The nursing home, being predominately a medical environment, relies overwhelming on pharmacology for addressing issues of pain management. However, as I have mentioned in previous articles, pain is more than just a biological issue. The subjective nature of the pain response, and the psychology of the individual, too often fails to be adequately considered in pain management. 

More can be done to assist with pain management in health care, especially within the nursing home environment. Many non-drug issues can not only enhance the emotional and psychological wellbeing of the nursing home resident, but can also help the person gain a sense of control over their lives, something that pharmacological remedies often fail to provide. 

The feeling of control is a necessary part of human existence. Human beings need to feel a sense of control over their lives. Pain, especially when it is chronic in nature, confers feelings of helplessness and a loss of control.  Furthermore, although pharmacological intervention helps with pain, many individuals often feel powerless to control their pain and become totally and exclusively reliant on pain medication. 

There is nothing wrong with using pain medication to control pain, but for many, pain relief can happen through other means or can also be enhanced through using medication with other nondrug complementary mind-body interventions. Many of these interventions can not only help control pain, but also psychologically empower the resident to feel that they have a sense of control over their lives, something that pain often robs them of.       

Even though there is greater acceptance of complementary nondrug treatments for pain, the dearth of such types of intervention within long-term care environments is quite conspicuous. Although there has been a continuing emphasis for proper pain evaluation and management in nursing homes, the overwhelming level of intervention is pharmacological, driven by the extant medical model that continues to dominant within the nursing home environment. 

This subsequently raises the question, "Are we truly doing everything that we can do to manage and control pain among nursing home residents?" From my perspective the answer would be no. Although we have become much better at evaluating and managing pain through the use of medications, we still have a number of strategies available that are never employed in the nursing home environment. Furthermore, many of these strategies often hold a greater psychological potential for removing the helplessness and powerlessness that many residents feel about their pain. 

So What Are Some of These Complementary Treatments?

Two very common types of mind-body complementary treatments are distraction and meditation. Distraction allows a person to move their attention from the pain that they are feeling. Getting involved in activities of any type, in which the nursing home resident focuses their attention on something other than their pain, can be a productive method of assisting in pain management. 

However, all too often nursing home residents fail to obtain the necessary level of activity that focuses their attention outward. Since many older adults with pain live in nursing home settings that fail to provide an optimal level of activity that can distract the resident from their pain, most residents are left focusing on their body, ruminating about the pain that they feel and sensitizing themselves toward noticing other forms of somatic complaints. 

Meditation is another means that can help the older adult feel a sense of empowerment and help to reduce the experience of pain. Meditation frequently works by calming the sympathetic nervous system that, when activated, can produce feelings of anxiety as well as possibly lead to the release of neuropeptides such as endorphins that act as the body's natural painkillers and can also enhance the mood of a person. Meditation however is a technique that often relies on practice to achieve effective results. Therefore it can be a harder technique to use among many older adults in nursing care facilities. However, this technique should not be excluded from being used on long-term care residents as part of a pain management regimen.

Imagery and visualization are similar to meditation. However, typically they are easier to employ, especially when using guided imagery. The basic principle of imagery and visualization is to help the resident imagine or visualize, typically with their eyes closed, an image. The image is usually pleasant and nonthreatening and it often confers a feeling of relaxation. 

For instance, visualizing walking on a sanding ocean beach, with warm ocean waves splashing against your feet, whiling also seeing a calm, deep blue ocean, can be a very relaxing as well as a pleasant image for many people. The goal is for the visualization to become so vivid that one can feel the grains of sand on your feet, the sun warming your skin, the water splashing your ankles, and even smell the ocean water through your visualization. This further leads to a type of distraction and relieves the person of many of the ruminating features that locks the on their pain experience. It further can also induce those endogenous opioids to be released naturally in the body, providing further natural pain reduction.    

Also important with imagery and visualization as well as with meditation is proper breathing. Breathing is very important for achieving a sense of calm and relaxation. Breathing by itself can be used as an effective relaxation technique. Slow rhythmic breathing and even visualizing one's breathing as one inhales and exhales can be one of the best means for total body relaxation as well as helping to address pain management issues. Breathing from the diaphragm and not the chest allows for the person to achieve a greater relaxation response. 

Unfortunately, pain often leads to anxiety and anxiety leads to shallow chest breathing. This chain of events further accentuates the anxiety a person feels and the pain that they experience. Frequently, when individuals learn to breathe diaphragmatically, the anxiety-pain cycle is short circuited.          

One of the most common responses to pain is to move away from activity. However, as many rheumatologists will tell you, conditions such as arthritis often benefit from exercise. Rheumatic pain conditions are among the most common found in the elderly. 

Here again, many nursing care facilities often fail to use an optimal level of exercise to assist with pain management. Often, after many residents come out of physical therapy, they will experience little, if any, regular exercise.  However, one of the best ways to address many issues of pain is through regular exercise. In fact, many forms of pain are often the result of a lack of movement and regular exercise, where through disuse we see contracting of muscle groups, tightening of ligaments and tendons, or even injuries that lead to pain after atrophied muscles groups contributed to falls and fractures. Therefore, instituting some form of regular exercise among all nursing home residents can prevent many forms of pain due to stiffening, tightening and contracting of muscles, tendons and ligaments.   

How many nursing care facilities use humor or music therapy as part of their pain management approach?  Again, there are very few that use these approaches even though they have been found to be effective is assisting with pain management.  Music has been found to be very productive in its therapeutic impact, and humor has been found to help assist with pain relief.  In fact, Norman Vincent Peale championed the use of humor therapy and credited its use for helping him with his recovery from cancer.   

With the growing body of work that is being done in mind-body medicine many hospitals have started to adopt many of the techniques that have been discussed, as well as others such as biofeedback, acupuncture, hypnosis, skin stimulation, yoga, and even spirituality and prayer. However, nursing care facilities are still lagging far behind in this area. 

In fact, many of these types of intervention are practically nonexistent in nursing care centers, especially as part of a pain management program. One has to ask why this is so?  Pain and pain management is one of the key indicators that is often examined as part of quality found in nursing home care. Yet, pain management continues to frequently exist on a single dimension, with continuous emphasis on the pharmacological management of pain with very little attention given to other mind-body complementary treatments. 

Even though the benefits of complementary mind-body approaches hold not only the benefit for improving pain management, but also augmenting the psychological and emotional status of the resident, they still are not frequently found as part of standard nursing home pain management intervention. When an awakening happens among nursing care facilities, realizing the benefits that these complementary approaches hold, we will then be able to say that the nursing home environments are not only addressing the quality of care as it relates to resident pain management, but the quality of life as well.      

Click here for an archive of Brian's Gerotalk columns.

Pain management is a prominent issue in long-term care. For many years providing pain medication on a regular basis was irrationally feared based on risking a potential addiction to the resident. As we have become more enlightened, the fear of addiction has abated and our focus has become more rationally directed toward maintaining resident comfort.  However, are we doing all we can to assist in pain management? 

For sure we are using important pharmacological agents that have important pain killing effects to enhance the comfort of our residents. Also, providing a pill often provides a quick remedy to the situation. However, is pain management dependent on more than just pharmacological intervention? Does providing a pain medication always enhance the best practice in addressing pain? Moreover, does this type of pain management in exclusivity enhance the quality of life that is sought for long-term care residents?

Although monitoring and assessing pain has become a greater focus in long-term care and although many individuals are much more skilled today in detecting pain than was often the case in years past, there still exists a considerable dearth of knowledge and skill in pain management. In nursing care facilities the nurses are often the key individuals that are suppose to be responsible for pain management. In reality, pain management is the responsibility of all individuals who work in the nursing home. This may be controversial, but it is a very important mindset to be put in place. 

Many nurses today are still ill trained in pain assessment and management.Furthermore, many other individuals such as nurse assistants and rehabilitation specialists are even in need of more training in this area.  In addition, individuals such as administrators, housekeepers, maintenance, social workers, and business office staff get little, if any, training in this area. Since pain can often manifest itself suddenly, such as breakthrough pain, frequently when other members who are not part of the clinical staff are with residents, this makes it even more important that all staff is trained in recognizing and assisting in the pain management process. 

Currently the pain management process is almost exclusively the purview of the medical staff. We have strongly medicalized pain management and subsumed this important topic under the physician and nurse. As a result it should be no surprise that we have so many individuals that can contribute to the process, yet fail to receive any training in pain management whatsoever. As many parents know, you do not have to be a physician or nurse to know when your children are ill or in pain. Furthermore, as many parents will tell you as well, they have often managed their children's pain and sickness without the intervention of physicians or nurses. This is in no way to deny the importance of physicians and nurses in the pain management process, but to say that these are the only two professionals that should be involved in pain management prevents the pain management process from being fully actualized. 

We need to accept the pain management process as not just a medical intervention, but a social intervention as well.   How can this be a social process? One may state that pain is a biological and biochemical process, and since it is a biochemical process, a type of biochemical intervention, especially pharmacologically based, is the only sensible approach to address this type of issue. However, pain in itself is far from an objective process, which can be empirically measured with pinpoint accuracy. Individuals experience pain differently, and pain is not just influenced by a person's biological threshold, but is also influenced by their perception, their culture, and their psychological state of being.  Therefore, pain in itself is often quite subjective in its nature, and how it is perceived, reported and demonstrated is strongly individual, predicated upon the phenomenological nature of each person.

We have all heard of the "placebo effect," in which a patient is provided with a supposed medication and experiences results that are highly efficacious. The person often subjectively creates pain, and the same subjective process often abates it. I am not contending that pain is not real for many of the residents that we service. In fact, I am arguing for the exact opposite: since pain is highly individualized among all individuals, including long-term care residents, we need greater intervention to deal with this important problem, more than just intervention by a physician, nurse and a pill.      

Because the phenomenology of pain is so complex and multifaceted, the way that it is addressed also has to complement this complexity. In limiting the nature in which we treat pain, using only the medical model of physician, nurse and pill, we continue to fall short in treating the resident holistically. As the placebo effect has demonstrated, pain is more than just a biological and biochemical feature of the body. It is based on the subjective and phenomenological states of the resident that we cannot always reach with medicinal agents. All heath care centers underutilize the range of approaches that can be used to address pain, but the long-term care industry is not doing much to enhance their productivity in this area. 

Many complementary nondrug methods such as acupuncture, biofeedback, distraction, imagery and visualization and meditation are very seldom, if ever, used in these types of environments. One may say that is because of the type of clientele found in nursing homes, which often have a large number of fail, dying, and demented individuals. However, this type of argument is often weak. Many long-term care residents can be quite receptive and workable with these types of interventions and yet they often never get the opportunity to benefit from these types of intervention. Others argue that these types of therapies should not exist in a medical environment. Yet again, this argument is just the same type of rhetoric that needs to be disposed of in regards to resident pain, especially if we want to address this important resident concern in a holistic manner.   

In conclusion, this author is arguing for a greater breadth and depth of pain management and intervention by the staff.  Pain is more than just a biological process than can only be targeted by medical personnel who are able to write prescriptions or dispense medications. Pain management is a social enterprise.  It is a uniquely subjective state that needs to be recognized, and because of the social factors involved in pain, pain management should also become a process of social intervention. Currently, too many nursing homes continue to treat pain one-dimensionally, failing to recognize the multidimensional makeup of this complicated process.    

The hippocampus is a region of the brain located in the medial temporal lobe, which is that area located on each side of person's head. If you look at your head and take the region where your ears are located, and pass an imaginary line into your skull from your ear region inward, you would pass through the hippocampal formation where the hippocampus is located. The derivation of the name, hippocampus, comes from its seahorse appearance that early neuroscientists noted during anatomical investigations of the brain.

The hippocampus has been known for some type to be instrumental in memory. For a number of years it was thought of as being the key anatomical site in the brain for memory. However, more current research has found that it is far from being the only part of the brain involved in memory. The hippocampus is still understood to be a very important part of the brain instrumental in memory. However, in reality, the hippocampus is one part of a large circuit in the brain that is important for memory.

Recent research has found that as memories age, different parts of the brain become involved in memory, working in a compensatory manner to apparently take the burden off of the hippocampus. In an article in the September/October 2009 edition American Scientific-Mind, the research findings of Larry Squire of the University of California at San Diego are discussed. Using functional MRI studies, Squire and his team were able to examine the changes in the neurophysiology of the brain and how these changes were related to memory. 

What Squire and his team found was that activity in the hippocampus area declined when the study's participants had to recall information for progressively longer periods of time, ranging from more immediate information up to many years. The team found that activity in the hippocampus region continued to decline up to about 12 years.  However, participants that had to recall information that was over 12 years old appeared to demonstrate hippocampal activity that stabilized after the 12-year period. Therefore, it appears that memory components connected to the hippocampus demonstrate progressively less neurological investment by the hippocampus in the energy it uses. Furthermore, it also appears that the hippocampus becomes less and less responsible for maintaining the currency of memory.

However, this is not the end of the story. With the plasticity that the brain has it appears to shift responsibility to for recalling those memories for that 12-year period to other areas of the brain. In particular, activity appears to increase in the frontal, temporal and parietal areas for recalling information for that period of time when the hippocampus is reducing its activity.

What is interesting is that many memory diseases of old age, such as Alzheimer's disease, start at the subcortical level, or the more evolutionarily primitive allocortical region. The hippocampus is one of the important brain areas that make up part of the deep inner allocortex. This can be another reason why many older adults with Alzheimer's disease often face shorter-term memory deficits at the start of the disease, with many of their long-term memories being preserved until later in the disease. I say "another reason" becomes we do know that Alzheimer's disease also influences a closely associated neural pathway that connects with the hippocampal region called the entorhinal cortex. 

The new research results by Squire, although not specifically addressing memory and the aging adult, does have implications for this age group. Although memory is a very important part for human existence, as we age memory becomes a more sensitive topic. Having greater knowledge of the inner workings of memory is essential for all professionals working with older adults. Squire's research does raise some interesting questions for this age group. 

First, are many of the normal forms of forgetfulness that we attribute to aging, often quite stereotypically, part of the same processes that are found among all ages? In other words, if this process of a progressive reduction in activity found in the hippocampus is found among all age groups, are many of the supposed memory tests for more short and immediate term memory given to older adults demonstrating any appreciably different results than would be found among other age groups and if so, what is the quantifiable difference?                                  

A second question that the new research raises is if, during the hippocampal reduction, there is a compensatory increase in activity in other areas of the brain, especially the frontal, temporal and parietal lobes, is this activity increase equipotent for all ages? Does the compensatory neurological enhancement found among these areas for recalling information during this period of time exist on equally quantifiable levels for all ages? Or is a neurological enhancement in activity also found to exist among older adults but at an activity gradient that is much lower than that found among younger individuals. Hence, are the roadways for travel of information still found to exist among older adults, but with a much narrower road carrying less information?

I find the current information very interesting, possibly leading to many answers to questions that have been posed in neuroscience, especially related to the aging brain. However, I also find the research posing other questions as they relate to the elderly that can as yet not be answered. Good research often answers many questions while raising many more. In particular in dealing with the brain, an organ we still know so little about, the questions continue to arise. As an organ, the brain is far from being static and the changes that can exist with age are numerous. We know that the brain has a level of plasticity that continues to exist even as we age.  Therefore, it becomes important to understand the  impact of Squire's research and how it can be used to help understand the aging brain.              

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

One of the important needs of an administrator is to select people that are well-rounded, and knowledgeable in their skills.  One of the important duties of a long-term care administrator is to select the appropriate people to fill the necessary positions within the long-term care facility. The administrator often has to select and fill important managerial positions, and the ramifications for selecting the correct people can have important implications for the proper functioning of the facility.  Therefore, the administrator has to be fully aware of the impact of their decision.  

Although most administrators are aware of the importance in selecting the correct person to fill important managerial positions, they frequently will make less than the optimal choice in their selection process.  A common mistake that I often hear, and one that often makes very little sense is, "the person is overqualified for the position." As they filter through a number of resumes, they will often disqualify those individuals that have considerable qualifications. Now, in the opposite direction, it makes perfect sense to eliminate those that do not have the necessary qualifications to take on an important managerial position.  However, at the other extreme, using the argument that you eliminated a person because "they are overqualified" is not a logical argument whatsoever.  Hiring a person is a binary distinction: They are either qualified or they are not qualified.  You can disqualify a candidate for not having the necessary qualifications, but to disqualify a candidate for being supposedly "overqualified" is an error in logic and can limit your candidate selection pool to suboptimal candidates.

Think of the lack of logical consistency that exists behind this type of statement. Although most individuals what to hire the "best" candidate they often will automatically disqualify certain individuals based on this error in thinking. How can one select the best candidate for a long-term care facility, or for that matter any job, if you disqualify certain individuals due to the "overqualified fallacy"? In reality, how can one be overqualified? What does this statement really mean? 

On many occasions individuals will use this illogical terminology to protect themselves. Many individuals, due to hubris, will attempt to protect themselves against hiring a person who is perceived to be too smart or too experienced. To hire a person that often has greater qualifications then themselves can be intimidating to many, but this type of hubris can also limit the administrator from hiring the best qualified person to fill an important position.

Another reason that is used to disqualify the supposedly "overqualified" person is that they will request too much money.  Most individuals that apply for positions often are quite aware of the salary range for these positions. However, many who are hiring for these important positions assume the person that is seeking these positions are totally naïve about the position's salary range. Therefore, the person who may want to come and work for the long-term care facility, with considerable qualifications and who would excel in this position, is presumptuously eliminated by those doing the hiring. 

Without providing an interview, many excellent candidates are frequently lost due to their resumes being thrown in the garbage without any follow up due to the all too assuming administrator thinking that they will not be able to afford the person. In our current economy, many workers who are very qualified are looking for work. Many also are able to bring a considerable level of skills and knowledge to the long-term care community. However, because those who are in charge of hiring continue to make assumptions without even speaking to the candidate, many facilities loss qualified personnel that can ultimately enhance the quality of the long-term care environment.

One last comment: As a corollary to the aforementioned assumption made about higher qualifications equaling too high of a salary, even when a person is interviewed and is determined to be an excellent candidate for the position, many will fail to hire the candidate since their requested salary is slightly hirer than the budgeted salary for that position. In many cases the administrator or other hiring personnel make another important error in thinking: they view the cost of the candidate on a purely monetary level. They look totally at the wage expense and fail to look at how the candidate themselves could potentially save costs for the facility in the long run. This myopic tendency to focus only on wages is all too frequently the only calculated interest that many administrators take into consideration. However, if the person has cost-saving qualities, going beyond the budgeted salary cap can make very good sense, especially when their skills will offset this higher salary and ultimately save the facility numerous costs that would not be saved by hiring a less qualified person.

The administrator and other hiring personnel within a long-term care facility often fall prey to common errors in thinking, which ultimately hamper their ability to select the best people to fill important positions. This can be a major problem and many facilities actually settle for hiring less qualified people due to presumptuous mental biases that administrators and other members of the hiring team hold. As mentioned, many people will often invoke the "overqualified fallacy," which has no logical basis. 

Furthermore, since many also suffer from "wage myopia," viewing the highly qualified candidate totally in light of a wage expense that they cannot afford, many will often fail to interview the person or disqualify them on the basis of being an over-budgeted wage expense. Yet, as was mentioned, one has to also look at the other side of the equation. Although the facility may pay a wage expense that slightly exceeds the budget for that position, the slightly higher expense paid out in wages may be recouped in savings in other areas that a highly qualified person can bring to the facility. Therefore, before an administrator makes cursory judgments toward disqualifying potential candidates based on the errors in thinking that were mentioned, it would behoove them to closely examine these potential biases that they may hold and the costs that these biases may have for the facility.                                     

It is no secret that our country is currently going through some very difficult economic times. With job losses increasing, the subprime problems leading to many issues of foreclosure, and many financial institutions failing or needing to be bailed out, many people hold the misconception that health care as an industry is immune to the larger economic problems that are found in society. I often hear many individuals saying that if you work in the health care industry, you do not have to worry about your job. It is interesting how many people feel that the health care industry is somewhat disconnected from the larger problems of society and are inoculated from many of the problems that other face in today's world. Health care, including long-term care, has to deal with issues that are faced by the rest of society. Yet, in doing so, one would hope our industry addresses them prudently due to the lives that are often dependent on our decisions.   

The economic climate of long-term care has always been an important consideration for administrators. It is amazing how many think that nursing homes are making a large amount of money in the business of caring for the elderly. On the basis of fact, most nursing home's margins are often not very far from zero, being at times slightly above or slightly below.  However, the reality is that nursing home care has always been about just that, care. 

Yet, even though these facilities have been predicated on caring for those that have not been able to care for themselves, many facilities nevertheless have tried to maximize their profit margins. Strictly speaking, there is nothing wrong with this, especially since health care is a business. However, the problem begins to rear its ugly head when management losses sight of the special business they are in, which is caring for the elderly, and starts to evaluate their entire business on the basis of the economics of the facility. If they attempt to maximize their profit margin at the expense of resident care, it is here that the problem exists. Unfortunately, and all too often, health care management, including long-term care managers and administrators, fail to understand that conducting business is not the same as conducting other forms of business.  In the business of long-term health care the lives of frail and dependent individuals are reliant on the decisions you make on a daily basis. 

We have witnessed that many forms of reimbursement have not kept up with the rate of inflation in the medical industry.  Because of this one of the most common ways that administrators use to control their economic environment is to target the workforce of the nursing care facility. In fact, health care organizations have introduced many tools to be used for control, such as various metric systems that informs management staff how many workers are needed for a given number of residents. Also common in the nursing home environment is using the metrics of hours per patient day, often referred to as HPPD's. Using measurements to help control excesses in any area are important. However, the administrator has to be aware that these numbers are not etched in stone and that in addition to staff-patient/resident ratios, one has to also calculate many of those intangibles that often do not lend themselves nicely to quantitative analysis. For instance, the acuity of an environment, based on wounds, bariatric issues, the number of acute illnesses that are currently exacerbating chronic conditions, or the increased number of roaming and confused residents, just to name a few, have to be considered and factored in to the control area. Again, as one can see these are not always easy to capture through a measurement device. Beyond attempting to post positive bottom line numbers is the need to post positive bottom line care. This must be first and foremost in the mind of administration.             

Also, during our current macroeconomic hardship that society is facing, the impact that it has on many businesses, including nursing home care, is prominent. As mentioned previously, health care organizations are not divorced from the larger economic problems in society as many have come to believe. On a daily basis workforce reductions are happening in all areas of society, including healthcare. Although long-term care often has some resistance towards engaging in this type of activity, especially with nursing staff, the problems of workforce reduction still exist. In some cases workforce reduction may be needed, but again, one has to be quite prudent in using this type of financial control mechanism. Administrators have to be aware that although they may be reducing overall labor costs that may have an important impact on the economic environment of their nursing home, here again, one has to be aware of many costs that cannot be measured, those intangible costs of losing social capital. Making workforce reduction often entails losing important social capital, such as those qualities of knowledge, experience, care, and quality that again are not easily quantifiable. Although reducing the workforce by two or three tangible and measureable units may come to save the administrator those measureable costs found in their income statement, the two or three tangibles units reduced could actually entail intangible social capital losses that may amount to really losing five, six or seven units of quality care. 

The business mindset, especially during difficult economic times, is often based on reducing those tangible and measureable units to bring greater harmony to those financial instruments that are often used in measuring the performance of a business entity. However, administrators and long-term care organizations that want to manage a health care organization exclusively in this manner are really deadwood. Unfortunately, health care administrators and health care organizations engaged in long-term care attempt too often to manage on a strictly business-based mindset. As we have witnessed currently in our society the common classical and neoclassical economic principles do not always work and attempting to use tangible economic measurements without paying attention to those intangible behavioral economic features has caused considerable problems for our society. This also applies to health care, including long-term care.  Attempting to navigate difficult economic times by using these so-called time honored traditions of managing microeconomic environments can ultimately impact quality care, which is the ultimate goal of any health care facility, in a negative manner.               

This article addresses some changes in certain F-Tags by the Centers for Medicare and Medicaid.  These are important changes that should be noted for those in nursing home care. 

Some of these changes have taken what was implicitly known and now made in much more explicit on a regulatory level. Click here to read the article.

In understanding the underlying genetic basis of Alzheimer's disease, we do know that genes play an important role. During the last couple of decades genes discovered on chromosomes 14, 19, and 21 have been implicated in this disease.  However it appears that the genetic influence on chromosome 19 appear to be the most significant. On chromosome 19 there are a family of genes called the APO genes, which is short for the apolipoprotein genes.  The subfamily of genes called the epsilon genes, often referred to as E2, E3, and E4, are the ones that appear to be the most significant for memory. In fact, these genes are also related to controlling triglycerides and cholesterol in the body and are therefore pleiotropic, meaning that a single gene can have an affect on many different body areas.      

Of the above epsilon genes, the E4 type appears to be the most insidious, especially toward Alzheimer's disease. Genes come in pairs called alleles. Having one E4 allele is bad but having two matching E4 genes is highly problematic, or as many have come to infer, a death sentence. But one has to remember that genes do not automatically dictate cause and effect qualities for diseases. Genes, like switches, have to be turned on.  If they are not turned on they cannot express themselves. Most individuals do not carry two E4 alleles. For those that do the probability for getting Alzheimer's increases dramatically, but, and this is an important but, some individuals do have two E4 alleles in old age yet are fully competent and have acute intellectual ability. Therefore, the first thing that this demonstrates is there is not an automatic, 100 percent likelihood of obtaining Alzheimer's disease even if you have two E4 alleles. 

Also, people of Asian descent often have the least likelihood of having two E4 alleles, followed by the white population and the African American population. Subsequently, one would therefore expect then that African Americans would have a greater likelihood of obtaining Alzheimer's disease, especially the early-onset type, given their greater predisposition for holding two E4 alleles.  But here again, things do not fit nicely into the larger scheme of the disease. Those who are most likely to acquire Alzheimer's disease are white individuals. Furthermore, just as some individuals who have both the E4 alleles do not acquire Alzheimer's disease, some individuals that do not even have one E4 end up developing Alzheimer's disease quite early in their lives. What this appears to be demonstrating is that Alzheimer's disease is polygenetic, with often more than just one type of gene involved in the process.  

What I hope that I have demonstrated is that many individuals that think their genetic predisposition is ultimately their destiny are wrong. Yes, we do know that certain genetic profiles, such as being homozygous for the E4 allele (having both the alleles), make a person more likely to develop Alzheimer's disease and possibly earlier in life than others. However, one's underlying genetics are not a mandate that ultimately provides 100 percent certainty that a person will acquire the disease. There are too many more elements that appear to be involved in developing Alzheimer's disease, and although genetics is important, it by know means provides the total picture.    

An ethical question that often has come up with our new knowledge of genetics, especially gathered in tracing the entire genome, is if we are able to know where the genes are located for this type of disease, why not test the person for them to provide individuals with information about their potential genetic predisposition for the disease.  However, one question that needs to be posed is what potential benefit would be gained if someone knew his or her genetic makeup?  Given that there currently is no cure for the disease, could harboring the knowledge that one carries the genetic predisposition actually cause more harm?  Harboring the knowledge of having the genetic predisposition could lead to psychological turmoil for a person, often impairing the quality of their life as they continue to live out their days waiting for the first evidence of the disease.   

Also, as was mentioned, even if the genetic testing revealed that the person had the most insidious genetic makeup, there is no guarantee that the person will ultimately get the disease. The genetic makeup often creates a predisposition, not a guarantee, yet we often view the predisposition of the genetic makeup as an inevitable end result of certainty. Therefore the person that obtains the test results and spends his or her days waiting for the first impending signs of the disease may be doing so for no reason, since the test cannot predict with certainty that you will acquire the disease.

In an age when there are many tests that are available and are very important and well used for preventative purposes, our current ability to test for a genetic basis of Alzheimer's disease may not be one of them.  Given that there are currently no cures for the disease, that a positive test is not a guarantee of acquiring the disease, and that there are probably numerous other factors that work in concert with a genetic predisposition, the ethical implications for harming the individual psychologically could be great. Although our current knowledge to pinpoint important genes is great, and often this scientific knowledge can be quite beneficial, we also have to be aware that sometimes attempting to interject too much science in our lives can do more harm than good.         

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

According to AHCA, many long-term care organizations are increasing the levels of services they provide:

• More than 36 companies are adding rehabilitation suites or units."
• 16 are planning to add new services such as Alzheimer's care, secured units, and respite rooms.
• 23 providers will start offering ventilator services.

At first blush this shows the increasingly progressive nature of many long-term care environments. It also demonstrates the need for many companies to attempt to capture higher reimbursement rates that these services potentially hold. However, although these services provide a greater potential for increased revenue as well as heighten the level of professional services offered, they do not come without a cost. 

There is a monetary cost based on the capital expenditures that definitely needs to be considered.  Equipment such as respirators, special safety devices for Alzheimer's residents, rehabilitation equipment that is purchased, as well as the construction costs all incur hefty capital outlays.

This is during a period of time when state and federal reimbursement is facing potential declines.  State governments are looking to make cuts during these difficult economic times in numerous areas that will affect Medicaid reimbursement and the Centers for Medicare and Medicaid are also looking for possible reduction in funding for skilled nursing care centers. 

So even as the skilled nursing care environment becomes increasingly competitive, with many companies looking to gain an edge on their competitors by adding more skilled services, the financial cost in doing so will be considerable.  As mentioned, in an era where many decisions to reduce reimbursement have been made, many companies have to make sure and be cautious in approaching this type of expansion. A good example of this can be found in the hospital industry, where many hospitals that also are part of a highly competitive environment, have actually put out incredibly great capital outlays, just to find out that they often have poorly calculated payback periods. 

However, there are other costs that will need to be examined as well. The staff that needs to carry out many of these services will definitely need to be upgraded as well. For instance, introducing a ventilator unit in a facility will entail hiring an optimal number of respiratory therapists that are on staff for 24 hours, seven day a week. Furthermore, many of the nurses that nursing care facilities rely on are typically licensed practical or vocational nurses. With ventilator units, often you need more nurses that are registered nurses and also specially trained with advanced cardiopulmonary training. Many facilities that decide to add neurological units will in turn need advanced nursing care and training among their nursing staff.

Upgrading training will not only be important for nursing staff, but it will also be necessary among social workers, activity professionals, rehabilitation staff, and in particular among certified nurse assistants.  Since most clinical care is provided by certified nurse assistants or CNA's, this group of workers will need greater periods of training. Most certified nurse assistant training is short and generalized, being focused on the traditional nursing care issues that are often found among the frail clientele of nursing care centers, such as providing basic care and assistance with the activities of daily living. 

With the provision of more complex clinical services, this group, which is often recipients of a very short period of training, will need to obtain greater levels of specialized training to address many of the more complex clinical needs that they will face. There are many that currently think that certified nurse assistant training is too short as it is. Therefore, with the introduction of specialized Alzheimer's services, ventilator care services, or neurological care services, certified nurse assistants will definitely need greater training to support the needs of the higher complexity of residents they will be working with daily.       

With increased training and the level of work that many of the specialized areas will lead to, remunerating workers so that their wages are commensurate with their training and workload with also enhance the cost for a facility. Again, one has to be mindful of the current economic climate in which government subsidization for services are being lessened rather than increased. Furthermore, one has to also be aware of the potential for increased liability, which will definitely increase as resident acuity increases.  Therefore, to minimize the risk, proper training and education of workers in these new specialized areas will be mandated, all escalating the cost to the nursing care center and for nursing services that will be provided to residents. 

As the culture of nursing homes continues to change, moving toward acceptance of a higher acuity clientele, and concomitantly more complex services, it will lead to not only greater costs for the long-term care industry, but much greater levels of training that many companies may not have totally envisioned.  As nursing care centers will address the needs of residents with greater clinical complexities than has been traditionally seen in long-term care, it will become imperative that many of the frontline individuals involved in the provision of clinical care will obtain greater levels of training.

Long-term care companies that envision enhancing the clinical complexity of its nursing care environment, as well as enhancing their revenue base through increasingly specialized services, will need to realize that the core element of these services, its professional staff, will also need to be part of these changes.  

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

All too often care provided to many older adults is offered in a manner that may be viewed as positive.  In many long-term care facilities those that provide care are often taught to assist older adults to an extreme. After all, nursing care centers are established for the provision of care, frequently to an elderly or frail clientele that needs considerable assistance with their activities for daily living.  In fact, one of the major tenets that individuals often think is essential for quality care is engaging in paternalistic intervention.  A common misconception is that there can never be enough care provided. Although many of use are aware that there is numerous long-term care facilities that have failed in providing sound quality care at an optimal level, more care does not always mean better care. 

I have to be careful in advancing this argument because some many take this out of context. I am not saying that nursing care facilities do not need high quality care at an optimal level. In fact, throughout the United States, most facilities still need considerably more improvement in the area. However, excessive and paternalistic intervention can be detrimental to the elderly, much like a smothering and overly protective parent who fails to allow their child to develop secure attachments and independency. Furthermore, just like a smothering parent who fails to let their child foster a level of emancipation necessary for optimal growth, a smothering caregiver can thwart the development of the elderly as well.

One of the major regulatory requirements that are found in long-term care deals with quality of care. The quality of care requirement states that,

"Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care." 

This requirement is the hallmark for providing optimal care with the intent to enhance the wellbeing of the individual and prevent nursing care residents from avoidable regression in their physical, mental and psychosocial wellbeing. Although the word optimal is not found in the regulation, the intent for optimal care is nevertheless implicit in the regulatory requirement. Therefore, one has to understand that optimal care is also the provision of care that fosters a personal independence and avoids feelings of learned helplessness and feelings of inefficacy.            

So what does all of this mean? Paramount in our understanding of providing necessary care is that intervention should be tailored to appropriately target the needs of the residents. Just as too little care can be detrimental to the wellbeing of the individual, so can too much care.  It has been found that providing excessive intervention can lead to elderly regression. Providing too much assistance actually can lead to the reduction in the nursing home resident's ability to remain independence as well as establishing feelings of learned helplessness, where the resident feels that they fail to have full control over their lives. Furthermore, it has also been found that many individuals who are provided with excessive levels of care actually have lower levels of self-esteem, frequently due to lower levels of self-efficacy. 

Not only is excessive physical intervention potentially problematic, but also the all to common verbal paternalism that is found in many nursing care facilities is a problem as well. Two types of verbal paternalism called "overaccommodation" and "baby talk" are frequently found in nursing care facilities. Overaccommodation happens when caretakers will speak louder or even slower, attempting to over accommodate for what are viewed as perceived deficits found among the elderly. Baby talk is a simplistic speech pattern that is often used toward the elderly, similar to that which is found when parents speak to their young children. Both types of speech often fail to take into account the concerns of the elderly and often inculcate into the older adult a feeling of inefficacy. Furthermore, these speech patterns are driven by stereotypes that are held by caregivers, viewing the elderly as being unable to understand what is best for them and therefore in need of paternalistic oversight. 

These problems fall under what can be conceived as the caregiver's pseudopositive attitudes toward elderly care. What this means is that although many caregivers actually view this type of excessive intervention or paternalistic speech patterns as positive, in reality they may be doing more harm than good. However, this pseudopositive attitude is not only found among caregivers, but the public in general, and it reflects the endemic ageism that is found among the elderly in our society. Most individuals would fail to see anything wrong with excessive care and paternalistic speech, viewing it as properties of perceived "good care."  Moreover, most would agree that given the amount of negative exposure that nursing care centers have received for substandard care, excessive care and intervention should be lauded. However, as was mentioned, extremes on both sides of what is optimum is potentially problematic and can have negative consequences for the quality of care that is rendered to the elderly resident.  

Therefore, it is necessary to look at the provision of optimal care. Care that is optimal should not only focus its support to fulfill the needs that elderly cannot provide for themselves, but also nurture the independence and control that currently exists in their lives.  Furthermore, caregivers have to be aware of their pseudopositive attitudes toward caring. They have to be aware that what they perceive as being positive may in fact hold negative consequences for the elderly. Although paternalistic attitudes and interventions are often viewed by caregivers and society as positive, being sensitive toward the negative consequences that these behaviors and attitudes may hold, as well as being sensitive to how ageism drives many of the perceived positive attributions of pseudopositive care will enhance quality care in the future.     

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

In the May 2009 edition of Scientific American Mind, a short article is provided on the research conducted by Scott Small at Columbia University. The article entitled, An End to Senior Moments: Lowing blood sugar levels may thwart forgetfulness, addresses the impact that higher blood glucose levels may have on proper brain function.  The article also may help explain why exercise is a powerful component to healthy aging, including a healthy brain.(1) 

It has been known for some time that as we age there is an increased likelihood for blood glucose levels to increase. Although the brain is a glucose hungry organ, consuming 20 percent of the glucose needs of the body, too much excessive blood sugar can be potentially problematic for the body and the brain. It appears that as we age the cellular membrane becomes less sensitive to insulin, which in turn prevents this important sugar from properly moving into the cells for energy and subsequently leading to elevated levels in the older adult's body.  When this happens many older adults are susceptible to Type II diabetes. 

Levels of blood sugar have been tied to potentially reversible memory issues at all stages of life. Those that suffer from hypoglycemic or hyperglycemic reactions often report problems with their levels of consciousness as well as with memory. The brain, although very dependent on glucose for its function, needs to strike a balance between not flooding itself with excessive levels of glucose as well as failing to not take in too little glucose. Yet, the brain is a very resilient organ that can often recover from excesses in either direction.

In the recent study completed by Small, he found that as we age the probability for increased blood sugar levels affecting memory can be considerable, and can help explain many of those periods of forgetfulness or less efficient functioning of memory that many individuals experience, and complain about, as they age.  In fact, many of these factors that are related to less efficient metabolism of glucose start to happen fairly early in life-in our late 30s and early 40s. This becomes quite interesting. One hypothesis that this leads to is what are the cumulative effects on the brain of uncontrolled blood sugar levels, and do those that have less control over their blood sugar levels become more prone toward dementia as they age due to the cumulative insults on the brain of unchecked blood sugar levels.

Small's study goes further in targeting the part of the brain that the higher blood sugar levels may disrupt, leading to memory problems. Although the hippocampus is known for being an important part of the brain for memory, a particular part of the hippocampal area known as the dentate gyrus appears to be particularly sensitive to higher glucose levels. According to Small's research this area, when inundated with excessive levels of glucose, appears to lead to problematic forgetfulness. 

This new research could have very important implications for the need to continue to remain active as one ages.  As stated, issues of glucose metabolism start fairly early in life, in ones third and fourth decades of life. Although the current research did not answer any questions on the cumulative effect of unchecked blood sugar levels on the brain, it does lead one to make hypothetical assumptions that need to be answered through future research.  However, more important to the current research is the continued support it provides for the need for regular exercise.

Small extrapolates from his current study that exercise may be potentially a very powerful tool for warding off many of the common age-related memory declines that are found among individuals as they age. In fact, due to the potential increase in blood sugar levels starting relatively early in life, the need for regular exercise may actually be more important as we age. Especially as it relates to brain health, as our normal metabolic processes decline with age, exercise can actually enhance the movement of glucose into cells and help reduce the excessive blood sugar levels that may lead to age related memory problems. This is actually very good news since many of the transient memory problems that plague us as we age can be reversed through exercise, leading to greater memory efficiency.

The article in itself does not provide a great epiphany. It has been known for some time that sugar metabolism can dramatically effect memory. Moreover, it has been known that exercise is an important source for warding off illness as we age. More recently, exercise has also been associated with helping to improve cognitive functioning and possibly enhancing neurogenesis. 

However, Small's study helps to illuminate and provide some sound, empirical understanding of how glucose metabolism may be implicated in the aging brain. It also addresses the specific area in the brain that inadequate blood-glucose metabolism targets and disrupts, leading to many age related memory issues, and this new finding may aid us in advancing brain health for the elderly. Although many know about the positive benefits of exercise on the body, especially for enhancing cardiovascular, pulmonary, and muscular strength and functioning, less often is exercise associated with the positive benefits it has on brain functioning. The implications that it has for getting more individuals involved in regular exercise are very important. 

Since cells become less sensitive toward moving glucose into the intracellular apparatus as we age, leading potentially to higher blood-glucose levels, which in turn can lead to excessive glucose targeting brain sensitive areas, and since exercise is an important mechanism for helping to move this biochemical molecule into cells, it is very important to make sure that individuals are getting the proper level of physical activity and exercise to compensate for age related reductions is glucose metabolism. With increased activity we may be able to ward off those so-called "senior moments" that many have come to assume as inevitable parts of the aging process.  Therefore, with this knowledge in hand we know that we need to get up, move around, and pay attention to our carbohydrate intake, which in turn may move us into those later years with a more youthful and better functioning memory that is not inevitably consigned to increased levels of forgetfulness.                 

                                                            Reference

1. Nikhil Swaminathan (2009).  An End to Senior Moments: Lowering  blood sugar levels may thwart forgetfulness.  Scientific American Mind, 20(2): 9.  

Although nursing care facilities have made considerable advancements in the quality of life offered, there still is substantial room for improvement.  One of the areas that need to be focused on is creating a culture that nurtures greater activity and promotes health.  In many facilities the esthetic improvements that have been made are great, but overall most nursing care facilities are still environments focused on tertiary care.  It may sound counterintuitive, but nursing care facilities have to invest more of their resources in preventative care!  You may be saying this sounds crazy.  Since most individuals found in nursing care facilities often suffer from considerable levels of chronic illnesses, what importance can be gained from offering more preventative care services.  Moreover, what other types of preventative services can be offered other than those normally offered, such as the influenza and pneumonia vaccines.  Let me briefly address this matter in further detail.

Although there are many areas that I can address, the one that I am going to focus on here, albeit briefly, is the need for increasing the levels of physical and mental activity in the elderly.  Even with advancements in the quality of living that we have witnessed in nursing homes in our country, today we still see most individuals in these setting relegated to a static and sedentary existence.  Increasing the level of physical activity has tremendous benefits for advancing the health of the elderly, preventing unplanned hospitalizations, maintaining a stable census, reducing nursing home costs, and ultimately enhancing the quality of life of older adults residing in these facilities.  Although nursing care facilities typically have physical, occupational and activity programs, many do not receive any physical and occupational therapy after they have exhausted their Medicare benefits and activity therapy is often too infrequent and frequently not targeted at preventative health care.  Also, the care staff is often focused on the secondary and tertiary care needs of the residents and often have little training in providing preventative health care services for the elderly. 

So what are these preventative services that I am mentioning in this paper.  Most of them involve exercise, both physical and mental, which enhance the wellbeing of the older adult's daily functioning.  Take for instance the problem of falls in nursing care facilities.  This is an epidemic problem in long-term care and one that has continued to plague even the best nursing care facilities.  One of the major problems is muscle weakness in the legs.  The leg muscles are one of the largest groups of muscles in the human body and they are responsible for providing support and balance.  In younger individuals who are active, walking frequently often will keep these muscles toned to prevent injury.  However, as we age and engage in more sedentary activity, which is especially found in many nursing care facilities, muscles atrophy.  First, greater levels of walking will help strengthen leg muscles, enhance balance, and prevent many unnecessary falls that often have the negative consequence of a fractured femur or hip.  Staff has to be trained in encouraging more leg strengthening activity and walking is probably the best exercise to enhance leg strength and general health.  However, what about leg squats!  You may be saying that this exercise is only used by younger individuals that go to the gym, but this is not true.  Think about moving up and done in a chair.  Many falls happen when the elderly are getting up or setting done in chairs.  One way to enhance leg strength is to encourage elderly, during the breakfast, lunch or dinner setting to sit up and down in a chair a few times.  During your post meal cleaning of residents this can be part of nursing intervention.

What about something like arm strength?  Older adults in nursing care settings loss a considerable amount of their upper body strength through disuse and sedentary lifestyles.  Here again, simple clinical interventions frequently throughout the day, such as having them lift small weights or involving residents in other forms of frequent isometric or isotonic exercise can help strengthen the arms that often support movements that are frequently done in their daily activity. 

Providing appropriate mental stimulation is important as well.  Frequently many within the nursing home environment think that playing pleasant music or playing bingo is adequate for mental stimulation.  However, here again, one has to wonder how much cognitive impairment happens in these types of environments due to not having adequate, challenging stimulation.  The key word here is challenging.  It is becoming evident that neurogenesis is often incumbent upon challenging the mind and that neurogenesis can happen throughout life.  Providing clinical education to have nurses and nurse assistants use reminiscence therapy, pose challenging questions for residents to think about, ponder and answer, and having activities that challenge the cognitive abilities of older adults is critical for proper mental stimulation.            

Many of these changes will provide a better quality of life through preventing injuries and illnesses that will happen through a static existence.  Our bodies are built for movement and this axiom does not just apply to those who are younger, but it applies to those of all ages.  Regardless of age, inactivity leads to weakness, frailty and preventable illnesses.  For older adults the acceleration in the reduction of functionality is even more of a problem that has to be guarded against.  This is an endemic issue in nursing care facilities.  All too often many residents will demonstrate precipitous declines that are quite preventable with the appropriate active intervention.  One has to wonder how many falls leading to fractures, slips leading to injury, illnesses due to compromised immune systems, confusion and delirium that is often attributed to age, and reduced ability in movement could be abated, forestalled or even prevented if greater levels of physical and mental activity would become part of the preventative culture of nursing homes.  All too frequently many nursing home residents end up with preventable physical and cognitive declines as well as end up being discharged to hospitals from nursing homes, also frequently preventable, due to succumbing to the ill effects of inactivity.  Turning our attention to not only treating disease, but also enhancing the health of the community is an important paradigmatic shift that needs to exist in nursing homes across the nation.      

As a person who has been involved in science and trained in this area, what practical importance can I see in philosophy, especially for healthcare practice and administration? First, I have come to be quite aware that science and scientific explanations are not always satisfactory. We live in an era where we think that reductionistic strategies found in scientific explanations can work in all areas, including healthcare management. Although some post-modernistic thinkers have questioned this as well, many of their explanations go to a different extreme, which often fail to be satisfactory as well. So where does having some level of philosophical understanding fit for those in healthcare and especially long-term care?

Many problems in healthcare are not easily reducible, and many fail to be explained by empirically clear and concise scientific tenets. Many of these problems lend themselves strongly to engaging in thinking that may not have one correct answer.  Understanding the philosophical complexity of our world helps us to think about the problems that are presented with a profundity that extends beyond the sciolism and triteness that many use to solve complex issues. 

Think briefly about the areas of ethics. Ethics is an area that has been, and still is, strongly influenced by the discipline of philosophy. Ethics is part of every aspect of our lives. The healthcare area is no exception. In fact, healthcare may be the one institution of our society in which ethics plays its greatest role. How many of us who work in long-term care are confronted daily with decisions that ultimately have a compelling and profound impact on our lives, on the lives of those that work with us, as well as on the lives of those that we serve. Of course healthcare is filled with many issues that are clear, in which we have an unambiguous and ethically firm understanding of what we need to do and how we need to act. 

When things are going well and when decisions are clear we often do not think much about the importance of having training and understanding in the area of philosophical ethics. However, during periods of ambiguity, when decisions that need to be made about issues are not clear cut, this is the period when we become acutely aware that science or some decision-making algorithm are often not available to help us through this difficult process.                

Furthermore, many of use are not aware that even though most of us are not formally trained philosophers, we all have a philosophy that helps shape how we come to see the world and understand problems. We all have particular sets of values, ideas and assumptions that shape how we come to understand and frame the problems that we are faced with daily. Therefore, it behooves us to understand more about the way we think, the way we come to understand problems, how we can better understand our own particular strengths and weaknesses, and how we can improve our thinking about the daily problems we face in long-term care.    

Look at the problems that we are faced with in long-term care that often tax our problem-solving ability. How many of us have had to advise or help counsel a family member about important matters such as their concerns about a dying family member and what type of treatment they should choose. What should be our ethical approach in this matter? Is there one correct approach?  Should we not provide any input since they are the guardian or durable power of attorney? In other words, is there a concise and empirically scientific explanation we can look to or a step-by-step algorithm that we could follow?  Typically not and this is why understanding the importance of philosophy and the philosophy of ethics is very important. 

The cancer or heart disease that the resident may be dying of is often easy to explain on a scientific level. But what about those stomach-turning human decisions that are not easy to reconcile? Decisions such as what type of care to provide or not provide, or in other words many of those decisions with a considerable level of relativity and ambiguity that fail to have clear parameters of correctness or incorrectness are the ones that we struggle with most. Moreover, these matters do not just cover health care issues, but issues related to workers, the work environment, as well as those problems that we personally face as being part of this environment.  

In writing this blog I am not attempting to instigate a heightened enrollment in local college philosophy classes. However, I am attempting to convey the importance of philosophy in the area of decision making in health care, in particular, long-term care.  Often, we eschew the importance that philosophical theory can have in our lives and yet, as mentioned, we all have a philosophy that shapes our views and our decisions. Quite important is the field of ethics, which health care professionals deal with daily.  Having an understanding of utilitarianism or deontological theory as it applies to ethics can have a powerful impact on how we come to view those ethical issues that we are frequently inundated with and fail to have any clear, correct answer for.  Furthermore, understanding more about the philosophical importance of these issues also will come to shape us as professionals in long-term care. 

So to answer the question that we started out with, "does philosophy have any practical importance to long-term care professionals," the answer is yes. The ability to use a discipline that helps us think more soundly about the myriad of compelling decisions that we are faced with daily will ultimately help with the betterment of our profession.    

Today, most people are familiar with the story of Enron. A company that was once looked at as one of the exemplary companies in the United States became a buzzword for corruption and mismanagement.  Although the problems that came to eventually destroy Enron were monumental, as mentioned it was once viewed as an exemplary company. What happened at Enron is a lesson for those in business and this lesson is transferrable to the health care sector as well. 

Enron as mentioned was once viewed as an exemplary company, which was growing and had sound leadership driving its corporate culture. Under Richard Kinder, the president of the company, the company flourished, and a corporate culture of trust was established. Kinder was viewed as a person that was quite meticulous and held others accountable for their behavior and for their roles in the company. Although strict, he did build a culture of trust that many felt comfortable with. They understood their roles and their expectations and although Kinder drew a line in the sand, establishing his area and what his expectations where for others, many felt that he did so without equivocation. 

With the movement of Richard Kinder out of the company and Jeffrey Skilling into the role of Chief Executive, things started to change. Skilling had a Machiavellian temperament for control and an unbridled hubris. Skilling introduced evaluation systems that would be made available to others in the company.  He also created an environment that found frequent turnover, fostering hegemony and fear throughout the corporate environment. This left many looking over their shoulder wondering if they would be the next person to be cut from the workforce. The environment that had previously been based on a level of trust and stability was now being replaced by a culture of paranoia based on Skilling's capricious and fear-inducing tactics. 

Skilling appeared to feel that introducing fear and fostering a sense of insecurity among the workforce culture was a positive management strategy. As the new culture and management style became set in place at Enron, it was almost inevitable that the organizational features that Skilling put into play would led to the formerly successful company to witness a destabilization of their cultural environment. We now know that it did and the stability and trust that was established by Kinder was destroyed by Skilling within a very short period of time. This for sure in not the only problems that Enron faced, which ultimately led to their demise, but the establishment of a "social Darwinism," with a cutthroat mentality and a lack of care for those in their work culture was significantly related to the downward spiral of this company.     

So what type of lesson does this hold for those in long-term care? The lesson is significant. In a health care environment, the importance of trust and collaboration is very important. Prior to Skilling's arrival at Enron there was a feeling of consistency and trust. The company flourished under leadership that encouraged a firm management style that emphasized a collaborative and trusting team approach. People were viewed as resources that needed to be tapped. However, when the culture moved to a dog-eat-dog environment, trust waned, collaboration waned and the workers came to view themselves as disposable cogs that occupied positions on a day-to-day basis. How often do we witness this type of style within long-term care? 

Think of how often we feel that we need to manage in secrecy, behind closed doors. For sure, there is need for this type of management. But all too often this type of management comes to dominate the administrator or other manager's styles, providing for a less than transparent environment. Workers come to feel that the culture is veiled in secrecy, with workers becoming paranoid about what is being discussed behind those closed doors. This in turn often erodes feelings of trust that are needed for a sound and efficient work environment. Furthermore, a level of hypocrisy often results where managers state they have an open door policy, yet spend most of their days is clandestine discussions or meetings. Workers pick up on these subtle clues that are provided by those in authority.

As we witnessed with Enron, when trust started to erode and when capricious policies were set, the breakdown of trust as well as the breakdown in the cultural environment as being a stable and predictable place eventually led to the downfall of the company. Workers became anxious about their jobs and they also became weary of working in such a strenuous and draining environment. The social Darwinist philosophy of "survival of the fittest," promoted distrust and continuously made workers view others in askance. Moreover, it ultimately led to workers viewing themselves as disposable commodities without any attention being paid to the person's self-worth. All too frequently we provide little attention to developing an environment or organizational culture based on trust. As those at Enron did, letting their profit and loss be the all determining factor that a worker's worth was measured by, many in long-term care fail to nurture the important factors of trust, stability, and security in the organizational environment.

Health care is a business, and long-term care is no exception. Yet, failing to recognize the importance of our human capital, those people that we depend on to carry out the important duties found in long-term care on a daily basis, is critical. If we fail to build a culture based on trust and respect, and fail to recognize that these needs are paramount for those that we manage, we too could face the same type of problems as an Enron. Therefore, rather than look at a company such as Enron and say it could not happen to us, we need to learn and understand how we can obviate such problems from occurring in the environments that we oversee and manage. History does not need to repeat itself if we can learn the lessons that it teaches us.