Category: Medication issues

Sleep deprivation and pain

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

Sleep deprivation and pain

Despite the fact that my search for column inspiration took place at 3 a.m., I chose the topic of sleep deprivation because residents regularly tell me about their own sleep disturbances. They also discuss their pain.

Though their aches often keep them up at night, a January 2019 article in the New York Times, “Why It Hurts to Lose Sleep,” suggests that there’s a more complicated relationship between sleep and pain.

Author Benedict Carey described research finding “that a single night of sleep deprivation reduced a person’s pain threshold by more than 15 percent.” In addition, “small deviations in the average amount of sleep from one day to another predicted the level of overall pain felt the next day.” Staying up all night — which has been known to happen in the long-term care setting — increased pain sensitivity by 15% to 30%.

This interaction between sleep and physical discomfort is particularly relevant to those of us working in eldercare. Increased use of pain medications not only raises pharmacy costs, but can lead to a host of other problems, including constipation, daytime drowsiness, increased fall risk, the possibility of addiction, medication interactions, breathing problems and more. Each of these complications can, in turn, lead to further difficulties.

Perhaps the silver lining in these significant complications will be that more attention is paid to sleep disturbances in long-term care.

I suspect that the shift-based nature of nursing care makes it easier to discount this issue. If an elder with disrupted sleep were at home keeping their caregivers awake, it would be a major problem for the family. In the nursing home, the nighttime care providers are already up, the daytime workers arrive to work rested and the administrative staff members aren’t around to directly observe the effects of unsettled sleep. It’s the residents who must contend with the mid-night disruptions of their peers.

One loud, agitated resident can awaken most of his or her neighbors. If, as this research suggests, all of those people feel discomfort more intently the next day, this could increase their requests for pain medications. Their fatigue might reduce their progress in rehab and increase their likelihood of irritability. This outbreak of insomnia, pain and aggravation should be attended to as much as scabies or lice.

For the entire article, visit:

Sleep deprivation and pain

‘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

The secret to LTC success? A focus on well-being

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

The secret to LTC success? A focus on well-being

Despite the diversity of the events I attended during my brief visit to the LeadingAge convention in Boston last week, a theme clearly emerged. The thread that ran through the varied offerings was well-being.

Retaining staff

In researcher and consultant Joanne L. Smikle, PhD’s talk on staff retention, rather than focusing on why employees are leaving, she looked instead at why they stay.

Based on her studies of long-term care organizations, she found that “if the leadership of the organization lacks passion, you will have trouble with retention and commitment.”

In healthy organizations, staff members “from the top of the house to the bottom of the house” stay because they can say, “I felt I mattered.” Experiences that contribute to that feeling: Recognizing staff in formal and informal ways, an open dialogue with staff rather than top-down communication, and a focus on the human elements enabling employees to make connections with each other, the residents and the families.

Dementia care

G. Allen Power, MD, FACP titled his presentation, “Enhancing well-being for people living with dementia,” so it wasn’t surprising that this was a central point in his talk.

He asserted that antipsychotics don’t work and don’t treat the true causes of the behaviors associated with dementia. Instead, he recommends focusing on the seven primary domains of well-being, which are part of the Eden Alternative model of care: identity, growth, autonomy, security, connectedness, meaning and joy.

In one instance, a resident who became agitated when he was prevented from leaving the building was allowed outside. The man looked at the cows in a nearby field and returned to spend the rest of the day calmly. The team, who subsequently learned that the resident had been a farmer whose daily routine included an early morning check on his animals, had given him not only autonomy, but had also affirmed his identity and added meaning and joy to his life. His agitation disappeared.

Keynote address

Atul Gawande, MD delivered a Monday morning keynote address. Author of the book “Being Mortal,” Dr. Gawande discussed ways in which to improve end of life treatment. He advocated for care that takes into account the desires of the patient and noted that there is more to living than extending the amount of time we live.

For the entire article, visit:

The secret to LTC success? A focus on well-being

Leonard Florence ALS unit entrance

Behavioral health care — not drugs — for dementia

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

Behavioral health care — not drugs — for dementia

Antipsychotic medications have proved ineffective at reducing the symptoms associated with dementia. They also have serious side effects in older adults, including restlessness, dizziness, higher likelihood of falls and other problems that can contribute to an increased risk of death.

Behavioral health interventions, on the other hand, have no such side effects and have been found effective in reducing behaviors such as aggression, care refusal and wandering.

Employing behavioral health techniques with people with dementia becomes increasingly valuable as facilities in this country endeavor to follow the Centers for Medicare & Medicaid Services guidelines and reduce the use of antipsychotic medications.

Global efforts

Dementia care is a pressing issue around the world, and other countries have made headway in shifting from medication to behavioral interventions. Psychologist Paula E. Hartman-Stein, Ph.D., of The Center for Healthy Aging, writes about international programs that implement behavioral health methods in the September/October edition of The National Psychologist.

Dr. Hartman-Stein spoke with Cameron Camp, Ph.D., an expert who consults with long-term care facilities in the United States and abroad.

France

Dr. Camp reports that the French government pays nursing homes to train their staff in non-pharmacological approaches to dementia. The training includes various strategies, including Montessori techniques such as those described by Dr. Camp in his excellent book, “Hiding the Stranger in the Mirror,” and other publications.

Australia

Camp notes that Alzheimer’s Australia provides funding to train staff in behavioral health approaches. Its website, Alzheimer’s Australia Information for Health Professionals, offers helpful information and brief videos that explain the techniques used.

Canada

In Canada, the Canadian Foundation for Healthcare Improvement reports on the success “beyond the team’s expectations” of an effort to reduce antipsychotic medications and implement non-pharmacological approaches. The project saved $400,000 in six months across the Winnipeg region.

STAR-VA in the USA

Here in the United States, the Veterans Health Administration, less constrained by the fee-for-service psychotherapy model that plagues the rest of the country, utilizes staff psychologists and other behavioral health professionals in their Staff Training in Assisted Living Residences (STAR-VA) model.

For the entire article, visit:

Behavioral health care — not drugs — for dementia

Diabetes care: Take two betta fish and call me in a week

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

Diabetes care: Take two betta fish and call me in a week

More than 25% of the US population over the age of 65 years has diabetes¹ and the numbers are far higher for those in long-term care. (Approximately one third of nursing home residents have diabetes.²)
Diabetics often need to track their blood sugar level multiple times daily and administer medication. Uncontrolled diabetes can lead to a host of medical problems, including heart disease, neuropathy, and impaired vision and falls, and can result in hospitalizations and rehospitalizations.

While guidelines suggest that elders with comorbid health problems need less intensive glucose control than younger healthier people (who are more likely to benefit from years of strict control), many residents in our communities still need to keep track of their blood sugar daily.

We can borrow an idea from a recent study of children with diabetes to help empower our elders toward better self-care in our senior communities and more successful transitions home from skilled nursing care.

In an effort to test pairing twice daily glucose checks with pet care, researcher Olga T. Gupta, MD gave betta fish and tanks to children ages 10 to 17 years. The children were asked to feed their fish and check their blood sugar at the same time, and to review their glucose logs with their parents when they cleaned the fish tank each week. The results of this pilot study showed a small but significant improvement in glucose control.

We can adapt this study to seniors and simultaneously take advantage of the health benefits of pet ownership. Caring for a pet has been linked to fewer doctor visits, improvement in activities of daily living, reduced depression and better heart health, among other rewards. ³

For the entire article, visit:

Diabetes care: Take two betta fish and call me in a week

Reducing antipsych meds: 5 ways psychologists can help (McKnight’s LTC News)

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

Reducing antipsych meds: 5 ways psychologists can help

With the mandate to reduce the use of antipsychotics, many facilities are looking for alternative methods to address the behaviors often associated with dementia. There are several good resources available for training staff (such as the Center for Medicare & Medicaid Services’ Hand in Hand toolkit and the Pioneer Network’s programs).

Within each facility is another good resource — your consulting psychologist. Here’s how psychologists can help:

1. Psychology is all about nonpharmocological alternatives. The most frequent question for any psychologist during their career is, “What’s the difference between a psychologist and a psychiatrist?”

The answer: “Psychiatrists go to med school and prescribe medications to help people feel better. Psychologists go to graduate school to study interpersonal interactions and talk with people to help them feel better.”

The cornerstone of what psychologists do is to look at behavior and find ways to treat people without medication. While psychologists might not be able to use the exact same techniques for those with memory loss, they can offer behavioral insights that aid the team.

2. Psychologists are trained to understand group dynamics. They can support ways in which your treatment teams are working well to help those with dementia and offer alternatives in areas where conflicts arise. For example, if psychologists have observed that mealtimes are stressful for staff and residents, they can offer suggestions that reduce triggers for behaviors on the part of persons with memory loss.

3. As part of their studies, psychologists collect and synthesize data. Combined with their group/team experience, this makes psychologists ideal sleuths to gather information from various team members about particular residents and identify the cause(s) of agitation.

The fact that they don’t necessarily leave at change of shift allows them the opportunity to discuss the cross-shift behaviors of the residents.

For the entire article, visit:

Reducing antipsych meds: 5 ways psychologists can help

The very anxious resident: A team approach (McKnight’s LTC News)

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

The very anxious resident: A team approach

“My mother was kicked out of her nursing home again,” my cousin told me. “They said they couldn’t handle her.” I phoned Cousin Belle’s new number in the afternoon.

“They didn’t give me my pain medication,” she said angrily. “They took away my walker and I need to use the bathroom. CAN SOMEBODY GET ME MY WALKER – I NEED TO USE THE BATHROOM!” She began sobbing. I heard another voice. “Did you hear what the man next to me just said?…You’re not a man?.. .I’m sorry, I can’t see…” Belle lost her vision several years ago, just like her father before her. “I helped people all my life,” she told her companion. Belle is a retired nurse.

She shouted again and I heard a staff member say, “Have some respect for the other residents.” Belle responded immediately, “Have some respect for me!”

“Let’s say the ‘Serenity Prayer,’” I suggested. “OK, let’s,” Belle agreed immediately. When we finished, she asked to say it again. She sounded calmer. “The woman next to me said it with me,” she remarked.

That story is about Cousin Belle, but it’s also the story of Gerry, Anna and a host of other residents I’ve seen over the years. Below are some suggestions for handling these challenging residents, coming from my perspective as a psychologist. I know there are many educated, experienced and compassionate people from other disciplines who will read this. If you have any additional tips, please add them in the comments section.

• Start afresh: If the current staff members are burned out and no longer responding well to the resident, it can be helpful to move the resident to a new unit or facility with a clean slate and fresh expectations. Notify the new team in advance so that they can prepare for the anxious resident and avoid repeating the same situation.
• Keep in close contact with the psychiatrist: The very anxious resident is likely to need medication for anxiety or depression, or at least to know that something is available if necessary. The early, frequent and regular attendance of the psychiatrist can reassure the resident and the team that an expert presence is guiding care.
• Give meds quickly: If residents are in pain or on a medication upon which they’ve become dependent, give the medication as soon as possible. Waiting will only increase their agitation and disturb other residents.
• Mollycoddle: A loud and anxious resident is likely to become louder and more anxious the longer they have to wait for their demands to be met. Just like with the medication, attend to their needs as soon as possible. Anxious people tend to be anxious because they feel out of control. Meeting their needs helps them feel more in control.
• Assign your most patient and compassionate aides: Satisfying a very anxious resident’s demands can be a never-ending task. Try to assign the type of person who will approach each call for assistance with a pleasant demeanor and not those who will let their displeasure be known with an unkind word or expression.

For the entire article, visit:

The very anxious resident: A team approach

Reducing antipsychotic medications? Try these behavioral interventions (LTL mag online)

Here’s my latest article on Long-Term Living magazine online:

Reducing antipsychotic medications? Try these behavioral interventions

With the recent focus on reducing antipsychotics in long-term care and substituting behavioral interventions, facilities may be left wondering what interventions to use and how to implement them. Here are ideas on how to prevent, investigate and monitor agitation on your units and address staffing needs to ease the transition from antipsychotic medication.

PREVENTION: BORROW FROM THE PSYCHIATRIC HOSPITAL

In a psychiatric hospital, the focus is on creating an emotionally healing environment—a therapeutic milieu. In long-term care, the focus is on providing high-quality physical healthcare and the frequently neglected therapeutic milieu can contribute to resident agitation. Take some time to walk your units and evaluate the emotional environment. This is what residents, and especially those with dementia, are reacting to and small changes can make a big difference.

Evaluate and adjust the physical environment. Is it disturbingly bright or so dark that older eyes can’t see who’s approaching? Is it very loud, with excessive overhead paging, chair alarms and shouting staff and residents? Is it too cold or too warm? Make environmental changes so that an older version of you wouldn’t mind spending time in the day room.

Provide appropriate programming. Are residents crammed together in a small area for long periods of time, creating the sensation of being trapped? Is the main activity a blaring television set? A therapeutic milieu is all about engaging the residents in appropriate activities with a pleasant flow through the day. Pursuits for residents with dementia can include music, baking, tactile and visual stimulation, etc. Providing activities off the unit offers additional stimulation to those who can tolerate it and lessens crowding in the day room. It can also offer a healthy diversion for cognitively intact residents.

Calm residents before they get agitated. The time for staff to act is when interactions between residents start to become tense, rather than waiting until an argument has broken out. Interventions such as distraction, redirection and a face-saving move to another location can be remarkably effective. Attending to individuals at early signs of distress can prevent episodes of full-blown agitation.

Use customer service techniques. Well-trained staff can often prevent agitation from occurring. Units can be transformed by charge nurses who speak to residents and staff alike in calm, respectful tones, address needs immediately and expect the aides working with them to do the same.

Staffing recommendations:  

• Train all your staff in customer service techniques.
• Offer special workshops for nurses, aides and recreation therapists on providing care and activities for residents with dementia.
• Consider hiring nurses with psychiatric experience who understand how to maintain a therapeutic milieu.

INVESTIGATE: PUT ON YOUR SHERLOCK HOLMES HAT

If a resident is agitated despite environmental changes, look for underlying causes.  Residents with dementia are often unable to speak through words, so they use other methods. Sometimes it takes a bit of sleuthing to figure out what they’re saying.

For more, visit LTL magazine online:

Reducing antipsychotic medications? Try these behavioral interventions

For more details on behavioral interventions, download Dr. El’s FREE report: Stop Agitating the Residents!

5 Reasons to Educate Residents About Their Illnesses (LTL mag online)

Here’s my latest article in Long-Term Living Magazine online:

5 reasons to educate residents about their illnesses

“How long have you had Parkinson’s?” the psychologist asked Mr. Jones during his initial evaluation.

“They just told me the diagnosis when I got here last week, but I suppose I’ve had it for a while.” He said it casually, but his hands were clenched and his voice held a note of tension.

“Did the doctor explain what it is or give you information about the Parkinson’s Foundation?”

“No. All I know is that it’s the same disease that young actor has—what’s his name?”

“Michael J. Fox.”

“Yeah, that’s the one.”

The psychologist assured the resident she’d bring him a pamphlet from the Parkinson’s Foundation the following week. It would work better, she thought to herself, if the medical staff provided the physical health information so she could follow up with the mental health aspects.

Residents often enter long-term care with surprisingly little knowledge about their conditions, whether they have a recent diagnosis or have been living with an illness for many years. This lack of information isn’t good for residents, families or facility staff.

Here are five reasons why we should teach our residents about the illnesses they live with:

1. Education leads to more active resident involvement in care.

When residents have information about their illnesses, they are more able to accurately report their symptoms to the medical team and to provide the type of information that improves treatment. A resident without knowledge is a passive recipient of medication and care; a resident with knowledge can partner with his or her medical team to address needs and find effective solutions. Joan, for instance, had multiple sclerosis and was keenly aware that the hot summer made it difficult for her to walk in rehab. She was able to work with her therapist to find more manageable activities so that she could continue with her rehab program during the summer months. Contrast this with Leon, who blamed himself for his MS symptoms, believed his difficulty walking was a personal failure, and was referred for psychotherapy when he stopped attending rehab. With encouragement and some psychoeducation about his illness, Leon was literally able to get back on his feet again.

2. Knowledge increases compliance.

Uneducated individuals are less likely to comply with treatment recommendations or may reject medications due to side effects without fully considering potential benefits. Individuals who understand why particular medications are given and how to cope with potential side effects are more likely to comply with treatment. They’re also more likely to have reasonable, informed objections for foregoing a particular course of treatment—reasons that can be readily understood and documented. For example, Lucille was initially resistant to the dialysis treatments that were recommended for her. Once she gathered information and spoke to some other residents in the dialysis program, she ultimately decided that its life-saving benefits were worth the time and discomfort of the treatments. Thomas, on the other hand, decided against dialysis and was able to explain and document his end-of-life wishes clearly, based on his knowledge of his illness.

3. Information reduces anxiety. 

For more, visit Long-Term Living Magazine online: 5 reasons to educate residents about their illnesses

Doctor-Patient Communication

Early in my blogging, I wrote a post for residents about how to speak to doctors, outlining what I call the Newspaper Headline Approach.  It’s designed for residents to make the most of their interactions with their physicians.  I was reminded of the Newspaper Headline approach when I read a recent Mind the Gap post by Stephen Wilkins, MPH titled Why It’s So Important For Physicians To Listen – The Patient’s Perspective.  How to talk and why to listen — a great combo.

Dr. El’s Newspaper Headline Approach

Talking to a medical doctor is not like talking to a normal person.  In a regular conversation, one person says, “Hi.  How are you?”  The other says, “Fine.  And yourself?” And they go from there.  If busy Dr. Shah stops by Mrs. Crenshaw’s room, inquires how she is, and hears that she’s “Fine,” he’s likely to be on to the next room before Mrs. Crenshaw can utter another word.  Instead, I suggest the Newspaper Headline Approach.