Posted: December 3rd, 2014

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.

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