Category: Resident care
Posted by Dr. El - June 28, 2011 - Anecdotes, End of life, Resident care, Role of psychologists
Nan was in the hallway, looking as thin and pale as I’d ever seen her.
“Are you okay? Do you feel well enough to meet today?” I’d heard in morning report that she’d been diagnosed with pneumonia.
“No,” she croaked, and then hesitated. “I mean, yes.” She looked at me intently. “It might be our last time.”
Alarmed, I wheeled her into her room, stopping along the way to pick up the newspaper, as she requested.
“You said ‘it might be our last time.’ Do you think you’re going to die before next week?”
“Yes.”
I could feel the tears coming. I’d known Nan for years and was very fond of her. “Is it okay if I cry for a moment?” I asked her, but even if it wasn’t, I couldn’t help myself, and it took a minute for me to get myself under control. Nan busied herself with her newspaper.
“Do you feel ready?” I asked her. We’d discussed her thoughts and expectations about dying in the past.
“Yes.”
“Is there anyone you want me to call?”
“No.”
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I came back later in the day to check on her and found her in bed. She asked me for water. “Would you like to go on hospice? They’d have someone here four hours a day to help you with stuff like this.”
She took a sip of the cup I held at her mouth, and shook her head no. I felt bad leaving her alone in her room.
—————————
On the way to work the next morning, I debated about whether or not to bring Nan some flowers. Would it violate my personal rule not to do things for one resident I wouldn’t do for another? I went back and forth for a while, and then decided that I’d probably do this for a resident I’d been seeing for a while who was dying and had no visitors to help them through to the end. I bought a flowering plant in a pot, not wanting to get something that might die before she did.
—————————-
“I brought you some flowers, Nan,” I told her when I came into the room the next day. “I’m going to put them here on the windowsill, and they’ll be like me watching over you.”
Her voice was weak. “You’re too good to me.”
“You know I’m very fond of you.”
—————————–
I came back to water the flowers after the weekend. “Someone else has done it already, Nan.” I remarked. Nan looked at me and nodded.
—————————–
By Thursday, Nan had passed.
I put the flowers on the desk at the nursing station.
Posted by Dr. El - May 3, 2011 - Personal Reflections, Resident care, Role of psychologists
When I worked in the psychiatric hospital, the focus of treatment was on the mental health of the patients. Physical complaints were usually thought of as an expression of mental illness and not reflective of an actual medical problem. We once sent a patient down to the tiny sub-basement medical clinic after she injured her left hand. The report came back with a thorough examination of her right hand, which was missing fingers after a self-inflicted gunshot wound ten years prior. Her left hand was still throbbing.
In nursing homes, I find the opposite situation. The focus is on medical care, and mental health concerns are “in the sub-basement,” so to speak. This is despite the intensely stressful experience of nursing home admission, as I’ve written about before: The Stress of Nursing Home Admission.
In her April 30, 2011 New York Times article, Jane Gross, founder of the NYT blog New Old Age, discusses the lack of mental health care in nursing homes. In Doctor Focuses on the Minds of Elderly, she reports on the work of psychiatrist Dr. Mark E. Agronin, my guest blogger last month. My favorite quote of the article, which is well worth the read:
Why, Mrs. Sachs asked, “do they send buses of psychologists to a high school every time there’s a tragedy,” but here, where death is constant, “there’s only a brief memorial service and cookies?”
Posted by Dr. El - April 26, 2011 - Anecdotes, Communication, Resident care
It was around Easter time one year when the following exchange took place:
“Hand me my peeps,” Isabelle commanded from her geri-recliner. She pointed to something behind me.
I turned and saw a package of yellow baby-chick-shaped marshmallows on her tray table. The word “Peeps” was written on the front of the box. I handed them to her and watched as she stuffed one, and then another into her mouth. As she picked up the third, I pointed to her red wristband. “I guess you’re careful about the sugar with the diabetes.”
“I don’t have diabetes,” she stated flatly, munching the third peep.
This was only the second time I’d seen Isabelle, and I’d had to convince her to meet with me today. I didn’t know if she had diabetes and had forgotten, or was in denial about it. It was unlikely that her wristband was the wrong color, but she sounded so certain I had to consider the possibility. “Red wristbands are for people with diabetes.”
“Everyone’s been saying that since I got here two months ago, but I don’t have diabetes. Check my chart,” she directed me. “Check it now.”
I went to the nursing station and pulled out the thick binder, reading through the diagnoses on the Physician’s Order Sheet. No diabetes. I went to the nurse, who thumbed through her records. “No,” she said, “she’s right. She doesn’t have diabetes. I’ll change her wristband after I finish what I’m doing.”
I went back to Isabelle, who’d been referred for anxiety, and told her what happened.
“I wonder what other mistakes they’re making,” she said.
I had my work cut out for me, but, for now at least, Isabelle was letting me on her team.
Posted by Dr. El - April 18, 2011 - Books/media of note, Depression/Mental illness/Substance Abuse, Resident care
I once heard a family member complain at the nursing station about a parent being on antidepressants.
“She can’t remember a thing. How can she be depressed?”
The nurse replied, “I know.”
 |
| Marc E. Agronin, MD |
We tend to associate Alzheimer’s disease (AD) and other forms of dementia primarily with memory problems, but as a geriatric psychiatrist who specializes in dementia, most of my consults are for mood and behavioral problems. In fact, rates of depression approach 40% in AD sufferers over the course of their illness. Depression may look differently, however, in the context of dementia. Irritability, agitation, and resistance to care might be seen as prominently as a sad mood. Loss of appetite and poor sleep are common manifestations of both dementia and depression, and can make it difficult to tease them apart. In clinical practice, we look primarily for a rapid decline from one’s baseline when depression strikes.
The cause of depression in AD likely has less to do with a psychological reaction to cognitive and functional loss and more to the damage the disease causes to brain nuclei that regulate moods and produce key neurotransmitters. As a result, antidepressants that we use to treat depression in younger and nondemented individuals can be used with similar efficacy and safety. In early stages of illness, talk therapy can also play a key role, and in all stages there may be benefit to therapeutic programming involving music, pets, and exercise.
As I make clear in my book “How We Age: A Doctor’s Journey into the Heart of Growing Old
,” we cannot adopt a fatalistic attitude or even give up when depression or other mental illnesses afflict AD patients. Not only is there much we can do to treat these symptoms, but there are always underlying strengths that can be tapped, including humor, creativity, sensory enjoyment, and the ability to interact in socially meaningful ways.
Posted by Dr. El - January 25, 2011 - Resident care, Transitions in care
I was a dork in high school. Oh sure, some of the people who knew me best realized I wasn’t quite as dorky as I appeared on the outside, but to most of the kids in my class I was not a sought-after individual.
Residents in geri-recliners are the dorks of the nursing home. For the uninitiated, geri-chairs are like chaise lounges on wheels. They are often difficult to maneuver, take up extra room in the elevator (thus reducing the chance of being transported to activities), and make it virtually impossible for residents to go out on pass with their families to enjoy a meal at home or in a restaurant. In addition, people tend to assume that residents in geri-recliners aren’t “with it.”
By contrast, those residents lucky enough to be able to use electric wheelchairs are like the captains of the sports teams, the shining stars. Residents who can wheel themselves around are the jocks, people in regular chairs are the cool kids, those in high-backed chairs are in the band, and residents who need their feet elevated are in the math club.
People are given geri-recliners to reduce pain and prevent skin breakdown, as they’re easier on the body than other chairs. There are good reasons for such chairs, but this post is a pitch for making these conveyances the chairs of last resort because of the effect they have on the social and psychological health of the residents confined to them.
If you know a method or product that allows residents to stay in other types of chairs with the same level of comfort as the geri-chair, or are aware of a geri-recliner that’s designed for maneuverability and user-friendliness, please add your thoughts in the Comments section.
Posted by Dr. El - January 10, 2011 - Communication, Medication issues, Resident care
THE PROBLEM:
Because of their personality styles, some nursing home residents don’t ask for their PRN (as needed, or “per request of the nurse”) pain medication when they need it. The reasons for this vary:
Psychologist, finding the resident in pain: “Why didn’t you tell the nurse?”
Passive: “I didn’t want to bother her.”
Macho: (grimacing) “I can handle pain.”
Forgetful: “I can ask for pain medication?”
THE SOLUTION:
- Counseling the passive or macho types about appropriate use of their pain medication
The forgetful person and those who don’t respond to counseling would fare better with:
- a standing order (medications dispensed at a specific time)
OR
- by having the nurse ask the resident if they’re in pain every time they’re eligible to get pain medication
Posted by Dr. El - October 5, 2010 - Common Nursing Home Problems and How Psychologists Can Solve Them, Resident care, Role of psychologists
A recent article in McKnight’s Long-Term Care News (September 2010) caught my eye: Attitude appears to affect healing process for wounds. The article cites a research study in the August issue of Dermatologia that found patients who were less depressed had wounds that healed faster. It also found slower healing in those who had “confrontational” coping styles and therefore had difficulty with the loss of control around waiting for a wound to heal.
It turns out this isn’t an isolated conclusion. A
2008 study in the Journal of the American Podiatric Medical Association found similar results regarding depression and healing. Stress and depression were found to affect healing in a
2001 study in Psychosomatic Medicine. In 2008,
researchers at Cairo University found the use of relaxation techniques helped reduce depression and improve wound healing and recovery in post-Coronary Artery Bypass Grafting (CABG) patients.
- Residents recovering from wounds or surgery
Posted by Dr. El - September 27, 2010 - Communication, Resident care
After my session with Evelyn, who painstakingly typed her thoughts on her computer, I stopped at the nursing station to relay her message.
“Can you tell me which aide works with Evelyn Booth in 302?” I asked the nurse.
“Ms. Johnson,” she said, and pointed to a Certified Nursing Assistant (CNA) in a light blue uniform.
Hearing her name, Ms. Johnson turned and glared at me. “How do you know it was me?”
Surprised, I smiled and spoke in a soothing tone to reassure her. “Did you work with Ms. Booth this morning?”
She put her hands on her hips and spit out a single word. “Yes.”
“Well, she wanted me to let you know she really liked the way you did her hair today.”
“Oh.” She appeared surprised by the compliment, but unwilling to discard her initial suspicion. “Thanks.” She turned and walked away.
In 14 years as a psychologist in long-term care, I’ve occasionally come across an aide who was willing to collaborate with me in helping a resident. We discussed troublesome behavior and found ways to work around it, shared information, and developed a friendly collegial relationship. I’m disappointed such instances are exceptions rather than the rule, and I’d like to see this change. The way I see it, the psychologist is the CNA’s friend, here to make your job easier, not to write you up.
The current punitive system, where CNAs are more likely to be disciplined than rewarded, poses challenges to collaboration, but I think we can do better. I’d like to find ways to bridge this divide, and I need your help. If you have suggestions, or experience with developing alliances between nursing staff and other members of the team, please leave them in the comments section, or send me an email via the Contact Me button. Let’s start the teamwork right here.
Posted by Dr. El - September 20, 2010 - Communication, Customer service, Resident care
Complaint #5: There’s no one here for me to talk to.
Untrue! But we need to prove it to residents by helping them connect with their peers.
The false impression they’re alone in the nursing home is based on several factors:
- New residents carry the prejudices of most people outside the nursing home, believing everyone inside is confused or too ill to carry on a conversation.
- The tendency of people to believe they’re unique, when in fact there are many uniquely interesting people in nursing homes. I know. I’ve spoken to them.
- Nursing home “old-timers” who are more alert tend to leave their units to attend activities. When newbies arrive, they try sitting in the hall or in the day room and, finding the more confused residents, they come to the conclusion that everyone is confused and then retreat to their rooms.
- Because most residents are visibly physically disabled, people often incorrectly assume they’re cognitively disabled as well.
Techniques for Family Members to connect residents include:
- Attending activities with loved ones and talking with other residents/families there.
- Asking nursing, recreation, and social work staff about other residents with interests similar to your loved one and helping to facilitate conversations about commonalities.
- Asking recreation, dietary, or nursing staff to seat your loved one near their friends during meals and activities if your loved one is unable to ambulate on their own.
Techniques for Staff Members to connect residents include:
- Introducing new residents to others with similar interests.
- Encouraging them to attend activities before they settle into spending their days alone in their rooms.
- Recognizing strengths and sharing them with others in the community. For example, a new resident agreed to be interviewed for a feature story in a nursing home newsletter.
- Helping residents establish a welcome committee.
Posted by Dr. El - September 9, 2010 - Communication, Customer service, Resident care
Complaint #4: Nighttime disturbances
The main culprits:
- TVs blaring into the wee hours
- Agitated neighbors
- Loud conversations between workers
Steps toward improved sleep hygiene:
- Implement a TV curfew and require night owl viewers to use headsets past the curfew
- Encourage night shift workers to report resident sleeplessness so sleep/wake cycle disturbances can be reversed and medications adjusted if necessary.
- As part of inservice training, address ways in which night staff can communicate with each other to avoid disturbing sleeping residents.
Good sleep hygiene on an individual basis can reduce irritability, improve memory, and promote healing. Good sleep hygiene on a unit-wide basis is good customer service that can benefit the physical and mental health of residents and reduce conflict between residents (it’s hard to be friendly toward someone who’s kept you up all night).
