,caregiving and other issues relatedto aging. She obtained herbachelor’s degree in psychologyfrom Wichita State University and amaster’s degree in social work fromthe University of Kansas. Debra is aLicensed Independent SocialWorker in the State of Ohio and aCertified Social Worker in the Stateof Michigan.

"��#��

Folstein, M.F., Folstein, S.E., andMcHugh, P.R. (1975). “Mini-mentalState: A Practical Method for Gradingthe Cognitive State of Patients for theClinician.” Journal of PsychiatricResearch, 12, 189-198.

Gerontological Society of America.Katz, S., Down, T.D., Cash, H.R, et al.(1970). "Progress in the developmentof the index of ADL." Gerontologist10:20-30.

Hedlung and Vieweg, “The HamiltonRating Scale for Depression,” Journalof Operational Psychiatry, 1979;10(2):149-165.

Karp, Erica, LCSW, Director. “TheFamily Questionnaire,” NorthshoreEldercare Management, Inc., 701Sheridan Road, Evanston, IL 60202-2501; 847-866-7466.

McGoldrick, Monica; Gerson, Randy;Shellenberger, Sylvia. GenogramsAssessment and Intervention, SecondEdition. February / ISBN 0-393-70286-3 / 240 pages

Parkin, Shelly. “EnvironmentalChecklist, ADL Checklist, NutritionalAssessment,” Golden Years Consult-ants, Inc., 1939 S. 300 W. Suite 104-44, Salt Lake City, UT 84115; 801-481-9480.

Paveza, Gregory J., MSW, Ph.D.,Chair, Faculty Committee.“Comprehensive GeriatricAssessment: Moving PeopleDown the Road to ContinuedIndependence.” School of SocialWork, University of SouthFlorida, Tampa, FL.

Voorhees, Ann, MSW,“Spiritual and Social Factors,”Horizon Mental HealthManagement, Venice, Florida.

Zale, Linda J., MA, “LivingSkills Assessment,” 8312 N.53rd St., Paradise Valley, AZ85253.

Zung, “A Self-Rating Depres-sion Scale,” Arch Gen Psychia-try, 1965; 12:63-70.

We sometimes must

reframe our own, and our

clients’ thinking to

celebrate small

accomplishments. Our

clients can become

empowered when given

choices that are goal-

attaining.

��

Electronic copies of theassessment tool and the familyquestionnaire can be obtainedby e-mailing Kimberly Hess atthe GCM office at:[email protected].

The MMSE and the depres-sion scales mentioned in thisarticle can be obtained by aweb search and/or by manypharmaceutical companiesthat offer these tools toprofessionals. GlaxoWellcome,Inc., at Research Triangle Park,NC 27709

��7

GCM

fall 2000


�� In 1971, a Deaf man named

Wayne Mix moved into the MountainMeadow nursing home in Colorado.Mix lived at the facility for 28 yearsbefore staff discovered that he couldcommunicate through sign language.Then one day Mix saw the daughterof another resident try to communi-cate with her mother using a handsign. Mix introduced himself to thedaughter, and “the walls cametumbling down” (Booth, 1999). Mixwas 81. Peggy Filer, a teacher whodoes some interpreting for Mix, saysshe “does not blame the nursing homestaff for what happened to her newfriend. But she can’t help but mournthe lost years of his life.”

Mix’s story is an extreme exampleof what can happen when a culturallyDeaf older person moves into a facilitythat is not prepared to identify andmeet the needs of Deaf residents. Atthe other end of the continuum thereare “Deaf” facilities that are run forand by Deaf people. In between theseendpoints are organizations withvarying degrees of expertise inserving Deaf clients. The purpose ofthis article is to explore this range oflong term care options for servingculturally Deaf elders. Most informa-tion is descriptive, reflecting a lack ofresearch on this topic.

Long term care for Deaf elders isan important issue for people who areconsidering residential alternatives forthemselves or family members. There

Long Term Care forDeaf Elders: Exploring

Residential Optionsby Laura Iversen

© Copyright 2000 by Laura Iversen. All rights reserved.

are well over 300,000 people who areculturally Deaf in the United States,and approximately 11 million personswho have some degree of hearing loss(Walsh and Eldredge (1989) inMosher-Ashley, 1997). Providers alsohave compelling reasons to learn moreabout the needs of Deaf elders; suchinformation can lead to improvedquality of care, increased compliancewith the Americans with DisabilitiesAct (ADA), and a better understand-ing of the needs of cultural minoritiesin general. Information for this articlewas gathered primarily from a litera-ture review, a review of Deaf andhearing websites on the Internet, andinterviews with several Deaf andhearing people involved in improvinglong term care services.

This article highlights some keyissues affecting long term careproviders and residents, to stimulatediscussion regarding long term carepractices and options. It does notrepresent an in-depth analysis of deafculture, hearing culture, or legalobligations under the ADA. Readersshould consult experts in these areasfor more information.

��Throughout this article, the terms

“culturally Deaf older people, Deafelders, and Deaf seniors” refer topeople over the age of 65 who useAmerican Sign Language (ASL) astheir primary means of communication,“associate principally with other Deaf

people, and share their commonculture” (Padden and Humphries, 1988in Green and Mosher-Ashley, 1997).Cultural Deafness is denoted with acapital “D” (as in “Deaf” elders).

Deaf culture refers to: “a set oflearned behaviors and perceptionsthat shape values and norms of Deafpeople based on their shared orcommon experiences” (Kannapell,1991). Some of the most importantvalues of the Deaf community include:

● “Their dignity as Deaf people,who, more fully than hearingpeople, operate in a visual-spatialworld;

● Their language (e.g., ASL);

● Their history;

● Their social organization andmores; and

● Their political agenda” (HarlanLane (1994).

Long term care (LTC) refers toresidential care for persons withserious chronic conditions (e.g.,nursing homes). However, generalhealth services, hospice care andassisted living are also discussed to alimited degree.

��

An understanding of LTC optionsavailable to Deaf elders is facilitatedby a review of the general experienceof Deaf clients’ interactions with thehealth care system. Beneficial andharmful aspects of the current healthcare system include the following:

Physicians and Deaf ClientsReport Difficulties in Communicatingwith One Another. Clear communica-tion between a practitioner and his/herclient is vital in diagnosing andtreating a patient’s condition. Unfortu-nately, Deaf clients have reportedmore problems than hearing people incommunicating with physicians,understanding them, and feelingcomfortable with them (Zazove et al.,1993). Older Deaf patients have alsodescribed problems with interpreterswho were unskilled and doctors’

��8

GCM

fall 2000



offices that did not have a TTY (atelecommunications device used tofacilitate communication between Deafand hearing people). Physicians havereported that Deaf patients are harderto communicate with - and less likelyto understand their diagnosis andrecommended treatments – thanhearing patients (Zazove andGorenflo, 1996).

Communication problems appearto arise most often when the mode ofcommunication used between providerand patient does not meet the needsof the patient. For example, signlanguage interpreters can be used tobridge the gap between English-speaking doctors and clients who useAmerican Sign Language; yet researchsuggests that physicians are unlikelyto use sign language interpreters,even when they believe that this is thebest mode of communication (Ebertand Heckerling, 1995). Physicians maybe unaware of their legal obligationsunder the Americans with DisabilitiesAct (e.g., Ralston, Zazove andGorenflo, 1996) or they may beconcerned about the added cost ofinterpreters (e.g., see Kulback, 1995).Deaf clients may be reluctant torequest an interpreter for a variety ofreasons, such as fear that physicianswon’t pay for the service, or anticipa-tion that the interpreter will beunskilled (Witte and Kuzel, 2000).

Writing is the most common formof communication in practitioner/patient encounters (Ebert andHeckerling, 1995). Unfortunately, thisis rarely effective, because for mostDeaf people, English is a secondlanguage; a Deaf client may or maynot be fluent in English (e.g., seeMacKinney et al., 1995). The averageDeaf 18-year old reads at approxi-mately the third grade level (Gallaudet,1992), reflecting the challenge oflearning written English when onedoes not hear the spoken word.

Speech reading is anothertechnique that physicians and Deafclients may use. However, this is not a

reliable method of communicationsince only 30 percent to 40 percent ofEnglish is visible on the lips (Shelp,1997)(Ebert and Heckerling, 1995).Therefore, even the best speechreaders can understand only a fractionof the message being communicated.

Access to Improved Communica-tion Can Improve Care. One of the fewcontrolled studies assessing the valueof using ASL in health care encoun-ters was conducted by MacKinney etal. in the mid 1990s. Researcherscompared the experience of Deafclients in the regular health caresystem to clients enrolled in a DeafServices Program. The study foundthat Deaf persons enrolled in a primarycare program that included full-timeinterpreters weremore likely to useASL, were moresatisfied withphysician communi-cations, and hadimproved preven-tive outcomes(MacKinney et al,1995).

CulturalSensitivity toDeafness VariesConsiderablyAmong Providers.Witte and Kuzel(2000) describethree levels ofcompetency inserving Deaf clients.At level one,providers have ageneral understand-ing of Deaf cultureand related commu-nication needs. In level two, theprovider has a more in-depth culturalunderstanding, and staff canfingerspell and use basic gestures.Level three describes providers whoare best able to relate to Deaf clients.

Studies and anecdotal evidencesuggest that some providers have along way to go in reaching even levelone, while others are surprisinglyaware of important cultural issues.

On the positive side, a growth inthe number of ethnic minorities in theUnited States and other factors have

motivated a rising number of providersto improve their ability to serveAmerica’s minorities. Slowly thiscultural awareness is being applied tothe Deaf community, and Deaf peopleare being viewed more as “a culturewith a unique language and not adisability” (e.g., see Barnett, 1999;McLeod and Bently, 1996; Luey,Glass, and Elliott, 1995).

In addition, research suggeststhat physicians accurately understandsome key facts about deafness. Forexample, in a 1995 study, 93 percent ofphysicians correctly believed that that“most people Deaf since birth orchildhood have a normal IQ” and 93percent believed that “the signs Deafpeople make with their hands are a

language” (Ebertand Heckerling,1995).

On thenegative side,Deaf peoplecontinue to reportexperiences withproviders who areculturally insensi-tive:

“…the doctorcame over andtapped me on theshoulder. Andhe’s mumblingand talking. And Isaid, “I’m Deaf…”And then hestarted yelling atme. And I said,“Hey, I’m Deaf. Ican’t hear at all!”And he kept ontalking and I kept

on saying, “What?” (Witte and Kuzel,2000).

A Deaf woman enters an emer-gency room, sick and weak, only tofind that ER staff is unable or unwill-ing to find an interpreter. She tries tocommunicate staff in writing. Staff areannoyed by her request for paper anda pencil (Iversen, 1999).

A Deaf woman and hearingdoctor use an interpreter during anappointment. The doctor addresses all

Communication

problems appear

to arise most

often when the

mode of

communication

used between

provider and

patient does not

meet the needs of

the patient.

��9

GCM

fall 2000



his questions and comments to theinterpreter, without looking at theDeaf client. The client feels left out,“like a ghost sitting in the room”(Iversen, 1999).

For many if not most of physi-cians, Deafness is understood only interms of pathology. With only“minimal attention” being given to theDeaf patient or Deaf culture in thecourse of medical education, “it is notsurprising that even the most well-intentioned medical student orphysician might know little about thistopic” (Witte and Kuzel, 2000).

Failing to Address Communica-tion and Cultural Needs SeverelyCompromises Quality of Care. Whencommunication and cultural issues arenot appropriately addressed, clientsare apt to misunderstand physicianinquiries, diagnoses, and treatmentplans, and providers are apt tomisunderstand symptoms and otherfactors about the client’s condition.These misunderstandings jeopardize aclient’s life and/or well-being. Anexample of this type of situation is anolder Deaf man who went to aphysician who would not use aninterpreter. The man did not under-stand the important self-care practicesassociated with diabetes, and hiscondition quickly deteriorated to thepoint that he needed skilled nursingcare (Interviews, 2000). In anotherinstance, a Deaf woman went to ahospital expecting a mammogram andinstead received a mastectomy.“When I woke up my breast wasgone,” she said, “I didn’t know whathappened” (Warner, 1996).

��

Poor communication and a lack ofcultural sensitivity are potentiallyserious problems for Deaf clients ingeneral, but they are particularlydangerous for older Deaf personsneeding LTC.

First of all, the Deaf elder resides

at the provider site rather than justvisiting it for an appointment or short-term stay. Thus, communication errorsand misdiagnoses can occur on a dailybasis.

Second, LTC residents typicallyhave several serious medical prob-lems, which can negatively affect theirability to advocate for themselves.Older residents may not have theenergy that is needed to educate andre-educatehearing people aboutDeafness. Physical and mentalimpairments may also compromise aresidents’ ability to express them-selves, understand others, and “makedo” with communication methods thatwere acceptable under optimalconditions. The presence of multipleconditions also increases the likeli-hood that linguistic and culturalbarriers will result in a patient’sserious injury or death.

Finally, employee shortages innursing homes may make staffreluctant to attend to the needs ofDeaf residents. Vacancies and highturnover rates are a serious problem.In Minnesota, for example, Sen. ChuckWiger (2000) laments that “our current[long term care] system encourages arevolving door of strangers providingcare. At this time, annual turnoverrates for health care workers are nearly50 percent, and one in eight positionsare vacant statewide.”

��

Residents of nursing homes andother LTC facilities need a variety ofservices, such as room and board,medical care, rehabilitative care, andsocial activities. The older Deafresident also has specific needsrelated to his or her culture andlanguage.

Communication needs of Deafresidents are unique and are ad-dressed by writer Matt Baldwin in a1995 article in DeafNation: “Deaf andhard of hearing persons in need ofnursing care are different in importantways from hearing persons in thesame situation. They have specialneeds. In addition to the heavyburden of serious illness shared by allnursing home residents, the Deaf and

hard of hearing have the additionalburden of lack of communication –both with other residents and with thestaff which is trying to address theirmedical and other needs.”

Providers may address communi-cation issues in a number of ways,such as using qualified interpretersand assuring that staff understandbasic communication issues.

��!�� ● Know when and how to use

ASL interpreters (Witte andKuzel, 2000); do not usehearing children or otherhearing relatives as interpret-ers (InfoBits, 2000).

● Make sure you understandand implement the require-ments of the ADA.

● Understand the limitations ofspeech reading and writing(Witte and Kuzel, 2000)(Shelp,1997).

● If a patient uses sign language,“keep his line of sight clearand his dominant arm clear.”(Shelp, 1997); do not start aprocedure while you are stillexplaining it (InfoBits, 2000).

● Use TTYs and the relayservice to improve telephonecommunications (Witte andKuzel, 2000).

● Assure adequate lightingGreene and Mosher-Ashley,1997).

Cultural needs associated withDeaf residents are related to communi-cation needs but encompass thebroader issue of Deaf culture normsand values.

Providers may address culturalneeds by respecting Deaf people asmembers of a linguistic and culturalminority. In adopting a culturalprospective of Deafness, long termcare staff would view Deafness assimply a difference between Deaf andhearing cultures, rather than viewing

��10

GCM

fall 2000

Deafness as a pathological condition.Staff would emphasize the abilities ofDeaf persons, support socializationwithin the Deaf and larger community,and see themselves as working withDeaf people, instead of “helping”them (Wixstrom, 1988).

��

● Complete “care plans with thepatient in attendance” becauseit is “the Deaf patient who bestunderstands his or her ownneeds and can collaborate todevelop the best possibleplan”(Casey, 1995).

● Recognize the diversity thatexists among Deaf clients andtreat clients as individuals. Forexample, ask about specificcommunication needs (whichmay vary greatly from patient-to-patient) and respect them(Iversen, 2000).

● Learn about Deaf culture,because “it is difficult to judge aculture standing on the fringeslooking in. One needs to becomebetter acquainted with a cultureto understand and appreciate itand, perhaps, become part of it”(Gannon, 1990).

● Understand and implement therequirements of the ADA.

● Speak directly to residents ratherthan beginning sentences tointerpreters with “tell him” or“ask her” (Shelp, 1997).

● In a Hearing facility, place Deafresidents on the same unit(Greene and Mosher-Ashley,1997).

● Create “an atmosphere ofunhurried respect” whereclients are comfortable raisingtheir concerns (Witte andKuzel, 2000).



�!��!��"��#��#!�#��$��

The long term care optionsavailable to Deaf seniors appear to beexpanding. On a practical level,however, the options remain quitelimited. Current options may beviewed along a continuum rangingfrom a “culturally unaware” facility onthe far left (see Figure 1) to a “cultur-ally Deaf” facility on the right.

%&�� '��(��)��

Facilities that are culturallyunaware have no awareness of, orservices related to, the specificcommunication and cultural needs ofDeaf residents. This may be the mostcommonly used option since it is themost widely available. In non-compliance with the ADA, culturallyunaware settings do not providepublic accommodations such as signlanguage interpreters, TTYs, andflashing alarm systems. The result isthat “Deaf individuals often do notreceive quality care even though theyare paying customers” (Andrews andWilson, 1991).

Another characteristic of aculturally unaware facility is that itconcentrates its effort on basic care,intentionally or unintentionallyignoring the communication andcultural needs of Deaf residents. Inmany nursing homes, staff are nottrained to identify or better communi-cate with seniors who are Deaf or hard

of hearing. Instead, “priorities remainfocused on areas of basic care such ashygiene, nutrition, and medication”(Green and Mosher-Ashley (1997).

Nursing home staff in a culturallyunaware facility may also fall prey tomyths or misunderstandings aboutDeaf people. They might believe, forexample, that all Deaf people are expertspeech readers, when in fact most ofwhat is said is not visible on the lips(King, 1998).

What happens when a Deafsenior lives in a culturally unawarefacility? Common sense and anecdotalevidence suggest that ignoring thespecific needs of a Deaf resident canlead to severe problems, as demon-strated in the case study of Mrs. R, anolder Deaf woman who lived in a“Hearing” facility (Andrews andWilson, 1991).

One problem facing Mrs. R andperhaps most Deaf residents inculturally unaware facilities is thatMrs. R was patronized, adverselyaffecting her quality of life. BecauseMrs. R and staff did not share acommon language, “she was oftentreated as is she were a child inca-pable of adult interaction.”

Mrs. R’s experience also indicateshow communication difficulties canlead to misdiagnoses and inappropri-ate treatment. In one instance, forexample, Mrs. R did not receive thepain medication she required becausehearing staff could not communicatewith her. Mrs. R’s problems in

)��%��

% * + ,“Culturally Unaware” “Limited Service” “Specialized Care” “Culturally Deaf”Facility Facility Facility Facility

No Deaf Some Deaf Special Units/ Deaf Services,Awareness Awareness Wings

No Special Some Special High Deaf Culture, andServices Services Awareness Staff

Many Special Many DeafServices Residents

��11

GCM

fall 2000



communicating with staff wereexacerbated when new staff came onboard, a situation commonly experi-enced by nursing home residents.

Mrs. R’s situation also indicatesthe extreme feelings of isolation thatmay come upon a Deaf senior living inan inappropriate setting. Otherresidents “who indeed were senilewould often mimic her voice or treather in a hostile manner.” In addition,“other patients who could talk withher most often did not but would pityher because of her Deafness.”

Unfortunately, “tragic personalstories such as [Mrs. R’s] are notuncommon in traditional long termcare facilities. Most are not focusedon the special communication needsof the Deaf and lack the propersupport equipment” (Mosher-Ashley,1997).

�� !� ��"

A Limited Service Facility is onethat primarily serves hearing residentsbut may, on occasion, have Deafresidents. When a Deaf resident ispresent, the nursing home implementssome changes to accommodate theclient. For example, the Deaf residentmay have access to an interpreter orassistive devices such as visualalarms and amplified telephones.

Without any data to draw from,one can assume that Deaf residentsliving in limited service facilities areless frustrated than Deaf residentsliving in culturally unaware facilities.As older focus group participantsnoted in their evaluation of the healthcare system in the Witte and Kuzel(2000) study, it is likely that Deafresidents “would clearly appreciate”even a basic level of cultural compe-tency. However, because services andcultural understanding are limited,limited service facilities are likely tofoster many of the same problemsseen in culturally unaware facilities(e.g., isolation, miscommunication, and

�#��$��#��%��&�'��(��)*��+�*,-

Number or Type of Examples of Services/ Other items ofClients Served Deaf Orientation Note

This unit is designed to Sign language interpreter Volunteer signingmeet the needs of Deaf and on staff, regularly companions visithard of hearing people. provided for events. regularly.

Serves approximately Visual door knockers Part of large10 residents. and emergency signals. health care system.

Occasional outings to Unstructured socializationDeaf community events. between Deaf residents.

Source: Ebenezer Society, 2000. Interviews, 2000.

�#�� '��(��*�� "��)�� +�*� '��-


Thirty-six consumers on Interpreters available. Orchard Hills is workinga specialized unit, 13 of to recruit more volunteerswhom are Deaf. Intergenerational activities from the deaf community;

with Deaf students. for example, recruitingstudents from the Detroit

Movies that are Day School for the Deaf“strictly ASL.” to participate in the

Adopt-a-grandparentprogram.

Sources: Warner, 1996 and Interviews, 2000.

�#��.��/� �#��0�(�� ),�0�1��2+�,1-


Provides specialized care to Culturally sensitive and One of approximatelypatients with end-stage disease. linguistically appropriate nine current or planned

services. Deaf hospice programsDesigned to assist deaf patients, in the US and Canada.as well as hearing patients Qualified interpreters.with Deaf family members.

Trained Deaf andhearing volunteers.

Sources: Greene and Mosher-Ashely (1997) and Interviews (2000).

�#��3��#&�"�� )��#&�"+��-


Two designated wings Provides access to Psychologist fluent infor up to 60 Deaf/HH residents. interpreting services. ASL provides counseling

services.Designed for residents Encourages interactionneeding skilled long term care. between Deaf residents.

Offers sign languageclasses to staff.

Source: website (www.deafnetwork.com/granburydeaf)

��12

GCM

fall 2000



inappropriate care). One can assumethat as a facility makes greater effortsto provide appropriate care, thequality of care will increase.

�� !��"

Specialized care facilities arefacilities that are generally designedfor hearing residents, but there is aspecial unit or wing designed to meetthe needs of Deaf residents. “Special-ized care” facilities might offerservices such as on-site interpreters,socialization among Deaf residents,and staff that is sensitive to Deafculture.

There appear to be only a handfulof sites across the United States thathave special units for Deaf residents(Warner, 1996; Granbury Care Center,2000). A list developed by TheNational Information Center onDeafness in 1996 shows 18 sitesacross the country that “have beenestablished to accommodate agedDeaf persons.” These sites includeapartments, board and care facilities,and nursing homes. Specific examplesof long term care facilities that havespecialized units or wings for Deafpeople are shown in Tables 1 through4 (see page 11).

While research on this subject islimited, descriptive materials devel-oped by sites offering specialized careemphasize potential benefits. Isolationmay be greatly reduced as residentshave opportunities to socialize withother residents who are Deaf, in bothstructured and unstructured situa-tions. The availability interpreters andstaff trained in ASL and Deaf culturecan facilitate clear communicationbetween staff, practitioners, andresidents, which is essential infacilitating successful diagnoses andcare plans.

#��$��$��"��!��"

Culturally Deaf facilities haveclearly been designed to meet the

specific needs of older Deaf residents.Such facilities are rare, with only a fewsites scattered across the UnitedStates and Canada (Mosher-Ashley,1997). Two settings that epitomize aDeaf facility are Columbus ColonyElderly Care (CCEC) in Westerville,OH and The New England Home forthe Deaf in Danvers, MA. Theseorganizations have been serving Deafpeople for about 100 years.

Columbus Colony Elderly Care(CCED) has “a tradition of servicewhich goes back to 1896, when thefirst Ohio home for the aged Deaf”was established. CCEC was incorpo-rated as a non-profit organization in1977. The primary mission of CCED isto: provide comprehensive long termcare services, principally to the Deaf.The second mission is to fostercommunication between the Deaf andhearing communities. CCED welcomeshearing persons, as well as the Deafand hard of hearing” (Columbus

Colony Elderly Care, 2000).

CCED has many specializedfeatures, such as staff who all receivetraining in sign language, “from thenursing department to the mainte-nance department” (Interviews, 2000).A large number of Deaf residentsallows for many socialization opportu-nities and promotes Deaf culture.

The New England Home for theDeaf (NEHD) was established in 1901to provide care for Deaf older persons.Located in a Victorian mansion, theNEHD is a boarding home for Deafelders who do not need skilled nursingcare. Many residents: “because ofincreasing physical disabilities,function below the skill level for afacility of this type but remain asresidents because there are no nursinghomes available that can meet theirneeds as Deaf persons” (Greene andMosher-Ashley, 1997).

�%��&��$ %$��"��"��'(��)��*��+,


CCEC is a 150-bed All staff trained in sign CCEC is operated by thenursing facility offering language; all activities Alumni Association of theboth skilled and are interpreted. Ohio School for the Deaf;intermediate care. it is the only nursing

Interpreters available facility “owned andIt serves both deaf and for off-site trips. operated by the deaf anddeaf/blind residents. the only facility for the

TTY service and phone deaf which is certifiedamplification available. by both Medicare and

Medicaid (Baldwin, 1995).”

Source: Columbus Colony Elderly Care (2000) and Interviews (2000).

�%��-��.�/��+� ��0��'��)��*�1�,


NEHD is a 30-bed board and Communication and NEHD was established incare home serving deaf deaf culture “are the top 1901. Low-incomeelders who “are unable to live priorities.” independent livingalone because of advanced apartments for deafag,e economic hardship, lack Staff must learn some people of all ages on sameof social support, or physical sign language; there campus; NEHD supportsimpairment.” are deaf employees five Regional

among the nursing aide, Communication Accessibleactivity and housekeeping Senior Citizen Centers.staff.

Source: Greene and Mosher-Ashley, 1997.

��13

GCM

fall 2000



The NEHD provides servicestailored to the needs of Deafresidents (e.g., all staff are requiredto become fluent in ASL) and has anextensive outreach program for Deafpeople living in the community (seeTable 5).

Again, apparently few if anystudies systematically document theexperience of deaf residents of Deaffacilities. However, one of the likelybenefits of living in such a facility isthat an environment oriented towardDeaf culture can decrease isolationand increase well-being (Greene andMosher-Ashley, 1997). Also,personal interaction betweencaregivers and residents can increaseif staff know ASL and appropriatecommunication strategies (Greeneand Mosher-Ashley); this increasedpersonal interaction can be vital inreducing misunderstandings,misdiagnoses, and general frustra-tion levels. Deaf-specific communica-tion methods can also allow resi-dents to enjoy a full range ofactivities on and off site.

A key advantage to living in aDeaf facility is the continued contactwith the Deaf community (e.g., otherresidents and volunteers). This canassist Deaf older persons in adaptingwell to life in a LTC residence (Greenand Mosher-Ashley (1997).

A videotape from the NEHDsummarizes many of the specificbenefits experienced by Deaf eldersliving in a culturally and linguisti-cally appropriate setting (NEHD,2000). A woman reports that beforeher mother moved to NEHD, shelived in an apartment where she waslonely, isolated, and “completely cutoff from human contact.” At NEHD,the daughter relates:

“All the little things add up andthat makes a big difference. Like atdinner time she can tell the serverthat she wants her meat well-done.She can ask the cleaning lady toclean her room while she goes out fora walk. She can go to the nurse and

say, “I don’t feel well.” The staff allknow ASL and she has so manyfriends. It makes mom happy. I reallyappreciate that.”

��Although some facilities are

increasinglysensitive tocultural issues,Deaf olderpersons experi-ence manybarriers to qualitycare. Theseobstacles primarilyrelate to poorcommunicationbetween providersand clients and alack of culturallyappropriateservices. Miscom-munications cancreate problemsranging fromdissatisfactionwith care, toinappropriatetreatment, todeath.

Long termcare facilitiesserving Deafelders can beviewed along acontinuum from“culturallyunaware” to“Deaf facilities.”Facilities along thecontinuum varyfrom no culturalaccommodationsto services whichmeet the linguisticand cultural needsof residents (e.g.,hiring staff that are fluent in ASLand familiar with Deaf culture andhaving a sufficient number of Deafresidents so that residents cansocialize with one another.)

Deaf seniors and health carepersonnel may experience numer-ous benefits when facilities are ableto meet the linguistic and cultural

needs of Deaf elders. Culturalcompetency on the part of the facilitycan increase improve communicationbetween staff and older patients,increase client well-being, and allowresidents to participate fully inactivities. Health care personnel are

also more likely tobe satisfied – andmore effectivelyutilized – whenmiscommunica-tions and inappro-priate care arereduced.

Nationally,the choicesavailable toCDOP may beslowly increas-ing. For example,new programssuch as GranburyCare Center havebeen added to thelist of optionsavailable to Deafseniors. Otherfacilities reportplans for expan-sion, addingassisted livingfacilities oradditional skilledbeds (Interviews,2000; see alsowww.lavistatexas).

Whileoptions aregrowing, theystill represent avery smallnumber offacilities. Itappears that fornow, culturallyDeaf olderpersons are oftenleft with few

appropriate options. Most states, forinstance, do not appear to have anylong term care facilities specificallydesigned for Deaf residents. Somestates that are attempting to establishmore options, such as Minnesota,report problems in obtaining neededfunds (Interviews, 2000).

“All the little

things add up and

that makes a big

difference. Like at

dinner time she

can tell the server

that she wants her

meat well-done.

She can ask the

cleaning lady to

clean her room

while she goes

out for a walk.

She can go to the

nurse and say, “I

don’t feel well.”

The staff all know

ASL and she has

so many friends.

��14

GCM

fall 2000

The LTC options available toculturally Deaf older persons shouldbe expanded. The heterogeneity ofDeaf seniors suggests that a variety ofoptions is needed that includesculturally sensitivehearing facilities,specialized carefacilities, and Deaffacilities.

��

Often, forDeaf individuals,the needs that arehardest to meet arethe ones hearingpeople take forgranted – simplecommunication, asense of commu-nity, a feeling thatyou have ameasure of controlover your owndestiny. With age,these needsbecome moreacute, and theyjust aren’t ad-dressed anywhere but in a fewspecialized settings (NEHD, 2000).

Appropriate, affordable optionsappear to be needed for the wholerange of residential care, from assistedliving to skilled nursing homes. Morechoices appear to be necessary in thefollowing aspects of care: facilitylocation, specific types of services,level of care, number and type ofcaregiving staff, size of facility,number of hearing/Deaf residents, andgeneral atmosphere. Options can beexpanded by adding to existingfacilities and/or building new ones,depending upon the specific needs ofa given area. Cultural competency maybest be achieved when Deaf eldershave the same type of choices thatHearing seniors have. (continued on page 15)


Facilities at any point along thecontinuum can take steps to becomemore culturally and linguisticallycompetent in serving deaf seniors:Many facilities across the country aremaking strides in meeting the culturalneeds of long term care residents. Tobecome even more culturally compe-tent, Hearing facilities can seek moretraining and education related to Deaf

culture, communi-cation needs ofdeaf clients andcompliance withthe ADA.

Hearingnursing homesmay be reluctantto make changesbecause of costand otherresource con-cerns. Greene andMosher-Ashley(1997) point out,however, that:many appropriatestrategies andenvironmentaladaptations“could beimplemented intraditionalnursing homesand board andcare homeswithout majortraining of thestaff or major

equipment expenditure.”

Deaf facilities and specializedunits can continue to improve theirability to serve clients by reassessingthe types of services provided andworking to add new programs andservices to meet changing needs. Forall types of settings currently orpotentially serving Deaf residents,ongoing input or administration fromthe Deaf community should helpassure that these programs continueto meet cultural needs.

More research is needed toassess the needs and preferences ofculturally Deaf older people: Itappears that little research has beenconducted regarding the long termcare options for culturally Deaf elders.

Anecdotal information suggests theneed for more options – but exactlywhat options are needed, and what isthe magnitude of that need? CulturallyDeaf elders know the answer to thesequestions, but it seems they rarelyhave been asked in any formal way.

Types of questions to be consid-ered in further research could include:If hearing facilities wish to improvetheir services, what are the highestpriority areas? How does the quality-of-life of Deaf residents in deaffacilities compare to the quality of lifeof Deaf residents in hearing facilities,or hearing residents in hearingfacilities? What steps can be taken toassure a range of affordable optionsfor culturally Deaf seniors?

In addition to assisting Deafelders, research on LTC options forDeaf seniors could also assist themillions of older persons who are Deafor hard of hearing, but not culturallyDeaf. For example, improved compe-tency in understanding how tocommunicate with persons who do nothear or are hard of hearing couldimprove quality of care for all longterm care residents who are Deaf, orhard of hearing. Research findingscould also assist providers in applyingthe lessons learned from Deaf cultureto other minorities living in LTCsettings.

Laura Himes Iversen is a geron-tologist based in White Bear Lake,MN. She has been researching andwriting in the field of health care andaging for more than 15 years, and hasworked as an independent contractorwith a variety of public and privateagencies for over a decade. Shegraduated from Carleton College(Northfield, MN) in 1982 with abachelor’s degree in psychology andearned master degrees in Gerontol-ogy (MSG) and Public Administra-tion (MPA) from the University ofSouthern California in 1985. Ms.Iversen has become increasinglyinvolved with the Deaf community aspart of her gerontological work andin the course of parenting a childwho is hard of hearing. She is in hersecond year of the ASL InterpretingProgram with St. Paul TechnicalCollege in St. Paul, MN.

Deaf facilities and

specialized units

can continue to

improve their

ability to serve

clients by

reassessing the

types of services

provided and

working to add

new programs and

services to meet

changing needs.

��15

GCM

fall 2000


��Andrews, Jean and Wilson, Howard. “TheDeaf Adult in the Nursing Home.”Geriatric Nursing (November/December1991):279-283.

Baldwin, Matt. “Nation’s Only Deaf-Operated Nursing Home, ColumbusColony, Expands.” DeafNation (October1995). (See http://members.aol.com/deafnation/1-DNWEB/01-OCT95/DN-1095.colony.html)

Barnett, S. “Clinical and Cultural Issues inCaring for Deaf People.” Family Medicine(January 1999) 31(1): 17-22.

Booth, Michael. “Freedom of Speech:Long-silent Man Returns to the World ofWords, Meaning.” The Denver Post(October 24, 1999) Pages 1A, 6A.Denver, CO.

Casey, Jane. “Seeing Deafness in a NewLight.” The Canadian Nurse (February1995):53-54.

Columbus Colony Elderly Care (CCEC).Brochure. CCEC: Westerville, OH.Received February, 2000.

Columbus Colony Elderly Care. Websiteat www.columbuscolony.org. Visited 2/28/00.

Ebenezer Social Ministries. Descriptivematerials provided in folder “We’reHelping Seniors Age with Dignity.” Pageon “Ebenezer Luther Hall” ReceivedFebruary 2000.

Ebert, David and Heckerling, Paul[1995a]. “Communication with DeafPatients.” JAMA (January 18, 1995)273(3):227-229.

Ebert, David and Heckerling, Paul[1995b]. In reply to an editorial. JAMA(September 13, 1995) 274(10):795.

Gannon, Jack. “Deaf Culture: It Is Us.”Gallaudet Today (Fall 1990):15.

Gallaudet Research Institute, Center forAssessment and Demographic Studies.“Score Summary of Stanford AchievementTests, Hearing Impaired Version, 8th ed.”Washington, D.C., 1992.

Granbury Care Center. Websitewww.deafnetwork.com/granburydeaf/home.html.

Greene, Albert and Mosher-Ashley, Pearl.“A Residential Care Alternative for

Elderly Deaf Persons.” Journal ofGerontological Nursing (August1997):32-36.

Hochman, Frank. “Health Care of theDeaf – Toward a New Understanding.”Journal of the American Board of FamilyPractitioners (January-February 2000)13(1):81-83.

Iversen, Laura (2000). “Serving Deaf andHard of Hearing Elders: Practical Tips forHealth Care Providers.” Healthcare andAging (Spring 2000) 7(1):1,7.

Iversen, Laura (1999). Personal interviewsconducted with several deaf consumers inwriting an article for Healthcare andAging. Interviews were conducted in theFall of 1999. For a copy of the article thatwas published based on these interviews,see Iversen, 2000 (above).

InfoBits. “Deaf and Hard of Hearing” (Aone page laminated resource for provid-ers). InfoBits, LLC: St. Paul, MN, 2000.

Interviews, February 2000. In completingthis research I participated in on-line,TTY or telephone discussions with twodeaf advocates/consumers in Minnesota,one hearing member of the Deaf commu-nity, and three hearing staff at LTCfacilities (representatives from the NewEngland Home for the Deaf (Danvers,MA), Mercy Living Center (Pontiac, MI)and Columbus Colony (Westerville, OH)).

Jacob Perlow Hospice at Beth IsraelMedical Center. Website.www.bethisraelny.org/services/hospice/hospice.html.

King, Jess Freeman. “Interacting with theDeaf.” Nursing Homes (January/February1988):20-21.

Kulback, Steven. “Letter to the Editor.”JAMA (September 13, 1995) 274(10):795.

La Vista website www.lavistatexas.com.Visited March 10, 2000.

Lane, Harlan. “The Mask of Benevo-lence.” Published by Alfred A. Knopf, Inc:New York. First published May 26, 1992.Fourth Printing January 1994.

Lotke, M. “She Won’t Look at Me.”Annual Internist Medicine (July 1995)123(1): 54-7.

MacKinney, TG; Walters, D.; Bird, GL;and Nattinger, AB. “Improvements inPreventive Care and Communication forDeaf Patients: Results of a Novel PrimaryHealth Care Program.” Journal of GeneralInternist Medicine (March 1995)10(3):133-7. Abstract reported in “Deafand Hard of Hearing Health CareLiterature Review Summary” GallaudetUniversity (Fall 1999).

MacLeod, RP and Bently, PC. “Under-standing Deafness as a Culture with aUnique Language and Not a Disability.”Advanced Practice Nursing Quarterly(Fall 1996) 2(2):50-8.

Minnesota Board on Aging. “NursingHome, Long-term Care Options Chang-ing.” Senior Spotlight (March – April2000) 29(2):7.

Myers, LL and Thyer, BA. “Social WorkPractice with Deaf Clients: Issues inCulturally Competent Assessment.”Social Work Health Care (1997) 26(1):61-76.

New England Home for the Deaf. “NewEngland For The Deaf” videotape.Produced by Events Video Productions,Inc. Received February 2000.

Padden, C. and Humphries, T. “Deaf inAmerica: Voices From a Culture.’Cambridge, MA: Harvard UniversityPress (1988).

Ralston, E.; Zazove, P; and Gorenflow,DW. “Physicians’ Attitudes and BeliefsAbout Deaf Patients.” Journal ofAmerican Board of Family Practice (May-June 1996) 9(3):167-73.

Shelp, Scott. “Your Patient is Deaf, NowWhat?” RN (February 1997):37-40.

Warner, Dell. “Seniors: Listening to DeafSenior Citizens.” The Detroit News(September 13, 1996). See http://detnews.com/1996/menu/stories/65041.htm.

Wiger, Chuck (Senator). “Nursing HomesAre In Crisis.” White Bear Press (WhiteBear Lake, MN) March 15, 2000. Page5A.

Witte, Todd; and Kuzel, Anton. “ElderlyDeaf Patients’ Health Care Experiences.”Journal of the American Board of FamilyPractitioners (January/February 2000)13(1):17-22.

Wixtrom, Chris (1988). Deaf CultureClass, Spring 2000. Jan McCreadyJohnson, St. Paul Technical College. St.Paul, MN.

Zazove, P.; Niemann, LC; Gorenflo, DW;Carmack, C; Merh, D; Coyne, J> andAntonucci, T. “The Health Status andHealth Care Utilization of Deaf and Hard-of-Hearing Persons.” Archive of FamilyMedicine (July 1993) 2(7):745-52.

�� I would like to thank the

people who reviewed thisdocument and helped to improveit. Special thanks to Jill Jepsen forher editing and formatting work.

��16

GCM

fall 2000

2000 CONFERENCE��ORDER��

��One volume manualincludes the following sessions:

1. The Pharmacotherapy Wave: Treatment Update-Long Term Care ImpactRoger J. Cadieux, MD, Hummelstown, PA

2. A Profile of Privately Insured Institutional ClaimantsJocelyn Gordon, Esq., BA, MS, Waltham, MA

3. An Introduction to the Web: How to Use the Power of the InternetJae E. Lawrence, BS, RN, LMT, CSA, CMC, Orlando, FL

4. Personality Disorders: Who is That Character in My Office Anyway?Roger J. Cadieux, MD, Hummelstown, PA

5. Life Before Death: Legal Issues Faced by the ElderlyMichael W. Connors, Esq., West Palm Beach, FL

6. High Tech & High Touch Approaches: Meeting at the AltarChristopher Gatti, Esq., MBA, Bala Cynwyd, PA, Peter Sterman, Ph.D.,Laguna Beach, CA, Nimish Parikh, Westboro, MA

7. Personal Digital Assistants (PDAs) and Mobile Internet Devices (3GPhones) - New Tools for the Wireless Internet EnvironmentNorman J. Hannay, BS, MPS, CMC, La Jolla, CA

8. Who is the Difficult Client?Grace H. Lebow, LCSW-C, Bethesda, MD, Barbara Kane, MSW, LCSW-C,MPH, Bethesda, MD

9. Confidentiality and Care Management: Who is My Client?Mary Kaplan, BS, MSW, Tampa, FL

10. How a Work/Life Benefit Company has Expanded to Become a “.com”Ellen E. Blizinsky, Portland, OR

11. Using the Internet to Find Relevant Resources Quickly, Convenientlyand FreeNeil Solomon, MD, San Francisco, CA

12. Intervention Strategy I: Working with Grown ChildrenGrace H. Lebow, LCSW-C, Bethesda, MD, Barbara Kane, MSW, LCSW-C,MPH, Bethesda, MD

13. Medicaid Estate Planning and CareManagement: Getting the Client the BestCare Possible While Preserving FamilySavingsScott M. Solkoff, Esq., Boynton Beach, FL

14. Building a Strong Foundation for YourElder Care BusinessCarol McIntyre, MSW, LCSW, RG, CMC,St. Charles, IL, Marsha R. Foley, RN, MBA,Riverwoods, IL, Debbie Reinberg, MA,Denver, CO

15. Care Managers and .coms - How a CareManager Can Use the .com to HelpMarket Their BusinessStacey Matzkevich, MSW, MSG, LCSW,Emeryville, CA

16. Intervention Strategy II: Phone LiaisonWork with Out-of-Town Grown ChildrenGrace H. Lebow, LCSW-C, Bethesda, MD,Barbara Kane, MSW, LCSW-C, MPH,Bethesda, MD, Carmen Morano, Ph.D.,Cooper City FL

17. Moral Decision Making: EthicalDilemmas of Geriatric Care ManagersStephen Sapp, Ph.D., Coral Gables, FL

18. Capturing Long-Term Care Insurance Dollars: National Accreditation ofYour Care Management/Home Care AgencyPhyllis Mensh Brostoff, BA, MSW, CISW, ACSW, Milwaukee, WI

19. Look It Up On The Internet - The New Internet Savvy Consumer ofMedical and Caregiving InformationKaren Stevenson-Brown, CPA, CMA, Normal, IL

20. Intervention Strategy III: Reaching the Caregivers and Other SupportPeopleGrace H. Lebow, LCSW-C, Bethesda, MD, Barbara Kane, MSW, LCSW-C,MPH, Bethesda, MD

21. Panel: End of Life Issues - Three PerspectivesMelinda Fitting, Ph.D., Moderator, Towson, MD, Stephen Sapp, Ph.D., CoralGables, FL, Mary Kaplan, MSW, Tampa, FL, Scott Solkoff, Esq., Boynton,Beach, FL

22. Panel of Geriatric Care Manager PartnersMichael W. Connors, Esq., West Palm Beach, FL, Karen Stevenson-Brown,CPA, CMA, Normal, IL, Joelyn Malone, MA, Minneapolis, MN, StephenFeldman, R.Ph., FASCP, Boston, MA

23. Technology Resources That Minimize Caregiver BurdenAnne Long Morris, BS, MPA, EdD, OTR, FAOTA, Springfield, VA

24. Success Stories with Difficult ClientsGrace H. Lebow, LCSW-C, Bethesda, MD, Barbara Kane, MSW, LCSW-C,MPH, Bethesda, MD, Arlene Saks-Martin, BS, MSW, LCSW-C, CCM, BCD,Baltimore, MD, Erica Karp, MSW, LCSW, CCM, Evanston, IL, Joan M.Richardson, RN, MSN, Reston, VA, Debra G. Levy, MSW, LCSW-C, LICSW,Silver Spring, MD

25. Making Medicare Work for Your ClientsDiane Archer, Esq., New York, NY, Susan C. Reinhard, Ph.D., Washington, DC

26. Sailing Into Retirement “Sink or Swim!”Laura J. Feldman, BGS, Washington, DC

�� Name ________________________________________________________________________________________

Company/Agency Name ________________________________________________________________________

Address ______________________________________________________________________________________

City _________________________________________ State ___________________ Zip ____________________

Phone ________________________________________ Fax ___________________________________________

� Check Enclosed � Please bill my Mastercard/VISA (check one)

Account # _________________________________________________________

Exp. ____________________ Signature _______________________________

� 2000 GCM Conference Manual @ $120.00 per manual ________________

Subtotal ________________

GCM Members less 25% ________________

TOTAL ________________

National Association of Professional Geriatric Care Managers

GCM1604 N. Country Club RoadTucson, AZ 85716-3102520/881-8008fax 520/325-7925www.caremanager.org

��17

GCM

fall 2000

�� This qualitative dissertation used

human ecology theory, continuitytheory and loss theory to look at thedomains of loss experienced bySoutheast Asian elders who haveresettled in Minneapolis/St. Paul, MN.Forty extensive life history narratives(five men and five women in each offour cultural groups: Cambodian,Hmong, Laotian and Vietnamese) wereanalyzed for lossdomains using lifehistory methods.Four domains wereidentified:

● loss of a way oflife,

● loss of keyrelationships,

● role loss, and

● fears about theloss of culturalheritage andcultural transmis-sion to youngergenerations.

An ecological spiral model wasproposed as one way to understandhow Southeast Asian elders experi-ence family life. This overview of thedissertation ends with the implicationsof this study for family life educatorsand other community workers tryingto assist Southeast Asian elders.

��

The purpose of this study was tolook at the domains of loss articulatedin the life history narratives of these

Loss in the Lives ofSoutheast Asian Elders

by Marcie Parker, Ph.D., CFLE

forty Southeast Asian elders. Therewere some limitations to the study.For example, the data results werenot personally collected by the authorbut were collected by two nativespeakers of each group then trans-lated into English and recorded inEthnograph. Also, no specificquestions about loss were asked inthe course of the interviews. Theremay be a perceived lack of

generalizability of these data.

On the other hand, the study has anumber of strengths. It is a qualita-tive analysis using a very large sampleof forty extensive life history narra-tives across four cultures and twogenders. Life histories are excellentfor studying change over time and theemic or insider’s view of the culture.This study also looks at familiescross-culturally, and attempts tobroaden the definition of the family forthe family field. It offers a critical re-examination of family life educationand how family life educators and

others in the community can betterassist these Southeast Asian elders.

��Loss is not an easy term to define.

In fact, it is often used by researcherswithout being first defined. Loss isnot experienced in the same way bypeople across different cultures andgenders (Rosenblatt, l993). In thisstudy, a loss story is an elder’sdescription, in response to theinterviewer’s question, of a particularkind of loss experience such as adeprivation [for example, loss of arural agrarian way of life or a deathsuch as the death of a child orspouse].

��In the course of this study, it

became clear that Southeast Asianshold complex communitarian values.This involves a strong sense ofinterdependence, a holistic view of thefamily, a collective and communitarian

outlook, andindividuals whoare nestled in thecontext of theextended family,where autonomyand independenceare not consid-ered as virtues tobe cultivated.This contrastswith westernvalues: indepen-dence and theindividualisticnature of eachperson, where

individuals seek to master life’s tasksand accomplish self-defined goals.

�� Human ecology theory (Bubolz

and Sontag, 1992) focuses on humanbeings as both biological organismsand social beings in interaction withtheir environment. It uses a nestedconcept, where the individual/familyhousehold, extended family, clan(among the Hmong), and community/village are the meaningful units. Inaddition to human ecology theory,


These Southeast Asian elders have many

concerns about the future. These are

expressed in terms of questions, such as,

“Who will take care of me and where will I be

buried?” They are also concerned about

their status in the family, sometimes feeling

useless and disrespected.

��18

GCM

fall 2000

this dissertation uses continuitytheory (Atcheley, 1989) as well as theMitchell and Anderson typology ofloss (1983).

��

Southeast Asian refugees haveresettled all over the world, includingAustralia, New Zealand, France andother parts of Europe, Thailand, andmany other areas. Over 1,100,000Southeast Asian refugees have cometo the United States since 1975. Largeconcentrations are found in California,Colorado, Minnesota and Wisconsinas well as along the East Coast. InMinnesota, there are about 60,000 to80,000 Hmong, 10,000 Vietnamese,6,500 Laotians, and 3,200 Cambodianswho have resettled. Southeast Asianelders in Minnesota tend to havemany needs, to be in poor health, tobe widowed, to live below the povertyline, and to have a number of func-tional difficulties with the activities ofdaily living as well as the instrumentalactivities of daily living.

These Southeast Asian eldershave many concerns about the future.These are expressed in terms ofquestions, such as, “Who will takecare of me and where will I be buried?”They are also concerned about theirstatus in the family, sometimes feelinguseless and disrespected. They alsoworry about their status in thecommunity, feeling they can’t get outand circulate freely and they no longerhead up important rituals or ceremo-nies. Some Southeast Asian eldersalso describe strong feelings ofhomesickness and a desire to return totheir homeland. These elders are alsoexperiencing intergenerational conflictin the family and complain that theirgrandchildren are not learning theirlanguage, that grandchildren do notrespect their elders, and they do notrespond to traditional forms of familydiscipline.

These Southeast Asian (SEA)elders also experience a number of

significant barriers to resettlement inthe United States. These includelanguage obstacles, economicdifficulties, separation from ancestralgraves, intense isolation,intergenerational conflict, and avariety of physical and mental healthproblems. In fact, many SEA eldersexperience depression, anxiety, severesleep disturbance and sleeplessness,loneliness, isolation, suicidal ideation,and posttraumatic stress as well as avariety of somatic symptoms.

On the other hand, SEA eldersbring a number of real strengths to theresettlement process. These includedevotion to family and community, alove of hard work, a reverence foreducation, very strong self-helpgroups designed to meet their needs,successful community role models,resilience, drive, flexibility, andadaptability.

�� Findings in this dissertation

described 99 instances of “loss of away of life” in the 40 narratives, eventhough these elders were never askeddirectly about loss in the course of theinterviews. The loss of a way of liferepresented such things as the loss ofthe whole physical context that madelife familiar and comfortable andincluded loss of homeland anddevastation due to warfare.

There were 128 instances of “lossof key relationships” where missingand dead children, spouses or otherrelatives were described. Alsoincluded in this category wereinstances of separation and lonelinessfrom family members who are geo-graphically dispersed [across thecountry or around the world] andrelatively inaccessible.

There were 84 instances of “roleloss”, such as loss of filial piety andintergenerational respect, loss ofstatus and respect, loss of pride andself-esteem, and loss of personalautonomy, often the ability to moveabout freely and to express oneselffreely in English.

There were 48 instances of the“fear of the loss of one’s culturalheritage”. This was represented byfears about not transmitting cultural

values and heritage to youngergenerations as well as difficulties inlearning the English language.

Sometimes, it can be difficult toknow where one kind of loss stopsand another one begins because theyaffect each other. It was not unusualto see these multiple losses across alllevels of the elder’s family, human-built environment, social-culturalenvironment and natural-physical-biological environment.

�� “It seems like I was a very happy,

healthy tree with a lot of fruits andsomebody else took away the fruitsfrom me.” (Mrs. TM, a 66 year oldCambodian woman)

The story of Mrs. TM gives aparticularly poignant example of theloss of key relationships. Herhusband died in 1971 from heartdisease. They had eight childrentogether, two of whom died when theywere babies. This left Mrs. TM withfour boys and two girls to raise. Fiveof these six children died in Cambodiaduring the war, from starvation or lackof medical care. As she relates,“….Those children I left behind aredead…The Khmer Rouge used mychildren for labor and then they killedthem.”

In addition to the deaths of herhusband and children, she has fourbrothers who starved to death underPol Pot and another three brothers andone sister who died of illness underthat regime. Her youngest sister stilllives in Cambodia. She has difficultysleeping at night and sleeps only afew hours because she worries aboutother family members from whom sheis separated.

She expresses the importance ofher only remaining living child to hersense of purpose in life and herinsecurities about the future. “I wantto stay alive because I want to see myson finish school and get a good job,so I can live with him. My son cantake care of me. I don’t have todepend on strangers anymore. Fornow, I know my son is going to takegood care of me, but in the futurewhen he has his own family he might



��19

GCM

fall 2000

change.” The importance of familyand staying together through life’sdifficulties was clearly expressed as afocal point for family identity in herlife history narrative. When her soncomes home to visit from college, shesays, “….I can’t sleep. I just sit therewatching his face while he is asleep.When I see his face, I think about myother deceased children. I keep myselfalive because he is my son. I don’twant him to be alone. We’ve beenthrough a lot of hardship together.You’re happy here [in the UnitedStates] only if you have family withyou.”

Mrs. TM says of her deadchildren, “….the fact that my childrendied was so unfair that I can’t acceptit. It seems to me like I was a veryhappy, healthy tree with a lot of fruitsand somebody else took away thefruits from me. I never thought thewar would make my life like this. Mychildren were still very young to die.”Of her life, she says, “I don’t talk to alot of people because the more I talkthe more I remember and I just want toforget about it.”

The difficulty of leaving Cambo-dia also has had an effect on her life.She knew that once she arrived inMalaysia enroute to resettlement inthe United States, she would never beable to return to Cambodia. She says,“I knew I was coming to America. Iwas worried because I did not speakEnglish and I was old with my sonwho was very young. I only knewFrench a little, so whatever it wasgoing to be I would try to speak asmuch as I could. I felt sorry for myson. We were very lonely with norelatives. I was afraid that if some-thing was wrong with me and I died,my son’s life would have no future.”She says she was impressed by themodernization she saw in the UnitedStates but she was not happy herebecause she missed her children somuch. Every time she went to agrocery store or a department storeshe cried. Those who have theirfamilies around them are happy shebelieves; she feels that whatever (continued on page 20)


problems they have, they are stillhappy because they are here togetherwith their families.

Despite these longings, she isalso disappointed with some of theyoung Cambodians. They don’t go towork and instead gamble and getdrunk. She believes that since elderlyCambodians cannot work here in theUnited States, it is fair for them to liveon welfare or social security. Butthose who are young and able to workshould do so. She says, “I completelydepend on the help from the govern-ment. I’m old and I can’t do anything.Emotionally I’m not as happy as whenI was living in Cambodia. I just hopethat I can go back to Cambodia.”

Mrs. TM is also concerned thatyoung Cambodians living in theUnited States forget their culture. Shesays, “I keep reminding them not toforget our culture. They can adapt tothe culture here, but they should knowwhat is good and what is bad. Theyshould not forget about our clothes orcharacteristics. These are ouridentifications. When I am persistentin reminding them they sometimeslisten to me, so it is worthwhile…..Iwant them to remember our cultureand religion. I always encourage theparents to bring their children to thetemple so that they can learn aboutour religion, culture, and traditions.Let them learn about each celebrationand festival we have every year. Iwant them to learn the manners in thetemple.”

It is clear that this woman, almostalone in the world except for one sonafter her family was killed, hasexperienced loss in many areas of herlife. We can see in her life historynarrative not only the loss of manykey relationships, but also her keenfeelings of loss for her homeland andway of life. She also tells us of herloss of role in the family and commu-nity due to the death of many familymembers.

��

This study offers some possibletheoretical enhancements to the familyfield. It proposes the ecological spiral

model as one way to understand themeaning of family life for SoutheastAsians.

The study sheds light on diverse,complex, ethnic family systems andproposes that for these SoutheastAsian families there is no real divisionbetween individual and family. Itlooks at non-normative loss inethnically diverse families. It demon-strates the relationship betweenhuman ecology theory, continuitytheory and the Mitchell and Andersontypology of loss. It applies continuitytheory cross-culturally to look atcontinuity and discontinuity inethnically diverse families. Finally, itexpands the Mitchell and Andersontypology of loss by adding “fearsabout the loss of cultural transmis-sion” to their scheme.

A Critical Re-examination ofFamily Life Education: What CanOthers do to Help Southeast AsianElders Currently Living in the Commu-nity?

This final section looks at familylife education and what, if anything,others in the community have to offerSoutheast Asian elders in the UnitedStates.

According to Tennant (1989),“...family life education is intended toenable adults to increase the effective-ness of their skills in daily living. Thisincludes relating to each other, copingwith life events and realizing personalpotential.” Note that, with its empha-sis on “realizing one’s personalpotential,” this definition may haveless applicability for Southeast Asianswho generally subscribe to a morecommunitarian and less individualisticfamily model.

The family field is relatively fluidand undefined, still based on westernwhite middle class models and values.There is also a tendency for family lifeeducators to want to maintain culturesas “frozen in time” and not to see themas dynamic, changing and adaptingsystems. In addition, family lifeeducation implies a didactic relation-ship, but the need is actually for amore mutually collaborative modelwhen working with Southeast Asianelders.

��20

GCM

fall 2000


One of the critical issues facedby family life educators and othersworking in the community today iseffectively meeting the needs of bothlater-life families and ethnic families.Family life educators and others maywant to consider spending timegetting to know the Southeast Asianelders. The goal is to find out whatthey want and to develop both formaland informal strengths and needsassessments. It is probably notreasonable for family life educators orother community workers to imaginethat they have an objective idea ofwhat these elders want in terms ofservices and support.

There were five cultures involvedin this study (American-the author’sown- plus four Southeast Asiancultures). Therefore these losses areviewed through a variety of complexlenses. There has been an overall lackof research in family life education onintergenerational differences anddiverse genders, ages, cultures andsocial classes. Family life educatorsand others working in the communitymust develop materials to target theneeds of diverse cultural, racial, andethnic groups. They need to acknowl-edge new family forms, work topreserve the continuity of cultures inthe process of transition and collabo-rate with elders and families to resolveintergenerational conflict as well asother family issues.

Possible Areas of Contributionfor Family Life Educators and OtherCommunity Workers:

Some possible areas of contribu-tion for family life educators andothers, following strengths and needsassessments with Southeast Asianelders and their families in thecommunity, might include:

● Empower elders and encourageagency/decisionmaking.

● Encourage elders to participate inlocal school programs [dress,foods, music, language, crafts——also elders could serve asvolunteer helpers in the class-rooms, especially where there are

young children of their ownparticular cultural group].

● Support Buddhist rituals andceremonies from other religiousaffiliations that are important toSEA elders.

● Support elders who clean andmaintain temples.

● Assist in celebrating ancestors’birthdays.

● Teach SEA youngsters Englishand encourage them to learn, atthe same time, their nativelanguages.

● Encourage ethnic music, danceand games.

● Bolster mutual assistance/mutualaid groups [members of thesegroups help each other withchildcare, transportation, educa-tional and business goals, loans,etc.].

● Work closely to support South-east Asian clergy who are servingSoutheast Asian elders.

● Encourage intergenerationalsewing, knitting and cookinggroups [where older womensocialize and share stories withyounger women].

● Encourage fishing expeditionsand scouting troops for SEAelders and young men.

● Help preserve and write downfamily stories for posterity [this issomething that is very highlyvalued by SEA elders].

● Encourage family/communitygardens and other group activi-ties.

● Assist with English as a secondlanguage (ESL) classes.

● Provide transportation andoutings for isolated elders.

● Help families locate large ceremo-nial spaces for huge communitycelebrations and rituals such asweddings, funerals and NewYear’s celebrations.

● Discuss parenting issues withelders and families so theyunderstand how values and lawsin the United States differ fromtheir own.

● Help develop seniors’ clubs andcongregate meal sites whereSoutheast Asian elders can meetand eat with those of theirlanguage/ethnic group.

��This study looks cross culturally

at non-normative loss in ethnicallydiverse families. It helps to broadenthe definition of family in the familyfield. It examines dramatic changes tothe roles of Southeast Asian men andwomen in the course of major changesto a way of life, key relationships,roles and cultural transmission. It alsoshows the key importance of elders assages, moral leaders and preservers ofculture, family stories and familyhistory. It offers some practicalsuggestions for ways that communityworkers can more effectively meet theneeds Southeast Asian elders in thecommunity.

��Atchley, R. (1989). “A ContinuityTheory of Normal Aging. The Gerontolo-gist, 29, 183-190.

Bubolz, M. M. and Sontag, M. S. (1992).“Human Ecology Theory.” In Boss, P.G., Doherty, W. J., LaRossa, R., Schumm,W. R. and Steinmetz, S. K. (Eds.)Sourcebook of family theories andmethods: a contextual approach. (pp.419-448). New York: Plenum.

Mitchell, K. R. and Anderson, H. (1983).All Our Losses, All Our Griefs. Philadel-phia: The Westminster Press.

Parker, M. K. (1996). “Loss In the Livesof Southeast Asian Elders.” DissertationAbstracts International, 57(6), (apublication of UMI Company).

Rosenblatt, P. “Cross-Cultural Variationin the Experience, Expression andUnderstanding of Grief.” In Frisk, D. P.,Lundquist, D. F., and Nelson, V. S. (Eds.)Ethnic Variations in Dying, Death andGrief: Diversity in Universality. NewYork: Taylor and Francis.

Tennant, J. (1989). “Family LifeEducation: Identity, Objectives andFuture Directions. McGill Journal ofEducation 24: 127-142.

Marcie Parker, Ph.D., CFLE, isSenior Qualitative Researcher withOptum®, a health information,prevention, wellness and self-carefirm in Golden Valley, MN.

��21

GCM

fall 2000

Alzheimer’s disease is a seriouschronic health issue for health careprofessionals today, but tools areavailable to assist clinicians, patients,and caregivers with the diagnosis andmanagement of the disease.

TriAD™ was introduced by EisaiInc. and Pfizer Inc in 1997 in collabora-tion with the Alzheimer’s Associationand The National Council on theAging (NCOA), and with input froman independent medical advisoryboard of Alzheimer's disease experts(Figure 1). It is an innovative andcomprehensive disease managementprogram designed to help address theconcerns of people with Alzheimer’sdisease and their caregivers, whilegiving them much needed informationabout the disease. This article willprovide an overview of the program,including access and enrollmentdetails.

��

Alzheimer’s disease (AD) is aprogressive, degenerative disease thatattacks the brain and results inimpaired memory, thinking, andbehavior. The causes of AD are notknown at this time, although sus-

Alzheimer’s Disease:Help Is Available

Through TriADTM, anInnovative and

ComprehensiveDisease Management

Programby Gayle K. Sobel, CDMS/R, CCM

pected causesinclude geneticpredisposition,abnormal proteinbuild-up in the brain,and environmentaltoxins. (Alzheimer’sDisease Facts, 2000)

AD is the mostcommon form ofdementia in theUnited States.(Costa et al, 1996)Currently, approxi-mately four millionAmericans haveAD; one in 10people over the ageof 65 years andnearly half of thoseover the age of 85years have thedisease.(Alzheimer’sDisease Statistics, 2000)

According to the US CensusBureau, the number of Americansaged 65 years and older is 34.1 million,comprising 12.7 percent of thepopulation. By 2030, that number isprojected to increase to 69.4 million,with 20 percent of the population at

age 65 years or older. (Delmar, 1999)

It is anticipated that the preva-lence of AD will increase based on thedemographics of the population of theUnited States. An estimated 14 millionAmericans are expected to have ADby the middle of the century.(Alzheimer’s Disease Statistics, 2000)

�� TM

Since its introduction, TriAD™has been available, free of charge, topeople diagnosed with AD, theircaregivers, and health care profession-als. Currently, approximately 16,000patients/caregivers and 16,000 healthcare professionals are enrolled in theprogram. For health care profession-als, enrollment in TriAD™ can beaccomplished by completing abusiness-reply card available from anEisai or Pfizer representative, or bycalling the toll-free TriAD™ Helpline,1-888-TriADHELP (1-888-874-2343).Patients and caregivers may enroll

through theirhealth careprofessional orthrough the toll-free TriAD™Helpline.

The purposeof TriAD™ is tosupport healthcare profession-als, patients, andcaregivers. Thefocus is to ensurethe best use ofhealth careprofessional andstaff time byproviding peoplewith AD and theircaregivers withmaterials aboutAD. Educationalbrochures andself-learning toolsgive clear

explanations about AD and directionto assistance such as communityresources. Ways to encourage patientcompliance with prescribed treatmentregimens also are provided. Thesematerials help people with AD andtheir caregivers to recognize mile-


According to the

US Census

Bureau, the

number of

Americans aged

65 years and older

is 34.1 million,

comprising 12.7

percent of the

population.

��22

GCM

fall 2000

stones in the progression of AD andcommunicate this information to theirhealth care professionals. TriAD™aims to improve the quality of life forits program participants.

TriAD™ is routinely reevaluatedand new components are developedin response to needs expressed byprogram participants.

�� TM��

Because AD is not always wellunderstood, management of thedisease requires clear communicationamong the health care professional,patient, and caregiver. Therefore,family members or other caregiversask the health care professional forexplanations, support, and resourcesto help them cope with the day-to-day stress of dealing with the personwith AD.

Among the TriAD™ materialsavailable for health care professionalsis the Clinician Toolbox, a bindercontaining practical tools for screen-ing, diagnosing, and assessingpatients with AD. Included in theClinician Toolbox are:

● Clinician Guide. A conciseguide that provides an overviewof the TriAD™ program, includ-ing a description of the compo-nents and instructions on how toenroll patients and caregivers, aswell as clinician information onAD compiled by the TriAD™medical advisory board.

● Differential Diagnosis of ADAlgorithm. A quick-referencetool to assist in the diagnosis ofAD.

● Clock Drawing Task. A pad ofsheets on which patients canperform this clock drawingexercise. Instructions forevaluating and scoring thepatient’s clock drawing areincluded. The ability to draw a

clock has been shown to beuseful in helping to differentiatenormal elderly people fromindividuals with cognitiveimpairment, particularly AD.(Mendez, 1992)

● Functional Activities Question-naire. A pad of questionnaireswith instructions for use toassess patients’ functionalimpairment in more complexactivities of daily living.

● Mini-Mental State Examination.A pad of scoring sheets withinstructions for use, along with alaminated card offering guidelinesfor administering this brief mentalstatus examination, considered akey assessment tool according toAgency for Health Care Policyand Research guidelines. (Costa,1996)

● Physical Self-Maintenance Scale.A pad of scoring sheets withinstructions for use. A laminatedcard describes the scale, which isused to assess a person’sperformance of basic activities ofdaily living.

Other TriAD™ materials available forhealth care professionals include:

● Communicating the Impact ofAlzheimer’s Disease to Patientsand Caregivers. A 15-minutecontinuing medical educationvideotape and accompanyingmonograph, sponsored andaccredited by The Johns HopkinsUniversity School of Medicine.The program offers health careprofessionals suggestions onhow to inform patients andcaregivers of the AD diagnosisand provide them with informa-tion on treatment options, long-term planning, and communityresources available to them.

● TriAD™ Today. A quarterlyprogram update on the number ofparticipants enrolled, withfeedback from health careprofessionals, patients, andcaregivers.

● Toll-free TriAD™ Helpline. Thisservice provides medical informa-tion about AD and community


�� !��"�� (continued from page 21)

resources, NCOA referral to legaland financial services, TriAD™enrollment information, andsupplies of TriAD™ components.

AD assessment tools will soon beavailable on computer disk so thathealth care professionals may printadditional copies of assessment formsand calculate and store the scores

#�� $

�� !�%��!��"��&�'��!

Renato D. Alarcón, MD, MPHPresident and Vice-ChairmanDepartment of Psychiatry andBehavioral SciencesEmory University School ofMedicine ChiefMental Health Service LineAtlanta VA Medical CenterAtlanta, GA

Robert P. Carroll, Jr., MDPhysician in private practiceNacogdoches, TX

Jeffrey L. Cummings, MDAugustus S. Rose Professor ofNeurologyProfessor of Psychiatry andBiobehavioral SciencesUCLA School of MedicineLos Angeles, CA

Steven T. DeKosky, MDProfessor of Psychiatry andNeurologyUniversity of Pittsburgh School ofMedicinePittsburgh, PA

John C. Morris, MDFriedman ProfessorDepartment of NeurologyWashington University School ofMedicineSt. Louis, MO

Pierre N. Tariot, MDProfessor of Psychiatry, Medicine,and NeurologyUniversity of Rochester MedicalSchoolDirector, Department of Psychiatryand Program in NeurobehavioralTherapeuticsMonroe Community HospitalRochester, NY

��23

GCM

fall 2000


�� !��(continued from page 22)

electronically.

�� TM�"��#��

TriAD™ program componentsavailable to patients and caregiversinclude the following:

● Patient/Caregiver Enrollment Kit.Contains an enrollment business-reply card and three educationalbrochures about AD and theTriAD™ program:

- Learning About Alzheimer’sDisease.

- Living With Alzheimer’s Disease.

- Support for Those Affected byAlzheimer’s Disease.

● Alzheimer’s Disease: OneQuestion at a Time…One Day ata Time… video. An educationalvideotape that introducesTriAD™, explains AD, diseasemilestones, and how to completethe Abbreviated Physical Self-Maintenance Scale.

● Alzheimer’s Disease: OneQuestion at a Time…One Day ata Time… booklet. A questionand answer booklet containingclear, simple answers to fre-

quently asked questions aboutAD.

● Abbreviated Physical Self-Maintenance Scale. A simplifiedversion of the health careprofessional Physical Self-Maintenance Scale, designed tobe completed at home by theperson with AD (if appropriate) orthe caregiver. The form should bebrought to the health careprofessional’s office at each visit.

● ADaptations for Living™. Anongoing series of newslettersproviding information to ease thecaregiving burden; includes bookreviews and suggestions forappropriate activities for peoplewith AD and their caregivers.

● Managing Alzheimer’s Disease:A Caregiver’s Resource Guide toCommunity Programs andServices. A booklet containingstate-by-state listings of AreaAgencies on Aging, othergovernment offices, adult daycare and respite services, and

service provides informationabout AD and communityresources, NCOA referral to legaland financial services, andTriAD™ enrollment information.

● Registration brochure for theAlzheimer’s Association’s SafeReturn program. Safe Returnoffers assistance if a person withAD should wander from homeand become lost. This program,sponsored by the Alzheimer’sAssociation, provides identifica-tion products and enters identify-ing information on people withAD into a central registry for afee. Upon request, information ona missing registrant is immediatelyfaxed to the local law enforcementdepartment, speeding up search-and-rescue efforts. If the personwith AD is found wandering, acitizen or law enforcement officialcan call the telephone number onthe person’s identificationbracelet or necklace, enabling theperson to be reunited with his/herfamily.

Many TriAD™ program materialsare also available in Spanish.

�� TM�"�� Eisai Inc. and Pfizer Inc. are

working with managed care organiza-tions to expand the reach of thisdisease management program to theirproviders and members. IncorporatingTriAD™ into managed care organiza-tions can help:

● increase awareness of AD

● integrate AD into the forefront ofdisease management in Medicaremanaged care

● place TriAD™ into cohesivesystems of care including care/case management and compliancemanagement

● evaluate the impact of TriAD™ onoutcomes in managed care

�� TM��

At this time, approximately 70percent of people diagnosed with ADare living at home, and they or their

Programs that provide education,

counseling, and support to caregivers

can substantially increase the time that

caregivers are able to care for people

with AD at home, particularly during the

early and middle stages of the disease.

both nonprofit and for-profitorganizations that serve peoplewith AD and their caregivers.

● Prescription Treatment forAlzheimer’s Disease: What toExpect From a CholinesteraseInhibitor. A brochure thatanswers caregiver questionsabout the effects of cholinest-erase inhibitors and explains whatcan be expected from treatment.

● Toll-free TriAD™ Helpline. This

��24

GCM

fall 2000

�� !��(continued from page 23)

families are paying an average of$12,500 per year in out-of-pocketexpenses for care. According to onestudy, the average annual cost fornursing home care of a person withAD can range from $42,000 to over$70,000. (Alzheimer’s DiseaseStatistics, 2000) One cross-sectionalstudy showed that delaying nursinghome placement for one year couldlead to a savings of more than $24,000per person with AD. (Leon et al, 1998)

Programs that provide education,counseling, and support to caregiverscan substantially increase the timethat caregivers are able to care forpeople with AD at home, particularlyduring the early and middle stages ofthe disease. (Mittelman et al, 1996)

TriAD™ provides support andeducation about AD to the threegroups of people that its namerepresents: the health care profes-sional, the person with AD, and thecaregiver.

"��#��#�� !��$�� TM��$��$��Toll-free TriAD™ Helpline,1-888-TriADHELP(1-888-874-2343)

Alzheimer’s Association (national office)919 North Michigan Avenue,Suite 1100Chicago, IL 60611-16761-800-272-3900website: www.alz.org

The National Council on the Aging(national office)409 Third Street, SWWashington, DC 200241-202-479-1200website: www.ncoa.org

�$%��&��Figures used in the Clock

Drawing Task are adapted with

permission from Nolan KA, Mohs RC.Screening for dementia in familypractice. In: Richter RW, Blass JP, eds.Alzheimer’s Disease: A Guide toPractical Management. Part II. St.Louis, Mo: Mosby-Year Book, Inc.;1994:81-95. © 1999 WB SaundersCompany. The Functional ActivitiesQuestionnaire is adapted withpermission of the GerontologicalSociety of America, from Pfeffer RI,Kurosaki TT, Harrah CH Jr, ChanceJM, Filos S. Measurement of func-tional activities in older adults in thecommunity.J Gerontol. 1982;37:323-329; permission conveyed throughCopyright Clearance Center, Inc.Permission to use the Mini-MentalState Examination has been granted:*1975, 1998 Mini Mental LLC. Used bypermission. The Physical Self-Maintenance Scale has been adaptedwith permission of the GerontologicalSociety of America, from Lawton MP,Brody EM. Assessment of olderpeople: self-maintaining and instru-mental activities of daily living.Gerontologist. 1969;9:179-186;permission conveyed throughCopyright Clearance Center, Inc.

Gayle K. Sobel, CDMS/R, CCM,is clinical managing editor atInnovative Medical Education.Formerly, she was a medical casemanager for a private case manage-ment company. She obtained herCertified Disability ManagementSpecialist certification (now retired)and Certified Case Managementcertification duringher 16-yeartenure as amedical casemanager. Ms.Sobel has alsoworked as a geriatricsocial worker at a long-term care facility.

'#��$�Alzheimer’s Disease Facts. Alzheimer’sAssociation, Chicago, Ill: 2000.

Alzheimer’s Disease Statistics.Alzheimer’s Association, Chicago, Ill:2000.

Costa PT Jr, Williams TF, Somerfield M,et al. Early Identification of Alzheimer’sDisease and Related Dementias. ClinicalPractice Guideline, Quick Reference Guidefor Clinicians, No. 19. Rockville, Md: USDepartment of Health and HumanServices, Public Health Service, Agencyfor Health Care Policy and Research.AHCPR Publication No. 97-0703.November 1996.

Costa PT Jr, Williams TF, Somerfield M,et al. Recognition and Initial Assessment ofAlzheimer’s Disease and RelatedDementias. Clinical Practice Guideline,No. 19. Rockville, Md: US Department ofHealth and Human Services, Public HealthService, Agency for Health Care Policyand Research. AHCPR Publication No.97-0702. November 1996.

Delmar D. Accommodating elderlypatients. Physicians Financial News.1999;17:S10-S15.

Leon J, Cheng C-K, Neumann PJ.“Alzheimer’s Disease Care: Costs andPotential Savings.” Health Aff.1998;17:206-216.

Mendez MF. “Development of ScoringCriteria for the Clock Drawing Task inAlzheimer’s Disease.” J Am Geriatr Soc.1992;40:1095-1099.

Mittelman MS, Ferris SH, Shulman E,Steinberg G, Levin B. “A FamilyIntervention to Delay Nursing HomePlacement of Patients with Alzheimer’sDisease.” JAMA. 1996;276:1725-1731.

��25

GCM

fall 2000

Oral health is an essential part oftotal health. The impacts of oralinfections on the management andresolution of the constellations ofother medical diagnoses are justrecently being considered.

The mouth is a part of the bodysystems, more specifically, thedigestive system. As a connectedpart of the total body, what goes onhere is as important as what occurs inany other parts of the body. Approxi-mately 65percent oftoday’s geriatricpopulation havesome or all oftheir naturalteeth, and thusrequire basicpreventive androutine dentalservices. Thehomebound orinstitutionalizedelderly areunable to obtainproper dentalcare in aconventional dental office. As ourpopulation ages, the need for deliveryof services for the elderly in non-traditional settings will increase.

Insurance coverage for thisessential portion of the body isminimal and capricious, especially forpersons with special needs and over21 years of age. This populationincludes our most vulnerable adults—elders, developmentally disabled,pregnant women, cancer patients,

Oral HealthConsideration forGeriatric Clients

by Judith C. Corbin, RDH, BSDH, FADPD

persons with disabilities from acci-dent, or disease. In most cases, healthinsurance may replace a lost limb butwill not close an opening in the roof ofthe mouth so that the person could eatand speak.

The inconvenience and disparityof insurance program non-coverageand other invisible chains that inhibitservices to this population rationaccess to oral health care.

The Surgeon General’s report on

inadequately maintained oral health.Chronic infections have recently beenshown as contributing factors inrelation to an increased incidence ofheart attacks, acute brain abcesses,rejection of implanted prosthesis,unexplained fever, decreased nutri-tional intake, and chronic upperrespiratory infections. Persons athighest risk are primarily those withcompromised immune systems;multiple medical diagnosis; thosetaking many different types ofmedications; those with functionallimitations; and those that needassistance with most activities of dailyliving.

Oral neglect can limit a client’sparticipation in such fundamentalactivities as eating a normal diet, oftencompromising their nutritional status,and consequently their overall health.Similarly, there is a high social cost oforal neglect from unpleasant mouthodors and overall facial appearanceand these may discourage theperson’s interaction with family,friends, and caregivers.

Within the dental profession thefocus of care has beenon repair and rehabili-tation. As the popula-tion ages, the focusturns toward control oforal infections andmaintenance of the oralstructures in morerealistic and lessinvasive modes formost effective out-come. Dentistry hasnot recognizedspecialty in geridontiaand funding for the fewresidency programshas been diminished.

For the dental hygiene professionthere is no career ladder and norecognized specialty in any area ofcare. Fiscal constraints on dental careare momentus since most third partygroup dental insurances cease atretirement and government programssuch as medicare have no dentalreimbursement provisions. Medicaidreimbursement for geriatric clients isadministered state by state and is

The homebound or institutionalized elderly

are unable to obtain proper dental care in a

conventional dental office. As our

population ages, the need for delivery of

services for the elderly in non-traditional

settings will increase.


“Oral Health for Healthy People 2010,”cites oral health care as an area ofcritical disparity. Lives are severelycompromised and lost for want of oralhealth care intervention—thispopulation is desperate.

In addition, the treatment ofmedical conditions prevalant amongthe geriatric population such as jointreplacements, congestive heart failure,or diabetes can be compromised by

��26

GCM

fall 2000

woefully capricious.

Just what are the implications fordentistry and geriatric care managerswithin this population? That is aquestion that has as many answers asthere are individuals who need specialdental considerations.

There is, however, a commonalitythat can have far-reaching aspects forall ages, and that is the developmentof an individual plan of care of oralinfection control (OIC). The assess-ment for and implementation of thisplan can be done at any point and anyage and should be regularly reas-sessed for effectiveness. Oralinfection control is medically essen-tial.

What is the purpose of this OIC?To answer that we must understandthat tooth decay (infection of hardtissues) and gum disease (infection ofsoft tissue), along with other oralconditions, are in fact infectionscaused by an accumulation of fooddebris, bacteria, bacterial toxins, anddead oral cells (all known as plaque)distributed over and into hard and softtissue cracks and crevices in themouth. The object of brushing/flossing (oral hygiene) is to break upthis infectious material so that themedication (toothpaste, mouthwash,and saliva) can reach the infected,ulcerated areas and help them heal.Oral infection control techniques arenot difficult but they do requireconsiderable fine motor skills, whichmany geriatric clients no longerpossess.

The initial OIC should be done bya dental professional, and care staffmust be provided with instructions inthe intricacies of delivering theservice. Access to care is of greatconcern since crisis dental care isoften the only service available to thegeriatric clients. Consequently, manyindividuals are without teeth in lateryears. Yet, having no teeth does noteliminate the need for infection controlin the oral cavity.

There are multiple benefits from

implementing a daily oral infectioncontrol regimen. The experienceallows care staff to observe manyconditions in the mouth and reportany lack of resolution. The individualbecomes more desensitized to thedental experience and when profes-sional dental repairs must be donethere is less need for physical andchemical restraint.The individual ismore sociallyacceptable in termsof alleviation ofinfectious odorswithin the mouth(halitosis). Thereis less incident ofaspiration ofinfectious biomassand possiblepneumonia. Theservice of debrid-ing and medicatingthe mouth by carestaff can also be anurturing experi-ence. Further,nutritional intake isenhanced by theability to chewwithout discom-fort. There is asignificant positiveimpact on the totalquality of life.

In the indi-vidual plan for oralinfection controlone considers thedisability, themedications, thesupport system,and the oralcondition (thewho, what, when,where, and why).Some individualsare able to effec-tively controldisease indepen-dently while others must havecomplete assistance. It goes withoutsaying that the care staff shouldalways allow and encourage theindividual to do as much as they areable. Yet, it must be recognized thatproper oral infection control cannot beoverlooked and if necessary the care

staff will be responsible for deliveringthe appropriate care.

The supplies needed for daily oralinfection control are simple: The carestaff should always wear latex or vinylgloves (to inhibit transfer of infectionfrom client to care giver and fromclient to client), use: two tooth

brushes (one fordebridement/medication andone for retractionof tongue orcheeks and asprotection of carestaff’s fingers),liquid/lubricant(water, mouth-wash, toothpaste,etc.), anddisposable towels(to wipe oraldebris off thebrush).

To allow forthe best possibleresults, theindividual shouldsit in a reclinerand the care staffshould positionthemselves to theside and back ofthe individual soas to cradle thehead with an arm.This allows thecaregiver tostabilize the headand retract thelips and cheek.The brush shouldfirst be dippedinto a lubricantsuch as mouth-wash. Debride-ment is accom-plished byplacing the brushbristles into eachcrack, crevice,

and microfiche of the hard and softdental tissues. Use a circular ormedication motion with even pressure(without hard scrubbing) throughoutthe oral cavity. Rinse the brushperiodically in the mouthwash or wipethe debris on a towel.

In the individual

plan for oral

infection control

one considers the

disability, the

medications, the

support system,

and the oral

condition (the

who, what, when,

where, and why).

Some individuals

are able to

effectively control

disease

independently

while others must

have complete

assistance.



��27

GCM

fall 2000

The ideal time for this treatment isbefore bedtime, but a thoroughdebridement once a day at any time isacceptable. The care staff shoulddiscuss the procedure before it isdone and explain that they aremedicating the client’s mouth.Remember, let the individual“brush”—the care staff does themedicating (infection control).

As each of you is aware, accessto dental care and the funding thereofis a primary concern for the individu-als in our care. Considering theperception of dental infections as lowpriority, non-life-threatening occur-rences, there are even less dentalservices available to the geriatricclient. So… look into your client’smouth…and take the time to do oralinfection assessments. This often-overlooked special care will undoubt-edly add another dimension in the lifeof the geriatric client, and may verylikely help save their teeth.

There are no simple answers.There are, however, pathways ofcreative adaptation as we assist oneanother in accessing resources andactivating systems on behalf ofgeriatric clients. Oral evaluation is anoften times overlooked portion ofcomprehensive geriatric assessment.The reasons for overlooking thisassessment have origin in a multitudeof invisible chains, which serve toration, care for this portion of thebody. Geriatric care managers couldbecome pivotal forces in the establish-ment of oral health care assessments.By including the mouth in the overallgeriatric assessment, resources couldbe established that could surmountsome of the barriers to dental care.Beginning with the next client, thinkabout the mouth!

Judith C. Corbin, RDH, BSDH, isa clinical dental hygienist whopractices with her husband inThomasville, GA. She has a certifica-tion in gerontology, is a fellow in theAcademy of Dentistry for Persons withDisabilities, and completed afellowship in Rehabilative Dentistry


As each of you is aware, access to dental

care and the funding thereof is a primary

concern for the individuals in our care.

Considering the perception of dental

infections as low priority, non-life-threatening

occurrences, there are even less dental

services available to the geriatric client.

with DECOD (Dental Education forthe Care of the Disabled) in Seattle,WA. She is a member of the AmericanDental Hygienists’ Association and1994 Recipient of Bausch and LombDistinctions in Dental Hygiene.

��Federation of Special Care Organizationsin Dentistry, www.foscod.org, 211 EastChicago Ave., Suite 948, Chicago, IL60611, (312) 440-2660

American Society for Geriatric Dentistry

Academy of Dentistry for Persons withDisabilities

American Association of HospitalDentists

Dental Education in Care of Disabled(DECOD), School of Dentistry, Univer-sity of Washington, P.O. Box 356370,Seattle, WA 98195, (206) 543-1546

��Meckstroth, R. et al., “Oral Care for theDependant Patient:” Teaching Video,West Virginia University, 1990

Corbin, J., “Oral Infection Control for theAging Person with DD:” Article CADD,University of Miami, Volume 3, Number2/Fall 1992

��

1604 North Country Club RoadTucson, AZ 85716-3102

BULK RATEU.S. POSTAGE

PAIDTucson, ArizonaPermit No. 3178

Have You Moved?If you have moved or changed jobs, please makesure the National Association of ProfessionalGeriatric Care Managers’ office is aware of yournew address, employer, phone number, and faxnumber. To update our records, complete theform below and return it to the GCM office.

Name: _________________________________________

Company: ______________________________________

New Address: __________________________________

City: ___________________________________________

State: _________________________________________

Zip: ___________________________________________

New Phone: ____________________________________

New Fax: ______________________________________

E-Mail: _________________________________________

�� GCM, 1604 N. Country Club Road,

Tucson, AZ 85716-3102Fax: (520) 325-7925


Date post:	23-Mar-2018
Category:	Documents
Upload:	ngokien
View:	220 times
Download:	4 times

Geriatric Care Management Journal Care Management ... Nursing in its many locations and emphasis of...

Documents