Me nta l He a lth Ne e ds of F a mily Ca re g ive rs: Ide ntifying - - PowerPoint PPT Presentation

Me nta l He a lth Ne e ds of F a mily Ca re g ive rs: Ide ntifying , E ng a g ing a nd Assisting

Sponsore d By:

U.S. Administra tio n o n Ag ing & Ame ric a n Psyc ho lo g ic a l Asso c ia tio n Se pte mb e r 14, 2011

U.S. DE PART ME NT OF HE AL T H AND HUMAN SE RVICE S, ADMINIST RAT ION ON AGING, WASHINGT ON DC 20201

PHONE 202.619.0724 | F AX 202.357.3523 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

Willia m E . Ha le y, Ph.D.

Sc ho o l o f Ag ing Studie s Unive rsity o f So uth F lo rida wha le y@ usf.e du http:/ / a g ing studie s.c b c s.usf.e du/ fa c ulty/ wha le y.c fm

T

• da y’s T

a lk

• Who a re c a re g ive rs a nd wha t do the y do ?
• I

mpa c t o f c a re g iving o n he a lth a nd me nta l he a lth

• K

e y fa c to rs fo r c a re g ive r stra in vs. re silie nc e

• E

ffe c tive inte rve ntio ns fo r c a re g ive rs

F unda me nta ls— c a re g iving is inc re a sing ly c ommon

• 52 millio n info rma l a nd fa mily c a re g ive rs

pro vide c a re to so me o ne a g e d 20+ who is ill

• r disa b le d
• 34 millio n a dults invo lve d in c a re g iving to

pe rso ns a g e d 50 o r o ve r

• 8.9 millio n info rma l c a re g ive rs pro vide c a re

fo r so me o ne a g e d 50+ with de me ntia

Family Caregiver Alliance, http://www.caregiver.org

F unda me nta ls of c a re g iving

• Mo st fa mily c a re g ive rs a re wo me n; spo use s

a nd da ug hte rs; “info rma l” (unpa id)

• AD c a re g iving , 60 ho urs pe r we e k a t ho me ; 9

ho urs e ve n a fte r NHP; 5-10 ye a r “c a re e r”

• Ho spic e lung c a nc e r c a re g ive rs, o ve r 100

ho urs pe r we e k

• Diffe re nc e s with o the r c o nditio ns a nd

disa b ilitie s (DD, stro ke , SCI , MCI )

Pe rc e nt of U.S. House holds With Ca re g ive rs by E thnic ity/ Ra c e

RETRIEVED FROM: HTTP://WWW.CAREGIVING.ORG/DATA/CAREGIVING_IN_THE_US_2009_FULL_REPORT.PDF

Wha t do c a re g ive rs do?

• “Wha te ve r it ta ke s”
• Ma y ra ng e fro m o c c a sio na l a ssista nc e to full-

time c a re

• I

nc lude s physic a l c a re , sympto m ma na g e me nt, e mo tio na l suppo rt, he lp with a c tivitie s o f da ily living

• I

nc lude s suppo rt while c a re re c ipie nt is in a fa c ility

• Co nc e pt o f “c a re g iving c a re e r”

Aneshensel et al., 1995

The Caregiving Career

Continued Depression/ Reengagement Distress Recovery Relief Psychological Appraisal Health Effects Initiate IADL CG Expand ADL CG Placement CG/ CR Trajectory Minor Benign Psychiatric/ Physical Morbidity Distress Death

Chronic Stre ss T ra je c tory in Ca re g iving

Death

Schulz, 2010

Ca re g ive r re ports of the most stre ssful pa tie nt proble ms in de me ntia

• Da ng e ro us b e ha vio r
• Ge tting lo st
• E

mb a rra ssing b e ha vio r

• Wa king the c a re g ive r
• Ag ita tio n, re stle ssne ss
• Ang e r, suspic io usne ss
• De pre ssio n
• No t me mo ry pro b le ms o r ADL

pro b le ms, inc o ntine nc e

Haley et al., 1987

Ca re g iving , He a lth, & Me nta l He a lth

• Hig h CG stra in a sso c ia te d with 63%

inc re a se d mo rta lity (vs. no nCG & lo w stra in)

• Hig h pe rc e ptio n o f CG stra in (vs. no o r lo w

stra in) a sso c ia te d with 12% inc re a se in stro ke risk

• AD c a re g ive rs sho w slo we r wo und he a ling
• Ca re g ive rs with hig h stra in sho w inc re a se d

de pre ssio n

Schulz & Beach, 1999; Haley et al., 2010; Kiecolt-Glaser et al., 1995; Pinquart & Sorensen, 2003; Roth et al., 2009

Re c e nt re sults

F ro m o ur surve y o f 43,099 a dults o ve r 45:

• Are yo u c urre ntly pro viding c a re o n a n o ng o ing

b a sis to a fa mily me mb e r with a c hro nic illne ss o r disa b ility?

– 12% sa y ye s

• Ho w muc h o f a me nta l o r e mo tio na l stra in is it o n

yo u to pro vide this c a re ? (no ne , so me , a lo t)

– 33% re po rt no stra in, 49% “so me ” stra in, 18% “a

lo t” o f stra in

Roth et al., 2009

Re la tionship of Ca re g iving Stra in to De pre ssive Symptoms

0.00 0.50 1.00 1.50 2.00 2.50 3.00 Non Caregivers No Strain Moderate Strain High Strain CESD - 4 Depression Roth et al., 2009

Ca re g iving a nd the Stre ss Proc e ss

• Prima ry stre sso rs—pa tie nt c a re
• Se c o nda ry stre sso rs—spillo ve r e ffe c ts
• Co nte xtua l stre sso rs—life g o e s o n
• Stre ss a ppra isa l—a ffe c te d b y pe rc e ive d

re so urc e s

• Psyc ho so c ia l re so urc e s c a n inc lude inte rna l

(kno wle dg e , c o ping , pe rso na lity, spiritua lity) a nd e xte rna l (so c ia l suppo rt, fina nc e s, se rvic e s)

Ca re g iving : A Ba la nc ing Ac t

Other chronic strains and life events Internal coping resources External coping resources Secondary stressors Primary caregiving stressors

Perkins et al., 2007

Ca re g ive r inte rve ntion c a n:

• De c re a se stre sso rs (lig hte n the lo a d)
• Alte r a ppra isa ls (Ho w b a d the stre sso rs a re ,

a nd wha t pe rc e ive d re so urc e s pe o ple ha ve to c o pe )

• T

e a c h skills o r in o the r wa ys b uild inte rna l re so urc e s

• Pro vide o r ra lly e xte rna l re so urc e s

E ffe c tive ne ss of de me ntia c a re g ive r inte rve ntions

• Psyc ho so c ia l inte rve ntio ns fo r CGs impro ve

multiple o utc o me s: b urde n, de pre ssio n, we ll- b e ing , a b ility/ kno wle dg e , a nd CR sympto ms

• CB the ra py & psyc ho e duc a tio na l inte rve ntio ns

(PI s) with a c tive CG pa rtic ipa tio n b e st a t impro ving CG de pre ssio n

• PI

s with a c tive CG pa rtic ipa tio n b e st a t impro ving multiple o utc o me s

• Mo re limite d e ffe c ts fo r suppo rt, re spite

Pinquart & Sörensen, 2006

Common type s of inte rve ntions

• Psyc ho e duc a tio na l—te a c h c a re g ive rs

info rma tio n a nd skills in ma na g ing de me ntia

– Distinc tio n, a c tive pa rtic ipa tio n vs. info rma tio n

• nly
• Suppo rt—Unstruc ture d, e mpha size

suppo rt fro m me mb e rs

• Co g nitive b e ha vio r the ra py—fo c us o n

c a re g ive r e mo tio na l re a c tio ns, te a c h wa ys to ma na g e c a re g ive r re a c tio ns

• Re spite / a dult da y c a re

0.1 0.2 0.3 0.4 0.5 0.6 0.7 Psyed Active Psyed Info Respite CB Therapy Support

Effect sizes for depression

Pinquart & Sörensen, 2006

T he NYU inte rve ntion

• 406 c a re g ive rs ra ndomly a ssig ne d to usua l

c a re or a n inte nsive c a re g ive r inte rve ntion prog ra m a t NYU

• 2 se ssio ns individua l c o unse ling
• 4 fa mily se ssio ns
• suppo rt g ro up me mb e rship
• a d ho c c o unse ling witho ut limit
• De sc ribe d in de ta il in a book

Mittelman et al, (2002)

8 9 10 11 17 35 52

W eeks Depressive Symptoms

Usual Care Treatment

Mittelman et al., 2004

7 8 9 10 11 52 104 156 208 260

Weeks Depressive Symptoms

Usual Care Treatment

Mittelman et al., 2004

Re sults- - e ffe c ts on NHP

• Our a na lyse s sho w tha t, with lo ng e r

dura tio n o f fo llo w up, the de la y in nursing ho me pla c e me nt in the tre a tme nt g ro up is 557 da ys, c o mpa re d with pre vio usly re po rte d de la y o f 329 de la ys

• Me dia n c o st o f NH c a re in F

lo rida is c urre ntly o ve r $75,000 pe r ye a r

Mittelman et al., 2006

Mittelman et al., 2006

Be yond “e ffic a c y”, to “e ffe c tive ne ss” studie s

• Curre nt tria ls tra nsla ting e vide nc e b a se d

inte rve ntio ns into c o mmunity using RE ACH, NYU, & ST AR-C pro to c o ls

• ST

AR-C pro to c o l (tra ins c a re g ive rs in b e ha vio ra l ma na g e me nt)

• Use d c o mmunity pra c titio ne rs to tra in

c a re g ive rs

• Ra ndo m a ssig nme nt to ST

AR-C ve rsus usua l c a re

Burgio et al., 2009; Teri et al., 2005

Re sults

• Community c onsulta nts we re a ble to le a rn a nd

a dhe re to the be ha viora l tre a tme nt protoc ol. Ca re g ive rs re c e iving ST AR- C tra ining showe d sig nific a nt improve me nts a t 6 month follow up in:

– De pre ssion – Burde n – Re a c tivity to be ha vior proble ms in the c a re re c ipie nt. – Ca re re c ipie nts a lso showe d be ne fits, inc luding :

• De c re a se d fre que nc y a nd se ve rity of be ha vior proble ms
• improve d c a re re c ipie nt qua lity of life .

Teri et al., 2005

Conc lusion

• Hig h stra in c a re g ive rs a t inc re a se d risk fo r

de pre ssio n a nd he a lth pro b le ms

• I

nte rve ntio n fo r c a re g ive rs ha s the po te ntia l to pro duc e lo ng la sting , life c ha ng ing , b e ne fits fo r c a re g ive rs

• Po te ntia l to sa ve c o sts a nd to minimize the

lo ng te rm da ma g e to c a re g ive rs’ live s

• I

mpo rta nt to b uild CG re so urc e s a nd do mo re to inc re a se c a re g ive rs’ a c c e ss to e ffe c tive inte rve ntio n

Me nta l He a lth Ne e ds of F a mily Ca re g ive rs: Ide ntifying , E ng a g ing a nd Assisting

Que stions?

Re fe re nc e s

• Ane she nse l, C. S., Pe a rlin, L

, I., Mulla n, J. T ., Za rit S. H., & Whitla tc h C. J. (1995) Pr

• file s in Car

e giving: T he Une xpe c te d Car e e r .

• Burg io, L

. D., Collins, I. B., Sc hmid, B., Wha rton, T ., Mc Ca llum, D., & De c oste r, J (2009). T ra nsla ting the RE ACH c a re g ive r inte rve ntion for use by a re a a g e nc y on a g ing pe rsonne l: T he RE ACH OUT prog ra m. T he Ge r

• ntologist, 49, 103–116.
• Ha le y, W.E

., Brown, S.L ., & L e vine , E .G. (1987). F a mily c a re g ive r a ppra isa ls of pa tie nt be ha viora l disturba nc e in se nile de me ntia . Clinic al Ge r

• ntologist, 6, 25- 34.
• Ha le y, W. E

., Roth, D. L ., Howa rd, G., & Sa fford, M. M. (2010). Ca re g iving stra in a nd e stima te d risk for stroke a nd c orona ry he a rt dise a se a mong spouse c a re g ive rs: Diffe re ntia l e ffe c ts by ra c e a nd se x. Str

• ke , 41, 331- 336.
• Kie c olt- Gla se r JK, Ma ruc ha PT

, Ma la rke y WB, e t a l. (1995). Slowing of wound he a ling by psyc holog ic a l stre ss. T he L anc e t, 346, 1194- 1196.

Re fe re nc e s

• Mitte lma n, M.S., E

pste in, C., & Pie rzc ha la , A. (2002). Counse ling the Alzhe ime r ’s Car e give r , A Re sour c e for He alth Car e Pr

• fe ssionals.

Chic a g o: AMA Pre ss.

• Mitte lma n, M., Ha le y, W. E

., Cla y, O., & Roth, D. L . (2006). Improving c a re g ive r we ll- be ing de la ys nursing home pla c e me nt of pa tie nts with Alzhe ime r dise a se . Ne ur

• logy. 67, 1592- 1599.
• Mitte lma n, M., Ha le y, W. E

., Cla y, O., & Roth, D. L . (2006). Improving c a re g ive r we ll- be ing de la ys nursing home pla c e me nt of pa tie nts with Alzhe ime r dise a se . Ne ur

• logy. 67, 1592- 1599.
• Mitte lma n, M., Roth, D., Coon, D., & Ha le y, W. E

. (2004). Susta ine d be ne fit of supportive inte rve ntion for de pre ssive symptoms in Alzhe ime r’s c a re g ive rs. Ame r ic an Jour nal of Psyc hiatr y, 161, 850- 856.

• Pe rkins, E

. A., L ynn, N., & Ha le y, W. E . (2007). Ca re g ive r issue s a ssoc ia te d with wa nde ring . In A. Ne lson & D. Alg a se (E ds.) E vide nc e base d pr

• toc ols for

managing wande r ing be havior

• s. (pp. 123- 142).

Ne w York: Spring e r.

Re fe re nc e s

• Pinqua rt, M., & Söre nse n, S. (2006). He lping c a re g ive rs of pe rsons with

de me ntia : Whic h inte rve ntions work a nd how la rg e a re the ir e ffe c ts? Inte r national Psyc hoge r iatr ic s, 18, 577- 595.

• Pinqua rt, M. & Söre nse n, S. (2003). Diffe re nc e s be twe e n c a re g ive rs

a nd nonc a re g ive rs in psyc holog ic a l he a lth a nd physic a l he a lth: A me ta - a na lysis. Psyc hology and Aging, 18, 250- 267.

• Roth, D. L

., Pe rkins, M., Wa dle y, V. G., T e mple , E ., & Ha le y, W. E . (2009). F a mily c a re g iving a nd e motiona l stra in: Assoc ia tions with psyc holog ic a l he a lth in a na tiona l sa mple of c ommunity- dwe lling middle - a g e d a nd olde r a dults. Quality of L ife Re se ar c h, 18, 679- 688.

• Sc hulz, R. S. (2010) Disc ussa nt c omme nts. Pre se nte d a s pa rt of a

symposium, “Popula tion- Ba se d studie s of stroke a nd informa l c a re g iving : T he RE GARDS a nd CARE S proje c ts” (D. L ., Roth, Cha ir), Ge rontolog ic a l Soc ie ty of Ame ric a me e ting s, Ne w Orle a ns, L

• uisia na .

Re fe re nc e s

• Sc hulz, R., & Be a c h, S.R. (1999). Ca re g iving a s a risk fa c tor for

morta lity: T he Ca re g ive r He a lth E ffe c ts Study. Jour nal of the Ame r ic an Me dic al Assoc iation, 282, 2215- 2219.

• T

e ri, L ., Mc Curry, S. M., L

• g sdon, R., & Gibbons, L

. E . (2005). T ra ining c ommunity c onsulta nts to he lp fa mily me mbe rs improve de me ntia c a re : A ra ndomize d c ontrolle d tria l. T he Ge r

• ntologist, 45, 802–811.

Ba rry J. Ja c obs, Psy.D.

Cro ze r-K e ysto ne F a mily Me dic ine Re side nc y Pro g ra m, Spring fie ld, PA b a rryja c o b s4@ c o mc a st.ne t www.e mo tio na lsurviva lg uide .c o m

T

• da y’s T

a lk

• Ho w to g e t the m in the do o r – o ve rc o ming

b a rrie rs to pro viding suppo rt se rvic e s to fa mily c a re g ive rs

• Ho w to g e t the m to he lp the mse lve s –
• ve rc o ming re luc ta nc e to re a c h o ut fo r a nd

a c c e pt suppo rt

• Whe n to re fe r to a me nta l he a lth spe c ia list

“I’m a n a nxious wre c k a t work”

• Do n, 46-ye a r-o ld, Afric a n-Ame ric a n ma n

se e king psyc ho the ra py fo r a nxie ty a nd “c a re e r b urno ut”

• Ha s wo rke d fo r 15 ye a rs in hig h-vo lume ,

hig h-pre ssure jo b a s b a nk a dministra to r

• But thinks c o nsta ntly a b o ut his mo the r with

COPD, disa b le d a nd a lo ne in he r ho me

• Ca lls he r 5 time s during the c o urse o f e a c h

da y a nd the n visits he r a fte r wo rk

Ba rrie rs to Re c e iving Ca re g ive r Support

• Ha s ne ve r he a rd o f a n Are a Ag e nc y o n

Ag ing o r fa mily c a re g ive r suppo rt pro g ra m

• No t sure wha t fa mily c a re g iving is
• Do e sn’ t think o f himse lf a s a fa mily c a re g ive r
• Mo the r wa nts no se rvic e s b e c a use she

do e sn’ t like stra ng e rs in he r ho me

• F

a mily do e sn’ t ta ke “ha ndo uts”

Cha lle ng e of Outre a c h

• Do n wo n’ t b e lo o king fo r fa mily c a re g ive r

suppo rt g ro up

• I

f I re fe r him to a fa mily c a re g ive r suppo rt g ro up (e spe c ia lly e a rly o n in his tre a tme nt with me ), he wo n’ t g o

• Ho w do we e ng a g e him in the pro c e ss o f

se e king suppo rt fo r himse lf a nd his mo the r

Outre a c h (c ont.)

• T
• re a c h so ns like Do n, we ha ve to g o b e yo nd

a dve rtising c a re g ive r se rvic e s. T wo ide a s:

1. Co mmunity e ve nts tha t de fine a nd no rma lize b e ing a stre sse d-o ut c a re g ive r witho ut b e ing e xplic itly “c a re g ive r” o r “suppo rt” e ve nts. E duc a tio na l se ssio ns o n ta king c a re o f a n a g ing pa re nt (Ca re g ive r Mo nth); o n dise a se spe c ific s (e .g ., de me ntia ) tha t c o ve rs fa mily impa c t

Outre a c h (c ont.)

• 2. Ma ke g re a te r use o f prima ry c a re po rta l

“Ma king the L ink” – a Na tio na l Asso c ia tio n o f Are a Ag e nc ie s o n Ag ing (n4a ) pro g ra m – so me suc c e ss b ut no t la sting Othe r mo de ls – No rthe rn Ca lifo rnia Ca re Ne two rk fo r De me ntia 0 fa xe d re fe rra ls fro m physic ia n o ffic e s – wo rke d we ll NYUCI in Prima ry Ca re – c a re g ive r c o unse lo r in Ve rmo nt prima ry c a re o ffic e s – g o o d da ta

E nc oura g ing Se lf- Ca re

• Ca re g ive rs a re no to rio us fo r ne g le c ting the ir
• wn ne e ds
• Do n wo uld ne ve r ha ve so ug ht se rvic e s if his

physic ia n ha dn’ t twiste d his a rm a nd if he wa sn’ t a t risk o f lo sing his jo b

• T

e lling c a re g ive rs tha t ta king c a re o f the mse lve s will b e tte r e na b le the m to c a re fo r the ir lo ve d o ne s is o f limite d e ffe c tive ne ss

Se lf- Ca re (c ont.)

• T

hre e I de a s: Ma ra tho n Me ta pho r; Ho no ring the Missio n; Re c e iving with Gra c e

• Ca re g iving a s a ma ra tho n:
• Ha ve to tra in to le a rn to pa c e o ne se lf
• Ha ve to le a rn the up-hills a nd do wn-hills o f

the la y o f the la nd (dise a se )

• Ha ve to le a rn to re ple nish a lo ng the wa y
• All a re e sse ntia l – o r do n’ t finish the ra c e

Honoring the Mission

• So lic it the sto ry o f g iving c a re
• Avo id pre ma ture a dvic e -g iving
• I

nq uire a b o ut me a ning o f c a re g iving in c a re g ive r’ s life

• I

de ntify a nd ho no r the c a re g ive r’ s se nse o f missio n

• Ra ise issue o f susta ina b ility
• I

nq uire a b o ut so urc e s o f suste na nc e

• http:/ / www.ro sa lynnc a rte r.o rg / E

BP_links/

Re c e iving with Gra c e

• Assumptio n: Mo st o f us wo uld ra the r g ive

tha n re c e ive

• But running b e st ra c e me a ns ta king in

suste na nc e , utilizing suppo rt

• Spiritua l tra ditio ns o f se e ing g iving in

re c e iving – o ffe ring o the rs the b le ssing o f do ing g o o d

• http:/ / www.ro sa lynnc a rte r.o rg / E

BP_links/

Me nta l He a lth Re fe rra l

• Ma jo rity o f c a re g ive rs will ne ve r ne e d fo rma l

me nta l he a lth se rvic e s

• Who do e s? T

ho se who a re so de pre sse d, a nxio us, a ng ry (a b usive ), g uilty tha t it is a ffe c ting the ir c a pa c ity to func tio n e ffe c tive ly a nd to pro vide a de q ua te c a re

• I

ssue o f se ve rity

Re fe rra l (c ont.)

• “Ca re g ive r b urno ut”: dre a d, te nsio n,

irrita b ility, a ng e r, fa tig ue , sa dne ss, disturb e d sle e p, diffic ulty thinking c le a rly a nd ma king de c isio ns

• Ofte n a pre c urso r to Ma jo r De pre ssive

Diso rde r (MDD)

• Do n is a nxio us, distra c te d a nd jumpy a ll da y

lo ng ; fra g me nte d sle e p a t nig ht

Re fe rra l (c ont.)

• MDD – sa dne ss, la c k o f e njo yme nt, sle e p

a nd a ppe tite disturb a nc e s, e xc e ssive g uilt, lo w se lf-e ste e m, fa tig ue , diffic ulty ma king de c isio ns, tho ug hts a b o ut dying ; a lso a nxie ty, so c ia l withdra wa l

• Ofte n disa b ling
• Psyc ho the ra py a nd drug tre a tme nts

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

Re fe rra l (c ont.)

• I

f po ssib le , re fe r to a c a re g ive r-sa vvy, me dic a lly kno wle dg e a b le the ra pist (e .g ., APA’ s Psyc ho lo g ist L

• c a to r http:/ / lo c a to r.a pa .o rg / )
• I

f c a re g ive r is re luc ta nt to g o to a me nta l he a lth pro vide r, urg e visit to prima ry c a re do c to r

• Bro a c h me nta l he a lth tre a tme nt a s a no the r

stra te g y to stre ng the n c a re g iving c a pa c ity – run the b e st ra c e

Me nta l He a lth Ne e ds of F a mily Ca re g ive rs: Ide ntifying , E ng a g ing a nd Assisting

Que stions?

De bora h A. DiGilio, MPH

Dire c to r, Offic e o n Ag ing Ame ric a n Psyc ho lo g ic a l Asso c ia tio n ddig ilio @ a pa .o rg www.a pa .o rg / pi/ a g ing

APA F a mily Ca re g ive rs Brie fc a se

• 2010 APA Pre side nt Ca ro l Go o dhe a rt, E

dD se le c te d F a mily Ca re g ive rs a s o ne o f he r Pre side ntia l I nitia tive s b a se d o n the b e lie f tha t APA c a n he lp o the rs to a ntic ipa te , re c o g nize , a nd re duc e the stre sse s o n fa mily c a re g ive rs a c ro ss the life spa n.

• APA Pre side ntia l T

a sk F

• rc e o n F

a mily Ca re g ive rs me mb e rs a re : Andre a F a rka s Pa te na ude , PhD, Ma rtha Cro wthe r, PhD, MPH, T imo thy E llio tt, PhD, ABPP, Willia m E . Ha le y, PhD, Ba rry J. Ja c o b s, Psy.D, a nd Sa ra Ho nn Qua lls, PhD. I wa s APA Sta ff L ia iso n.

• I

t is a ntic ipa te d tha t the Brie fc a se will b e use ful fo r ye a rs to c o me , with sma ll c ha ng e s a s the fie ld pro duc e s ne w a ppro a c he s, ne w re se a rc h finding s, a nd ne w to o ls a nd re so urc e s.

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he Brie fc a se is de dic a te d to the millio ns o f fa mily me mb e rs who c a rry a ma g nific e nt lo a d o f re spo nsib ility a nd c a re o n a da ily b a sis.

U.S. DE PART ME NT OF HE AL T H AND HUMAN SE RVI CE S, ADMI NI ST RAT I ON ON AGI NG, WASHI NGT ON DC 20201 PHONE 202.619.0724 | F AX 202.357.3523 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

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U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

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U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

U.S. De pa rtme nt o f He a lth a nd Huma n Se rvic e s, Administra tio n o n Ag ing , Wa shing to n DC 20201 PHONE 202.619.0724 | F AX 202.357.3555 | E MAI L a o a info @ a o a .g o v | WE B www.a o a .g o v

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