Assessing Safe and Independent Living in Vulnerable Older Adults: Perspectives of Professionals Who Conduct;

Assessing Safe and Independent Living in Vulnerable Older Adults: Perspectives of Professionals Who Conduct; Aanand D. Naik, MD, Mark E. Kunik, MD, MPH, Kristin R. Cassidy, BS, Jeethy Nair, MD, and John Coverdale, MD, MEd Objectives: The objectives of this study were to describe social services and health professionals’ per- ceptions of vulnerability among older adults living in the community and to elicit how these profession- als screen vulnerability in community and in-home settings. Methods: Focus group sessions were conducted and analyzed using standardized methods of qualita- tive analysis. Participants included social services and health professionals (n
45) who routinely en- counter vulnerable older adults. Results: Four themes characterized vulnerability: the inability to perform activities of daily living, lack of social support, sociodemographic factors, and neuropsychiatric conditions. When screening older adults, participants reported evaluating basic cognitive abilities, decision-making processes, and the capacity to adequately plan and safely perform everyday tasks. Participants stated that screening is best performed by an interdisciplinary team in the home setting and preferably on more than one occa- sion. Conclusions: Social services and health professionals in this study described routinely screening for vulnerability in community-living older adults using a multidomain approach. These professionals en- dorse the use of assessments that screen an older adult’s cognitive and functional capacities for safe and independent living. Further research is needed that integrates routine screening for vulnerability by community social services professionals with the assessments and interventions conducted by primary care physicians. (J Am Board Fam Med 2010;23:614–621.) Keywords: Vulnerable Populations, Independent Living, Aging, Behavioral Sciences, Decision Making, Geriatrics, Qualitative Research Older adults represent a large and growing propor- tion of the typical primary care provider’s practice. 1 Older adults report that living safely and indepen- dently in their own home is a principal health goal. 2 Disability, aging, and illness can adversely affect the ability of an older adult to live independently by increasing one’s vulnerability to health and safety risks within the home. 3 Vulnerability is the failure to engage in acts of self care that adequately regu- late safe and independent living, or to take actions This article was externally peer reviewed. Submitted 31 March 2009; revised 12 March 2010; ac- cepted 12 March 2010. From the Houston Health Services Research and Devel- opment Center of Excellence (ADN, MEK, KRC, JN) and the Veterans Affairs South Central Mental Illness Research, Education and Clinical Center (ADN, MEK), Michael E. DeBakey Veterans Affairs Medical Center; the Alkek De- partment of Medicine (ADN, MEK) and the Menninger Department of Psychiatry and Behavioral Medicine (MEK, JC), Baylor College of Medicine; and the Harris County Hospital District (ADN, JC), Houston, TX. Funding: This study was supported by a bioethics project grant from the Greenwall Foundation (ADN) and with re- sources and the use of facilities at Houston Veterans Affairs Health Services Research and Development Center of Excel- lence (HFP90-020). Dr. Naik is also supported by a K23 grant from the National Institute on Aging (5K23AG027144) and a Doris Duke Charitable Foundation Clinical Scientist Develop- ment Award. The views expressed herein are those of the authors and do not necessarily reflect those of the Department of Veterans Affairs or Baylor College of Medicine. None of the funding agencies played a role in the design and conduct of the study, analysis and interpretation of the data, or the preparation and approval of the manuscript. Conflict of interest: none declared. Corresponding author: Aanand D. Naik, MD, Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VAMC (152), 2002 Holcombe, Houston, TX 77030 (E-mail: [email protected]). See Related Commentary on Page 564. 614 JABFM September–October 2010 Vol. 23 No. 5 http://www.jabfm.org to prevent conditions or situations that adversely affect personal health and safety. 3–6 Vulnerable older adults may display poor personal care and nutrition, have difficulty managing basic medica- tions and personal finances, or live in unsafe envi- ronments regardless of physical appearance or be- havior. 3,7 Furthermore, vulnerable older adults are at risk for neglect, exploitation, and numerous safety hazards, as well as functional impairment, medical morbidity, and death. 8–11 Thus, a common denominator among vulnerable, community-living older adults may be the diminished ability to per- form personal care tasks and protect themselves. Primary care interventions that target vulnera- ble community-living and homebound older adults have demonstrated effectiveness at reducing mor- tality and placement in long-term care. 12,13 The issue of assessing vulnerability, therefore, is of par- ticular importance to primary care physicians. However, the clues to recognizing vulnerability are often not readily apparent during routine primary care visits. 3,14 Assessments done in outpatient set - tings may lead to erroneous assumptions about an older adult’s vulnerability. 15 Furthermore, hospital staff and outpatient clinicians rarely have the op- portunity to observe patients’ home environments to ascertain their ability to live safely and indepen- dently. 16 One goal of assessing vulnerability is to identify and implement interventions that prevent further impairments and harms to allow older adults to continue to live at home. Assessments that are conducted in patients’ homes are more effective at tailoring interventions to reduce vulnerability. 13 Financial and geographic barriers are important impediments to home-based primary care services in most settings. In one study, more than half of primary care providers reported that they con- ducted home visits; however, only 8% perform more than 2 visits per month. 17 Physicians who report that they perform routine home visits tend to be older and live in rural areas. 17 Family medi - cine residency programs provide specific training for geriatric assessment, including home-based pri- mary care, but with variable emphasis on assessing vulnerability. 1,18 Primary care physicians continue to endorse the importance of home-based assessments of vulnera- bility as part of their scope of practice. 19 To address this gap, primary care physicians sometimes rely on the services of other clinical and social services professionals. 17 Primary care physicians cannot rely on a standardized assessment battery for vulnera- bility because of the heterogeneity of assessment tools across clinical and social services disci- plines. 3,20 In addition, their recommendations for interventions are limited by a lack of consensus across disciplines of what constitutes vulnerability for safe and independent living among older adults. 3,21 Methods Study Design and Sample The overall aim of the current study was to address these critical issues from the perspective of social services and health professionals who often conduct assessments in the homes of community-living older adults. First, participants were asked their perceptions of the dimensions of vulnerability among older adults living in the community. Sec- ond, participants were asked to identify how they go about screening for vulnerability in community- based and in-home settings. From these results and the available literature, a framework can be pro- posed for integrating community-based screening methods with more comprehensive strategies for clinical assessment and intervention primarily di- rected by primary care physicians caring for vul- nerable older adults. This qualitative study consisted of 5 focus groups (n
45) held between January and April 2007. Participants were purposively sampled to ob- tain perspectives and experiences from a range of clinical and social services professionals. 22 We chose 5 sites from which to gather our sample: a community-based social services organization (n
6); a multidisciplinary geriatrics team from a pub- licly funded community hospital (n
9); an aca- demic geriatrics faculty from a medical school (n
8); case managers with State Adult Protective Ser- vices (n
10); and an interdisciplinary provider group of case managers, psychologists, lawyers, and social workers affiliated with a county Guardian- ship program (n
12). A contact from each group identified potential participants. Overall the focus groups provided a heterogeneous sample of profes- sional disciplines and organizational missions. All participants had worked with older adults or had experience with addressing issues related to the study questions. We introduced the project at each focus group with a statement of purpose. We explained that the doi: 10.3122/jabfm.2010.05.090065 Independent Living in Vulnerable Older Adults 615 A Research Critique demonstrates your ability to critically read an investigative study. The critique must be attached to the article and follow APA guidelines. Limit your report to six (6) typewritten double spaced pages. Use the following categories as headings. *Please attach the Research Critique Evaluation form to your report. One (1) point will be subtracted from total points if Critique evaluation is not attached. Research Problem/Purpose (20 points) •    State the problem clearly as it is presented in the report •    Have the investigators placed the study problem within the context of existing knowledge? •    Will the study solve a problem relevant to nursing? •    State the purpose of the research Review of the Literature (5 points) •    Identify the concepts explored in the literature review. •    Were the references current? If not, what do you think the reasons are? • Theoretical Framework (5 points) •    Are the theoretical concepts defined and related to the research? •    Does the research draw solely on nursing theory or does it draw on theory from other disciplines? •    Is a theoretical framework stated in this research piece? •    If not, suggest one that might be suitable for the study. •    Variables/Hypotheses/Questions/Assumptions (15 points) Variables/Hypotheses/Questions/Assumptions (15 points) •    What are the independent and dependent variables in this study? •    Are the operational definitions of the variables given? If so, are they concrete and measurable? •    Is the research question or the hypothesis stated? What is it? Methodology (30 points) •    What type of design (quantitative, qualitative and type) was used in this study? (5 points) •    Was inductive or deductive reasoning used in this study? •    State the sample size and study population, sampling method and study setting. •    Did the investigator choose a probability or non-probability sample? •    State the type of reliability and the validity of the measurement tools. •    Were ethical considerations addressed? Data Analysis (10 points) •    What data analysis tool was used? •    How were the results presented in the study? •    Identify at least one (1) finding. •    Summary/Conclusions, Implications & Recommendations (5 points) •    What are the strengths and limitations of this study? •    In terms of the findings, can the researcher generalize to other populations? Explain. •    Evaluate the findings and conclusions as to their significance for nursing. PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET AN AMAZING DISCOUNT :)