Mental Status Exam

© 2013 Therapist Aid LLC Provided by TherapistAid.com

Client Name Date

OBSERVATIONS
Appearance □ Neat □ Disheveled □ Inappropriate □ Bizarre □ Other
Speech □ Normal □ Tangential □ Pressured □ Impoverished □ Other
Eye Contact □ Normal □ Intense □ Avoidant □ Other
Motor Activity □ Normal □ Restless □ Tics □ Slowed □ Other
Affect □ Full □ Constricted □ Flat □ Labile □ Other
Comments:

MOOD
□ Euthymic □ Anxious □ Angry □ Depressed □ Euphoric □ Irritable □ Other
Comments:

COGNITION
Orientation Impairment □ None □ Place □ Object □ Person □ Time
Memory Impairment □ None □ Short-Term □ Long-Term □ Other
Attention □ Normal □ Distracted □ Other
Comments:

PERCEPTION
Hallucinations □ None □ Auditory □ Visual □ Other
Other □ None □ Derealization □ Depersonalization
Comments:

THOUGHTS
Suicidality □ None □ Ideation □ Plan □ Intent □ Self-Harm
Homicidality □ None □ Aggressive □ Intent □ Plan
Delusions □ None □ Grandiose □ Paranoid □ Religious □ Other
Comments:

BEHAVIOR
□ Cooperative □ Guarded □ Hyperactive □ Agitated □ Paranoid
□ Stereotyped □ Aggressive □ Bizarre □ Withdrawn □ Other
Comments:

INSIGHT □ Good □ Fair □ Poor Comments:

JUDGMENT □ Good □ Fair □ Poor Comments:

Jean Galiana &
William A. Haseltine

Solutions to the Most
Pressing Global

Challenges of Aging

Aging
Well

Aging Well

Jean Galiana • William A. Haseltine

Aging Well
Solutions to the Most Pressing Global

Challenges of Aging

ISBN 978-981-13-2163-4 ISBN 978-981-13-2164-1 (eBook)
https://doi.org/10.1007/978-981-13-2164-1

Library of Congress Control Number: 2018962361

© The Editor(s) (if applicable) and The Author(s) 2019. This book is an open access publication.
Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons licence and indicate if
changes were made.
The images or other third party material in this book are included in the book’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the book’s
Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copyright holder.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, express or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

Cover illustration: Halfpoint

This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721,
Singapore

Jean Galiana
Vital Research
Los Angeles, CA, USA

William A. Haseltine
ACCESS Health International
New York, NY, USA

v

This book is a product of ACCESS Health International (www.accessh.
org). ACCESS Health is a think tank, advisory group, and implementa-
tion partner dedicated to assuring that everyone, no matter where they
live and no matter what their age, has access to high-quality affordable
healthcare. ACCESS Health works in low-, middle-, and high-income
countries. In high-income countries, our focus is on care of older adults
and those with dementia. This book identifies and analyzes policies and
practices in the United States that serve as models of excellence in elder
care and optimal aging. We chose the title Aging Well because we believe
that well-being should be the number one focus of all aging care, sup-
ports, and interventions. A companion book Aging with Dignity exam-
ines similar topics in Sweden and several Northern European countries.

Our method was to identify organizations in the United States that
exemplify the best in elder care and optimal aging. We then interviewed
the leaders and champions of those organizations and programs. The full
text of the interviews is available on the ACCESS Health website or at
this link: www.accessh.org/agingwell. Here, we analyze our findings and
present them in the broader context of elder and dementia care and social
inclusion. Our focus areas include long-term care financing, person-
centered care, coordinated primary care, home-based palliative and pri-
mary care, support for those living with dementia and their caregivers,
acute and emergency care in the home and community, the combination

Preface

vi Preface

of health and social care that addresses the social determinants of health,
and housing, social inclusion, purpose, and lifelong learning.

From these interviews we abstract eight key lessons for achieving high-
quality affordable elder care and effective systems that support social
inclusion and purposeful aging. Those lessons are:

• The availability of affordable long-term care insurance is essential to
improve access and sustain the costs of caring for older adults.

• Person-centered care is a lynchpin of high-quality care and well-being
for older adults.

• Support and palliative care in the home and community setting is
essential for making care accessible to older adults that honors their
care and late-life priorities.

• Coordinated primary healthcare improves elder care quality and acces-
sibility and lowers healthcare costs.

• It is imperative that we build systems of support and inclusion for
those with dementia and their caregivers.

• Delivery of acute and hospital-level care in the home and community
is essential to lower healthcare costs and improve access, health out-
comes, and well-being for older adults.

• Social inclusion and the opportunity to live a purposeful life are essen-
tial to the happiness and well-being of older adults.

• Combining health and social care with upstream interventions to treat
the biopsychosocial and environmental needs is the way forward to
sustainable systems of care that improve function, well-being, and
independence.

The book identifies and details global aging challenges and, chapter by
chapter, offers innovative and impactful solutions to those challenges that
our interviewees have designed. It is our genuine hope that providers and
government entities around the globe that are seeking methods to improve
their elder care and social support systems will find ideas, inspiration, and
possibly collaborative opportunities to enhance the well-being of older adults.

Los Angeles, CA Jean Galiana
New York, NY William A. Haseltine
July 2017

vii

We thank all those who contributed their time and thought to help us
understand the issues facing older adults and what can be done to ensure
that all have access to high-quality affordable care and the opportunity to
live productive and active lives.

Claude Thau patiently described the rocky history of the long-term
care insurance industry and why many still do not have long-term care
insurance today.

We learned the true meaning of patient-centered care culture from
Christopher Perna, the former CEO and President of the Eden Alternative.

Rebecca Priest from St. John’s explained how to build an operational
culture around person-centered philosophies.

The leadership of Beatitudes Campus brought the person-centered
concept to a new light with their Comfort Matters™ palliative care for
those living with dementia.

Dr. Allen Power made us think about the possibility of not segregating
those who have dementia from the rest of the community.

They all convinced us that person-centered communication and care is
almost always a better option than the use of antipsychotic medications
to meet the needs of someone living with dementia.

Dr. Allan Teel of Full Circle America, Dr. Diane E. Meier of the Center
to Advance Palliative Care, and Dr. Kristofer Smith of Northwell Health

Acknowledgments

viii Acknowledgments

inspired us with their dedication to enabling aging in place and where
patients receive the right care in the right setting and live with dignity
throughout their life.

Kristofer and Allan have been making house calls for all of their careers
because they know that it improves access to care, costs less, and signifi-
cantly contributes to the well-being of their patients.

Allan connects his patients to local supports and services so that his
patients stay engaged and connected to their neighborhoods.

Diane remains vigilant in her pursuit to make palliative care available
in all care settings.

Drs. Michael Barr and Erin Giovannetti of the National Committee
for Quality Assurance gave us a compelling case for the patient-centered
medical home to improve coordinated efficient primary care.

The Director of the James J.  Peters VA Medical Center, Dr. Erik
Langhoff, uses technology to improve access to high-quality care for
veterans.

Dr. Mark Prather and Kevin Riddleberger with DispatchHealth and
Dr. Kristofer Smith with Northwell Health are proof positive that deliv-
ering acute medical care in the home and community improves access
and quality at a fraction of the cost.

Dr. Bruce Leff with Johns Hopkins School of Medicine showed us that
providing hospital-level care in the home to patients who qualify can
reduce care costs and produce higher-quality health outcomes.

Timothy Peck, Garrett Gleeson, and XiaoSong Mu with Call9 are con-
tributing to the well-being of patients living in skilled nursing by provid-
ing technology-enabled emergency care and palliative care around the
clock.

Dr. Mary Mittelman with the NYU Caregiver Intervention has proven
the value of supporting the informal caregiver for someone living with
dementia.

Jed Levine and Elizabeth Santiago tirelessly support those in the early
stages of dementia and their caregivers with their vigorous programs at
CaringKind.

Davina Porock impressed upon us the importance of the built envi-
ronment of the hospital for those living with dementia.

ix Acknowledgments

Karen Love and Jackie and Lon Pinkowitz remind us of the vital
importance of fighting the stigma of dementia with thoughtful
community conversations. They also noted the importance of involving
those with dementia in policy and program design.

Brian LeBlanc shared his journey of living for dementia and his stories
about his impactful advocacy efforts.

June Simmons with the Partners in Care Foundation impressed upon
us the need to combine social care and healthcare and address social
determinants of health through evidence-based prevention programs.

Sarah Szanton with CAPABLE proved that it is possible to improve
function in frail older adults by providing home modifications with nurs-
ing and occupational care to support the goals and priorities of
participants.

Joani Blank invited us into her home at the Swan’s Market cohousing
community in Oakland, California. We spent a half-day seeing how
cohousing promotes community inclusion and multigenerational
connections.

Rebecca Priest with St. John’s and the management of Beatitudes
Campus regaled us with stories of resident-run activities that facilitate
productive living and generativity.

Anne Doyle surprised us with the amount of lifelong learning  and
intergenerational connections taking place at Lasell Village, a retirement
community on the campus of a college.

Mia Oberlink formerly  with the Center for Home Care Policy and
Research impressed the importance of involving older adults in the design
of all initiatives that serve them. Ruth Finkelstein formerly  with the
Robert N. Butler Columbia Aging Center and the International Longevity
Centre USA is committed to ensuring that employers who retain and
attract older employees are honored so others will follow suit. Ruth and
Dorian Block are combating the stigma of aging by telling the stories of
older adults who exceeded life expectancy in New York City and are liv-
ing vibrant productive lives.

Lindsay Goldman with Age-Friendly NYC expressed the need for
public and private partnerships to make environments accessible to those
of all ages and abilities. She explained that older adults must be consid-
ered in all areas of city planning and policy making.

x Acknowledgments

Emi Kiyota showed us how multigenerational community hubs con-
tribute to resilience after natural disasters and serve as places of produc-
tive engagement and social inclusion.

Dr. Paul Tang, formerly with the Director of the David Druker Center
for Health Systems Innovation, uses social connections as a form of
health prevention by connecting patients to a timebank where they
exchange tasks and teaching of hobbies and new skills.

Our research was supported by the William A.  Haseltine Charitable
Foundation Trust.

xi

ACCESS Health International is an independent, nonprofit think tank
that works for the provision of high-quality, affordable care for all, includ-
ing the chronically ill. Our method is to identify, analyze, and document
best practices in helping people and to consult with public and private
providers to help implement new and better cost-effective ways to offer
care. We also encourage entrepreneurs to create new businesses to serve
the needs of this rapidly expanding population. Our goal is to inspire and
guide healthcare professionals and legislative leaders in all countries to
improve care for their own people.

About ACCESS Health International

xiii

1 Demographics 1

2 Healthcare in the United States 7

3 Long-Term Care Financing 19

4 Person-Centered Long-Term Care 29

5 Home-Based Palliative Care and Aging in Place and
Community 59

6 Coordinated Primary Care 79

7 Emergency Medicine and Hospital Care in the Home and
Community 91

8 Support for Those Living with Dementia and Their
Caregivers 117

Contents

xiv Contents

9 Merging Health and Social Services 139

10 Purpose and Social Inclusion 159

11 Eight Lessons for Social Inclusion and High-Quality
Sustainable Elder Care 203

Index 217

xv

William A. Haseltine, PhD He is the Chair and President of ACCESS Health
International. He was a professor at Harvard Medical School and Harvard
School of Public Health from 1976 to 1993, where he was founder and the chair
of two academic research departments, the Division of Biochemical Pharmacology
and the Division of Human Retrovirology. He is well known for his pioneering
work on cancer, HIV/AIDS, and genomics. He has authored more than 200
manuscripts in peer-reviewed journals and is the author of several books, includ-
ing Aging with Dignity: Innovation and Challenge in Sweden and Affordable
Excellence: The Singapore Healthcare Story.

Jean  Galiana, MASM, RCFE In her role at ACCESS Health International,
Jean Galiana successfully promoted key messages about elder care and optimal
aging to engage policy makers, healthcare providers, the general public, and
stakeholders. She managed qualitative research projects to discover, document,
and advocate for best practices in aging in the United States. Currently Jean works
in communications and survey research for Vital Research in Los Angeles,
CA. She obtained her undergraduate degree in business from Lehman College
and holds a master’s degree in aging services management from the University of
Southern California Leonard Davis School of Gerontology.

About the Authors

xvii

Fig. 1.1 Rectangularization of the global aging pyramid from 1970 to
2060 2

Fig. 1.2 Global distribution of population 65 and over in 2015 and
2050. Source: U.S.  Census Bureau, 2013, 2014a, 2014b;
International Data Base, U.S. population estimates, and U.S.
population projections 3

Fig. 1.3 Potential support ratios by region, 2015, 2030, and 2050.
Source: UN Department of Economic and Social Affairs 4

Fig. 3.1 Growth in demand for LTSS. Source: Bipartisan Policy Center 20
Fig. 4.1 Green House at Penfield 36
Fig. 4.2 Penfield Green House Great Room 36
Fig. 4.3 Mr. H’s binder 40
Fig. 4.4 St. John’s to traditional skilled nursing regional comparison 42
Fig. 5.1 Palliative care gap 70
Fig. 8.1 CaringKind entrance welcome 121
Fig. 8.2 MedicAlert® bracelet and necklace 128
Fig. 9.1 Results of HomeMeds PLUS Pilot Program. Source: Partners

in Care Foundation 147
Fig. 10.1 AdvantAge Initiative. Age-friendly Measures 176

List of Figures

1© The Author(s) 2019
J. Galiana, W. A. Haseltine, Aging Well,
https://doi.org/10.1007/978-981-13-2164-1_1

1
Demographics

The commitment of ACCESS Health International to elder care and
optimal aging is fueled by the global change in demographics. The popu-
lation over 60 is expected to double to 22 percent, reaching 2.1 billion
from 2000 to 2050.1 The demographic shift is attributed to increased life
span, lower mortality rates, declining immigration rates, and lower fertil-
ity rates. Figure 1.1 is an example of the rectangularization process from
1970 to 2060.

The 100-year shift that began in 1950 is only 17  years past its mid-
point.2 By 2060, the pyramid will resemble a dome shape. Some predict
that it will morph into the shape of a rectangle3 because, in many coun-
tries, the oldest old (85+) population is growing the fastest.4 The global
population of those 85–99 is projected to increase by 151 percent from
2005 to 2050, while the population of those 100+ is expected to increase
by more than 400 percent5 (Table 1.1).

The demographic shift is occurring at varying rates throughout the
world (Fig. 1.2). The United Nations reported that, in 2015, almost 25
percent of the world’s population 60 and over lived in China and that
only four other countries account for another 25 percent including the

2

United States, Japan, India, and the Russian Federation.6 The projected
growth rate for the over 60 population also varies from country to coun-
try, but is expected to continue to grow globally until 2060.

Potential Support Ratio

One result of the demographic shift is that there will be substantially
more older people who need care and fewer younger people to provide
the care. This care conundrum is reflected in the potential support ratio—
the number of workers (age 15–65) to the number of retirees (65+). The
potential support ratio has been declining substantially from 2000 to
2050 (Fig. 1.3).

With the shrinking potential support ratio, who will care for the grow-
ing number of older adults? Immigration is one answer, but the overarch-
ing response should be that healthcare and social support systems become

Fig. 1.1 Rectangularization of the global aging pyramid from 1970 to 2060

Table 1.1 Projected global population increase by age group 2005–2050

Age Percent increase (%)

0–64 21
65+ 104
85+ 151
100+ 400

Source: National Institute of Aging

J. Galiana and W. A. Haseltine

3

Fig. 1.2 Global distribution of population 65 and over in 2015 and 2050. Source:
U.S. Census Bureau, 2013, 2014a, 2014b; International Data Base, U.S. population
estimates, and U.S. population projections

Demographics

4

more efficient to meet the significant needs of this cohort. Informal
caregivers make invaluable contributions, but they cannot meet the com-
plex care needs of the growing older population. This care gap is further
magnified when considering the rates of comorbidity and cognitive and
functional limitations of the older population.

We will begin with some facts about healthcare in the United States
and then describe solutions to the challenges we have laid out.

Notes

1. World Health Organization (2015). Global strategy and action plan.
2. Bongaarts, J. (2009). Human population growth and the demographic

transition. Philosophical transactions of the Royal Society of London,
364(1532), 2895–2990.

3. (2014). The next America. America’s morphing age pyramid. Pew
Research Center. http://www.pewresearch.org/next-america/age-pyramid/.
Accessed March 2016.

Fig. 1.3 Potential support ratios by region, 2015, 2030, and 2050. Source: UN
Department of Economic and Social Affairs

J. Galiana and W. A. Haseltine

5

4. National Institute on Aging. Why population aging matters: A global per-
spective. Trend 3: rising numbers of the oldest old. https://www.nia.nih.
gov/publication/why-population-aging-matters-global- perspective/trend-
3-rising-numbers-oldest-old. Accessed January 10, 2016.

5. Ibid.
6. United Nations, Department of Economic and Social Affairs, Population

Division (2015). World Population Ageing 2015 (ST/ESA/SER.A/390).

Open Access This chapter is licensed under the terms of the Creative Commons
Attribution 4.0 International License (http://creativecommons.org/licenses/
by/4.0/), which permits use, sharing, adaptation, distribution and reproduction
in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, provide a link to the Creative Commons licence and
indicate if changes were made.

The images or other third party material in this chapter are included in the
chapter’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the chapter’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds
the permitted use, you will need to obtain permission directly from the copy-
right holder.

Demographics

7© The Author(s) 2019
J. Galiana, W. A. Haseltine, Aging Well,
https://doi.org/10.1007/978-981-13-2164-1_2

2
Healthcare in the United States

United States Health Spending and Outcomes

The health spending of the United States is the highest among the OECD
countries. It was 2.5 times greater than the OECD average in 2013.1
Health spending accounted for 16.4 percent of the gross domestic prod-
uct in 20132 and, in 2020, it is projected to represent 20 percent.3 By
2040 it is estimated that one third of all spending in the United States
will be on healthcare.4,5 Despite all of the spending, the health of
Americans lags behind. This is, in large part, a result of America divesting
from prevention and health promotion programs. Another contributing
factor to such poor health outcomes is that the United States does not
invest enough in building robust systems of primary care.6 Although the
United States spends close to the same amount as other Western coun-
tries on healthcare and social supports combined, the United States
spends proportionately less on social services and more on healthcare to
treat people after they become ill7 from what are often preventable dis-
eases. Adults in the United States are more likely than adults in other
developed nations to forgo necessary healthcare because they cannot
afford the cost.8 From 2010 to 2012, 54 percent of people with chronic

8

illness reported that cost was a barrier for them to access care. The patients
surveyed reported that they skipped medications, treatments, and doctor
visits because they could not afford the cost.9 Life expectancy is shorter in
the United States than most OECD countries. As of 2013 life expectancy
in the United States was 78.8, while the OECD average was 80.5.10 In
2014 the Commonwealth Fund ranked the United States healthcare last
among 11 countries.11,12 The measures included access, equity, quality,
efficiency, and healthy lives. Because of these findings, the government
and many health systems in the United States are creating new care mod-
els to address the issues of healthcare access, quality (including patient
satisfaction), and cost. Many of these innovations are designed to serve
older adults because the older cohort interacts with the healthcare system
more than others.

Our ultimate goal, after all, is not a good death, but a good life to the very
end. (Atul Gawande, Being Mortal: Medicine and What Matters in the End)

Optimal Aging

In the United States and internationally, there is a continuing focus on
community supports and inclusive societies that allow older adults to
remain active and engaged. This focus includes age-friendly cities, inclu-
sive housing, and employment opportunities. Most of the improvement
in healthcare and inclusive environments will positively affect those with
dementia, but providers and city planners are also committed to imple-
menting dementia-specific care and support measures.

Geriatric Workforce Shortage

Geriatricians are a critical factor of high-quality care for older adults. The
United States is already struggling with the ability to care for the older
population with the high rates of dementia and other chronic illnesses
and is lacking in a workforce that with appropriate training.13 According
to the American Geriatrics Society, as of 2015, the United States was

J. Galiana and W. A. Haseltine

9

short of 9500 geriatricians.14 This shortage threatens to grow as the popu-
lation ages. The World Health Organization cites that to meet the need
of the growing older population, all healthcare providers must be educated
in gerontology and geriatrics.15 Some suggest that having more geriatri-
cians in the hospital setting could reduce costs.16 This is important
because 25 percent of Medicare spending is attributable to inpatient hos-
pital care.17 Geriatricians are trained to understand and diagnose cogni-
tive problems and functional challenges with activities of daily living.
They also are knowledgeable about how drugs act differently in the aging
body and are adept at polypharmacy management. Additionally, geriatri-
cians are trained to manage multiple comorbidities and understand that
health management is often the primary focus rather than cure.

Prevalence of Chronic Disease

Longevity and lifestyle choices such as smoking, alcohol, and obesity
have contributed to people developing more chronic illnesses. The occur-
rence of multiple chronic conditions increases with age,18 which com-
pounds the burden of caring for the growing aging population. Almost
one half of older adults in America are living with both chronic condi-
tions and functional limitations.19 Eighty percent have at least one
chronic condition, and 50 percent have at least two.20 Approximately 75
percent of Americans 65 and older are living with multiple chronic
conditions21 and 20 percent are living with five or more chronic condi-
tions.22 The oldest old population (80 and older) is growing most rap-
idly23,24 and has the highest rates of comorbidity.

The number of people living with dementia is projected to increase by
more than 200 percent, from 44 million in 2014 to 135 million by 2050.25
One in nine people 65 and older have dementia. The statistics, however,
do not accurately represent the prevalence of dementia because an esti-
mated 50 to 90 percent of dementia cases go undiagnosed.26,27 The global
average rate of undiagnosed cases of dementia is 75 percent.28 The rates of
undiagnosed dementia vary from country to country. The highest rates are
found in the low- and middle-income countries.29 It is nearly impossible
to separate elder care from dementia care after the age of 75 because that

Healthcare in the United States

10

population represents 81 percent of the cases of dementia.30 As we men-
tioned, the oldest old is the population that is growing the fastest. Thirty-
two percent of that cohort have received a diagnosis of dementia.31

It is more expensive to meet the complex care needs of people with
multiple chronic conditions. Many will also need supportive help because
those with multiple chronic conditions experience higher levels of poor
functional status.32,33 Older adults who are living with five or more
chronic illnesses have, on average, 50 prescriptions and 14 different phy-
sicians and make 37 office visits annually.34 Those with multiple chronic
conditions account for 71 percent of the total healthcare spending in the
United States.35 The fee for service individuals with multiple chronic con-
ditions, who are beneficiaries of the government-sponsored Medicare,
accounts for 93 percent of the total Medicare spending.36 The unsustain-
ability of medical costs is an incentive for the Centers for Medicare and
Medicaid to support more efficient, less costly, and better quality systems
of care for the sickest people. The financial burden is also borne by people
living with multiple chronic conditions through out of pocket costs and
the high price of prescription medications.

Meeting the healthcare and social needs of the older population is a world-
wide public health challenge. To properly and sustainably meet the needs of
older adults, providers must challenge fragmented and complex care and
social support systems and implement coordinated, person- centered care
across a variety of care settings and providers. Providers must also foster
chronic disease self-management programs and other forms of patient
engagement. Two important concepts that we address throughout the book
that serve to promote higher-quality accessible care with greater patient satis-
faction at a lower cost are person-centered and value-based care.

Person-Centered Care

One theme that occurs …