Gerotalk : Wellness

The Effects of Pseudopositive Attitudes

Brian Garavaglia — Tue, 02 Jun 2009 16:52:00 GMT

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.

Blood Sugar Levels May Be Critical to Preventing Memory Loss

Brian Garavaglia — Tue, 12 May 2009 19:14:00 GMT

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.

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.

Depression and Pseudo-Dementia in the Long-Term Care Population

Brian Garavaglia — Tue, 12 Aug 2008 17:30:00 GMT

What interests me is how often stereotypes dedicate care. In society, individuals still assume older adults should be depressed and that it is part of normal aging. Furthermore, in long-term care this stereotype is even further consolidated. It is often assumed that older adults in long-term care settings, even more so than their same age counterparts in mainstream society, should be depressed, especially due to their presence in a long-term care setting. It becomes an interesting phenomenon, where behaviors that are abnormal, which depression definitely is, now become "normalized" for long-term care residents because of their age and the social context that they live in.

Therefore, it is important to address the issue of depression in long-term care settings. Furthermore, it is important to address how many individuals with depression also get misdiagnosed with dementia, a condition that is called pseudo-dementia. In the upcoming paragraphs I will briefly discuss this problematic issue that is often found in long-term care residents. Moreover, I will discuss how this problem can be addressed by changing our stereotypic views of older adults in long-term care settings.

The elderly in long-term care often face two stereotypic misconceptions: It is normal to be old and depressed and it is normal to be old and cognitively impaired. Therefore when an older adult is found to be depressed or to be impaired on a cognitive level, this behavior has often become "normalized" in long-term care settings. Furthermore, it is often falsely assumed that both conditions are intractable. Yet, there are many instances when cognitive impairment that is being experienced by older adults can be improved and even eliminated. One of these circumstances happens when elderly individuals become depressed. When individuals become depressed they will often have memory issues. When younger adults become depressed and have memory problems it often becomes a symptom of their depression. However, when many older adults become depressed and develop memory issues, especially in long-term care settings, the attribution that is often made is the person has an inevitable level of dementia.

Depression among older adults in long-term care is quite prevalent. Furthermore, it often goes untreated and unnoticed. Frequently, one of the characteristic symptoms of depression is memory impairment. As stated above, when it is manifested by those who are younger it becomes a prominent feature of their depressive illness. However, what about the older adult in the long-term care setting that starts to forget and has other cognitive issues? How can one determine if it is depression or dementia? After all, it is quite commonplace to see dementia among many long-term care older adults?

What even complicates the issue further is that the elderly pose a complicated clinical profile. Especially in the long-term care environment, the elderly often have a myriad of clinical issues that can complicate the diagnosis of depression and make it very difficult to rule out dementia. However, a diagnosis of dementia often becomes an easier grab bag diagnosis. This is influenced by the stereotypes that we hold about the elderly in general, and the elderly in long-term care in particular, which regards this age group as inevitably destined to be demented to varying levels.

Another confounding factor is that depression in many older adults is often atypically manifested. The sad affective presentation and loss of pleasure that is found among many with major depressive disorders can actually be masked in different symptoms such as anxiety, behavioral outbursts and the inability to sleep, which coupled with confusion and memory loss, may be taken as the so-called "sundowners" features of those with dementia. The atypical nature of many depressive disorder in older adults, coupled with prevailing cognitive symptoms, often lead many to overlook depression as being the cause of these memory issues.

Another important issue is that although many long-term care professionals are quite dedicated toward the provision of care, many come to the profession having very little training in this area. Most physicians who work in long-term care were not trained as geriatricians, and often work in long-term care facilities in addition to their other practice. Many nurses have completed much of their training in acute care health care facilities. Also, most social workers, psychologists and psychiatrists have spent most of their training addressing the problems of a more youthful population.

Therefore, many of these professionals are not as uniquely sensitized toward the special needs of the older adult populations in long-term care as those who have special training in this area. Furthermore, many of these professionals bring stereotypes that they have learned about old age and the elderly to the clinical setting, which in turn fails to allow them to see beyond this misconceptions and leads them toward missing a diagnosis of depression.

Many fail to understand the overlapping significance between depression and dementia in the older adults. Therefore it is often assumed that these two disorders exist in exclusivity. However, in reality, depression in older adults can lead to memory disturbances and other cognitive issues that mimic dementia (see diagrams below). Although most forms of dementia cannot be eradicated, pseudo-dementia caused by depression is quite treatable once the underlying depression is lifted.

Therefore, very important in addressing the complicated issue of targeting depression in those elderly is overcoming many of those harmful stereotypes that can make us loss sight of this important underlying problem. Furthermore, hopefully one will come away without automatically assuming that memory issues found to exist among older adults are not just inevitable consequences of their age or of being a resident in a long-term care environment. Hopefully, after reading this brief article, the reader and long-term care professional will come away with an increasingly sensitized eye for understanding the implications of depression among elderly in long-term care and how many memory problems may be corrected with the appropriate diagnosis and treatment of depression.

The Importance of Creating Workplace Spirituality in Long-Term Care Environments

Brian Garavaglia — Mon, 28 Jul 2008 16:16:00 GMT

When someone hears the word spirituality, along with a statement of attempting to introduce it into the workplace, what immediately comes to mind is someone attempting to interject their religious beliefs into the workplace environment. Although this may be one interpretation of workplace spirituality, in this case the theistic nature of such a definition is not the focus. The emphasis that will be part of this discussion will be more secular in nature. Workplace spirituality as a secular rather than a sacred phenomenon is a topic that has recently been spoken about, and even though there is not a great deal of empirical research on this topic, its introduction into a long-term care environment does make some intuitive sense.

Workplace spirituality or organizations that foster such spirituality look to nurture the worker and the needs they bring to the organization. Spiritual organizations that foster individual needs in these areas often garner reciprocal benefits in their own right. At the basis of workplace spirituality is an understanding that people have spiritual needs, needs within the individual that are not necessarily religious, but are based on an inner need for meaning. People need to achieve a sense of meaning. They also have a humanistic need to potentiate themselves as human beings, to develop to their full human potential.

Sense human beings spend a great deal of their lives in work environments, spiritual organizations look to tap the inner resources of individuals. This in turn applies to long-term care environments, which as organizational environments can also become spiritual organizations that tap the often untapped resources of their workers. Since individuals spend a considerable portion of their lives in work environments, nourishing the spiritual needs of individuals, helping them find meaning through their work, is critical in organizations that nurture an organizational spirituality.

Why is this important for long-term care? Many individuals who work in long-term care environments have done so for many years and continue to dedicate a considerable portion of their lives to this type of work and work environment. In fact, many of us, when asked who we are, come to provide answers such as nurse, administrator, caregiver, physical therapist, etc. Generally speaking a key factor in shaping all human beings' identities is the work that they do. Spiritual organizations come to understand this and attempt to help the individual with their inner needs through shaping the organizational culture and environment to target many of their inner, spiritual features. Organizations that help foster this also obtain reciprocal benefits in that workers that are more fulfilled also can work more productively for the organization itself.

This is important for many long-term care facilities. Nursing care facilities that have successfully achieved a spiritual organizational environment not only enhance worker productivity through satisfaction with their work, but also have lower worker turnover and increased levels of trust. This latter quality is extremely important. Successful organizations depend upon successful teamwork. Moreover, for successful teamwork to exist a sense of trust has to exist as well among the team players. In a healthcare environment that is predicated on the care that it provides frail and sick individuals, teamwork not only on the administrative levels, but also on the line levels is extremely important for the success of the organization and for the lives of those that they serve. Therefore, organizational spirituality not only helps foster the needs that individuals have, but also fosters the growth and development of the organization itself.

Another important need that helps foster the growth of the individual in spiritual organizational environments is enhancing their sense of security, but here again the need is reciprocal. Human beings need to feel secure and that includes feelings of security in their work environment. But this need is not just unilateral. Spiritual organizations recognize the importance of their workers and in these types of long-term care environments the benefit of fostering a sense of worker security helps reduce worker-management conflict, turnover, and enhances the care, morale, and the general well-being felt about the environment. Therefore, spiritual organizations do not just provide inner levels of personal growth on a psychological level for the workers, but they also derive the benefits from their worker's personal growth as well.

Key to human development is establishing a sense of purpose and meaning and possibly no other factor in our lives provides use with this sense of purpose than the work that we do. Work in all areas of society has to nurture more than just the base needs for people, but they have to nurture many of those higher level needs that provide us with a sense of meaning and purpose in our lives. Health care workers, especially due to the close interaction with other human beings that they serve, have a special affinity with the customers they service. Their sense or purpose is tied to more than just the production of widgets, but to the nurturance of other human lives.

However, this type of work is also very difficult and emotionally draining at times. Therefore, it is important for long-term care organizations to recognize the purposeful importance that long-term care workers derive from their work, yet spiritual organizations also recognize that they need to help promote their worker's feelings of purpose and help guard against those destructive forces that may lead to burnout or stagnation of human growth.

A long-term care organization that invests in the development of a spiritual organization helps to nurture the fundamental needs that human beings have, which is for personal growth. Workers in all walks of life often identify with the work that they do. It often provides them with a very important piece of their personal identity.

Long-term care workers are no different. Many individuals who work in long-term care often do so for more than a casual passing. Many workers in long-term care have worked in this area for numerous years and identify with the work that they do as a critical part of their identity. It is because of this that long-term care organizations have to pay greater attention to stroking the important spiritual foundation that helps to provide purpose and meaning for them in their daily lives. Furthermore, as was mentioned, the benefits of developing a culture based on a spiritual organization that targets the internal needs of the worker are not unilateral, but reciprocally come to hold benefits for the organization as well.

Organizations that infuse their culture with the beliefs in a spiritual workplace come to find that the benefits they sow ultimately lead to greater team cohesion, less turnover, higher levels of morale, less tension between different work groups, a more enjoyable work environment, and workers that have a greater ethic toward the provision of care. Because of this the investment toward achieving a spiritual organization will ultimately lead to a work environment that is more productive and workers that are more satisfied. Such a win-win situation for the organization and the individual need to be further investigated for possible implementation in many of our long-term care facilities.