Blog

Using light to improve sleep, reduce agitation

Here’s my latest article on McKnight’s Long-Term Care News:

Using light to improve sleep, reduce agitation

Poor sleep, reversed sleep/wake cycles, depression and falls are common problems in older adults. In addition, elders with dementia frequently experience late afternoon agitation, or “sundowning.” Because our residents live in a communal environment, a single individual’s agitation or late-night roaming can create a unit-wide problem for staff and other residents.

Research suggests there may be a solution that involves no medication or side effects. The answer could be the use of light.

According to Mariana Figueiro, Ph.D., professor and Light and Health program director at the Lighting Research Center at Rensselaer Polytechnic Institute, the results of the research on light are “very robust.” As she states in the January 2016 American Psychological Association Monitor, “I have no question that if you deliver the right light in Alzheimer’s patients, you improve their behavior; you will improve agitation; they will sleep better.”

Reduced ability to process light

Our bodies receive light via three different types of photoreceptors, the Monitor article explains, and it stimulates the brain in various ways to regulate sleep. As we age, the ability to process this light diminishes. In combination with age-related changes in the circadian rhythms that regulate sleep/wake cycles, reduced production of melatonin which aids slumber, and lifestyle adjustments such as decreased physical activity and exposure to outside light, this contributes to the sleep difficulties of older adults.

Some studies indicate that sleep disturbances have been associated with a buildup of beta-amyloid, a hallmark of Alzheimer’s disease. Researchers speculate that sleep helps to flush toxins such as beta-amyloid out of the brain. By improving the sleep quality of our residents, we therefore may be aiding them in many ways.

Light table

Theorizing that residents with dementia spend a great deal of time sitting around a table, Figueiro created a “light table” using an edge-lit LED television for the surface. This allows staff and residents to interact normally while receiving the appropriate amount of bluish white illumination. Her studies show a significant improvement in the quality of sleep of participants and a significant reduction in depression and agitation. Both of the latter held up fours weeks after the light source was removed.

For the entire article, visit:

Using light to improve sleep, reduce agitation

See video above or click here: http://wnyt.com/article/stories/s3920645.shtml

Upcoming Quality Initiatives

Here’s my latest article on McKnight’s Long-Term Care News:

Upcoming Quality Initiatives

Last week I was speaking about the needs of younger residents at the North Carolina Health Care Facilities Association convention and had the opportunity to hear a presentation by David Gifford, MD, MPH, Senior Vice President of Quality and Regulatory Affairs of the American Health Care Association (AHCA). He was discussing what providers could expect from upcoming AHCA quality initiatives. I was listening with a clinician’s ears and, aside from feeling grateful that I’m a clinician and not an administrator, several points stood out for me.

• Turnover is going to be added to the 5-Star Rating System. Better-rated facilities will be expected to have a turnover rate of 40% or less. He didn’t specify how to accomplish this, but my article, “Keys to reducing turnover in LTC,” offers many suggestions to address the problem. As I noted in the column, a 2007 Donoghue and Castle study found that “increasing the number of aides per resident from 33 per 100 to 41 per 100 reduced CNA turnover from 65% to 41% and also lowered LPN and RN turnover.” Taking that action alone could bring your facility to the sought-after turnover rate.

• Analyze problems with the right attitude. When doing a root-cause analysis of challenges such as falls, infections, pressure ulcers, etc., Gifford recommends operating from the assumption that “everything is preventable” rather than a defeatist whaddayagonnado stance. (OK, I’m paraphrasing that last part.) In his experience, this attitude makes a big difference in finding areas of potential change.

He also points out that difficulties frequently stem from a systems problem or lack of skill rather than a knowledge deficit on the part of staff. Rather than providing knowledge-focused in-service trainings in an attempt to rectify situations, ask staff members what “frustrates” them about a particular problem and whether they have suggestions about how to remedy it.

• Use pilot studies. When making needed modifications, start with a very small sample rather than immediately making a facility-wide adjustment of systems. Follow the model of “one staff member, one resident, one day.” This trial run provides the opportunity to see how the new system works and creates staff buy-in before committing the entire facility to the changes. Staff buy-in is enhanced if the selected staff member is someone respected by peers.

For the entire article, visit:

Upcoming Quality Initiatives

Seeing Virginia (an anecdote): Part Two

Seeing Virginia: Part One

Like many of my residents over the years, Virginia had been a nursing assistant prior to her retirement. In our early sessions, I encouraged her to discuss how it felt to be “on the other side of the stethoscope,” as I put it, but she was too focused on the plot to steal her home.

I spoke to her social worker about it. “I’m not sure if Virginia is going to benefit from therapy because she’s pretty confused, but is there any reality to her worry about her house?”

Her social worker sighed. “I was hoping when she first got here that she could go home, but her daughter is selling her house so that’s not going to happen.”

I could see how that could be interpreted as theft.

I kept meeting with Virginia, making mental notes on how much time in each session was spent on agitated theories versus reasonable discussion of confirmable events. I met her comments about plots with empathy and redirection; I greeted her reports on attending activities with enthusiasm. Our early meetings were about 90% agitation and 10% reality, then 80/20, then 70/30. We were making progress.

A minor health crisis proved mentally beneficial. We discussed her doctor’s recommendations, things she could do to take care of herself and what to expect when she went to the hospital for her medical procedure. The conversation was now 80% reality.

The week after her return from the hospital, she expressed concern about her roommate. “Tell them to check her for a rash. I thought I noticed something last night.”

They checked. There was nothing. But Virginia the nursing assistant was back.

‘Just a picture of her butt’ — an analysis

Here’s my latest article on McKnight’s Long-Term Care News:

 ‘Just a picture of her butt’ — an analysis

In “A potential lawsuit in every worker’s pockets?”, McKnight’s Editorial Director John O’Connor describes two of many recent incidents of long-term care workers using their cell phones to record residents in embarrassing situations and post the photo or video to social media.

Despite leading to termination of employment and lawsuits, some of the employees involved appear to have no idea that this behavior is a serious ethical breach. Staff writer Emily Mongan offers the following quote in her article on this topic: “They just blew everything out of proportion,” [the offending employee] said. “It was just a picture of her butt.”

Wondering how an employee could possibly think posting a photo of a resident’s behind to social media would be a reasonable action to take, I contacted psychologist and social media expert Keely Kolmes, PsyD , to find out.

Changing expectations of privacy

Dr. Kolmes notes that it’s become commonplace for people to record moments from their lives and post them to social media, generally without consent from others who might be captured in the photos or videos that are shared.

For example, while I get my daughter’s permission before I post anything about her to my private Facebook page, I occasionally find her featured in photos with friends on their pages without prior approval. Posting friendly pictures is considered acceptable in one’s personal life (and a parent who asks permission from their child is, I suspect, unusual).

One might argue that there’s a distinction between personal and professional situations, yet similar situations frequently occur in professional settings as well, such as discovering you’ve been featured in a photo on the website of an organization after attending their conference or on your facility website after the holiday party.

Most people are pleased to be highlighted in such photos, but if an organization expects employees to follow their social media policy, these situations are a prime opportunity to show workers that the policy is being followed at the corporate level as well. At facility events, for instance, notify staff members that photos will be taken and may be posted.

Resident/staff boundaries: Whose life/home is it?

For the entire article, visit:

‘Just a picture of her butt’ — an analysis

Seeing Virginia (an anecdote): Part One

The first time I met 87-year old Virginia, it was immediately apparent why the nurses had made the referral. She spoke too quickly, words pouring out one after the other without pause. She had vague theories that a staff member was trying to steal the house she’d vacated a few months ago and attempting to steal her boyfriend as well. She couldn’t identify which staff member it was, nor could she recall what day it was or the name of the United States president. “He’s got a wife and two kids, I remember that much,” she told me.

Her gray hair was orange at the ends, giving her an unfortunate clown-like air; the flowers on her hat emphasized this effect. Her fingernails had been painted red weeks ago with only small bits of color remaining. She lifted up her floral shirt despite my protests to show me that she had no bra in her clothing collection.

“Do you think I’m crazy?” she asked with concern at the end of the interview.

“I think you’ve got a lot going on,” I demurred, “and I’d be happy to try to help you sort it out.”

“I wish you would,” she replied, satisfied.

Seeing Virginia: Part Two

Dr. El’s subversive guide to culture change

Here’s my latest article on McKnight’s Long-Term Care News:

Dr. El’s subversive guide to culture change

We often think of culture change as a formal process initiated by company leaders that involves setting organizational goals and moving employees in big and small ways toward those goals.

But culture change also can be a grassroots effort that shifts the dynamics between residents, staff and community, one unit at a time.

Altering expectations

As a psychologist, I’ve been trained to observe the interactions of groups of people. The current dynamics of many long-term care settings involve residents who are in the passive role of “recipients of care” while the staff members are in the active role of “providers of care.” The residents are frequently isolated from each other and from the community outside the facility. They feel bored and useless, leading to depression.

Leaders in the culture change movement, the Eden Alternative calls loneliness, helplessness and boredom the “three plagues” of long-term care. Its aim is to eliminate these plagues through transforming the culture of the facility. Another culture change resource, the Pioneer Network, refers to the need for elders to have, among other things, “purposeful living.”

These organizations and others offer tried-and-true paths to alter the dynamics of your facility, but not every setting is ready for them yet. If you’re working in a culture-change-resistant organization and find yourself yearning for a way to make a difference — today — consider the possibilities here.

Grassroots culture change ideas

• Purposeful pursuits such as knitting and crocheting

As part of a therapeutic recreation program, these crafts can dramatically shift the dynamics noted above, especially when the needlework has a point. (Sorry, I couldn’t resist!) Residents who are working together to make lap blankets for new residents or hats for premature infants change from being passive recipients of care to active providers of care for others within the facility and in the larger community. Industrious and engaged residents show workers that elders can contribute to the world despite their age and physical or mental limitations. (For more on this, see the Recreation audios on my website. For more on therapeutic knitting, visit stitchlinks.com.)

• An active welcoming committee

Entering long-term care is very stressful for newcomers and an effective welcoming committee is an excellent way for long-time residents to recognize their own value and share their expertise.

For the entire article, visit:

Dr. El’s subversive guide to culture change

What’s not to like?

It was the third week I was meeting with Mr. Schwartz, an 85-year old man with a thick mustache and a penchant for suspenders. I found him watching TV in the dayroom, surrounded by some of his peers. I crouched by his wheelchair so I could speak to him at eye level.

“Hi Mr. Schwartz, I came by to see how you were doing. Can we talk in your room for a while?”

“Sure, young lady!” he replied without hesitation, seeming eager to see me despite not being able to recollect my name.

“I can give you a push to your room,” I offered. “It might be easier since you’re holding that cup of tea.”

“Tea!” Mr. Schwartz exclaimed, with mock astonishment. “I thought it was beer!”

I laughed heartily and he smiled with pleasure.

‘Honest’ placebos help without side-effects, expense

Here’s my latest article on McKnight’s Long-Term Care News:

‘Honest’ placebos help without side-effects, expense

Older residents frequently enter long-term care with multiple medications prescribed for their varying health conditions. In fact, it’s the polypharmacy itself that can bring them to our doors due to harmful medication interactions and symptoms such as dizziness that lead to falls, hospitalizations and the need for increased care.

In long-term care, geriatricians often work to reduce the number of medications their patients receive. A 2011 review in the journal Gerontology suggests that the use of a placebo may be a worthwhile tool in this effort.

Typical purpose of placebos

A placebo is often thought of as a harmless substance used as a control in research to determine the effect of actual medications. In order to be proven effective, the experimental medication must be significantly more beneficial to subjects than the placebo because simply receiving a pill is found to have beneficial effects.

In other words, medical conditions can improve just by thinking that the pill one is taking is going to help, even if it has no medical properties. (This is why I like to read the copy on, say, a bottle of hair conditioner — to enhance its psychological effects … I’m only half-kidding.)

Atypical use of placebos

The studies reviewed in the 2011 Gerontology article consider the placebo not as a control condition but as a substance worthy of study in and of itself, investigating factors that influence its level of effectiveness.

They examined the use of placebos as an analgesic, to address anxiety and depression and for Parkinson’s disease and consistently found a significant reduction in symptoms — especially when paired with verbal suggestions that the placebo will be successful.

‘Honest’ placebos

In Jo Marchant’s “A Placebo Treatment for Pain” in the New York Times this month, she writes of a 2014 study that found that a placebo was 60% as effective as a pain pill. What’s more, when the actual pain medication was labeled “placebo,” it reached 60% of its usual effectiveness.

Even more remarkably, these results held up when the placebo was honestly labeled as such. Despite knowing that the pill they were taking was a placebo it was still half as effective as the pain medication.

(I find this mind power incredible, so much so I almost ended each of the sentences in this section with an exclamation point!)

Application to seniors

For the entire article, visit:

‘Honest’ placebos help without side-effects, expense

A Second Look

As I was rushing past the nursing station, Sophia, a 93-year old woman wearing a red velour sweatsuit, was sobbing and calling out for help. She was sitting among a row of other residents who were watching television and passersby.

“What’s the matter?” I asked, stopping to kneel by her wheelchair.

“I want someone to put me
back to bed,” Sophia replied. “I’m so tired.”

“I’ll find someone to help you,” I reassured her. “It might take a little while, but someone will put you back to bed.”

I looked up, scanning the area for an aide or nurse. My eyes met those of a 30-something uniformed delivery man waiting for the elevator. “I bet you must run out of here at night,” he commented. His hardened voice held fear and disgust.

“Actually,” I told him matter-of-factly, “I like it a lot.”

With that, his face relaxed and his tone softened. “I’m really glad to hear that,” he said, sounding relieved. He looked around the room with what seemed to be a new perspective on the situation. The elevator doors opened. “Have a good day!” he called out, smiling.

I found the charge nurse and let her know about Sophia’s need to get back to bed. When I came back to the nursing station again a little while later, Sophia had returned to her room.

Growing Good

Here’s my latest article on McKnight’s Long-Term Care News:

Growing Good

Woohoo! My first column of 2016.

Which was started during a bout of insomnia in the last week of 2015.

What did I do when sleep failed me? What electronics-addicted individuals often do in the middle of the night. I grabbed my computer, caught up on email, and headed over to Facebook to find out what my Friends had been up to.

There I discovered a post about a company founded by two brothers called Life is Good, which emerged from the standing request the founders’ mother had for them as children in a chaotic home environment: Tell me something good about your day.

This helped the brothers become “glass half full” kind of guys, the type of people who donate 10% of their profits to help children overcome adverse childhood experiences.

And what does a T-shirt company have to do with long-term care? Well…

What if we started off this brand new year asking ourselves and our coworkers, employees and residents to tell us something good?

What if we put time and thought into focusing on the positive — into growing the good — and reminding ourselves why we’re all here working with elders?

I predict we’ll have more productive staff, better functioning teams, and happier residents.

It’s not just me doing the predicting. The Positive Psychology Center, led by director Martin Seligman, Ph.D., describes positive psychology as “the scientific study of the strengths that enable individuals and communities to thrive.”

For the entire article, visit:

Growing Good