Special Needs of the Older Adult

Vision

Normal aging of the visual system takes place at varying degrees, depending on genetic factors and lifestyle choices. These changes in the visual system are related to the eye structure itself and to the mechanisms of visual processing in older adults. (For a full discussion of how the visual system works, please refer to Chapter 24.)

Because vision is such a critical sensory system in humans and plays a significant role in social interactions and safety, any decrease in vision can have an impact on an older adult’s ability to engage in full participation of life. An occupational therapist may be seeing a client with low vision as a primary diagnosis or as an underlying secondary diagnosis. At times no diagnosis has yet been made, and the occupational therapist can encourage the client to see an eye care professional so that the best correction can be obtained if glasses are worn and the client’s eye health can be evaluated and addressed. Because the visual system is such a specialized sensory system in the body, it is recommended that any practitioner working in this area use the many opportunities and resources within the field of practitioners serving the blind and visually impaired.

In the older adult population it is estimated that 33% have some form of vision-reducing eye disease by the age of 65.^21,91 Normal aging in the eye creates a number of changes. As the eye ages, the cornea becomes thicker and more opaque and the lens becomes less elastic, which in turn decreases accommodation, or the ability to make a change from distance to near vision. This condition is called presbyopia. Presbyopia occurs so universally that nearly everyone older than 55 requires some type of corrective lens to be able to read.⁷⁴ The lens of the eye may also become more opaque and eventually result in a cataract. Clouding of the lens can be gradual enough that an older adult is not aware of a change in color vision and a decrease in overall vision until the disease is well advanced and occupations have been affected. The iris muscles tend to atrophy, which causes the pupil to constrict. This makes it more difficult for the eye to bring enough light in for the retina to work effectively. The macula (used for central vision), which is part of the retina, has a decreased number of cones and therefore a decrease in effective color discrimination. The rods (peripheral vision) of the retina decrease and are less sensitive. There is also a decrease in the ability to transition between light and dark. Night vision is more difficult for older adults. The need for additional light increases with each decade, and the cones need increased light to effectively discriminate colors. Contrast sensitivity also decreases because of these changes in the eye structures. All these changes in the anterior portion of the visual system make it more difficult to adjust for the changing visual requirements of life.^74,76 Because of her cataracts, Marie’s occupational therapist will need to pay close attention to components such as task lighting, visual contrast, and layout during her home evaluation. The occupational therapist can then make recommendations for changes that will decrease Marie’s likelihood of future falls and increase her likelihood of remaining at home successfully.

In addition to the natural changes in the visual system, the incidence of macular degeneration and diabetic retinopathy, which destroy central vision, is high. Any neurologic disease that affects the brain will more than likely affect the visual system. This can be seen with such diseases as multiple sclerosis and Parkinson’s disease. Peripheral vision is affected by various conditions, including glaucoma, retinitis pigmentosa, and field cuts related to acquired brain injuries such as stroke. Vision accounts for a high percentage of the sensory information that we use to participate in occupations. When visual acuity is reduced, as can occur in older adults, self-sufficiency in ADLs and IADLs may be decreased, the potential for falls is increased, and an increase in depression may be seen. It is an all-encompassing system that has an impact on every other perceptual system in the body.^53,91

When looking at vision functionally, it can be divided into central field functioning and peripheral field functioning. Each category tends to have a different impact and also different treatment goals. Central visual loss (such as is seen with macular degeneration) takes away part or all of the fine detailed vision that we use for reading, shopping, community mobility, and leisure activities.⁶³ During treatment the client should be encouraged to make an appointment with an eye doctor to provide the best prescription and to assess eye health. Something key to remember in any evaluation or treatment is that if a client wears glasses, they need to be worn to elicit the best performance.

Four keys of treatment to enhance participation are magnification, lighting, contrast, and organization. Magnification helps make the object larger on the retina so that the brain has more sensory input for processing. This may be accomplished by bringing the object closer to the client, such as with lenses, magnifiers, and electronic magnifi-cation. Because of occupational therapy’s involvement in assistive technology and with the increase in all areas of technology, electronic visual enhancement may become the most popular with the older adult population in the future. There are ways to read or to be read to that are now economically feasible for almost every client. Computers come with magnification programs already installed for those with a visual impairment. Other electronic magnification devices can be used in multiple settings to increase the ability to see functionally. Each state has an agency whose mission is dedicated to providing low-vision service for the blind and visually impaired. There are also national and local service agencies and vendors for products. The American Occupational Therapy Association has recognized low vision as an appropriate area of specialization.

Lighting is an important component of vision and includes not only the type of light but also where it is placed. It should be close to the task and in a position to avoid any glare. Glare in a room may be controlled by window dressings or changing locations in a room.

Contrast sensitivity is the ability to detect detail when gradation between an object and the background is subtle. An example might be a white banister on a white wall in a hallway that a client is unable to see or pouring coffee into a black cup. With poor contrast sensitivity, it would be impossible to discriminate between the background and the object. This has a functional impact not only on living tasks but also on mobility. Contrast and contrast sensitivity are an important part of how well someone sees to function. It is strongly associated with reading performance, mobility, driving, and face recognition.⁷⁶ Persons with central visual loss may isolate themselves from friends and family because they can no longer recognize those close to them and are embarrassed. A component of contrast sensitivity is often glare.

Organization is the fourth principle of treatment to consider. Decluttering, grouping by function, and organizing objects can eliminate what has been called “visual static.” An older adult with low vision is then able to more easily find and use the tools needed during a task.

With peripheral field loss (such as seen with glaucoma or retinitis pigmentosa), mobility becomes an issue because of loss of part of the visual field. Central vision is often spared during this disease process. With field deficits, older adults can have difficulty using their environmental context effectively and consistently. Other areas of participation that may be affected by visual field loss include driving, shopping, financial management, and meal preparation. Grooming may also be affected by field loss.⁹⁰ Many older adults with peripheral field loss are able to function independently within their living environment because they rely on the habit of navigation rather than their vision. However, the field loss becomes more apparent and function decreases when the older adult is in an unfamiliar situation. Treatment would include more effective use of scanning for detection of items. It is within occupational therapy’s scope of practice to work on mobility as related to familiar space and ADL training. Teaching of mobility outside the familiar should be referred to an orientation and mobility specialist.

Hearing

Hearing is a multistep process in which sound waves result in vibration of the eardrum and movement of the ossicles. This movement is transferred to the fluid medium of the cochlea within the inner ear. The hair cells in the cochlea turn these vibrations into nerve impulses. Any impedance such as ear wax, ear infection, or hair cells that have died will have an impact on what is perceived as sound.⁷⁴ Generally, with normal aging there is a gradual progressive loss called presbycusis. Environmental factors may contribute to an increase in this loss, as may genetic factors and gender differences. Sound seems muffled to older adults. It becomes more difficult for older adults to be able to separate background and foreground noise.⁷⁴ Hearing loss is a common chronic condition that is seen in older adults. Anywhere from 33% to 87% of the older population in the community have some form of impairment.⁶³ There is increasing evidence that in addition to the ear and its parts, the central nervous system plays a part in the ability to perceive speech in a naturalistic environment.⁹⁴ With hearing loss, participation may be limited in the area of phone use, socialization, safety, and participation. Because the sound is muffled or the older adult has difficulty separating foreground and background noise, it may take longer to process what is being said. This loss is gradual and a person often compensates through lip reading. Older adults affected by hearing loss may isolate themselves from others and stop participating and socializing with family and friends. Treatment needs to take hearing loss into consideration when recommending adaptive strategies to older adults.

Dual Sensory Loss

When one sense is impaired, the other senses are relied on more heavily to interpret social cues, physical cues, and safety cues. With both visual and hearing loss, or what is often termed dual sensory loss, the impact is that much greater. It is estimated that 23% of people older than 81 years have some degree of dual sensory impairment.⁷ Dual sensory loss is typically considered hearing and vision, although a decrease in the tactile system could also make participation and adjustment difficult for an older adult. The combination of loss in more than two sensory systems is considered multisensory loss.

• Continuation or recurrence of a condition that first emerged earlier in the person’s life

• First appearance of a disorder that was already present in latent form (e.g., a mental health liability from the past that has been exacerbated in old adulthood, as when developmental issues remain unresolved)

• New mental disorder occurring in later life

Alcohol Abuse

Alcohol abuse may be considered a hidden disease in later life because many older adults who drink alcohol, particularly men, do so at home.^50,83 Symptoms of alcohol abuse include an increased tolerance of the effects of the substance and increased consumption over time. Older adults are more susceptible to the effects of alcohol, even when they consume less of it, because of age-related changes such as decreased liver and kidney function and reduced water content and body mass. Many older adults are taking medications, and the concurrent use of alcohol and use or abuse of medications can lead to a greater risk for intoxication or toxicity. Substance abuse leads to increased accidents, greater risk for falls, poor nutrition, poor hygiene, increased mental health problems (e.g., depression, delirium, dementia, and psychosis), a higher suicide rate, higher risk for disease (e.g., liver disease, cancer, cardiovascular problems, and diabetes), and increased mortality. Physicians may not regularly question older adult clients about their drinking habits; moreover, if the client does disclose that he or she drinks alcohol, the physician may minimize the severity and consequences. Generally, heavy drinking is defined as 12 to 21 drinks per week.⁸³ The CAGE (acronym for its four questions) questionnaire is useful in screening for alcohol abuse.²² Effective interventions include self-help groups such as Alcoholics Anonymous, counseling, psychotherapy, and medications. Occupational therapists may ask older adults questions from the CAGE questionnaire. It is anticipated that alcohol abuse will increase in older adults as baby boomers age because this cohort has a greater history of alcohol abuse than the current cohort of older adults does.⁸³

Depression

The rate of major depression is relatively low—about 5% or less in older adults³¹ according to the DSM criteria of depressed mood and loss of interest or pleasure in activities, significant weight loss or gain, sleep disturbance, psychomotor agitation or retardation, fatigue, feelings of worthlessness, loss of concentration, and recurrent thoughts of death or suicide.

Older adults are less likely to report dysphoric symptoms or express hopelessness, both benchmarks for a diagnosis of major depression. The presence of depressive symptoms notwithstanding, a type of subclinical depression seems to increase with advancing age, especially in women and when symptom-based assessments are used. Depressive symptoms and syndromes have been identified in 8% to 20% of older community residents.^2,27 The symptoms (associated with depression) most frequently reported by older adults are fatigue, difficulty waking in the early morning, difficulty going back to sleep, and memory complaints. These complaints are less likely to include sadness (e.g., hopelessness, worthlessness, thoughts of death, wanting to die, and suicide), but this pattern of complaints leaves the older adult at increased risk for subsequent functional impairment, cognitive impairment, psychologic distress, and death.²⁸

Suicide is a major risk in late-life depression. Caucasian men between the ages of 60 and 85 years have an increased risk for suicide, especially if they are 85 and older, have a medical illness, or live alone. Many saw their physician within 1 month of the suicide.⁸³ Mortality from other diseases, such as heart disease and cancer, has been linked to depression.

The incidence of depression in older adults may be higher than reported because of underreporting or lack of recognition.⁴⁴ Many health care providers focus on somatic symptoms and link patient complaints to a succession of physical problems without screening for depression. Risk factors for late-life depression include persistent insomnia, unresolved and untreated grief after the death of a loved one, and structural neuroanatomic changes (e.g., enlarged lateral ventricles, cortical atrophy, increased white matter, decreased caudate size, and vascular lesions in the caudate nucleus).⁸³

Depression may increase the degree of disability associated with several medical conditions and negatively affect rehabilitation outcomes. Depression may also complicate the clinical picture of dementia or cause complaints and symptoms that are confused with dementia.⁷⁰ Depression can have a major influence on the engagement of an older adult in occupational performance areas, including ADLs, IADLs, and social participation. Older adults are not likely to seek intervention for depressive symptoms, perhaps because myths about aging create the mistaken belief that depression is inevitable and justifiable. Other barriers to intervention are lack of access to care or the need to be stoic. Occupational therapists in all geriatric settings should screen for depressive symptoms in older adults if it is not being done by other health care professionals. Screening measures include the Geriatric Depression Scale⁹⁶ and the Beck Depression Inventory.⁵

Theories abound regarding the causes of depression. One theory proposes that depression is biologic in nature and may result from medications (toxicity) and certain somatic illnesses. A second theory suggests that depression is really a reaction to the stress of illness or disability. Depression can be treated successfully with medications in most cases. Clients can return to previous energy levels and again take pleasure in life. Occupational therapists can help clients regain lost occupations, develop pleasurable and health-promoting routines, learn how to reframe events, change habits of nonproductive thinking, develop social contacts, and experience success.

Anxiety

Anxiety disorders are also common in older adults, but these conditions have received much less attention. Anxiety usually begins earlier in life and infrequently in late life, the most common disorder being a phobic anxiety disorder.⁸³ Anxiety disorders may take various forms:

Biologically based explanations for age-related anxiety suggest that it may be associated with changes in neuro-transmitters, decreased noradrenergic function, side effects of some medications, and anxiety-like symptoms of medical conditions (e.g., myocardial infarction or pulmonary embolism). Worry or “nervous tension,” rather than specific anxiety syndromes, may be more important in older adults. Anxiety symptoms that do not fulfill the criteria for specific syndromes are reported in up to 17% of older men and 21% of older women.⁸³ From a psychologic perspective, older adults may in fact have a realistic basis for their anxiety.²⁹ It is not uncommon for anxiety to coexist with depression and other mental disorders.⁸³ Anxiety may be related to concerns about pain, safety, memory loss, fear of the unknown, finances, or caregivers. Anxiety may be crippling when it interferes with attention, memory, enjoyment of pleasurable events, social skills, and the ability to begin or follow through with the therapy program.

Activities of Daily Living

ADLs have been discussed throughout the chapter as different areas of functional decline have been reviewed. One area of dysfunction is the urinary tract system, which results in incontinence. Incontinence is an problem that is difficult to talk about but frequently experienced. However, treatments are available. The likelihood of incontinence increases with older age, although it can be experienced at any age. It is often viewed as a concern for women, but men experience it as well. Clients may not bring up this problem on their own, but it can be broached in a sensitive manner by the therapist. Treatment sessions can address management of the incontinence, but referral can also be made to specialists who work in this area.

Weight loss is a trigger to assess multiple areas of occupation to see what may be contributing to the problem. An individual who has been losing weight could have difficulty chewing because of poor dentition or ill-fitting dentures, swallowing, or feeding, and an occupational therapist or speech therapist may be able to help remedy the problem. However, older adults may also be losing weight because of difficulty preparing meals, transporting food within the kitchen, grocery shopping, or getting to the store or restaurant or because they do not like eating alone but have become isolated during mealtime. They may also have difficulty sitting comfortably at the table or maintaining an appropriate posture for feeding and eating.

Functional mobility should always be assessed carefully because many older adults experience changes in this area. Falls frequently take place during the course of routine daily activities, such as entering the bathroom or putting dishes away in the kitchen. Marie fell while reaching for a towel, an activity that she performed every day. Over the course of time, however, this familiar activity had indeed become dangerous as Marie experienced a decline in her balance and more arthritic pain in her knees. Marie had not adapted her techniques for functional mobility as her abilities changed, which placed her at higher risk for falls and injury.

An older adult may use an assistive device for mobility, although it may not be used all the time. Sometimes individuals are self-conscious in public and may use a cane or walker only at home. Others feel comfortable walking in their home environment or using the furniture to help maintain their balance at home but will use a device when walking long distances. It is important to ask each client about a variety of situations to ensure an understanding of how the client maneuvers in different settings.

Older adults are more likely to have a number of assistive devices. Hearing aids, glasses, shoe orthotics, reachers, and many other devices may be part of the daily routine for an older adult. Care of these items may become more difficult as clients experience changes in their body structures and functions. For example, manipulation of a hearing aid for cleaning may become difficult, and the client may fear dropping it. Declines in vision that require glasses may make it more difficult to see when the glasses are dirty or whether the prescription needs to be adjusted. It is important to not only ask about but also observe a client caring for personal devices to accurately determine when intervention is necessary.

Personal hygiene and grooming can become more difficult in later years because of potentially impaired sensory functions and range of motion. For example, it is difficult to pluck a whisker when it cannot be seen or to trim toenails when clients cannot reach their feet. However, just because grooming is difficult does not mean that it is not important to an individual. An occupational therapist can go through the grooming routine and needs with clients and help them identify alternative strategies to accomplish these tasks. Marie’s occupational therapist made a recommendation for using a magnifying mirror with a light so that Marie could see better to apply her makeup. Marie’s therapist also worked with her to find grooming tools, such as a hairbrush and a toothbrush, that had wider handles to reduce the pain in Marie’s hands and improve her grip during self-care. Toilet hygiene may also become challenging, and an apparent lack of hygiene may be due to difficulty performing the task rather than inattention or lack of caring.

Older adults may still be sexually active. This is an important area of human interaction but also a very sensitive one to discuss. Many conditions that older adults may experience can affect their sexual activity. Individuals who have just suffered a heart attack may be concerned about whether their cardiovascular system can handle the stress of sexual activity, or a person who has just undergone a hip replacement may wonder whether there are any safe positions that will not endanger the healing hip. This may be a difficult subject for a client to bring up, so a comprehensive occupational therapy program will include questions to broach the subject, should the client wish to discuss such concerns (please see Chapter 12 or individual chapters addressing the aforementioned diagnoses for more detailed discussion).

Instrumental Activities of Daily Living

Older adults often provide care for others, be they a spouse, a grandchild, a pet, or a friend. Health events can interrupt clients’ performance of these activities and even cause them to question long-held roles. Rehabilitation care is often focused on a client’s ability to maintain self-care, but it is imperative that the occupational therapist understand other potential caregiving roles in the client’s life. Treatment can then incorporate a focus that helps the client return to independence in care of others or find ways to adapt these tasks or seek assistance.

Community mobility can be a very sensitive subject for many older adults who are used to being independent in getting where they want to go when they want to go there. Driving can become more difficult for many different reasons, from visual impairment to cognitive deficits and limited range of motion. The occupational therapist is often called on to assist in evaluating whether an older adult is still safe to drive. There are driving specialists, many of whom are occupational therapists, who can assess everything from the fit between client and car to whether the client demonstrates safe skills for on-the-road driving. In many situations, referral to one of these specialists is appropriate. Some older adults, such as Marie, have already curtailed driving but may not be aware of other community mobility resources, such as public transportation or low-cost van service. In Marie’s town there was a senior services van that provided low-cost, conveniently scheduled transportation to locations within the city limits. Marie’s occupational therapist helped teach her how to sign up for and use this van, which helped Marie regain independence within her community. When assessing other areas of occupation, such as religious observance or shopping, it is important to also assess community mobility. Participation in some areas of occupation may have declined simply because it has become too difficult to get to the necessary location.

A comprehensive occupational therapy program will address safety and emergency maintenance. This includes preparedness, such as having a list of emergency contacts near the phone and the client carrying a cordless phone at home. Especially for older adults, this also includes knowing what to do in case of a fall. Training in how to fall, how to assess oneself after a fall, and how to safely maneuver on the ground and call for assistance is invaluable for an older adult and can be taught by the occupational therapist or assistant.

Community-based occupations, such as going to the pharmacy, out to eat, or to the grocery store, can be intimidating to an older adult who has experienced a health event. In some rehabilitation settings it may be possible to work with the client in actual community settings to help restore both independence and confidence. Marie and her occupational therapist used the senior van service to take a trip to the grocery store, where Marie had a chance to implement the joint protection techniques that she learned in the clinic within a real community setting. Even when such outings are not possible, treatment within a facility can and should replicate components of these occupations.

Rest and Sleep

Sleep can be a difficult area of occupation for older adults, partially in light of the natural changes in body structure and function. However, it may also be due to occupational imbalance and can be addressed by the occupational therapist. Assessment of sleep preparation includes whether clients can make their bed, close the curtains so that early morning light does not awaken them, and lock the doors to feel secure. Assessment of sleep participation includes whether the client can use the bathroom during the course of the night or monitor the safety of a spouse who might wander during the early morning. These areas are very appropriate for an occupational therapy treatment program to address.

Work

Although many individuals retire at the age of 65, many are also still employed. When performing an initial evaluation it is important to ascertain the client’s employment status and to be prepared to address the area of work in treatment if it is still part of the client’s life. Volunteer work is also often part of an older adult’s repertoire of occupations and is just as important as paid employment. Paid and volunteer work may present the need to do on-site community evaluations so that the client can prepare for re-engaging in these occupations. The occupational therapist may also be called on to help the client in retirement preparation or adjustment so that the transition is as smooth as possible.

Leisure

Leisure activities are an important part of daily life for older adults. However, they can be difficult to address directly in treatment because of many third party payer restrictions regarding treatment goals. Nonetheless, it is often possible to incorporate a client’s leisure interests into treatment activities to enhance participation and carryover, even if there is no direct goal for these activities. In the skilled nursing environment, it may be possible to design a functional maintenance program for a client that involves recreation activities to address particular functional or treatment goals as well (see Chapter 16 for more information).

Social Participation

Engaging in activities with others is critical for older adults but can also become more difficult. Changes in transportation options can affect whether a person can participate in community activities, as can concerns about whether a location has adequate lighting, handrails to help with balance, crowds that may jostle the older adult, accessible bathrooms, or easily understood directions and instructions. The occupational therapist can be of particular assistance in assessing a community environment and making recommendations for adaptation to promote the participation and independence of older adults. Incorporation of family and friends into treatment, as directed by the client, can also help ease concerns about what a client can safely do and can often support increased client participation in social activities.

Two well-known studies, the USC Well Elderly Study^16,35,54 and the Wellness Program for Older Adults,⁵⁵ have demonstrated that occupational therapy intervention that addresses prevention efforts for older adults living in the community enhances ADLs, IADLs, physical and mental health, occupational functioning, and life satisfaction. Because occupational therapists and assistants play a role in the very personal aspects of an older adult’s life, they can address modification of components of occupations that are important to an older adult either in a group setting or in individual treatment before it becomes problematic for the older adult. This can be done through a community model and results in an overall increase in participation by older adults and an increase in quality of life.

• Adults need to understand the reasoning behind the learning.

• Adult learners bring a breadth of experience and knowledge to learning situations.

• Adults are willing and ready to learn whatever is necessary.

• Adults are typically pragmatic and willing to learn things that will help them in day-to-day experiences.

• The greatest motivator is internal pressure.

• Processing of information takes longer than it does for younger adults.

• Elaboration of information involves making connections between the new information and building on or making additional associations to existing knowledge.

• Strategies that group information in an organized way promote effective storage.

• Attending to the internal and external contextual factors during the learning process and recreating these contextual factors for later retrieval significantly improve remembering.

• Using stored information repeatedly strengthens the pattern of connections by rehearsing, using, and practicing.

• Providing cues that offer opportunities for recognition or matching information with previously learned information is more effective than not providing external associational cues and expecting free recall of information.

Review Questions

1. Agency for Health Care Policy and Research. Recognition and initial assessment of Alzheimer’s disease and related dementias: Clinical Practice Guideline No. 19, AHCPR Publication No. 97-0702. Bethesda, Md: Public Health Service, U.S. Department of Health and Human Services, Agency for Health Care Policy and Research; 1996.

2. Alexopoulos, GS, Meyers, BS, Young, RC, et al. Vascular depression hypothesis. Arch Gen Psychiatry. 1997;54(10):915–922.

3. American Occupational Therapy Association. Occupation therapy practice framework: domain and process, 2nd edition. Am J Occup Ther. 2008;62(6):625–683.

4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

5. Beck, A, Steer, R. Beck Depression Inventory manual. San Antonio, Tex: The Psychological Corp; 1987.

6. Bengtsson, T, Lindstrom, M. Childhood misery and disease in later life: the effects on mortality in old age hazards experienced in early life, southern Sweden, 1760-1894. Popul Stud (Camb). 2000;54(3):263.

7. Bergman, B, Rosenthal, U. Vision and hearing loss in old age. Scand Audiol. 2001;30:255.

8. Brashers, VL. Structure and function of the pulmonary system. In McCance KL, Huether SE, Brashers VL, Rote NS, eds.: Pathophysiology: the biologic basis for disease in adults and children, ed 6, Maryland Heights, Mo: Mosby, 2010.

9. Burns, E, Goodwin, J. Immunodeficiency of aging. Drugs Aging. 1997;11(5):374.

10. Campbell, JE, Herge, EA. Challenges to aging in place: the elder adult with MR/DD. Phys Occup Ther. 2000;18(1):75.

11. Carlson, JC, Riley, JC. A consideration of some notable aging theories. Exp Gerontol. 1998;33(1-2):127.

12. Craik, F, Jennings, J. Human memory. In: Craik FC, Salthouse TA, eds. The handbook of aging and cognition. Hillsdale, NJ: Erlbaum, 1992.

13. Cristofala, V. The destiny of cells: mechanisms and implications of senescence. Gerontologist. 1985;25:577.

14. Curb, JD, Ceria-Ulep, CD, Rodriguez, BL, et al. Performance-based measures of physical function for high-function populations. J Am Geriatr Soc. 2006;54:737.

15. Deeg, D, Kardaun, J, Fozard, J. Health, behavior and aging. In Birren JE, Schaie KW, eds.: Handbook of the psychology of aging, ed 4, San Diego, Calif: Academic Press, 1996.

16. Clark, F, Azen, SP, Zemke, R, et al. Occupational therapy for independent-living older adults. JAMA. 1997;278(16):1321–1326.

17. Crimmins, EM. Trends in the health of the elderly. Annu Rev Public Health. 2004;25:79.

18. Crimmins, EM, Saito, Y, Ingegneri, D. Trends in disability-free life expectancy in the United States, 1970-90. Popul Dev Rev. 1997;23(3):555.

19. Crowther-Radulewicz, CL. Structure and function of the musculoskeletal system. In McCance KL, Huether SE, Brashers VL, Rote NS, eds.: Pathophysiology: the biologic basis for disease in adults and children, ed 6, Maryland Heights, Mo: Mosby, 2010.

20. Donovan, ML, Corcoran, MA. Description of caregiver uplifts and implications for occupational therapy. Am J Occup Ther. 2010;64(4):590.

21. Ellexson, MT. Access to participation: occupational therapy and low vision. Top Geriatr Rehabil. 2003;20(3):154.

22. Ewing, J. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252(14):1905.

23. Ferrini, AF, Ferrini, RL. Health in the later years, ed 3. Boston, Mass: McGraw-Hill; 2000.

24. Finch, CE, Crimmins, EM. Inflammatory exposure and historical changes in human life-spans. Science. 2004;305:1736.

25. Fitzpatrick, KE, Vacha-Haase, T. Marital satisfaction and resilience in caregivers of spouses with dementia, Clin. Gerontologist. 2010;33(3):165.

26. Folstein, MF, Folstein, MF, McHugh, PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189.

27. Gallo, JJ, Lebowitz, BD. The epidemiology of common late-life mental disorders in the community: themes for a new century. Psychiatr Serv. 1999;50(9):1158.

28. Gallo, JJ, Rabins, PV, Lyketsos, CG, et al. Depression without sadness: functional outcomes of nondysphoric depression in later life. J Am Geriatr Soc. 1997;45(5):570–578.

29. Gatz, M, Kasl-Godley, J, Karel, M. Aging and mental disorders. In Birren JE, Schaie KW, eds.: Handbook of the psychology of aging, ed 4, San Diego, Calif: Academic Press, 1996.

30. Gatz, M, Smyer, M. Mental health and aging at the onset of the twenty-first century. In Birren JE, Schaie KW, eds.: Handbook of the psychology of aging, ed 5, San Diego, Calif: Academic Press, 2001.

31. Gurland, BJ, Cross, PS, Katz, E. Epidemiological perspectives on opportunities for treatment of depression. Am J Geriatr Psychiatry. 1996;4(Suppl 1):S7.

32. Hayflick, L. New approaches to old age. Nature. 2000;403:365.

33. Inouye, SK, Fearing, MA, Marcantonio, ER. Delirium. In: Halter JB, Ouslander JG, Tinetti ME, et al, eds. Hazzard’s geriatric medicine and gerontology. New York, NY: McGraw-Hill, 2009.

34. Inui, TS. The need for an integrated biopsychosocial approach to research on successful aging. Ann Intern Med. 2003;139(5):391.

35. Jackson, J, Carlson, M, Mandel, D, et al. Occupation in lifestyle redesign: the Well Elderly Study occupational therapy program. Am J Occup Ther. 1998;52(5):326–336.

36. Jeste, DV, Alexopoulos, GS, Bartels, SJ, et al. Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next 2 decades. Arch Gen Psychiatry. 1999;56(9):848–853.

37. Karp, JF, Reynolds, CF, Butters, MA, et al. The relationship between pain and mental flexibility in older adult pain clinic patients. Pain Med. 2006;7(5):444.

38. Kausler, DH. Learning and memory in normal aging. San Diego, Calif: Academic Press; 1994.

39. Keysor, JJ, Kette, AM, Haley, SM. Development of the Home and Community Environment (HACE) instrument. J Rehabil Med. 2005;37:37.

40. Kitzman, DW, Taffet, G. Effects of aging on cardiovascular structure and function. In McCance KL, Huether SE, Brashers VL, Rote NS, eds.: Pathophysiology: the biologic basis for disease in adults and children, ed 6, Maryland Heights, Mo: Mosby, 2009.

41. Knowles, M. The adult learner: a neglected species. Houston, Tex: Gulf Publishing; 1984.

42. Koncelik, JA. The human factors of aging and the micro-environment: personal surroundings, technology and product development. In: Windley P, Scheidt R, eds. Physical environments and aging: critical contributions of M. Powell Lawton to theory and practice. Philadelphia, Pa: Haworth Press, 2003.

43. Law, M. Participation in the occupations of everyday life. Am J Occup Ther. 2002;56(5):640.

44. Lebowitz, B, Pearson, J, Schneider, L. Diagnosis and treatment of depression in late life: consensus statement update. JAMA. 1997;278(14):1186.

45. Letts, L. Assessing safe function at home: the SAFER tool. AOTA Home Community Health SIS Q. 1995;2(1):1.

46. Levy, L. Cognition and the aging adult, ed 2. Bethesda, Md: American Occupational Therapy Association; 1996.

47. Levy, L. Cognitive aging in perspective: implications for occupational therapy practitioners. In Katz N, ed.: Cognition and occupation across the life span: models for intervention in occupational therapy, ed 2, Bethesda, Md: American Occupational Therapy Association, 2005.

48. Levy, L. Cognitive aging in perspective: information processing, cognition and memory. In Katz N, ed.: Cognition and occupation across the life span: models for intervention in occupational therapy, ed 2, Bethesda, Md: American Occupational Therapy Association, 2005.

49. Levy, L. Information processing and dementia. II: cognitive disability in perspective. OT Pract. 1999;10:CE-1.

50. Levy, L. Mental disorders in aging adults, ed 2. Bethesda, Md: American Occupational Therapy Association; 1996.

51. Liebig, PS. Using home modifications to promote self-maintenance and mutual care: the case of old-age homes in India. In: Taira ED, Carlson JL, eds. Aging in place: designing, adaptation, and enhancing the home environment. New York, NY: Haworth Press; 1999:79–99.

52. Loeser, RF, Jr., Delbono, O. Aging of the muscles and joints. In Halter JB, Ouslander JG, Tinetti ME, et al, eds.: Hazzard’s geriatric medicine and gerontology, ed 6, New York, NY: McGraw-Hill, 2009.

53. Lotery, AJ, Wiggam, MI, Jackson, AJ, et al. Correctable visual impairments in stroke rehabilitation patients. Age Aging. 2000;29:221.

54. Mandel, DR, Jackson, JM, Zemke, R, et al. Lifestyle redesign. Bethesda, Md: American Occupational Therapy Association; 1999.

55. Matuska, K, Giles-Heinz, A, Flinn, N, et al. Outcomes of a pilot occupational therapy wellness program for older adults. Am J Occup Ther. 2003;57(2):220–224.

56. McNulty, MC, Johnson, J, Poole, JL, Winkle, M. Using the transtheoretical model of change to implement home safety modifications with community-dwelling older adults: An exploratory study. Phys Occup Ther Geriatr. 2003;21(4):53.

57. Miller, B. Theories of aging. In Lewis CB, ed.: Aging: the health care challenge, ed 4, Philadelphia, Pa: Davis, 2002.

58. National Research Council. Structure of the aging mind. In: National Research Council: The aging mind: opportunities for cognitive research. Washington, DC: National Academy Press; 2003.

59. Nicolle, LE. Urinary tract infections. In McCance KL, Huether SE, Brashers VL, Rote NS, eds.: Pathophysiology: the biologic basis for disease in adults and children, ed 6, Maryland Heights, Mo: Mosby, 2009.

60. Oeppen, J, Vaupel, JW. Broken limits to life expectancy. Science. 2002;296:1029.

61. Orgel, L. The maintenance of the accuracy of protein synthesis and its relevancy to aging. Proc Natl Acad Sci U S A. 1963;49:517.

62. Orgel, L. The maintenance of the accuracy of protein synthesis and its relevancy to aging. Proc Natl Acad Sci U S A. 1973;67:1496.

63. Perlmutter, MS, Bhorade, A, Gordon, M, et al. Cognitive, visual, auditory, and emotional factors that affect participation in older adults. Am J Occup Ther. 2010;64(4):570.

64. Petersen, RC, Smith, GE, Waring, SC, et al. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol. 1999;56(3):303–308.

65. Pfeffer, RI, Kurosaki, TT, Harrah, CH, Jr., et al. Measurement of functional activities in older adults in the community. J Gerontol. 1982;37(3):323–329.

66. Pizzi, MA. Promoting health and occupational participation with caregivers. In: Scaffa ME, Reitz MA, Pizzi M, eds. Occupational therapy in the promotion of health and wellness. Philadelphia, Pa: Davis, 2010.

67. Pizzi, MA, Smith, TM. Promoting successful aging through occupation. In: Scaffa ME, Reitz MA, Pizzi M, eds. Occupational therapy in the promotion of health and wellness. Philadelphia, Pa: Davis, 2010.

68. Pynoos, J, Caraviello, R, Cicero, C. Lifelong housing: the anchor in aging-friendly communities. Generations J Am Soc Aging. 2009;33(2):26.

69. Pynoos, J, Nishita, C, Perlman, L. Advancements in the home modification field: a tribute to M. Powell Lawton. J Housing Elderly. 2003;17(1/2):105.

70. Reifler, B. Detection and treatment of mixed cognitive and affective symptoms in the elderly: is it dementia, depression or both? Clin Geriatr. 1998;6:17.

71. Rusting, R. Why do we age? Sci Am. 1987;267(6):130.

72. Sabata, D. Home and community health context: what does the environment mean to occupation? AOTA Home Community Health SIS Q. 2004;11(2):1.

73. Sabata, D. Home modifications: applying evidence to practice. AOTA Home Community Health SIS Q. 2005;12(2):3.

74. Sandmire, DA. The physiology and pathology of aging. In Robnett RH, Chop WC, eds.: Gerontology for the health care professional, ed 5, Boston, Mass: Jones & Bartlett, 2010.

75. Saxon, SV, Etten, MJ, Perkins, EA. Physical change and aging: a guide for the helping professions. New York, NY: Springer; 2010.

76. Scheiman, M, Scheiman, M, Whittaker, SG. Low vision rehabilitation: a practical guide for occupational therapists. Thorofare, NJ: Slack; 2007.

77. Seeman, T, Crimmins, EM, Huang, M-H, et al. Cumulative biological risk and socio-economic differences in mortality: MacArthur Studies of Successful Aging. Soc Sci Med. 2004;58:1985–1997.

78. Smith A, ed. Memory. San Diego, Calif: Academic Press, 1996.

79. Stark, SL, Somerville, EK, Morris, JC. In-home occupational performance evaluation (I-HOPE). Am J Occup Ther. 2010;64(4):580.

80. Stevenson, MR, Hart, PM, Montgomery, A-M, et al. Reduced vision in older adults with age related macular degeneration interferes with ability to care for self and impairs role as carer. Br J Ophthalmol. 2004;88(6):1125.

81. Strehler, B. A new age for aging. Nat Hist. 1973;2:8.

82. Sugerman, RA. Structure and function of the neurologic system. In McCance KL, Huether SE, Brashers VL, Rote NS, eds.: Pathophysiology: the biologic basis for disease in adults and children, ed 6, Maryland Heights, Mo: Mosby, 2009.

83. www.surgeongeneral.gov/library/mentalhealth.

84. Tabert, MH, Albert, SM, Borukhova-Milov, L, et al. Functional deficits in patients with mild cognitive impairment: prediction of AD. Neurology. 2002;58(5):758–764.

85. United States Administration on Aging. Census data and population estimates. 2000 census, 2008, retrieved 04-20-2010 from http://www.aoa.gov/OaORoot/Aging_Statistics/Census_Population/Index.aspx.

86. United States Administration on Aging. Census data and population estimates. data on aging, most recent population estimates, national, 2011, retrieved 01-23-2011 from http://www.aoa.gov/AoARoot/Aging_Statistics/Census_Population/Index.aspx.

87. United States Administration on Aging. Projected future growth of the older population by age. 1900-2050, older population as a percentage of the total population, 2008, retrieved 04-20-2010 from http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth.aspx.

88. United States Bureau of the Census. Sex by age by types of disability for the civilian non-institutionalized population 5 years and over. Curr Popul Rep. 2000.

89. Walford, R. The clinical promise of diet restriction. Geriatrics. 1990;45(4):81.

90. Warren, M. Pilot study on activities of daily living limitations in adults with hemianopsia. Am J Occup Ther. 2009;63(5):626.

91. Watson, GR. Low vision in the geriatric population: rehabilitation and management. J Am Geriatr Soc. 2001;49(3):317.

92. Wilcock, A. Population health: An occupational rational. In: Scaffa ME, Reitz MA, Pizzi M, eds. Occupational therapy in the promotion of health and wellness. Philadelphia, Pa: Davis, 2010.

93. Weiner, DK, Rudy, TE, Morrow, L, et al. The relationship between pain, neuropsychological performance, and physical function in community-dwelling older adults with chronic low back pain. Pain Med. 2006;7(1):60.

94. Wong, CM, Ettlinger, M, Sheppard, JP, et al. Neuroanatomical characteristics and speech perception in older adults. Ear Hear. 2010;31(4):471.

95. Yaffe, K, Blackwell, T, Gore, R, et al. Depressive symptoms and cognitive decline in nondemented elderly women. Arch Gen Psychiatry. 1999;56:425.

96. Yesavage, JA, Brink, TL, Rose, TL, et al. Development and validation of a geriatric depression scale: a preliminary report. J Psychiatr Res. 1982-1983;17(1):37–49.