HOW TO CHOOSE A NURSING HOME FOR A PERSON WITH DEMENTIA Part III

A term that has gone out of use in the nursing home community is “custodial care,” and with good reason. The current term for care is “person centered care.” These terms are the difference between living and existing.

With custodial care you are existing but do people only want to exist? Existing means to; be present, to be alive, to be in existence, and to be surviving. Custodial care meant that the nursing home was protecting the elderly. They were charged with safe keeping and at times total guardianship of the elderly in their care. As was frequently said at that time, patients were kept “clean, dry and visitor ready.”

With time, thinking changed in the nursing home community, and people started to think about how they would like to be taken care of. Being clean, dry and visitor ready didn’t seem all that appealing. Now the thought is, if you look at all of your favorite activities over a period of time, and realize that you will never again do those things, how would you feel?

Take Ann who is now in her early seventies. Ann loves to cook, especially she likes to make soup. She makes two different soups every week. She likes to bake, making her favorite pumpkin muffins often, freezing them and eating them infrequently for a treat. Ann was a school teacher for many years and now works as a teacher’s assistant three times a week. She really enjoys staying in touch with the school atmosphere, other teachers and of course the children. Ann loves music, she sings in her church’s praise choir and she enjoys playing the piano. Ann also loves to knit and does her own small art projects making bookmarks as gifts for friends. She enjoys getting together with family and friends as often as she can.

Going to a nursing home in the future where she would only exist wouldn’t work for Ann. Living compared to exiting means; continuing your life style, maintaining your habits and activities, remaining active and relevant through being busy. Having dementia or not Ann would want to continue to; enjoy being with children, having her favorite foods, doing art, listening to music, being social, and remain connected to her faith.

Finding that nursing home that understands “person centered care,” and the concept of living over existing, is the best choice for a nursing home, for a person with dementia.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

SUDDEN CONFUSION – GO TO EMERGENCY ROOM

While it is easily seen when a person has a dramatic change in consciousness and they are in a stupor or coma, delirium is not that easy to identify. The emergency department is usually the point of entry into the hospital for the confused elder. The ER runs at a high speed and it is necessary for an accurate diagnosis for the patient’s family or friends to give a good history.

Patients in a deep sleep or stupor, who can only be aroused with extreme physical stimulation are in a medical emergency. The emergency room personnel assume that the person is not always so difficult to arouse, and they recognize the emergency. However identifying changes in a patient with delirium is much more difficult because the hospital staff do not know how the patient usually is. This puts the burden of communicating the emergency situation on the accompanying family member.

It is estimated that ER physicians miss the diagnosis of delirium in 57 to 83% of cases. This wastes valuable time for the patient, time that they need for early intervention. This missed diagnosis can be due to the fact that the elder themselves do not know why they have come to the hospital. Or if the elderly person is agitated they may even be admitted to the psychiatric ward, without a good assessment.

Giving a good mental history:

  • when did you first notice a change in mental function?
  • do these changes seem to come and go – get worse or better over time
  • does the person have problems paying attention – give an example of what is normal for this person and how they are now not acting normally – having difficulty carrying on a conversation – getting distracted and changing the subject
  • patients who are inattentive may actually fall asleep when they are not engaged in conversation, this change in sleep/awake patterns needs to be stated
  • the patient now has rambling thoughts and disorganized thinking
  • if the patient has had any recent falls, this is a very important piece of information and will help the physician in their physical examination – looking for possible head trauma
  • maintain an accurate list of all of the elder’s medications as well as any over the counter medications they are taking – maintaining this list will make it much easier in an emergency situation
  • share with the emergency staff if the elder has a history of alcohol abuse or use of sedatives
  • has the elder ever experienced an episode like this in the past?

Being prepared and ready with this pertinent information is impressive and will more likely get the attention of the emergency personnel than saying “He is just not acting right.”

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

SUDDEN CONFUSION – CAN THE PERSON WITH DEMENTIA GET DELIRIUM?

Many people, including those in healthcare use the terms dementia and delirium interchangeably. Even tho they are not the same, patients can have both conditions at the same time. A person with dementia can certainly develop delirium, they are even more inclined under certain circumstances, to develop delirium.

The person with several disease processes as well as dementia, will be the person at most risk for developing delirium. Research has shown that the person with dementia has a lower mental reserve and less ability to adjust to a physical assault. That assault can come in the form of an infection such as a urinary infection or upper respiratory infection. Because the person is more vulnerable due to their dementia, they can under these circumstances develop delirium.

Other factors creating an increased likely hood of developing delirium are advanced age, history of alcohol abuse, poor nutrition, poor physical function, poor vision, hearing loss, dehydration, congestive heart failure, extreme pain (such as that related to a fracture), and many medications especially narcotics. Many times the cause of the delirium will not be found.

When the person is admitted to the hospital they are at increased risk to develop delirium if they have dementia. Due to the nature of the running of a hospital, the confused person may have physical restraints to keep them safe if they are trying to get out of bed unassisted. The elderly who are incontinent may now have a catheter for the purpose of obtaining urine specimens as well as easier care considerations. These possibilities as well as the likelihood of the elder now having an increased number of medications can result in an increased risk of developing delirium.

In the United States, hospital emergency rooms are currently seeing approximately 18 million patients 65 years and older. As the population ages, the number of visits to the emergency room by the elderly will increase dramatically as well. The potential for large numbers of the elderly population going to the emergency room for sudden confusion and developing confusion when admitted to the hospital is increasing. All of this adds up to an expectation of  not only the increase in elderly persons with dementia but also the increase in cases of delirium.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

HOW TO CHOOSE A NURSING HOME FOR A PERSON WITH DEMENTIA Part I

Choosing a nursing home for the person with dementia, is about where the person is in their disease process, as well as what their finances are and will be. The competition is currently very high for nursing homes caring for persons with Alzheimer’s disease.  This climate has brought forward many, very innovative programs. Programs that include plants, animals, special menus and dining options, activity programs for special interests, art, music, and the list goes on.  When a person is in the early stage of Alzheimer’s disease, they are more able to make use of special programs. Later in the disease process the person will have less interest or ability to participate in such programs.

Because many of the high end programs are usually found in private pay facilities, when assessing the elder’s finances, it makes good sense to use those resources when the elder can most enjoy them. Knowing that there is a progression to this disease, and that there is a slow decline, helps in planning. In the early stage of the disease, more funds should be available not only for the nursing facility but also for community events.  Going on outings, shopping, to a movie, out to lunch, to the zoo, etc., these opportunities need to be available.

When visiting a nursing home ask to see the activity calendar. Look for not only internal opportunities but for those outside events. Ask how they are funded, does facility have their own van, do nursing assistants accompany the elders as well as activity staff.

I well remember a nursing home that sponsored an outing to the zoo for its patients. The patients who participated were in early stage of Alzheimer’s disease.  Everything was going fine until the first patient went to sit down on a park bench and missed the bench falling to the ground. About 30 minutes later a second patient did the same thing. (both without injury)  The nursing home administrator decided it was time for this group to return to the facility. Thereafter a group never went out without a member of the nursing department, trained in Alzheimer’s care, in attendance.

Ask if there is a special memory loss unit? Is there a director of that unit? Interview the director and inquire not only about their program but also how they assess their patients for activities. The director should use terms like “person centered care” as well as vocalize an interest in your loved one’s history and “favorites.” Favorite foods, beverages, sports, music, any art interests, and more questions that would help the facility to design a program for your loved one.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

SUDDEN INCREASE IN CONFUSION IN ALZHEIMER’S PATIENT – IS THAT EVEN POSSIBLE?

Harold came into the skilled nursing facility, admitted from the local hospital. Harold lives at Pleasant Meadows, an assisted living community where he has been independent. The problem arises when the nurse from the skilled facility  calls the nurse from Pleasant Meadows. The Harold that the nurse now describes in not the man the Pleasant Meadows nurse has know for the last 6 month, before he went to the hospital. Harold?  Uncooperative, disoriented, unsteady on his feet, falling, with generalized weakness? No, no the nurse from Pleasant Meadows insists that they (the skilled facility) don’t know what they are doing and don’t know how to take care of Harold.

Sadly this scenario is not unusual, for one healthcare facility to accuse another of not knowing what they are doing. Doesn’t the fact that because Harold already has the diagnosis of Alzheimer’s disease mean that it is understood that he is confused? Yes, Harold is always confused, but this new Harold is in an altered mental state. He was admitted to the hospital with pneumonia. Infections in the elderly many times can cause confusion. This infection caused Harold to experience a rapid decline in his mental functioning and an increase in his confusion.

Sudden increase in confusion can result in very vague symptoms. The family member might say he is “not acting right”, has different behavior, is either more sleepy or more agitated, is extremely distracted,  has recent inappropriate behavior. These sudden changes can come within days or even hours of onset. The great difficulty comes in diagnosing why the individual is suddenly more confused. As well as realizing that it is going to take much more time for the problem to resolve compared to the fast onset.

Harold will continue to have increased confusion even after he has recovered from his pneumonia. And Harold is likely not to return to his previous level of mental functioning.  This infection has tragically caused him to lose some mental clarity  and has resulted in progression of his dementia. Right now Harold needs one on one care, with people who explain the environment and what is going on, as well as protecting him from unsafe activities. All the while giving his mind the time to heal as well as his body.

Yes, it is not only possible for someone with Alzheimer’s disease to suddenly become more confused, it is more than likely when there is an infection involved. A sudden increase in confusion, or delirium continues to be misunderstood.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

ALCOHOL RELATED DEMENTIA – THE DR. JECKEL & MR. HYDE STORY

Howard was a particularly difficult new patient in the dementia unit. Howard was young – only in his mid fifties, strong and very fit at least physically, not mentally.  Howard was easily upset, especially if a staff member told him “No”. And Howard presented us with many opportunities for saying no, as he literally ran through the unit. Having seen other patients like Howard, I asked his wife if Howard had had a drinking problem. She looked very surprise at the question, and yes Howard had been in the habit of drinking daily.

I then asked her if Howard had shown a significant change in personality when drinking, yes he did.  His demeanor changed and she remembered him having almost a “day and night personality change”. Eventually a Dr. Jeckel and Mr. Hyde personality switch was going on. Howard being normally a happy person, when starting to drink would soon become excessively friendly and happy to the point of being obnoxious. He would be very social and then become almost celebratory in his mood. When guest were over frequently jumping into the pool fully clothed.

After a seemingly shorter and shorter time of drinking,  Howard would literally check out, having a flat expression and appearing somewhere else.  His expression would then become very dark and scary while his vocabulary became suggestive and often he was vulgar.

Fortunately  Howard hadn’t been the drinker who becomes immediately angry, aggressive, rage-full and ready to fight. Of the two personality shifts the happy drinker is easier on the family, but maybe makes it harder for them to identify a drinking problem earlier.

So how much is too much, when it comes to drinking? Moderate consumption of alcohol is considered 1-2 drinks a day. A significant history of drinking is 35 or more drinks a week for a man and 28 a week for a woman.  Alcohol is quickly absorbed into the blood stream and goes directly to the neurons in the brain. Alcohol causes an increased release of dopamine in the brain (the pleasure/reward neurotransmitter), and over time you need a larger and larger amount of alcohol to realize the same effect.

When caught early, brain damage due to alcohol can be reversed. Alcoholism is caught too late when long term excessive consumption has been a toxin to the brain, resulting in neurological damage and changes to the brain including brain shrinkage.  Drinking to the point of drunkenness is particularity harmful to the brain.This was Howard’s story, and is he now is at the point where Dr. Jeckel is gone and all that is left of Howard is Mr Hyde.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

IS DEMENTIA THE SAME AS MENTAL ILLNESS?

Mental illness is a broad term for disorders that affect thinking and behaviors. That, at first glance, can sound like dementia. However, there are known causes for many forms of mental illnesses. Also, strong effective treatment programs will include cognitive behavioral therapy, which is not used for persons with dementia.

Mental illnesses range from mood disorders; major depression, anxiety disorders, panic disorders, personality disorders, obsessive-compulsive disorder, to psychiatric disorders; anti-social, narcissistic, schizophrenic, and so many more.  These conditions are traceable to poor parenting practices, childhood trauma, bereavement, unemployment conditions, social stresses including cultural stresses, as well as abuses; drug abuse, cannabis, and alcohol abuse.

Cognitive behavioral therapy involves helping the individual in identifying their distressing thoughts, while seeing how realistic these thought patterns really are. This therapy, stresses working on distorted thinking, and coming up with positive problem solving techniques. Consistently focusing on how valid the person’s thoughts are, as well as examining how useful this thinking is to the individual. Cognitive behavioral therapy when successful will change troubling behaviors.

In order to be successful with this therapy the person has to possess the ability to reason. Loss of reason and judgement are early signs of dementia. As well as loss of the ability to focus, persons with dementia due to Alzheimer’s disease, are very easily distracted.  Persons with dementia, due to Alzheimer’s disease, will have short term and eventually long term memory loss.  Memory loss not a symptom of mental illness.

Above all, despite the changes seen in the individual with a dementing illness, he is not really distressed by his losses. For the most part his frustration is due to misunderstanding the environment and cooping with the loss of communication skills.  In contrast, persons with mental illness are very much distressed by their thoughts and behaviors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DEMENTIA 101 – DISEASES CAUSING DEMENTIA

Dementia is not a disease, but rather a combination of symptoms that may accompany a disease or physical condition.  These changes or symptoms, begin with memory loss, and slowly progress to the person having difficulty caring for themselves and eventually becoming totally dependent on others. The symptoms must include memory loss and at least one of the following to indicate dementia.

  • Loss of language skills, understanding words, spoken or written as well as the ability to speak coherently.
  • The loss of the ability to recognize objects and eventually people.
  • The loss of the ability to initiate and follow through with motor skills.
  • The loss of reason, judgement, planning and ability to follow through with a plan.

These changes have to be severe enough to interfere with the person’s ability to live independently, to be considered dementia. When the elder suffers only from occasional memory problems, that are not interfering with daily activities, they are considered to have mild cognitive impairment.

Alzheimer’s Disease: is the most common cause of dementia affecting between 50% – 70% of those diagnosed with dementia. By the time a person is 85 years old they will have about a 50% chance of developing Alzheimer’s Disease.

Vascular Dementia: The second leading cause of dementia is experiencing a stroke. This is not a slowly progressing dementia, it progresses as the elder continues to have small strokes causing more damage to the brain.

Lewy Body Dementia:  Named for the round structures, or Lewy bodies found in the brain. This is frequently connected to the person who has, Parkinson’s disease with dementia.

Frontotemporal Dementia: This dementia doesn’t present with memory loss until much later in the disease process. The first signs are personality changes, and lack of empathy for others.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

WHEN DEMENTIA AND CONFUSION AREN’T PERMANENT – SUDDEN DELIRIUM

I receive emails from families who can’t understand what has happened to Mom, Dad, Uncle Charlie and so on. You see this person was just fine a couple of weeks age, driving, shopping, living alone, balancing their check book, and now the doctor says Mom has Alzheimer’s disease and needs to live in a nursing home. What usually happened is that Mom had an infection, an accident, change in medication or surgery and this put Mom into a state of delirium

Synonyms for delirium are; irrational, raving, deranged, and yes even demented. Once the stress is over, the elder returns to their previous state of cognition. But what if Mom is in the hospital when she becomes delirious? The hospital personnel don’t know Mom and  don’t recognize her delirium. Mom will be labelled a confused, demented elder and medicated to keep her under control and “safe.” This will only lead to increased confusion making Mom appear even more confused.

The presence of delirium can indicate that the elder’s brain has a decrease in capacity and may indicate an increased risk of developing dementia. The healthcare community sees delirium frequently with the elderly and infrequently with the young. The same person can have had no history of delirium, even though they have experienced several hospitalizations, yet when they are old, they become confused and disoriented every time they are admitted.

Whenever there is a sudden change in an elder’s ability to think, focus, reason, and remember, look back to whatever stress could have caused the change. The longer the person suffers from delirium, the more chance it will not be resolved.

Remember Alzheimer’s Disease is slow, delirium is fast and doesn’t have to be permanent.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

BUILDING BRAIN HEALTH PROTECTS AGAINST DEMENTIA – DON’T PERFUME YOUR OXYGEN PART III

Whether it is bath soap, air freshener, laundry products, scented candles, or the cologne on the check out clerk at your local grocery, we are surrounded by scented air. While it is law to list ingredients on these products, there is a significant loop-hole. The word “fragrance” in so many products used every day, represents many substances the average person would not consider a pleasant odor. These chemicals masquerading as a fragrance, are for the most part derived from petroleum and coal tar products.  These chemical concoctions are found is products all around us, and are directly related to many health concerns.

These chemical mixtures are protected under a misconception that they are “trade secrets.”  There might have been a time in years gone past that the combination of certain essential oils and flowers were highly protected secrets. However these days, the secret that is being protected, is where these chemicals come from and what they do to human health.

Current research is telling us compared to other senses, the sense of smell is directly connected to brain health. That smells are able to pass the blood brain barrier, that protects the brain from many other forms of attack. These hundreds of fragrances created in laboratories, with many times banned chemicals, are responsible for many disorders. Surrounding ourselves with all of these scents is leading to negative emotions, irritability, brain fog, fatigue, headaches, dizziness, tremors, convulsions, and the list is growing.

There is recently even a new term for that person, who through the use of strong smelling products, intrudes on others. It is “second hand fragrance” similar to second hand smoke. It is when one person makes a decision to use several strong smelling products (shampoo, deodorant, hair spray, perfume, laundry products) and by doing so contaminates the air quality of others. There was a recent report on the news regarding sunscreen products, and they found many people bought a product not on how effective it was for sun protection, but because of the way it smelled.

The elderly as well as the very young are at increased risk for neurological problems connected to fragrances that pass the blood brain barrier. Yet many times the offender is an elderly person who has become so addicted to their fragrance, that they literally no longer smell it.

If you have been guilty of second hand fragrance, do what people did years ago, put a little vanilla extract behind your ears.

Suggested reading: “Get A Whiff of This” by Connie Pitts

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing