Falls Presentation

Report
Prevent Those Slips and Falls:
Tips for Assessment and Strategies to Prevent Falls
• Peggy McConnell, GNP-BC
• Rhonda Brodrick, MSN, RN
College of Nursing
• Mike Stoots, Ed. D.
College of Public Health
East Tennessee State University
This project was partially supported by grant number UB4HP19051-02-00 from the
Department of Health and Human Services Health Resources and Services
Administration (HRSA). Contents are solely the responsibility of the authors and do
not necessarily represent the official views of HRSA.
1
Some Falls are funny!
2
Most Falls are Not
3
Objectives
At the conclusion of this session, participants will be
able to:
• Describe the reasons falls are of special concern in the older adult
population.
• Identify the possible results of falls in the older adult population.
• Identify intrinsic and extrinsic factors that increase the older
adults' risks for falls.
• Describe Level A and Level B categories of evidence-based
interventions that reduce fall risk in older adults.
• Recognize resources that will help provider/agency build a stronger
fall prevention program.
4
Definition of Fall
A fall is defined as unintentionally coming to rest on the ground or
other lower level in a way that is not the result of a major intrinsic
event (i.e., heart attack, stroke, or seizure) or an overwhelming
external hazard (i.e., hit by a vehicle).
5
Why are falls important?
The answer to this question incorporates data from several
sources:
•
•
•
•
•
Demographics
Significance of falls
Healthy People 2020
Results of falls
Potential for Prevention
6
By 2030 almost 70 million which is
double the 35 million in 2000
Population over 65
(In millions)
80
2010 – First baby
boomers hit 65
70
1900
1920
60
1940
1960
50
1970
1980
40
2000
2010
30
20
2020
10
2030
0
E
L
N E
1900
1920 1940 1960 1970 1980 2000 2010 2020 2030
C
Year
Administration on Aging, 2000
7
Demographics
• All nations are facing an aging population.

Increasing life expectancy in the U.S. (Male/Female)
U.S. National Center for Health Statistics

U.S. Census Bureau prediction

“The world is aging so fast that within a decade there will be more
people 65 and older than children under 5 for the first time”
8
Demographics
In the United States, the elderly population is
expected to be 20% of the total population by 2030.
The Old-Old (greater than 85) cohort is the fastest growing
cohort.
9
How significant is the problem?
• Falls are the leading cause of injury death and nonfatal injury in older adults.
• One out of three people age 65 and older living in the
community will fall each year
• Those who fall at least twice are twice as likely to fall
again
• The majority of those who fall do not seek medical
attention
• Fall risk increases as age increases.
10
How significant is the problem?
• Of those who fall, 20% to 30% suffer moderate to severe
injuries that make it hard for them to get around or live
independently and increase their chances of early death
• Falls are the most common cause of traumatic brain injuries
• The most common fractures are of the spine, hip, forearm,
leg, ankle, pelvis, upper arm, and hand
• Complications resulting from falls are the number one cause
of death from injury in both men and women aged 65 and
older.
11
Quiz
12
Click the
Quiz button to edit this quiz
Growing Public Health Concern
• Healthy People 2020 identifies fall prevention as a major focus.
• Also identified as major focus by National Council on Aging
(NCOA), Administration on Aging (AoA), American Geriatrics
Society (AGS), Center for Disease Control (CDC), Medicare and
Medicaid (CMS), US Preventive Services Task Force
13
Results of Falls
• Morbidity
• Health Care
Utilization
• Mortality
• Physical Function
• Independence
14
Fear of Falling
Many people who fall, even those who
are not injured, develop a fear of falling.
This fear may cause them to
limit their activities, leading to
reduced mobility and physical
fitness, which increases their
actual risk of falling.
15
Results of Falls
Hip fractures are the most frequent type of fallrelated fractures.
• The cost of hospitalization for hip fracture averaged about
$18,000 and accounted for 44% of direct medical costs for
hip fractures.
• After a hip fracture
• 2-3 times more likely to die within one year
• 25% in a nursing home one year later
16
Results of Falls
• According to the CDC
• In 2000, the total direct medical costs of all fall injuries for people
65 and older exceeded $19 billion: $0.2 billion for fatal falls, and
$19 billion for nonfatal falls.
• Costs are expected to increase as the population ages.
• By 2020, the annual direct and indirect cost of fall injuries is
expected to reach $54.9 billion (in 2007 dollars).
17
So Why Do Older Adults Fall?
• Because of their comorbidities, causes of falls in
older adults are rarely due to a single cause.
• Two Major Cause Categories
• Intrinsic (inside the body or personal)
• Extrinsic (environmental)
• Most falls result from a complex interaction
between individual and environmental factors
18
Intrinsic (Individual)
Risk Factors for Falls
• Gender
• females at greater risk than males
• Age
• risk increases significantly for 80 and older
• Impaired information interpretation and/or judgment
• mild cognitive impairment, dementia, Alzheimer disease
• Impaired sensory input
• diminished vision and/or hearing
• Functional impairment
• lower extremity weakness, alterations in gait and balance,
diminished reflexes, delayed reaction response
19
Intrinsic (Individual)
Risk Factors for Falls
• Medical Conditions:
• Diabetes
• Cardiovascular - Orthostatic or post-prandial
hypotension, Hypertension, Dysrhythmias, Heart
Failure
• Pulmonary – pneumonia, COPD
• Foot problems - bunion, callous, toenails
• Neurological – Stroke, Parkinson disease
• Nutrition Deficits - Low body mass index, decreased
intake of protein and nutrients
• Altered urinary function – infection, incontinence
• Depression
20
Extrinsic (Environmental)
Risk Factors for Falls
• About half of falls are
precipitated by an environmental
hazard
21
Extrinsic (Environmental)
Risk Factors for Falls
• Medications
• As the number of medications increases, the risk of medication
reactions, interactions, and side effects increases.
• Fall risk increases with polypharmacy (use of 4 or more medications)
and the use of psychoactive medications (tranquilizers,
antidepressants)
 Alcohol Consumption
 Increased risk of interaction between
medications and alcohol
 Heavy alcohol consumption (> 14
drinks/week) shown to be associated
with increased falls
22
Extrinsic (Environmental)
Risk Factors for Falls
Courtesy Walt Disney Studios
The majority of older adults desire to remain in their own
homes
‣ Most live in “Peter Pan” Homes - Designed for those that
never grow old!
‣ The majority of older homes have multiple hazards.
‣ Older adults are often unaware of the hazards in their
homes.
‣ Biggest challenges for older adults are multiple steps/stairs
and unsafe bathrooms.
23
Extrinsic (Environmental)
Risk Factors for Falls
Environmental hazards:
• Poor lighting
• Slippery surfaces
• High-gloss floors
• Stair hazards
• Clutter
• Storage problems
• Tripping hazards
• Pets/pet-related objects
• Improper use of
equipment
24
Farming and Falls
40% of farmers in US are above the age of 55
25
Older Farmers
• Webinar on “Older Farmers and Falls” at the following
OVAR/GEC web download:
http://www.mc.uky.edu/aging/documents/gec/Webinar%203
%20Mental%20Health%20-Reed51112.pptx
• Information on agricultural safety as it pertains to
preventing fall related injuries in farm workers
http://www.nasdonline.org/document/208/d000006/pre
venting-injuries-from-slips-trips-and-falls.html
26
Risk Factors for Falls
• Research has shown that fall risk increases
greatly when the number of risk factors
increases from 1 to 4 or more.
• Age related changes can decrease the ability to
avoid a fall after encountering a hazard or
unexpected trip.
27
Quiz
28
Click the
Quiz button to edit this quiz
What Can We Do?
Newly published evidence based guidelines:
‣ January 2010 - American Geriatric Society and the British
Geriatric Society published the most current AGS/BGS
Clinical Practice Guideline: Prevention of Falls in Older
Persons
‣ December, 2010 - US Preventive Services Task Force
addressed primary care interventions to prevent falls in
older adults
Michael YL, et al "Primary care–relevant interventions to prevent falling in older adults: A systematic evidence review for the
U.S. Preventive Services Task Force" Ann Intern Med 2010; 153: 815-825.
29
What Can We Do?
Evidence-based guidelines stress:
• Recognition of the risk factors that lead to
increased falls
• Assessment to identify those at risk for falls.
• Intervening to address the modifiable risk factors
30
Screening for Falls in the Acute and
Long Term Care Environments
 Complete scheduled assessments with the
screening tools designated by the facility’s fall
protocol
 Two frequently used fall screening tools
◦ Hendrich II Fall Risk Module
◦ Morse Falls Scale
31
Screening for Falls in the Community
The American Geriatric Society (AGS) recommends providers ask
about falls at least once a year
 Have you:
◦ Fallen two or more times?
◦ Fallen and hurt yourself?
◦ Been afraid that you would fall because of a balance or walking
problem?
If the answer is yes to any of these questions, a multifactorial fall risk
assessment should be completed.
 The report of a single fall requires (at minimum) a gait and
balance evaluation.
32
Positive Screening . . . Now what?
• Regardless of whether the client
is in an inpatient facility or in the
community, more information is
needed
• In order to intervene effectively,
an in-depth assessment is needed
to identify the problem area(s)
What is included in a multi-factorial fall assessment?
33
Client’s Fall History
 History of falls – Have you fallen before? What
were the circumstances of your fall(s)? Have you
had injuries resulting from a fall?
 Medication review – What prescription and over
the counter medications do you take? Do you
use any herbal supplements?
 History of relevant risk factors – Do you have
acute or chronic medical problems such as an
infection or arthritis?
34
Physical Observations
• Cognitive Function – judgment, evidence of acute or
chronic confusion
• Sensory Deficits – vision and hearing
• Cardiovascular Function – heart rate and rhythm,
postural pulse, postural blood pressure
• Musculoskeletal Function - muscle strength, gait,
balance, mobility levels, reflexes, lower extremity joint
function
• Extremities – signs of trauma, examination of the feet
and footwear
35
Functional Assessment
• Independence in activities of daily living (ADL)
skills
• Katz Index of Independence of ADL
• Need for assistive devices
• Appropriate use of assistive devices currently in
use
• Exploration of fear related to falling
36
Environmental Assessment
• Check for Safety: A Home Fall
Prevention Checklist for Older Adults
Developed by the CDC through support from the
CDC and MetLife Foundations
Retrieved at:
http://www.cdc.gov/HomeandRecreationalSafety/F
alls/CheckListForSafety.html 1/28/13
Check for Safety PDF
37
Gait Assessment
 Frequently used tests of gait or balance
include:
 Get up and Go test (Mathias, (1986);
 Timed Up and Go test (Podsiadlo et al,1991),
 Berg Balance Scale (Berg et al, 1989),
 Performance-Oriented Mobility Assessment
(Tinetti 1986; Tinetti et al 1988).
 Gait and Balance can readily be assessed by
the “Get Up and Go Test” which is
demonstrated on the following slide.
38
Gait Assessment
39
Gait Assessment
• Patients who take less
than 10 seconds are
usually considered
normal.
• Patients who take
longer than 30
seconds tend to need
assistance with many
mobility tasks.
40
Gait Abnormalities






Inability to stand
without use of hands
Unsteadiness upon
standing
Short steps
Asymmetry
Wide-based gait
Slow gait


Deconditioning, hip or knee
pain
Orthostatic hypotension,
balance problems, weakness

Weakness, Parkinson disease
Stroke, Arthritis

Fear, balance problems


Fear of Falling, weakness,
PVD, COPD, CHF
41
Quiz
42
Click the
Quiz button to edit this quiz
General Interventions for Fall Prevention
 Acute or Long Term Care
◦ Scheduled screenings to
identify those at risk
◦ Environmental Assessment
to identify/correct hazards
◦ Maintain client mobility
◦ Educate caregivers (staff &
family)
◦ Individualized safety
measures
 Community
◦ Annual screening (at
minimum)
◦ Medication review
◦ Home hazard assessment
◦ Educate client/caregivers
◦ Address visual deficits
43
American Geriatric Society Clinical
Practice Guideline Interventions Level “A”
 Evidence Based Practice Level “A” Interventions
(Good evidence was found that the intervention improves health
outcomes and the conclusion is that benefits substantially outweigh
harm.)
◦
◦
◦
◦
◦
◦
◦
Individualized Fall Risk Assessment
Identify Fall Risks
Home Environment Assessment by HCP
Home Environment Modification
Direct Implementation of Interventions by HCP
Exercise
Vitamin D Supplementation
44
American Geriatric Society Clinical
Practice Guideline Interventions Level “B”
• Evidence Based Practice Level “B” Interventions
(At least fair evidence was found that the intervention improves health
outcomes and the conclusion is that benefits outweigh harm.)
•
•
•
•
Medication Modification
Cataract Surgery if Indicated
Treatment of Postural Hypertension
Dual Chamber Pacing if Indicated
• To prevent syncope
• PDF Version of Guidelines
45
US Preventive Services Task Force
Community-dwelling adults:
• In older, community-dwelling adults, interventions that
appear effective in preventing falls include exercise or
physical therapy and vitamin D supplementation.
• In older, community-dwelling adults, interventions to
prevent falls are not associated with significant adverse
events.
• Source link USPSTF
46
Exercise Programs (Level A)
Strong recommendation for activities that
increase balance, strength and gait training
(AGS & USPSTF)
• Numerous studies support the use of exercise programs in
conjunction with other interventions
• Campbell (1999), Steinberg (2000), Tinetti (1994), Clemson (2004),
and Day (2002)
• Exercise needs to be sustained for at least 6 months to be
effective
•
AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons, January 2010. retrieved at
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendati
ons/2010/ 3-15-10
47
Exercise Programs
• Physical Therapy for strengthening and
balance and gait training
• Evidenced based community health
promotion programs such as A Matter of
Balance, Otago, Stepping On, and Tai Chi:
Moving for Better Balance
• Others
http://www.ncoa.org/improve-health/center-for-healthy-aging/fallsprevention/community-programs.html
48
Exercise Programs (Level A)
http://go4life.nia.nih.gov/exercise-guide-video
http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/default.htm
49
Exercise Programs (Level A)
Yoga
There is growing evidence
that yoga can improve
physical well-being,
including balance, range of
motion, blood pressure,
pain, fatigue, and general
health.
50
Other Evidence-Based Community
Exercise Programs Supported by
Administration on Aging (AoA)
• Tai Chi Moving for Better Balance http://www.ncoa.org/improvehealth/center-for-healthy-aging/tai-chi-moving-for-better.html
• A Matter of Balance http://www.mmc.org/mh_body.cfm?id=432
• Stepping on
http://steppingon.com/
• Otago
http://www.cdc.gov/HomeandRecreationalSafety/Falls/compendiu
m/1.2_otago.html
51
Tai Chi and Qigong
Recent updates to the American
Geriatrics Society show that activities
such as Tai Chi are recommended as
part of the exercise component of fall
prevention interventions.
52
Benefits of Tai Chi
Benefits of targeted, meditative movements may include:
• Increased physical activity, improved balance and quality of
life
• Delayed functional decline
• Improvement in chronic health conditions (arthritis, blood
pressure)
• Perceived improvements in psychological well-being and
quality of life
• Increased social support
53
Tai Chi
54
Games to Improve Muscle
Strength and Balance
• Wii Fit
• Wii Games such as bowling
55
Vitamin D Supplements
(Level A) AGS & USPSTF
• Vitamin D deficiency impairs muscle strength and
neuromuscular functioning
• At least 800 IU per day for those with proven Vitamin
D deficiency
• Consider a supplement if a deficiency is suspected or
the client is at risk for fall
The American Geriatrics Society. (2010). AGS/BGS Clinical Practice Guideline:
Prevention of Falls in Older Persons
56
Modify Home Environment
(Level A)
• Arrange for a home environmental
assessment by a health care provider
(HCP)
• Structural Challenges
• Safety Hazards
57
Modifying “Peter Pan” Housing
58
Modifying “Peter Pan” Housing
• Limit throw rugs
• Remove extension cords and other tripping hazards
• Make sure stairs have handrails and are safe
• Installation of safety equipment
• Lowered light switches, raised outlets, wider doors, ramps, grab
bars
59
Things are not always as they seem!
‣ Moving furniture is
generally not
recommended unless
it poses a definite fallrisk hazard.
‣ We have "cognitive
maps" of our
environment; that is,
we are able to
maneuver in our home
environment with eyes
closed.
60
Bathroom Modifications
Large percentage of falls occur in the bathroom
•
•
•
•
Grab bars
Non-skid rugs
Shower adapters
Elevated seating surfaces
61
Medication Modification
(Level B) AGS

Keep the total number
of medications
(prescription and over
the counter) as low as
possible.

Eliminate or replace
medications that are
known to be associated
with increased falls.
62
Medications Associated with
Increased Falls (Level B)
•
•
•
•
•
•
Antipsychotics
Antidepressants
Benzodiazepines
Some Antihypertensives
Diuretics
NSAIDS
•
Woolcott, J. (2009). Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Archives of Internal Medicine
169, 1952-1960.
63
Improve Visual Acuity
(Level B) AGS
• Assess vision at regular intervals
• Expedite cataract surgery
• Educate older adults NOT to wear
multifocal lenses while descending
stairs
• In a study by Harwood et al.
(2005) there was a 40% decrease
in falls post cataract surgery
64
Manage Postural Hypotension
(Level B) AGS
• Encourage older adults to increase fluid intake if not
contraindicated by chronic health issues
• Remind older adults to change positions slowly
• Sit for few minutes before standing
• Stand for a few minutes before walking
• Regularly review blood pressure medications
• Use of multiple BP medications may increase risk of falls
65
What else can we do?
• Educate the older adult population
• Pain Management
• Manage foot problems/footwear
• Stay informed of new information and
technology
66
When Targeting Older Adults
•
•
•
•
•
Keep messaging positive
Don’t use fear-based messaging
Stress maintaining independence
Avoid using term “exercise”
Keep fall prevention tips – easy, fun, doable,
inexpensive
• Frame as a “life span issue” not an aging issue
• Debunk fall myths
Schneider, E.C. (2009). Falls Prevention Awareness: Findings and Lessons Learned
from State Coalitions on Falls Prevention. National Council on Aging, Washington,
D.C. http://www.ncoa.org/improve-health/center-for-healthy-aging for publication
67
Education
• Education about fall prevention
needs to be tailored to the
individual
• Do not focus on single interventions

Educate on safe performance of
daily activities

Individually tailored exercise
programs

Learn how to fall

Create a fall safe environment
68
Everyone falls so learning to fall safely is vital.
69
70
Education: Learn How to Get Up After A Fall
If everyone falls, then we must learn to get up safely.
71
Education: Learn How to Get Up After A Fall
72
Education:
Assistive Devices
• Often used incorrectly by older adults
• Ask where the device came from (PT, family
member, neighbor, etc.)
• Canes should be used on the “good” side
• Height of walkers and canes should be
about the level of the wrist
73
• May need a referral to PT for evaluation
and training in correct use.
Pain Management
• Leveille et. al. (2009)
• Pain is associated with a 1.5 fold increase in falls.
• Chronic pain produces more falls than acute pain.
• Those with two or more sites of pain had higher rates
of falls.
• In
 In comparison to pain free
people, those in severe
pain have a 77% increased
risk of falls and those with
mild pain have a 36%
increased risk of falls.
74
Pain Management
• How do you treat the pain
without causing higher risk of
falls?
• Do we have an answer?
• No, finding a balance between
pain relief and increasing fall
risk is very difficult!
75
Manage foot problems/Footwear
• Bunions, toe deformities, ulcers, and
deformed nails predispose the elderly
to falls (Tinetti et al., 1988)
• Elderly may have trouble knowing foot
position
76
Manage foot problems/Footwear
• Inspect feet regularly for
problem areas.
• Wear shoes that fit and are
laced or buckled.
• Avoid high heels, backless or
slip-on shoes, and shoes with
worn soles.
77
• Use anti-slip pads on soles.
Quiz
78
Click the
Quiz button to edit this quiz
Multifactorial Intervention
to Prevent Falls
79
Falls Case for Community Setting
78 y o Ms. J. fell early this morning in her bathroom. She lives alone in a
small one bedroom apartment in public housing. She did not have a fracture
but did develop a large bruise on her right thigh. Ms. J. is recovering from
pneumonia and had recently returned from the hospital where she received 3
days of IV antibiotics and then was discharged home to complete the
antibiotics orally. She has a medical history of hypertension as well as Type 2
Diabetes Mellitus. She is on multiple medications including a diuretic. She
uses a walker sometimes.
She said that since returning from the hospital she has had difficulty sleeping
because of her cough and has been taking Benadryl 25 mg which she picked
up over the counter several months ago.
80
As clinician, drawback to
following AGS recommendations
• Lack of knowledge of available assessment tools
• Lack of knowledge of evidence based
interventions
• Time factor in short office visit setting
• Cost
• Resources
• Lack of adequate reimbursement
81
Examples of New Technologies and
Devices that address injury reduction
• Nonskid socks:
http://www.rehabmart.com/category.asp?cat=Fall_Prevention
• Safe environments:
http://www.environmentalgeriatrics.com/
• Smart Homes:
• Georgia Tech Aware Home
• ADT QuietCare
82
Other Resources
• A Matter of Balance: Managing Concerns about Falls www.mainehealth.org/pfha or call your local Area
Agency on Aging at 1-877-353-3771 (toll free)
A Tool Kit to Prevent Senior Falls www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm , fall fact
sheets, brochures, publications from the CDC.
• No Falls Kentucky http://www.nofalls.org/ website
offers resources for seniors and their families as well as
professionals
83
Other Resources
• Falls Free Initiative National Council on Aging
http://www.ncoa.org/improve-health/center-forhealthy-aging/falls-prevention/falls-free-initiative.html
• Easy-Exercise and Screening for youwww.easyforyou.info
• Fall Prevention Center of Excellence- www.stopfalls.org
• Home Safety Council - www.homesafetycouncil.org
84
Other Resources
• National Council on the Aging-Center for Healthy Aginghttp://www.ncoa.org/improve-health/center-forhealthy-aging/
• National Institute on Aging Information Center
• www.nia.nih.gov/healthinformation/publications
• http://go4life.nia.nih.gov/exercise-guide-video
• National Institute on Health Senior Healthwww.nihseniorhealth.gov
• National Resource Center for Safe Agingwww.safeaging.org/default.asp
85
Falls Free Coalitions (HCP, public health, aging
services and others to address fall prevention)
42 states:
www.ncoa.org/fallsmap
86
Things to watch for in future
• Falls Prevention Awareness Day, first day of Fall
each September – this year 46 states participated.
Theme “Standing Together to Prevent Falls”
• Stopping Elderly Accidents, Deaths, and Injuries 2012 (STEADI Tool
Kit) based on AGS clinical guidelines CDC STEADI Site This toolkit
will have resources for self assessment, clinicians and education.
• View Ehrenreich-NCOA-Webinar-08-14-2012(PDF)
• Geriatric Education Center initiatives on Falls Prevention
• NCOA, CDC, AoA, Archstone activities and research to decrease falls
• Welcome to Medicare Physical and Yearly Physicals for Medicare
participants
87
National Falls Prevention
Awareness Day
• National Falls Prevention Awareness Day is observed the first day
of Fall (September 22 , 2012) to promote and increase public
awareness about how to prevent and reduce falls among older
adults. (46 states this year)
Website has multiple promotion resources www.ncoa.org/FPAD
• Falls Prevention Awareness: Findings and Lessons Learned from
State Coalitions on Falls Prevention. National Council on Aging
View PDF
• www.stopfalls.org Falls Prevention Center of Excellence with fall
prevention ideas and resources
88
STEADI Tool Kit “What is it?”
• The Stopping Elderly Accidents, Deaths, and Injuries (STEADI)
toolkit is a evidence-based comprehensive approach to
reducing falls in the elderly through clinicians based on
American Geriatrics Society Guidelines (AGS).
• The STEADI toolkit contains suggestions on how to talk to
patients, training materials, provider resources, and patient
educational materials for both assessment and intervention
strategies to prevent falls in the community.
• Scheduled to be available December 2012 :
http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/i
ndex.html
• Centers for Disease Control. (August 28, 2012). Using STEADI
for Screening, Fall Risk Assessment, and Care Management
(webinar): View PDF
89
Falls are a growing public
health issue
During this hour presentation:
• Two Older Adults died due to a fall.
• 240 Older Adults were treated in the ED for fallrelated injury
…But many falls are preventable!
Interventions can successfully reduce the rate of
falls and improve quality of life for our older
adults.
National Council on Aging, May 2012
90

similar documents