Gerotalk : Clinical

Changing Brains

Brian Garavaglia — Wed, 31 Dec 2008 15:46:00 GMT

Are you paying enough attention to your residents' cognitive wellness? Read my latest column on the ADVANCE Web site.

Matching Residents to Facility Resources

Brian Garavaglia — Fri, 29 Aug 2008 14:41:00 GMT

It is no surprise to anyone who works in health care that census is always a critical issue for long-term care facilities. This especially is an important focus for many skilled nursing care facilities. As more assisted living facilities are now taking many residents that at one time was the purview of nursing facilities, many nursing facilities today are in competition for residents that are being more difficult to get to help bolster their census numbers. However, because census is such a driving force for nursing facilities, and since many facilities are in competition with many other nursing care facilities for the same residents, a common error often happens: Many facilities attempt to take anyone they can obtain in the referral process. This is a critical error than can come back to haunt the nursing facility.

A few principles need to be adhered to regardless of whether the facility is a for-profit or a not-for-profit facility. First, the facility must remember that they are there to service the resident to the best of their ability. The ethical principle of beneficence has to be always followed here. Although census is a key driving force for the sustenance of the facility, so to is following this important ethical principle of doing no harm to help further the resident and their health status. Taking residents that you cannot support with the skill level of your facility is unethical and inappropriate.

Another major principle that follows from this is that the administrator and other administrative personnel such as the director of nursing, have to know their staff, the knowledge capital that is found in their facility, and the supplies and other supportive factors that will enhance their ability to provide the appropriate level of care. For instance, if a person comes in with a significant level of wound care that is needed as well as a wound vac, and your facility fails to have a sound wound care personnel that can address this issue, your facility can face great liability in this area. When you admit a resident it is implied understanding that you have reviewed the case and feel comfortable with the ability to care for the resident's needs.

Revenue is very important on the business or administrative level in long-term care. However, this often is at variance with sound clinical judgment on taking a resident. Another important principle that needs to exist is never let your bottom line business mentality become so myopic that it clouds your ability to see the larger context of the resident care environment. Many individuals will often try to close the sale of a resident, similar to that of a car sales person. A sales or marketing plan in long-term care is always dealing with human beings and not inanimate widgets.

Making sure the proper people, skills, accoutrements and such are in place all need to be considered. Admissions decisions are too often driven from a purely business point of view-how can we increase our census and with it, our revenue. Administrators and other nursing home administrative personnel who manage on this level often fail to understand that management happens within a larger context, both internal to the facility and external to the facility, and both factors have to be considered in the larger context of appropriate resident to facility fit.

Quality care and resident population stability is driven by making sure that the resident to facility fit is appropriate and conducive for not only the resident, but also the staff. If the resident has care issues that exceed the facilities resources it can be quite problematic. On one level it may actually be so expensive to care for such residents that the bed that they are occupying, nevertheless, is causing the facility to incur a tremendous financial hardship. Furthermore, the clinical complexity of the resident may actually outstrip the knowledge capital and resources in the facility.

However, more often than not, the staff feels the pressure and stresses of not having the appropriate skills to care for residents that are not a proper fit with the skill level of the facility. Take for instance a nursing facility that chooses to admit more residents with psychiatric issues that many nurses, or physicians, may not feel comfortable with in treating since they have not worked with this type of clientele before, or very sparingly. Can nurses and certified nurse assistants be trained to address the unique concerns that some of these residents have? Yes, but remember there is a learning curve. Is it fair to say to improve our census we will take more individuals with behavior problems even though our staff is not comfortably trained with this type of resident. Definitely not! Not only is it not serving the resident well, but having staff work in apprehension because they know their skills are not appropriate to care for these types of residents on a wider scale will often lead to errors and poorer levels of care.

Furthermore, it is a hardship for many residents. They need to feel comfortable with the facility and skill level of those that take care of them. Residents and family members often become cognizant of a facility and staff that lack the skills to appropriately address the resident care issues. Not only does this taint the reputation of the facility, but the legal liability that exists here can be quite costly.

A final principle that needs to be stated is that quality is the driving force for nursing care facilities. Although everyone is looking for a quick fix to their census problems, quality drives census in a number of areas. Understanding your facility's capabilities shapes quality. Tailoring your residents to the fit of your facility shapes quality. These in turn lead to a facility having a strong reputation in the community. The reputation of the facility leads to census development. However, the leaders of the facility have to be realistic about what their capabilities are and where their strengths lie. Exploiting the strengths of the facility will lead to better quality of care, which subsequently leads to a strong reputation and better census growth and stability. Conversely, one has to also understand their weaknesses. All facilities have weaknesses, yet attempting to enhance their census be admitting residents that fall into these areas of weakness is a recipe for disaster.

It is a categorical imperative that nursing care facilities understand the importance of matching residents to the facility's strengths and therefore proper facility fit. If you find yourself saying that "I think we can take care of this resident," this often is a sign of attempting to place a round block in a square peg. If the fit fails to exist and you are not able to knowingly and adequately address the resident's needs, then you need to be conscious of this and let that resident be admitted to a facility that is more able to do so. Just because many skilled nursing home are called ‘skilled," does not mean the same skill level exists in all facilities. Skill is not a constant, but is a variable that has to be closely monitored to provide appropriate and quality resident care. Continuing to view census myopically, viewing just the numbers and failing to understand the larger qualitative context of the resident to facility fit is often a major error that is learned by many the hard way.

Pharmacologically-Induced Depression in Long-Term Care

Brian Garavaglia — Wed, 20 Aug 2008 16:37:00 GMT

It is no surprise the older adults take more medication that other age groups. Furthermore, it is probably no surprise that older adults in long-term care take on average double the amount of medication of the average older adult who lives outside a nursing care facility. Typically speaking, as one increases the amount of medication, the likelihood for medication side-effects from interaction happens as well. Furthermore, metabolic changes in the older adult often lead to greater medication sensitivity and the potential for adverse effects that are often not found among younger individuals taking similar dosages. One of the common side-effects are manifestations of depression and even depressive disorders.

Take for instance common blood pressure or anti-hypertensive medications. Common antihypertensive agents such a beta-blockers, e.g., atenolol or propranolol, can cause fatigue, lethargy, symptoms related to depression, as well as depressive disorders themselves. Other types of anti-hypertensive medications like calcium channel blockers such as nifedipine or verapamil can also cause lethargy and depression. As one can imagine, treatment of hypertension is very common in long-term care facilities. Blood pressure medications as well are quite common, with many older adults often using more than one type of blood pressure medication. In addition, blood pressure medication at times can cause drowsiness and this coupled with feelings of lethargy are often mistaken for depression. When the medication is adjusted, changed or eliminated these apparent depressive symptoms, which are nothing more than pharmacologically-induced side effects that mimic depression, are eliminated.

Many older adults in long-term care settings also have Parkinson's disease. A very common treatment for Parkinson's disease, a disease that results from a depletion of dopamine in a part of the brain called the substantia nigra, a critical area of the brain for movement, is often treated with Levodopa and its analogs. Although in many cases this drug and drugs pharmaceutically similar that help aid in reducing Parkinson's symptoms benefit the resident, especially in abating their symptoms. However, often higher doses are needed over greater periods of time and these drugs can led to depression. In fact, major depression that is caused by these medications is frequently viewed as a nonreversible symptom of their disease.

Many individuals in long-term care are also frequently treated for cardiovascular disease such as arrhythmia or heart failure. Arrhythmias are irregular heartbeats that vary in their level of severity. Heart failure is the progressive weakening of the heart muscle. Both conditions often are treated with medications that can cause symptoms of depression. Drugs such as Digitalis and other cardiac glycosides can lead to symptoms of fatigue, feelings of apathy and low motivation and depression. Furthermore, drugs that are antiarrhythmic in nature, used to regulate the heat rhythm, such as Lidocaine, or Procainamide also can lead to feelings of depression.

Cancer is a condition that is often found among many residents in long-term care facilities. Some of these individuals are being treated for their cancer with antineoplastic agents, drugs that are used to treat various forms of cancer. Although we have all heard of many of the other forms of unpleasant side effects that accompany cancer treatment such as nausea and vomiting, depression is also found among these agents. Here again it is often hard to determine whether the drug is causing depression or whether the person is depressed due to their clinical condition. Furthermore, many of these drugs also have side-effects leading to anemia. Anemia can lead the person to feel weak, tired, and listless, symptoms often mistakenly taken as depression.

Drugs such as antibiotics used to treat bacterial infections also hold the potential for depressive side-effects. Commonly used agents such as Cipro and other fluoroquinolones, tetracylines or Cycloserine have been assoicated with depression. Most individuals would frequently not associate antibiotic agents with possible symptoms of depression, yet as is evident, these drugs can and do hold the potential for pharmacologically-induced depression.

Most individuals who work in long-term care have also witnessed that breathing issues are also quite common. Many nursing home residents often use more than one pharmaceutical agent to treat a pulmonary condition. The use of cortisone based agents, such as prednisone taken orally or even breathing treatments that have cortisone based agents or analogs have been associated with symptoms of depression as well as depressive disorders.

Finally pain control is often a very important part of resident care in long-term care environments. Narcotic agents, such as morphine or codeine, not only control pain but depress the central nervous system. These drugs do hold the potential for causing depression. Even less powerful pain control agents such as salicylates and NSAIDs hold the potential for creating symptoms often assoiciated with depression. One has to wonder how often many symptoms of depression are pharmaceutically induced by pain medications given the amount of medication that is used to control pain.

The list could go on, but it would not be beneficial to continue and develop a litany of medications that are associated with depressive symptoms. Suffice it to say that medications have many side-effects and the potential for adverse pharmacological effects increases with age. Furthermore, since many medications have these effects and since many older adults in long-term care use a large number of medications, it is often difficult to determine which medications, or which combinations of medications, may be causing depression or depressive symptomatology. But, it should be evident that many symptoms of depression within the long-term care environment can often be caused by the very medications that are being used to help them with problems in other areas.

Because older adults in long-term care settings use many medications and because depression is quite common in older adults in these environments, it is very important for many professionals in nursing care facilties to become sensitized to the potential that pharmacological treatment and intervention hold in causing mood disturbances such as depression. All too often many individuals look to treat depression by adding medication to an already large medication regime, e.g., antidepressant medications. In many cases this is quite appropriate. However, instead of always looking to treat the symptoms of depression through adding another medication, it may be beneficial to first look at all the medications that the resident is taking and possibly take away certain medications that may hold the potential for causing these symptoms.

Increasing the Social Emphasis to Override Mechanistic Clinical Standards

Brian Garavaglia — Thu, 10 Jul 2008 14:22:00 GMT

To be old is to be demented, and this statement especially sounds in clarion fashion when dealing with older adults in long-term care settings. Yet, although many take this statement at face value, in reality one must pause with concern due to the widespread acceptance of such stereotypes.

Regardless of how many professionals who deal with the elderly in all phases of health care, including long-term care, consider themselves enlightened and immune toward stereotypic misconceptions, clinical thinking about old age is still filled with misconceptions that often lead to faulty diagnoses. Since the predominant features of long-term care continue to be strongly entrenched in dealing with pathology, often at the exclusion of the social individual, those who are responsible for addressing the social needs of older adults, those involved in "social" work and "social" services need to become vanguards toward making sure misconceptions do not come to minimize the quality of existence of the elderly in long-term care.

Human beings are social individuals, yet as we age or as people enter institutional settings they often are treated quite mechanically, similar to machines that wear down. In fact, at one time this analogy on the pathophysiological level, called the wear and tear theory of aging, was given strong credence toward explaining older adults (Christiansen & Grzybowski, 1999) However, although more recent scientific discoveries have failed to lend credence to this theory, it still comes to hold intuitive appeal toward dealing with aging and issues found in older adults. One can see how misconceptions and variable levels of dehumanization can emanate from viewing older adults and their bodies quite mechanically in the clinical realm.

Furthermore, long-term care environments such as nursing facilities continue to remain quite institutional. Even with the Edenization movement led by William Thomas, most nursing care facilities continue to be institutional environments that do little to nurture the important social qualities that create the social individual and separate the social person from being a mere biological entity (Thomas, 1996). Nursing care facilities continue to be "total institutions," which subordinate the older adult's social existence to the clinical mechanics of palpation and auscultation and allow very little room for older adults to grow and express their unique human qualities as individuals (Goffman, 1961). Moreover, often the paternalistic attitudes found by staff in these institutions further enhance the disempowering self-esteem that older adults come to feel about themselves.

In the first paragraph I mentioned that one of the egregious misconceptions about aging is that dementia is inevitable. Although many people, including medical and long-term care professionals embrace this simplistic and stereotypic thought pattern, it leads to problems that are compounded beyond the mere stereotype. Most individuals who are older adults as a whole do not encounter dementia and only approximately 25 percent of memory issues can be attributed to aging itself (Garavaglia, 2007).

Furthermore, even though individuals in long-term care environments face a greater probability of having an organic brain pathology such as various forms of dementia, patients who are part of long-term care environments are often "assumed" to have various levels of cognitive impairment. Therefore a norm of cognitive impairment comes to dominate the staff's perception of how they come to view older adults. In reality, this view is just an extension of the norms in general society that have typically assumed older adults as slower in their thinking abilities and are likely in the throes of senility. Most of this is based on a poor understanding of the aging process and an inability to distinguish between what I term the senescence versus senility error, with the former indicating normal aging versus pathology indicated by the later.

If we put together the probability of dementia increasing with age, and add to that most people in nursing care facilities usually have considerable levels of chronic medical conditions, compounded further with stereotypes that assume inevitable and pathological cognitive decline, we now have a labeled population situated in an institutional environment with its own labels that envision any kind of forgetting as a sign of brain pathology. However, although many manifestations of dementia are indeed truly biological pathologies, some are not, and this is where the labels and stereotypes can lead to self-fulfilling prophecies that may influence faulty diagnoses.

It must be remembered that boredom, lack of sensory and mental stimulation, depression, metabolic instabilities, the increasing number of medications used among this group, as well as a host of other conditions can lead to memory disturbances and other cognitive symptoms. When these symptoms are found in younger populations they often lead medical staff to assume some underlying pathology causing the cognitive changes. However, with older adults, it is often assumed that this senile or disease based symptom is part of normal aging or senescence, or again the senile versus senescence error. When an elderly person experiences these cognitive changes in long-term care facilities the likelihood of stereotypes and the self-fulfilling prophecy that they carry frequently lead to labels of dementia with very little further investigation into whether it is truly an organic cognitive pathology.

Where does this lead us to this point in this analysis? For one it is evident that older adults still face a considerable level of discrimination and subsequent stereotypes and labels or what Butler (1969) came to refer as "ageism" that creates a false understanding of this population. Furthermore it has been explained how these stereotypes are accentuated in long-term care facilities, which further can lead to faulty clinical diagnoses and cognitive profiles. Finally, when individuals are placed in a mechanistically clinical environment that fails to nurture their social needs, regression of their holistic existence, including their cognitive abilities, can decline quite precipitously.

Therefore it is at this point evident that there needs to be individuals in a long-term care environment that can understand the implications for nurturing the social and not just the physical being. It is here that the "social" worker (I use this term loosely, meaning that it can be not just a degreed social worker, but all clinicians that focus their needs to the social aspects of the individual) needs to be more than a clinician involved in taking psychosocial histories.

Those involved in the social services and social work area of long-term care have to understand the problems that are faced by older adults in these types of environments. They need to play a key role in making sure that older adults are not pigeonholed into neat and convenient diagnostic classifications without assisting and advocating for a greater holistic understanding and investigation into the older adult's condition. It is at this point that social services personnel responsible for social intervention, which does not necessarily have to be relegated to just the social worker, becomes the priest of the social soul of the older adult. With so much emphasis on the mechanistically and often depersonalizing elements of clinical medicine, there has to be individuals that remain focused on nurturing, maintaining and enhancing the social being. Again, ultimately there needs to be an understanding of the importance for all individuals in long-term care to nurture the social being of older adults, including those who are clinically involved with their biological functioning. They should not see themselves as any less absolved or responsible for nurturing the social self.

Therefore now is the time for the social paradigm with its "social practitioners" in the long-term care settings to become increasingly involved in the medical environment as social medicine specialists. Paying attention to the social and emotional development of the person, being sensitive to areas of social regression, and understanding how to enhance the lives of older adults in an often sterile, physical environment can only lead to greater pleasure for the elderly that they service and help enhance their very important niche in this important area of healthcare.

References

Butler, R (1969). Ageism: Another form of Bigotry. The Gerontologist, 9, pp. 243-246.

Christiansen, J. L & Grzybowski, J. M (1999). Biology of Aging, McGraw-Hill, New York.

Garavaglia, B. (2007). The Pitfalls of Diagnosing Dementia: Looking beyond Patient Age. Long-term Care Interface, July/August, 2007, Vol 8, No 4, pp.46-48.

Goffman, E. (1961). Asylums: Essays on the Social situation of Mental Patients and Other Inmates. Doubleday Anchor, New York.

Recognize Alzheimer’s as a Social Disease

Brian Garavaglia — Thu, 19 Jun 2008 14:52:00 GMT

Alzheimer's Disease is a progressive and debilitating disease that often leads to a person's inability to understand and be aware of their conscious existence. As a disease it is incurable and due to its inevitable progression, leads to one of the most frightening human conditions that exists. However, Alzheimer's disease and many associated dementias is more than just a progressive neurological disorder. Too often long-term care professionals come to view this as a physical disease, a disease that disassembles that normal neurological structure of the cerebral cortex. However, in addition to the physical manifestations that are part of its pathology, it is a disease that leads to the destruction of the social soul, which behavioral scientists have often referred to as the self.

The "self" is a unique component of human beings. We are not born with a sense of self (Handel, Cahill & Elkin). Our sense of self emerges with our overall development. Individuals are born as biological entities with some primitive biological reflexes, but at birth we have no understanding of what we are and how we are separate and unique entities from our environment (Handel, Cahill & Elkin; Santrock). Therefore, at birth we are living and breathing biological entities but with no self we fail to hold many of the qualities that we come to equate with being "human." This is especially evident from many studies, both in humans and other primates that have unfortunately been victims of severe abuse, neglect, and isolation.

As individuals develop our sense of self through social interaction, we come to develop into social beings, or as Elliot Aronson has come to refer to humans as a "social animal."(Aronson) It shapes our consciousness, how we come to view the world and ourselves, how we come to think and feel about ourselves, and most importantly, how we come to obtain those traits that we come to view as making us "human." However, possibly the most important part of our sense of self is the concept of "reflexivity." This shapes our mind to come and view ourselves as an "object" to itself. As conscious human beings our ability to see ourselves as others would see themselves is critical.

For instance, we develop important emotions such as pride, envy, and embarrassment because we are able to see ourselves as an object, viewing ourselves as others come to see us. However, as those long-term care personnel who have worked with individuals that suffer from this disease know, as the disease progresses, many of the person's social skills rapidly deteriorate. Patients suffering from this disease fail to be able to view themselves as an object, and this is often found in many forms of social behavior becoming compromised, such as undressing in public or taking their teeth out and placing them on the dining room table while others are eating.

What is happening in these instances is they lose their ability for shame and embarrassment, higher level social emotions that requires the reflexivity of the self. These emotions develop when we are able to see ourselves as others do, and they allow most people to understand what is appropriate or inappropriate behavior in any given situation. With a sense of self, it allows us to understand what others expect of us and how others will view us if we fail to live up to the social norms of particular situations. The person with Alzheimer's disease, whose self is slowly dying, is unable to understand these implications.

Furthermore, it is also very frustrating for many caregivers and family members to watch, since most cannot comprehend why their resident, or why a son or daughter's mother or father, is unable to understand may of these simple social graces that most of us take for granted. They fail to realize that the disease is more than just biological, but with the slow death of self, the important social nature of the person, that which makes are truly human, is slowly degenerating as well.

Long-term care staff often face continued needs to address older adults with this disease and the antisocial behavior that is often found among these elderly as the regressive spiral leads to a infantile level of self-consciousness, which further leads to behaviors such as disrobing, wandering without any concern for themselves, or urinating in public places. What is happening here? Again, the self, which allows us to control our behavior by seeing ourselves as others do; the part of ourselves that is important for higher level emotions such as pride, envy, embarrassment, shame, empathy, and even love; the part of ourselves that is important for understanding social situations and expectations that others hold; is dying along with the neurological tissue.

This is often noticed by many who care for residents that suffer from this disease when they attempt to explain to those who suffer from the disease their socially compromised behavior and its antisocial manifestations. In the earlier stages of the disease the explanation does revive some remnants of the self, as is evidenced by the resident demonstrating some awareness of their social transgressions when they are made aware of them by the long-term care worker. However, in the later stages, as workers attempt to explain their behavior to the resident, the resident often will stare blankly at the worker, similar to very young children being reprimanded for inappropriate behavior, both of whom are not able to understand the consequences of their actions due to not having the appropriate requirements for a truly social self.

In the child's case, their self will continue to develop and they will eventually be able to understand the social significance of their behavior. However, the person with Alzheimer's will never be able to understand the ramifications of their behavior and will only continue to spiral downward. For the child the self will mature and grow; for the person will Alzheimer's, the self will continue to regress and die. Therefore, Alzheimer's disease is more than a physical disease, but also a social disease, robbing the person of the essence of their humanity.

In summary, many individuals have come to view Alzheimer's disease as an exclusively biological condition. However, probably it most egregious impact is on the social nature of the human individual. With Alzheimer's disease comes the demise of what makes us human, our social self, and with it the ability to reflexively see ourselves as an object to ourselves. This becomes such an essentially important fact to understand about our human nature, and how Alzheimer's disease obliterates our human nature through its assault and eventual destruction of the self, that to not understand it leads clinicians and practitioners that deal with this population empty in their own right.

The implication to understand the social aspects of dementia, and the obliteration of the self, makes this disease as mentioned previously not just a neurocognitive disease but a social disease as well. The implications for treatment also should follow as well toward viewing it as a social disease with needed social intervention by long-term care professionals. Although biological treatments are still essential, by themselves they do very little to humanize individuals with these diseases that are ultimately so dehumanizing. Therefore, long-term care facilities must also invest more time in keeping those with this disease engaged in their social surroundings to slow and minimize the demise of the social self, the most egregious and frightening condition that is found in humans.

References

Aronson, E. (1980). The social animal. New York, Freeman Press.

Handel, G., Cahill, S., & Elkin. F. (2007). Children and society. Los Angeles, Roxbury

Publishing.

Santrock, J. W. (2006). Life-span development, 10^th ed. Boston, McGraw-Hill