When a family member or friend is visiting the elder in the Nursing Home, here are four things to look for:

1. Be aware of the elder’s pain. Pain is the most underreported problem in nursing communities. This applies to the general nursing home population and even more so for those with dementia. Sometimes the elders can’t express their pain in words, so those who know them need to be alert and able to read their body language. Signs of pain in elders with dementia may be increased restlessness.

Elders with chronic pain should have routine orders for pain medication. Orders for pain medication written “as needed” are not appropriate for chronic pain. When the order is “as needed” for someone with arthritis, that means we have to rely on the nursing assistant to notice that when they bend the elder’s knees and observe a grimace, or the joint may be swollen or warm to the touch, the elder is hurting.

When elders suffer from any kind of chronic pain they don’t sleep well. Fatigue is another symptom. Or they may not eat well or start to withdraw. A nursing assistant is there to assist, and it lays a heavy responsibility on them – for which they’re not trained – to observe and communicate pain accurately to the nurse.

This is when the family can be of tremendous help and support to the staff. When the family members observe signs of pain, they can communicate effectively by stating the behavior, area of the body, and provide any history the nurses need.

I noticed that Mom is rubbing her knees,” a daughter might say. “She has had problems with arthritis in the past and it must be bothering her again.” The daughter might have said that after spending hours with her mother. Nurses saw her mother only at brief intervals.

Book excerpt: Please Get to Know Me – Aging with Dignity and Relevance available at Amazon.

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing



In a Nursing Home, family members aren’t always the recognized authorities on their loved one’s condition. Yet, they are an invaluable resource for the nursing staff. Family and friends have the one-on-one time, usually for hours, that the facility isn’t able to provide. The best time for the staff to catch a change in condition is when they assist an elder to get up for the day or help her get into bed.

However, that is when problems occur because the staff member may:

  • Not be the usual caregiver
  • Be a caregiver who’s not perceptive
  • Be the caregiver who sees a change but assumes that “everyone already knows”
  • Be someone with poor communication skills
  • Be a new nursing assistant or one with little experience

Such a situation places responsibility on the front-line workers who have the least amount of education. Such workers may think of their job primarily in terms of the tasks they have to accomplish. When asked specific questions, they usually have the answers, but didn’t realize they needed to pass the information on to the nurse.
That isn’t an uncommon problem, and questions naturally arise. For what should the family watch and listen? What is the most effective way to communicate the observation without seeming confrontational or judgmental?

Book excerpt: Please Get to Know Me – Aging with Dignity and Relevance available on line at Amazon

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing


The last two weeks you can’t listen to network news without hearing about measles. The numbers have just gone over 100 giving the media the ability to say “over 100 cases now reported.” How about these numbers? In 2012, 29.1 million people were diagnosed with diabetes. That was up from 2010 when the number was 25.8 million, an increase of 3.3 million people in just two years.

In 2012, it was reported 245 billion dollars were spent on the total costs of diabetes. More than 1 in 5 healthcare dollars went to the care of persons with diabetes. People diagnosed with diabetes, who suffered heart attacks, strokes, kidney failure, blindness and even amputation. And yet this isn’t even the worse part of the story.

The researches tell us the numbers to be watching are the pre-diabetics. Those who have no idea the path they are on. Current estimates are that this is 40-50% of the country, about 140 – 150 million people.

A great way to find out if you are going to be one of those statistics is to have a blood test. The A1-C blood test that measures not just what you ate last night but your blood sugar levels for the last 3-4 months. A normal reading on this test is 5.6% or under, a pre-diabetes reading is 5.7 – 6.4 and diabetes is 6.5 and higher.

Current recommendations are that children 12-15 have their first blood test to establish a baseline number. But also the blood test is not a bad idea, in order to catch those children who are eating their way to pre-diabetes on junk food. Giving the children, a chance to get used to getting sugar from fruit and eating fewer starches by reducing portion size.

So while millions of Americans are eating their dinner and watching the news, instead of being scared by Ebola or measles they should be scared of that dinner plate.

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing


Anyone who has ever attended a concert has experienced a large group of people with synchronized brains. As a piece of music is played with emotion, dopamine is released in the brain and a person experiences pleasure. Added to that, a recognizable rhythm pattern and everyone’s brain is happy and synchronized.

Music affects deep emotions in the brain, releasing dopamine. As soon as a well-loved melody begins, small amounts of dopamine are released in the brain in anticipation. Anticipation, of the strong emotional, well remembered places in the music, yet to come. You know those parts that everyone remembers and sings along to. During especially emotional moments in the music an increase of dopamine is released. Dopamine makes, listening to familiar music with familiar rhythm, very rewarding for the listener.

Dopamine has long been considered the feel good neurotransmitter in the brain. A high level of dopamine helps with physical movement, positive emotions and is the reward transmitter. Many positive things in life can increase dopamine in the brain and music is one of them.

When a piece of music is unfamiliar the brain tries to search for that familiar rhythm, or note sequence. In the case of a jazz piece where there are odd or unexpected rhythms. The brain can’t connect to something familiar. Not only will dopamine not be released, but the experience may become difficult, stressful and unpleasant.

Give the confused person with dementia an opportunity to have that happy, good feeling music has to offer. Play some familiar music that allows the listener to “feel” a memory. Then go the extra step and synchronize your brains, sing along.

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing


The traditional color for healthcare workers has been white. There are good reasons for this. Many times when I have walked into a bedroom of an elderly confused person to check on them, if the elder wakes they immediately say “nurse”. I would reassure them that everything was alright, but that white uniform said much more.

White of course reflects and stands out in a dark room making the caregiver easier to see. White is connected in everyone’s brain with good, pure, heavenly, and clean. This perception doesn’t change when a person gets old or confused.

On the other hand when an athletic team wants to intimidate their opponent they will wear black. A team dressed in all black will look larger and more dangerous. Add a little red to that athletic uniform and red adds the message stay away, danger.

Any clothing in very dark, almost black, colors might be difficult for a confused elder to see, and they may only see black. Happy colors are in the yellow family. Also light green is considered a color that improves mental functioning. Green has been shown to improve test results with students, and light blue is shown to be a stay-awake color. The combination of white with yellow, light green or light blue is the perfect combination for caregiving.

Archive pictures show Florence Nightingale in her familiar uniform of long black dress. But that dress was softened by her white lace collar and lacy cap. Even pictures in her old age showed her in the same combination with the addition of a white lace shawl. However, for many years the color of healthcare has been white.

Every time research is conducted on what profession people think is the most trustworthy, nursing rises to the top. So dress the part, especially if you provide care at night, wear white and you will hear your elder say “nurse.”

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing


Of course the elderly and seniors are afraid of falling, but Beth was only 31 when she fell on ice in a parking lot. Beth was late for work and walking much too fast for the slippery conditions in the parking lot that day. And the parking lot as slick as it was, made her fall even harder, resulting in a fractured wrist.

Walking in winter weather calls for extra diligence in:

  • Taking care of your body, for it to function as limber and flexible as possible. Warm up your legs, feet and knees before you go out in snow and possibly slippery conditions. A great way to warm up feet is with a warm water soak in Epsom salts. Difficulty walking can be due to inflammation which will make tissue painful, tight and stiff. Knees, legs and feet can be especially vulnerable to inflammation, and that inflammation can be tracked back to poor food choices. Avoid inflammatory foods; sugar, white flour, white potatoes, white rice, and pretty much anything that is white.
  • Exercising – to improve strength and balance. Maintain a regular exercise routine and on days when the elderly cannot get out, it is even more important to exercise. Stretch before going out, stretching improves circulation and limbers the joints and muscles.
  • Careful, but appropriate use of pain medications. Just as a person in a healthcare situation would take a pain medication before going to therapy, so also medicating before walking outside maybe just as appropriate. Arnica gel is a great topical for pain, swelling and stiffness. There are new reports all the time on the benefits of Ibuprofen medications for inflammatory pain relief.
  • Dressing for the weather. Now that you have those legs, knees and feet warmed up, keep them that way. Three light layers of clothes are preferred to one heavy layer. Be aware of any clothing that might be too restrictive, and actually decrease the ability to move. I personally love the new warm light weight fabrics – long underwear anyone?
  • If the elderly use a cane or walker they should also use that walking device, in winter weather. However caution needs to be taken when rubber tips on canes/crutches become wet – they can be extremely slippery on a hard surface indoor floor.

Many elderly people become isolated in winter and suffer from depression. Going outdoors, enjoying fresh air, nature and socializing is so necessary to protect against depression in winter.

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing


The John Hopkins Medicine research study just released their findings that there are specifically 22 types of cancer that are attributed to bad luck. After 5 billion were spent in cancer research last year, we are now at the bottom of the barrel, talking about bad luck.

They did report that some cancers were directly attributed to lifestyle choices. However other than smoking and not wearing sun screen, they still returned to the theme of bad luck. Why it has been asked does one person who smokes die from cancer and another is seemingly unaffected. The only answer seems to be hereditary problems, or of course it stinks to be them, and they have bad luck.

But just maybe the lifestyle choices should also include how often those smokers stopped at fast food places. How old was the smoker who developed cancer, how long had they been smoking, and oh yes, how many Big Mac’s have they enjoyed?

The only thing related to what people were putting in their mouths in the study, was that of course people need to manage their weight.

At the same time the Agriculture, Health and Human Services Department are coming up with a new and improved version of the “my plate.” (The former food pyramid) This one is reported to be dietary guidelines that are plant based, at the expense of meat. The basis seems to be not only that plant based diets are more sustainable. But, that the increased plant versus meat diet is more health promoting and environmentally friendly.

Lucky for all of us, that people are getting more interested in saving the environment, maybe now we can start to concentrate on saving more people.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing



The time for a back rub is, any time. For the caregiver of a potentially difficult elderly man, a good time could be right before getting ready for bed. The back rub can be given over clothes, making it a good transitional activity. Just saying “here, I have a few minutes, let me give you a back rub,” takes it from a procedure, to a gift from a friend.

Many of the confused elderly have increased agitation in the evening. A back rub can reassure the elder; that they are not alone, provide feelings of trust in the caregiver, bring the elder to the present moment, reduce resistance in the elder at bedtime or bath time, increase the sense of wellbeing and calmness in the elder, and then will help the elder fall asleep more easily while providing a better quality of sleep.

The back rub guidelines:

  • Beginning the backrub at the shoulders is a good idea, always avoiding the neck area of any individual of any age. The neck should be manipulated only by a trained professional because of the sensitive nerves located in the neck.
  • Caregivers should have short finger nails as a precaution. You will be massaging with the flat of your hand, however long fingernails can pose a hazard.
  • If the backrub is given directly to the elder’s skin, warm up the lotion rubbing it between the palms of your hands. (a back rub given in bed, directly to the elder’s skin can be located on this site Archived at September 13, 2010)
  • If the elder has any open areas of the skin, use gloves.
  • For the elder in clothes and in a seated position, use small circular strokes. Begin the strokes at the shoulder blades, right circles to the right and left handed circles to the left over the shoulder blades.
  • Continue those small circular movements down the elder’s sides and then across the lower back and moving up the sides of the spine. This can be repeated several times.
  • The circular strokes increase circulation and the back rub can end with long flowing, relaxing strokes.

Taking the time to give something as simple as a massage may reduce the need for pain medication or a behavioral medication, improve joint flexibility as well as skin condition, decrease the chance of bed sores, and make the elder happier, more flexible and easier to care for.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing


Part II

The hand massage is an easy skill for anyone to acquire and yet it provides so much to the elder in the way of comfort, reassurance, communication, and caring.

Hand massage guidelines:

  • Some elderly people should not have hand massage; if they have any broken or irritated areas of their skin, if they have inflammation of their joints, if in any way the massage seems to be causing pain, or they have very thin and fragile skin that appears bruised.
  • Beginning a hand massage with clean hands (for both elder and caregiver) is very important and can be part of the event. A small basin of warm water with a small amount of soap can be a great way for the elder to relax and warm up those stiff joints.
  • Clean towels should be handy and a clean towel placed under the elder’s hand for support during the massage.
  • A hand massage is performed in a very slow, rhythmic pace. This is an opportunity to communicate to the elder, through your touch, I am with you.
  • A hand massage, while done with a light touch, is done totally encompassing of the elder’s hand, providing full contact with the caregiver’s hands.
  • Provide a quiet and calm environment – TV and talk radio always off. Soft music is fine and can make the event even more relaxing.
  • A light lotion is used with hand massage (not oils) either unscented or lightly scented with lemon but not perfumed.

The Hand Massage:

  1. If the person is in a wheelchair you can support the hand and arm with a bed pillow, if the person is able to sit with a small bedside table in front of them the hand can rest on a small towel on the table.
  2. The stroke is similar to the stroke used for applying a lotion, smooth, light and flowing.
  3. The caregiver’s fingers are relaxed and use the gentlest of pressure.
  4. Small circular motions can be made with the flat portion of the fingers and palm of the hand, alternating with times of sandwiching the elder’s hand between the caregivers and giving reassuring pressure.
  5. The hand massage can be effective in as little as 3-5 minutes, alternating the flowing stroke, circular stroke and moments of gentle pressure.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing



Zelda has lived here for several months, but when I gave her a hand massage, I felt like I got to know her for the first time” said Zelda’s caregiver.

Providing human touch improves the quality of life for those who are ill or in their later life stages. Touch in the form of a massage gives an opportunity for one-on-one attention from the caregiver. Instead of casual touch during times of providing care or completing a task, this touch is intentional and focused.

Each of us has within us the power of a healing presence that we can give another person through a smile, our focused attention and most of all by putting our hands on another person. Touch is a very real and strong form of communication.

There are several types of touch used in healthcare as well as by the person caregiving in the home. Caring touch is used to comfort or encourage another person. Putting your arm around the elder’s shoulders, or stroking the head of a person in pain is caring touch. The task touch is used in bathing, dressing and general care of the person. There is also a protective touch that is used when you take the elder’s arm to support him walking.

Many times the caregiver just doesn’t think they have the time or the skill and training to do compassionate touch. They may think this is just something a professional, or someone in hospice care does, but just the opposite is true. This is a caregiver tool for everyone, which provides as much satisfaction for the caregiver as for the individual receiving care.

The very simple hand massage can calm a restless elder, bring focus to the elder suffering from delirium following surgery, and provide comfort for the dying. And like Zelda, give the gift of a warm memory, for the caregiver.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing