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There are some nursing home warning signs to watch for.
As those wanting to help and protect our aging parents and other loved ones, we need to be very careful in how we select nusring homes for them.
Here are the first two paragraphs for a Toronto Star article from a few months ago that underscore the reasons for flashing warning signs for us all:
Three troubled Ontario nursing homes — including a Mississauga home — have been ordered to stop accepting new residents due to substandard care.
The crackdown came this week after the Ministry of Health and Long-Term Care ordered each to “cease admissions,” meaning no new residents are allowed to move into the homes.
The message for us:
Be very thorough and intense about examing any nursing home for your parents or other aging loved ones. Make sure you take the time to look carefully at the facility and what it offers.
Take the sniff test: can you smell urine in the hallways, common rooms, shared bedrooms?
Talk to staff, residents, and family members of residents. Ask probing questions.
In fact, if you want to be extra careful, come spot visit at various times of day and night a few times to get a sense of the care giving going on.
There are lots of optons out there. Take your time, be patient, research. After all, you're making decisons that will impact the lives of your aging parents and perhaps other elderly loved ones.
One always hopes that as medical practitioners, we will be able to focus our attention on the medical issues faced by seniors and help families cope with the fears, disappointments and tragedies that are faced by loved ones in the midst of what are often life-altering illnesses. In short, as physicians, we want to minimize emotional pain among the elderly and aging.
Throughout our initial medical training, and most often during post-graduate training programs, the primary focus in general is: what is the “best of medicine” and what does “evidence-based medicine” tell us about treatment decisions and their ultimate impact on health, well-being and, often, the likelihood of death?
This is particularly the case in the care of the older adult – whether in geriatric medicine or eldercare.
What is often surprising and baffling, especially to younger physicians, is the situation where the core of what appears to be the challenge in care provision is negatively tinged by what might be called family “strife.”
At times, however, a more appropriate term would be venomous, hateful actions—actions that ultimately will be destructive to the family fabric. This should not be
surprising to anyone who has even a modest understanding and familiarity with the world of literature—whether limited to English works, or more broadly including European or other literature.
Those medical trainees who have worked with me have in all likelihood heard me either seriously or humorously say, “If I were king, all first degrees would be in English literature.” Or when there is a complex family dynamic playing out, I might say, “It’s King Lear—if you have not read it ever or lately, read it or read it again—it’s all there.”
Sometimes I feel like that great American comic Jimmy Durante, who was quoted as saying, “I have a million of them, a million of them,” referring to his often delectable jokes. According to an online biographical history, it has been said that “I’ve got a million of ’em” is what Durante (1893-1980) often said after telling a corny joke. Durante was credited with “I’ve got a million of ’em” in a 1929 newspaper story.
I say this when referring to complex family situations in which what appears to be the worst in human interactions seems to be playing out. Often the issue is related to money (or property), and if one is in a position to hear the story from all the parties, it often becomes clear that, for whatever reason, the pot has come to a boil at this juncture of life.
This is usually because the flame heating the water that’s not boiling has been on for what appears to have been many years. Most of us know of such stories, hopefully not in our own families, but it is unlikely that there is a family who is not familiar with a “Lear-like” scenario in someone close to them.
Greed, jealousy, hurtful memories, mean-spirited personalities, events that occurred—sometimes decades earlier— that were never resolved or that left indelible scars are often the reasons cited for the enmity I have had the good fortune to observe that, on some occasions, especially when a parent, in particular, is dying, though it could be another relative, there is the possibility of repairing long held animosities and bringing long-estranged family members back together.
It does not always succeed, but I have witnessed the monumental efforts of health-care staff—especially those in social work, nursing and medicine, although any and all of the health-care staff can be key—in bridging the emotional moat that often separates family members. It may not always work, but I believe it is always worth the effort.
Living with the result of lifelong family strife is often disabling, and the scars that occur and that are left can have long-lasting negative effects on people’s lives and their own abilities to have meaningful and binding relationships with their siblings and offspring.
Here is a very thoughtful piece by the ever-helpful ANDRÉ PICARD in a recent Globe & Mail column. He notes from a study that in fact, we can delay the onset of dementia by taking some proactive steps for ourselves and our aging loved ones.
There are few things that aging baby boomers fear more than dementia, a condition that robs one of memory – and too often dignity – and leaves you dying little by little, piece by piece.
The numbers are frightful: An estimated 564,000 Canadians are currently living with dementia, and that figure is expected to rise to 937,000 within 15 years.
Globally, it is estimated that almost 50 million people are afflicted with dementia and that is forecast to rise to 131 million by 2050.
The data are grim – even without mentioning the impact on caregivers, the health system and the economy. Yet, there are little glimmers of hope – in particular, research showing that dementia is preventable, at least in part.
A study published in medical journal The Lancet shows one in three cases could be prevented or delayed if people took better care of their brains.
Based on a review of scientific literature and mathematical modelling, a panel of 24 global experts identified nine factors that increase the risk of dementia and how much those risks could be lowered if they were addressed:
Mid-life hearing loss: 9 per cent;
Failing to complete secondary (high-school and above) education: 8 per cent;
Smoking: 6 per cent;
Failing to seek early treatment for depression: 4 per cent; Physical inactivity: 3 per cent; Social isolation: 2 per cent; High blood pressure: 2 per cent; Obesity: 1 per cent;
Type 2 diabetes: 1 per cent. All told, the potential risk reduction adds up to 36 per cent – but, of course, health problems are easier to avoid in theory than in practice.
Still, some important lessons can be drawn from this list of modifiable risk factors. While things such as smoking and inactivity are commonly seen as lifestyle choices, they are largely symptoms of poor socioeconomic conditions.
That’s a reminder that, as Dr. Martin Prince of the Institute of Psychiatry, Psychology and Neuroscience at King’s College London writes in The Lancet: “Dementia selectively affects the old and frail, women and the socioeconomically and educationally disadvantaged.”
The research also drives home another key point: The brain changes at the root of dementia occur years before the onset of symptoms.
Dr. Antoine Hakim, emeritus professor of neurology at the University of Ottawa, stresses this point in his new book, Save Your Mind: Seven Rules To Avoid Dementia. While the script for dementia is written early, perhaps as early as our teenage years, he writes, the risk of dementia is modifiable – up to and including when symptoms of cognitive decline begin – because of the plasticity of the brain.
Dementia is caused by the death of brain cells. But Dr. Hakim notes that most cases are not Alzheimer’s – characterized by tangles and plaques in the brain – but caused by vascular problems such as high blood pressure and stroke. In other words, what’s good for the heart is good for the brain (and vice versa).
Of his seven golden rules for brain health and reducing dementia risk, Dr. Hakim’s No. 1 recommendation is to “save for a rainy day,” to grow the brain’s capacity and resiliency by exercising it like a muscle.
We can’t prevent dementia from killing people, but we can delay its onset. A one-year delay would translate into nine million fewer cases by 2050; a five-year delay would halve the prevalence of dementia globally in that same time period.
Want to stave off dementia? Read. Write. Play music. Be physically active. Be socially engaged. Eat healthy food. Maintain a healthy weight. Sleep well. Don’t sit mindlessly in front of the TV. Those simple counsels are the best tools we have in a world in which there are no drugs or treatments that prevent dementia.
There are 100 billion neurons, trillions of contact points known as synapses and 600 kilometres of blood vessels in the brain, and “everything we do – and don’t do – affects the health of these cells and their connections,” Dr. Hakim writes.
Dementia is not a natural consequence of aging. Risk depends, in part, on genetics, and on the lifestyle “choices” we make. (And we have to be careful with that word because major factors such as poverty and education are rarely a choice.)
As The Lancet notes, “dementia is the greatest global challenge for health and social care in the 21st century.” But it is not a runaway train. We have the ability prevent – or more realistically, delay – the disease. And keeping dementia at bay, even temporarily, can change a lot of lives.
We can save a lot of minds by using our heads.
Are we ignoring the immunization needs of the elderly? The recent New York Times opinion piece by Louise Aronson, a professor of geriatrics at the University of California, San Francisco, offers an interesting proposition. about the needs of those in their 70s and up. Read it by clicking here:
It just happened to my wife, an avid early morning walker. She does everything ‘right’ in terms of the ‘right’ shoes, coat, scarf, hat—you name it –she does it. The only thing she does not do is make sure the weather is perfect and receptive to activities of middle, later age, and elderly individuals.
The Mayor of the City of Toronto recently called to safety islands to be created for the elderly and aging to use when crossing busy and large intersections. This is has been an issue on my mind for a long time. The piece below I wrote last year precisely about this all too common threat.
Bottom line: We must protect the elderly and aging when crossing streets.
Watching the ribbon of news on roll across the bottom of my television is often very disturbing.
This is an email from a long time friend on the west coast.
Her point is simple and poignent… a nursing home drama: wrong treatment.
Her challenge: how to help her failing fahter.
It's not pretty, and so many of us experience the same trauma.
Please read on.
On Thursday, dad's geriatric psychiatrist contacted me to discuss his treatment. The facility is saying he is being aggressive, so they are looking at his meds to adjust. Less than a half hour later the doctor called me back asking if the facility had contacted me because they are indicating they will send him to emergency where he will essentially be sedated. The doctor doesn't agree with this and has him on the waiting list to get into the geriatric floor at the hospital.
Dad is physically fine, he gets around and is busy. He tends to get into other people's rooms and moves everything around and tries to fix things. His eyesight is really bad, so he feels for things. One care aide at the home is calling this aggressive behaviour. He has had a couple of incidents, but they were because he was alone and could have been redirected, no one was hurt or even close to being hurt. Dad jokingly does a one two jab action, then laughs. It is a jest, not aggressive whatsoever. His main care aides say he is the least aggressive person, but busy and gets into things. The facility have told us we have to be there from the time he wakes until he goes to sleep or they will send him to emergency here he will be sedated and returned to the facility or he may not have anywhere to go.
The home has a lack of staff and often there is often no LPN on his floor. If they are on breaks there is no one there. This is a dementia unit for high needs patients. They will move in temporary replacement staff that do not have dementia training, nor read the patients charts and make comments such as why are we even feeding these people.
They have lost his shoes, his dentures, his glasses, they don't shave him and I have to ask for him to be changed. They are supposed to contact us when incidents occur and they haven't.
It is appalling. I am putting in a formal complaint to the health authority, licensing board, and ministry. The disease is hard enough on its own without having to deal with the system. Not sure why I am sharing, except that I know you went through the disease part. This is not the norm as far as care, is it? I am working with the doctor and hopefully we can get him into a place that has adequate care.
Maybe you need a follow up book on how to ensure your parent is being cared for?
Clearly, her father needs the right kind of care.
He seems to need regular attention and care. And a way to vent his interets and energy. It seems he's not violent or dangerous. But ongoing stimulation may be needed.
Bottom line: the system needs stronger checks and balances. It needs to be able to effectively understand and manage the needs to those who are suffering from various stages of dementia.
Here is an excellent recent article in the Globe & Mail about medications and the elderly. Well worth the read and some reflection.
My mother is in her 70s and suffers from a lot of health problems. I am very worried that she has been given too many different medications that are too strong for her. What should I do?
It’s possible that your mother may need all the drugs she is currently taking. But it’s also true that patients sometimes get prescribed drugs and remain on them when they are no longer required.
“Doctors are really good at starting medications, we are not so good at stopping them,” says Dr. Kimberly Wintemute, the primary care co-lead of Choosing Wisely Canada, an organization dedicated to reducing unnecessary medical treatments.
During a hospital stay, for instance, a patient might be given a sleeping pill or a heartburn drug and the prescription keeps getting renewed.
Over time, a patient can end up on a growing list of medications. About twothirds of seniors living in their own homes take five or more drugs, according to data collected by the Canadian Institute for Health Information. One-quarter of seniors are prescribed 10 or more medications.
Each new drug that’s added to the mix increases the risk of adverse side effects and medication interactions.
» The elderly are especially vulnerable to these problems. Not only do they tend to have more chronic conditions than younger people, but the aging process can also change the way the body handles medications.
For instance, the liver and kidneys – which play a key role in processing and excreting drugs – tend to work less efficiently as we age.
In fact, the liver can sometimes become overwhelmed trying to handle several drugs simultaneously. As a result, certain medications don’t get “activated” and essentially won’t work.
“Picture a bus and everyone is trying to get on at the same time – some people are not going to fit and will be left behind,” explains Dr. Cara Tannenbaum, co-director of the Canadian Deprescribing Network, a group that is trying to prevent the inappropriate use of medications.
Furthermore, as we age, we lose muscle mass which is replaced with fat and that can cause problems because some drugs are stored in fat tissue. This means medications can linger longer in the body and thereby exaggerate their effects, Wintemute says.
Another concern is the government approval process for new medications. Drugs are usually tested on relatively young people with just one medical condition – not elderly individuals with multiple ailments. “We don’t always know how a new drug is going to act in very old and very frail people,” says Dr. Debbie Elman, the lead physician for the Academic Family Health Team at Sunnybrook Health Sciences Centre.
Patients may suffer from a host of side effects and drug interactions including confusion, dizziness, fatigue, constipation, diarrhea, incontinence, weight loss, depression, agitation, anxiety as well as sexual dysfunction. It can be difficult to tell if a particular symptom is caused by a medication or if it represents a new medical ailment. A patient might be wrongly diagnosed with dementia or another medical condition even though a drug is really to blame.
So, what can be done to reduce the risks posed by multiple medications?
First and foremost, a patient should get all medications at the same pharmacy, Elman says.
She points out that patients are often treated by several medical specialists – and each one may be prescribing different medications. No single doctor may have a complete picture of what a patient is taking. However, when all prescriptions are picked up at the same drug store, the pharmacist can check for potentially hazardous drug combinations.
The pharmacist can also conduct a review of a patient’s medications and help determine if some may no longer be appropriate.
For a thorough assessment, the pharmacist will need to know if the patient is also taking any non-prescription drugs, herbal remedies or vitamin and mineral supplements. It’s important to keep in mind that so-called “natural” health products may interact with medications and either reduce or intensify their effects.
Tannenbaum says many patients don’t know why they are taking certain medications or what they do.
She suggests that patients, or their family members, should use the website medstopper.com to learn more about their medications. Simply type in the name of a drug and up pops a great deal of useful information, including if a certain medication might be particularly risky for seniors. Another website, deprescribing.org, provides guidance on how to wean off a medication that may be harmful or is no longer needed.
Of course, patients shouldn’t quit taking a drug without consulting their medical specialists or family doctor. But by first talking to a pharmacist and checking out the recommended websites, they can at least have an informed discussion with the physician responsible for their medical care, Tannenbaum says.
Paul Taylor is a patient navigation advisor at Sunnybrook Health Sciences Centre. He is a former health editor of The Globe and Mail. You can find him on Twitter @epaultaylor and online at Sunnybrook’s Your Health Matters.
Choose the right substitute decision makers (SDM) now.
With all the recent focus on what is now called advance care planning (ACP) in the medical and social work literature, it is important for people especially middle-aged and older people to understand what is at stake.
Using the old terminology of a "living well" there has been a transformation from what used to be a few words in a document somewhere or as a conversation with the family member likely to be the SDM that for example the parent "would not want any heroics" if they develop a terminal illness. The reality is that is no longer enough to help those empowered to make such decisions on your behalf. The new world of medicine has many things that can be done that are no longer considered "heroics" but just part of contemporary every day medicine.