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Can Elders Be Bullies? By Jessica Girdwain Are older adults in long term care facilities intimidating other residents? Concerns about bullying are nothing new. But usually bullying arises in schools or neighborhoods where young people insult, intimidate, or hurt others, namely their peers. But geriatricians and aging experts have observed elements of bullying invading elder communities as well. Elder bullying can occur for numerous reasons. “There comes a time when older adults lose their freedoms. Being in a home or facility changes their lives, and that can be hard for them to handle,” says Matthew Coppola, MD, a primary care physician at Allegheny General Hospital in Pittsburgh. That, he says, possibly sparks bullying—a problem that can spread within long term care facilities. Coppola has been speaking out about what he calls an emerging and pervasive problem. What constitutes bullying among older adults? “I define it as when the will of the bully is placed upon a senior in a way that they don’t seek out or wish for, and they want to avoid it. This can be verbal, physical, or emotional abuse,” Coppola says. In verbal abuse, the bully may use mannerisms or words to “run the roost or control certain aspect of another elder’s day. It’s about the tone of their voice or what’s being said,” Coppola says. It’s not necessarily swearing—it may be as simple as one resident saying to another that he or she can’t sit at a certain table during bingo games. Emotional abuse can be found in the familiar and nearly analogous cliques we all remember from high school. “There was the jock table, the nerd table, the geeks—and you sat in your section. It’s similar in an eldercare facility. Maybe one resident used to play at a specific bingo table with a group and suddenly that group no longer has a seat for them,” Coppola explains. Among elders, physical abuse doesn’t have to involve willfully hurting another. Usually it occurs when an elder makes a physical gesture that’s intimidating, such as grabbing a wheel on another elder’s wheelchair or pushing a walker to get him out of the way. Regardless of the type of abuse, health care providers should know that it’s disturbing to elders as Coppola has noted. He has recently made a series of presentations to older adult groups describing the problem and called “Bullying in Your Golden Years.” Often the catalyst for elder bullying is the move into an eldercare facility. “Sometimes, seniors may act out physically or emotionally to make their point to their family,” Coppola explains. “I see elders struggling with the fact that their children are living a classic fast-paced yuppie life and not listening that Mom doesn’t want to go into that setting right now.” Increasing Trend? It’s not well known just how widespread elder bullying is. “In my experience, I don’t think the issue of bullying is very common,” says internist and geriatrician Andrea Fox, MD, medical director of the Squirrel Hill Health Center in Pittsburgh. However, Fox admits that individuals who have a history of bullying or intimidating others aren’t likely to change with age. “Most likely, the elders that are considered bullies have been bullies their whole lives. Sometimes when you’re in a group living setting, your inner tendencies arise, and those underlying negative characteristics are always there,” she says. “Some of these people living at long term facilities have known each other since kindergarten. One woman has a boyfriend, and the others are jealous of her. She was always popular. The point is, it doesn’t change.”  Coppola agrees that it’s not a widely pervasive or well-researched issue. Fortunately, he says, “We’re finding that more facilities are putting standard policies in place on how to handle bullying.” He talks to older adults about setting up a bullying committee (and recommends other facilities do the same), which accomplishes two things: It helps victims know they’re not alone and warns the bullies themselves. Protecting Potential Victims To identify individuals who might be bullied, health care practitioners should take notice if an elder withdraws from social interactions, Fox says. Maybe he or she used to go out but suddenly stops engaging in activities or remains in his or her apartment or room during mealtime. “Those are hallmark signs of elder abuse and are the same symptoms we’d look for in a bullying situation,” she says. The most important issue related to bullying—and the reason health care practitioners should stay attuned to it—is that it may be a sign of an underlying medical condition, according to Fox. Providers should use a bullying incident as an opportunity to determine what the underlying issues may be. Use it as an opportunity to look for sudden changes in personality. For example, an older adult may have been a sweet person previously and then suddenly begins to act mean and out of normal character. Of course, an illness or dementia should be considered. “Sometimes people who thought that that older man was just a mean and nasty guy, they really have a brain disease that doesn’t allow them to control their behavior, and they can’t be who they used to be,” Fox says. Fox recalls a female patient who had a problem with the people with whom she sat during meals. The patient complained that she couldn’t understand one of her tablemates because of a heavy accent; she hated how another took her teeth out. “The thing was, she had been sitting with them for quite some time, and it suddenly bothered her,” Fox explains. The patient had a history of depression, so Fox was alerted that she might be experiencing further depression. “Bullying is an indication that you need to dig deeper about what’s going on.” The answer also could lie in alcohol or drug dependence. “They may need an intervention,” Fox says. Patients may be in danger when health care professionals fail to examine the issue of bullying and follow up appropriately. Fox, who presents expert witness testimony in various courts, recalls the case of two older men who lived in a long term care facility. “They hated each other, but the staff didn’t do much to intervene,” she says. “One day they got into an argument, and one suffered a fatal fall.” Of course, such circumstances are rare, Fox says, but prove that health care practitioners should be aware of the consequences. “The staff kept telling them not to argue, but that doesn’t do much when it comes to older adults who are cognitively impaired. The two men needed to be completely separated,” she explains. On the other hand, if a thorough mental and physical examination reveals no underlying medical condition, an elder resident may just not be a nice person. “In that case, a group setting may not be the right environment for someone,” Fox says. She recommends that health care practitioners ask family members about a resident’s personality, especially before he or she enters a care facility. Is the elder likely to be a socializer or a loner? If the latter, the elder may not thrive in a highly social situation. “Healthy aging is about being adaptable and making new friends,” Fox says. “Socializing is one of the most important things for helping an elder stay on top of his or her game.” — Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines.

Adults With Intellectual and Developmental Disabilities:

Adults With Intellectual and Developmental Disabilities:
A Unique Population

By Carolyn C. Tinglin, MSc, RN
Today’s Geriatric Medicine
Vol. 6 No. 3 P. 22
Older adults with intellectual and developmental disabilities can present clinicians with unique challenges related to appropriate assessment and treatment. Providers need to develop the skills and sensitivity necessary to effectively treat these patients.
Adults with developmental disabilities are living longer, healthier, more meaningful lives. Within the past seven years, advancements in medicine and public policy changes, along with a societal push for inclusion, have provided physicians with an opportunity to play a pivotal role in promoting, managing, and delivering care that supports a high quality of life for older adults with intellectual and developmental disabilities (I/DD).
Many health care providers, people with disabilities, and families are unfamiliar with the latest information about the age-related health issues that affect people with I/DD. A need exists not only for more research in this area but also for disseminating information and for improved preventive and surveillance strategies across the life span for adults with I/DD. These strategies include targeted health education programs, appropriate screening, and community health promotion programs.
The number of adults with I/DD aged 60 and older is projected to nearly double from 641,860 in 2000 to 1.2 million by 2030.1 Adults with I/DD are more likely to develop chronic health conditions at younger ages than other adults because of biological factors related to syndromes and associated developmental disabilities, limited access to adequate health care, and lifestyle and environmental issues. These adults experience higher rates of obesity, sedentary behaviors, and poor nutritional habits compared with the general population.
Additionally, adults with I/DD can have a shorter life span compared with other older adults, which is thought to be caused by an accelerated aging process, manifest in their increased rates of cataracts, hearing loss, osteopenia, and hypothyroidism and a genetically elevated risk of developing Alzheimer’s disease. In fact, until the latter part of the 20th century, most individuals with I/DD experienced markedly shortened life expectancies, particularly in institutional residences.
However, aging adults with I/DD now often live well into old age in community settings. Families often provide specialized care early in the lives of these patients who are no longer left to languish in institutions. Group homes can offer adequate housing options for adults with I/DD whose parents or families cannot care for them. As individuals with I/DD are living longer, geriatrics providers and care team members need to learn about the characteristics, health care needs, and common clinical issues in this population.
Challenges
Public policies increasingly have supported the rights of people with disabilities to live in the communities of their choice. Making this relevant to people with I/DD requires a corresponding increase in environmental supports to allow their full community participation. Until they reach the age of 21, individuals with I/DD are eligible to receive support services (eg, education, training, health promotion) through the Individuals With Disabilities Education Act. When eligibility for these services ends, the task of securing support shifts from the educational system to the individual and his or her family or other caregivers.
This task becomes more challenging over the individual’s life span as aging-related changes impact both the person with I/DD and his or her supporting family members. Key challenges that must be addressed by communities, families, and adults aging with I/DD include improving the health and function of these adults and their families, enhancing consumer-directed and family-based care, and reducing barriers to health and community participation.
Adults with I/DD generally see primary care physicians less often in comparison with the general population. Several barriers contribute to this, including the following:
• lack of access to primary care providers who are knowledgeable and experienced with the I/DD population;
• behavioral issues that could negatively impact the individual’s cooperation for tests, injections, etc;
• communication issues that make interaction among the provider, caregiver, and patient difficult;
• physical challenges (eg, cerebral palsy) that make it physically difficult to access a health care facility;
• environmental issues that may involve sensory challenges (eg, lighting, sound, smells) that interfere with a patient’s ability to effectively participate in the visit;
• burn out that renders caregivers unable to manage their own health in addition to the health of an adult with I/DD, including taking the adult to scheduled appointments; and
• a shortage of time for providers to accommodate adults with I/DD who may have communication and behavioral difficulties that create challenges to patient assessment and treatment.
Unique Needs
Certain conditions are strongly associated with adults with I/DD and are more prevalent among this population. For example, there is a higher incidence of dental disease, functional decline, mental illness, bowel obstruction, gastrointestinal cancer, and obesity. Additionally, hearing impairment and vision loss are common in older adults with I/DD because of preexisting undiagnosed pathologies.
Regularly scheduled screening and assessments (yearly or every six months, if required) is recommended along with a multidisciplinary approach to health maintenance. Key health issues that require careful examination include the following:
• Pain and distress: Nonverbal patients can be assessed with a caregiver’s help as well as pain assessment tools adapted for adults with I/DD.
• Polypharmacy: It’s common for the I/DD population to have numerous medications prescribed by various providers. It’s important to sort out medication use, capacity to follow the medication regime, and assistance required to support medication compliance.
• Vision and hearing: Screen for cataracts and glaucoma (yearly for those aged 45 and older) and assess hearing, especially in light of reported changes in behavior. (Cerumen impaction may be a common cause.)
• Dental disease: General oral examinations may reveal the need for further investigation or closer monitoring by a dental professional.
• Musculoskeletal disorders: Adults with I/DD are at high risk of osteoporosis and contractures related to reduced or limited activity. Osteoporosis occurs earlier in the I/DD population compared with the general population. Osteoarthritis also is an area of concern.
• Gastrointestinal disorders: Screening plays an important role in the identification of gastroesophageal reflux disease. Colon cancer screening follows the same protocol used in the general population.
• Vaccinations: Recent research reveals that adults with I/DD do not receive vaccinations at the same rate as adults in the general population.
Special Consideration
Adults with I/DD who also have mental health issues often are misdiagnosed. Psychiatric screening is imperative and tools such as the Abberant Behavior Checklist and the Psychiatric Assessment Schedule for Adults with I/DD are most helpful.
Nonverbal patients pose a more complicated challenge, and it may be difficult to make a clear diagnosis when symptoms such as delusions and hallucinations are present. Leading practice suggests the use of an interdisciplinary team of primary care providers, psychiatrists, and psychologists to manage psychological, emotional, and behavioral issues.
Most patients are accompanied to medical appointments either by a professional caregiver or a family member. Although a caregiver’s input can be helpful, clinicians are encouraged to not only include a patient in all interactions but also to speak directly to the patient unless communication becomes a barrier. Even patients who have no verbal communication skills should be addressed by name during the visit and included in conversations pertaining to the routines and processes.
Health goals for adults with I/DD are similar to those that apply to the general population: to maintain or improve community participation, support a good quality of life (as defined by the individual and/or caregiver), promote wellness, and minimize acute care visits.
Care Approach
Careful planning prior to examining an adult with I/DD will ensure good use of scheduled time and no overlooked assessments. When planning for tests and screenings, there are important questions to consider, including the following:
• What is the best way to communicate with this patient? This information can be obtained from someone who knows the patient well or directly from the caregiver.
• Will the environment hinder the flow of the appointment (eg, distracting sounds, enclosed space, proximity to other patients)?
• Are there sensory issues that may impede the appointment (eg, smells, light, white noise)?
• Does the patient require sedation to complete any tests or exams?
• Can the caregiver assist with the visit (eg, repositioning the patient, answering questions)?
• Are any other health care team members needed to complete the visit, such as nurses, audiologists, speech therapists, or dietitians?
• Does the patient use adaptive devices (eg, iPad, communication cards, voice interpreters)?
It’s important to consider the accommodations in terms of staffing and procedures that may need to be made during the course of the visit.
Current research provides no specific age range or cutoff that clearly defines the geriatric adult with I/DD. Typically, aging adults with I/DD may not have mobility or functional issues as observed in older adults in the general population. Adults with I/DD in their 40s may present with conditions commonly seen in the general population after the age of 70 (eg, diabetes, mental health deterioration, chronic respiratory conditions). Regularly scheduled physical exams play an important role in the monitoring and management of acute and chronic health conditions.
Clinicians can utilize care coordination to help monitor and manage the health of patients with I/DD. Care coordination does not need to be elaborate or increasingly time consuming. But because of the complex needs of this patient population, understanding and communicating with the patient’s network of support ensures that all medical and social professionals involved with the patient are clear about the patient’s health goals and strategies developed to accomplish those goals.
Tapping Into Resources
A collaborative approach has proven to be the most successful in the care of adults with I/DD. Clinicians can rely on several resources to develop a plan of care for I/DD patients. Caregivers provide a good source of personal and practical information, and community support agencies such as the Developmental Disabilities Services and the Administration on Intellectual and Developmental Disabilities (at the federal level) that connect patients with community resources and funding are an instrumental part of the care continuum. Accessing information from community resources may be necessary to get a better understanding of a patient’s level of function in the community in order to set realistic health goals. The patient and/or a caregiver will be able to provide background information regarding which specific local community agencies provide him or her with financial and social support.
— Carolyn C. Tinglin, MSc, RN, is a health consultant working with youths and adults with dual diagnoses of intellectual and development disabilities and mental health needs. She has worked extensively in long term care, specializing in psychogeriatrics throughout the United States and Canada.

Reference
1. Heller T. People with intellectual and developmental disabilities growing old: an overview. Impact. 2010;23(1).

Case Study
Rita, 49, lives in her own home with care staff who have known her for more than 15 years. She is nonverbal, using signs and grunts to communicate her needs. Diagnosed with autism, her developmental age is 1 1/2.
Rita’s primary caregiver reports that she has been much more irritable than usual, sometimes hitting and spitting at staff. Her sleep routine has changed over the last three months. She has been getting little sleep, with no more than four hours of uninterrupted sleep per night.
She is visiting the physician’s office/clinic for the first time and is scheduled for a new patient exam. Rita’s previous physician encounters addressed only specific urgent physical matters.
Preparation
Weeks prior to Rita’s appointment, it was necessary to assess the pertinent information related to her visit, as follows:
• If Rita can’t make treatment decisions independently, who is responsible for doing so?
• Can Rita’s caregiver provide any background information about previous physician visits, hospitalizations, dental care, and/or psychological testing? Can the caregiver provide consent to obtain information from Rita’s other health care providers?
• If Rita has behavioral issues, does she require any as-needed medications to help her relax prior to the appointment? Are there favorite toys or objects that can be brought to the appointment?
• How much time should be scheduled for this appointment? Can Rita tolerate sitting or limited movement for this length of time?
• Does Rita have sensory issues? Will they affect how the exam is conducted?
It also was important to assign specific staff members to assist with Rita’s examination and treatment.
The Appointment
It was necessary to keep Rita’s wait time to a minimum. For many adults with I/DD, sitting quietly in a waiting room for long periods of time may contribute to soreness, pain, or increased irritability.
A friendly face goes a long way, so one staff member was assigned to assist Rita for the duration of her appointment, greeting Rita and her caregiver, providing reassurance and comfort, and preparing Rita for the new patient exam.
After being greeted and seated in the exam room, Rita and her caregiver could engage in familiar activities such as reading or playing with personal toys or objects.
Once in the exam room, Rita spontaneously began self-stimulation (“stimming”) by rocking back and forth and humming. Rita often does this when feeling anxious. The clinician waited until the stimming stopped. (An alternative would be to ask the caregiver to attempt to calm the patient or even redirect her attention to something else she enjoys.)
Before beginning the exam, the clinician explained to Rita and her caregiver what would be done and confirmed with the caregiver what assistance would be needed. Short, direct face-to-face communication worked best with Rita.
Rita’s tolerance dictated the exam’s success. It was necessary for the clinician to monitor Rita’s responses and modify procedures as necessary. For example, had Rita become agitated when the clinician attempted to assess her lungs, the caregiver and assigned staff member could have assisted with calming Rita while the clinician moved on to the next aspect of the exam. The overall goal is to make the experience a positive one for all involved.
During the exam, it was necessary for the clinician to maintain periodic communication with both Rita and her caregiver. “Checking in” with a patient helps to establish trust and can help relieve anxiety. Checking in can be as simple as saying, “Rita, we’re almost finished here. Are you OK? You’re doing a fantastic job!”
After the Appointment
Once the appointment was finished, the clinician reviewed his findings. With a collaborative approach in mind, he needed to decide whether other team members or clinical professionals could be instrumental in maintaining a good quality of life for Rita.
The clinician had staff follow up with the caregiver by phone or e-mail to communicate the next steps for Rita’s care and discuss subsequent appointments. He also asked for feedback regarding Rita’s appointment, soliciting suggestions for improvement if there were any.

Useful Resources for Clinicians
• Guidelines for Structuring Community Care and Supports for People With Intellectual Disabilities Affected by Dementia (http://aadmd.org/sites/default/files/NTG_Guidelines-posting-version.pdf)
• Bridging the Aging and Developmental Disabilities Service Networks: Challenges and Best Practices (www.acf.hhs.gov/sites/default/files/aidd/bridgingreport_3_15_2012.pdf)
• Primary Care of Adults With Developmental Disabilities — Canadian Census Guidelines (www.cfp.ca/content/57/5/541.full.pdf)

Are Scaly, Dry Skin Spots Actually Precancers?

By Ellen Marmur, MD
This underrecognized precancer often thought of as “sunspots” frequently goes unnoticed.
We all know someone who fits the bill: fair skinned, covered in “sunspots” after having spent their younger days soaking up the sun, getting a nice bronze tan (or sunburn) while unwittingly bathing in harmful ultraviolet rays. While education around skin cancer has increased dramatically, it doesn’t help the generations of sun worshippers for whom the damage already has been done. I know because I’m a former sun worshipper who has survived skin cancer. For the people described above, proactive skin care and screening is essential.
One of the most common, but also most unknown, precancers of the skin is actinic keratosis (AK). When I ask people whether they know what it is, I usually get the response, “I’ve never heard of it.” This is somewhat alarming given the fact that these precancerous spots are the third most frequently diagnosed skin problem, affecting more than 58 million Americans.
As a dermatologist, I am proud of and happy about the education regarding melanoma and skin cancer protection. However, education regarding the treatment of precancers, such as AK, is still lacking. It’s important because despite the fact that most AKs remain benign, approximately 5% to 10% develop into squamous cell carcinoma within roughly two years.1
So what is AK? It’s a precancerous skin condition often mistaken for sunspots and typically is diagnosed in older adults. AK is the result of years of cumulative sun damage and most prevalent in people who have spent a lot of time in the sun over the course of their lives.
AK most often appears on parts of the body regularly exposed to sunlight, such as the face, scalp, ears, neck, hands, and arms. It’s also more common in people with fair skin.
AK is characterized by dry, scaly, rough-textured patches on the skin that can range in color and vary in size. It’s not typical for the sun to affect only small patches of the skin. Therefore, people who are diagnosed with AK usually will develop more spots over time.
Since there is no way to know which AK spots will become cancerous, it’s important to seek care from a dermatologist, as frequent skin examinations are the key to early detection and prevention, especially if patients suspect they have AK.
AK treatment options including the following:
• Photodynamic therapy: This involves applying a photosensitizing agent to the AK. The treated area is exposed to a light that activates the agent. The period between application and exposure varies depending on the photosensitizing agent used. This treatment targets only the AK and causes little damage to the surrounding normal tissue. Some redness, swelling, and a burning sensation often occur during therapy.
• Cryotherapy: Liquid nitrogen is used to freeze the spots, with no cutting or anesthesia required. This method causes the lesion(s) to shrink or become crusted and then fall off. After treatment there may be temporary redness and swelling. In some patients, this treatment can cause permanent white spots on the skin.
• Topical medication: This involves applying a topical medication to the affected skin. The course of treatment can range from days to weeks, depending on the topical medication used. Redness, swelling, and ulceration may occur during treatment.
• Curettage: This procedure uses a curette to scrape off damaged cells. A local anesthetic is required. Scarring and skin discoloration may occur at the treatment site.
• Chemical peel: Chemicals are applied directly to the affected areas, causing the top layer of skin to slough off. This layer of skin usually is replaced within seven days. Anesthesia is necessary for this procedure, and temporary discoloration and irritation can occur.
• Dermabrasion: This procedure involves using a rapidly moving brush to remove the affected skin. Local anesthesia is used. Following the procedure, the skin appears red and raw. It can take several months for the treated area to heal.
• Surgical excision: With surgical excision, the entire lesion plus some healthy tissue is removed. Scarring is possible.
• Lasers: This treatment involves focusing a laser on the lesion, cutting through the skin tissue without causing bleeding. Local anesthesia may be required. This treatment can cause pigment loss in the skin.
As always, it’s imperative for patients to consult a dermatologist if they believe they have AK. More information is available at www.spotsigns.com. This site has various educational tools including a list of signs, prevention advice, and treatment options. It can even help someone find a dermatologist.
— Ellen Marmur, MD, is an associate professor in the dermatology and the genetics and genomic research departments at Mount Sinai Medical Center in New York City.
Reference
1. Fuchs A, Marmur E. The kinetics of skin cancer: Progression of actinic keratosis to squamous cell carcinoma. Dermatol Surg. 2007;33(9):1099-1101.

Fee Increase

As of July 1, 2013, the cost of the skills examination will rise by $5.00.  Currently the skills fee is $35, and the increase will change it to $40.

Skills examination:     $40

Written Examination:  $35

TOTAL OF                  $75

The rise in the skills examination is to accommodate the cost of hiring the skills examiner, the skills examination room and all equipment. 

It will also enable the skills centers to increase the wages of the skills examiner, which has not been changed much in the last 15 years.

This is posted on our website and the application to test and expired application to test on our website will reflect these changes.

Beginning and Ending procedures set to music

I do not know what student wrote this. I found them handwritten on the desk. Very cute, whoever the author is.

Ending Procedures

To the tune of “This Old Man”

Prop them up

Put bed down

Call cord, water and the phone

Put the side rail up and lock the bed in place check the rugs and empty the waste

Open the drapes

Care for stuff

Can never wash your hands enough

Bring the family back

And tell the nurse you’re done

Charting’s always so much fun

Beginning Procedures 

To the tune of "If you’re happy and you know it"

Wash your hands

And then everything you need

Then knock and wait then proceed

State your name and ask the theirs

Kick their friends out of the chairs

And then pull the curtain, privacy indeed

Then explain what you’ll be doing face to face

Say it slowly clearly, ask if it’s ok

And then ask them to please help you

Have them do all that they can do

Raise the bed so that your spine won’t be erased

Here's one of our students singing the song

http://www.youtube.com/watch?v=MHcahjNTA3s&feature=youtu.be

http://youtu.be/_E3P0i7x3Lw