Dictionary Takes Note of "Aging-in-Place"

From yesterday’s e-newsletter of the Gerontological Society of America:
“At the end of every December, the New Oxford American Dictionary announces its Word of the Year, and “aging-in-place” was a runner up for 2007. Although the term is well known to providers of aging services, the New Oxford American Dictionary has defined aging in place for the general public as ‘the process of growing older while living in one’s own residence, instead of having to move to a new home or community.’”
Concepts, once revolutionary, find their way into mainstream dictionaries! Aging in place is an experience that ALL of us want. We never want to leave home. How this is lived out in continuing care retirement communities is addressing this naturally-borne wish. It all amounts to taking the services where the people are, rather than taking the people to where the services are. It works. It enhances quality of life greatly.

Philosophical Values Underlying Transformative Nursing Homes

Dr. Bill Thomas speaks of his Greenhouse Project, one of several approaches to culture change, as being based

NOT on the physical or organizational structure of a typical nursing home,

NOT on the structure of a hospital, and

NOT on sickness and disability.


Rather, Thomas’ conscious approach, along with his colleagues within the culture change movement, is based on

“An environment worthy of older people,

an environment of intentional community vs. institutionalization.”

Thomas continues, “It is based on a vision of growth, vitality, human development and the “miraculous power of love and affection in the lives of people young and old.”

Does this seem like something all nursing homes should strive for? If you see yourself as someone who might 'end up' in a nursing home, would you choose such an environment over nursing homes as we know them today? In which setting do you think life would be better for you and for the staff?

Does the argument gain any strength with the added fact that the day-to-day operations in a transformed nursing home cost no more than in our traditional nursisng home, with the added fact that staff retention is much higher in transformative nursing homes and that they report much higher job satisfaction?

It's worthy of a good discussion. Add your comment by clicking on the "comment" right below this post and follow the simple directions. "Let's talk."

A Place Where Love Matters

Did you see the Lehrer News Hour this evening, January 23, with the story about transformative nursing homes? Dr. Bill Thomas, geriatrician and nursing home reformer was interviewed in one of his “Green House” nursing homes in Lincoln, Nebraska.

The twelve-minute story highlights two primary characteristics of the Green House concept – characteristics of all transformative nursing homes. The first, making the nursing home HOME, with all the implications that follow. The residents interviewed testify to that. So do the front line workers in a more indirect but compelling way. From the transcript:

Ebmeier, Nursing Home Administrator, and the shahbazim, (plural for shahbaz, name for traditional certified nurse assistants), tell the story of one former Green House elder, Mary Valentine, who celebrated her 101st birthday in the Green House.

JOYCE EBMEIER, Administrator: One of the shahbazim went to her and said, "Well, Mary, what do you want to do? What shall we do so that you have a great birthday?" And she looked at the shahbaz and she said, "You know, what I really want is a margarita and a cigarette."

SUSAN DENTZER, Narrator: And that's what she got, as seen in this picture, taken as she and her daughter celebrated on the Green House's front porch. When Valentine died soon after that memorable day, the shahbazim were crushed. They told us that was the downside of life in the Green House, saying goodbye.

THOMAS COOPER, Shabaz: The night after she had passed, my dog (note the place of animals in this setting) went into her room, and jumped up on her recliner, and sat where Mary used to sit. That was really emotional for me, and for the whole group of shahbazim, and the whole team.

JOYCE EBMEIER, Administrator: Death gets harder in a Green House because, when you are smaller and when you are engaged in the way that the shahbazim are engaged in the lives of the elders they love so much, it is like losing your dearest family member.

The video shows a hanging plaque which reads: “In memory of Mary Valentine. May her spirit protect, nurture and sustain all who enter here.”

DR. BILL THOMAS: In long-term care, love matters. And the heart of the problem is institutions can't love.

At this point in the story, I experienced a strong resonance with Dr. Thomas’ differentiation between home and the institution. I was remembering the death of a friend in a nursing home early one morning just a couple of years ago. When the mortuary personnel came to remove the body, I accompanied them as they rolled the body-laden gurney down the long hall to the exit. My action was a conscious effort to form a kind of honor guard. As we passed the nurses station, the two employees sitting there, kept their heads down, apparently engrossed in paper work. Neither even looked up. Neither acknowledged the sacredness of the moment. Neither acted in a way that would indicate there had been a personal relationship with this person. I remember my feelings of shock and sadness. That is an example of “institution.” Institutions can’t love. Institutions that hold our elders need to be transformed into HOME.

The second characteristic of transformative nursing homes addressed in this story refers to improved physical and psychological functions. The video shows an elderly woman (age, 95) making her way with a walker with relative ease and confidence. Her daughter tells the interviewer that when her mother was living in a typical nursing home setting she had been bed bound. In this transformative nursing home, the daughter continues, “they started working with my mother. . .and it wasn’t very long before she could get up and take a few steps. And now, you can see she does pretty good (sic) with the walker getting around.”

The video spends some time on the financial aspect which, I believe, is more relevant to Green Houses as such, not transformative nursing homes generally. The Green House Project is a trademarked name and requires adherence to many particulars, including using Green House Project blueprints for the construction of each home. Generally, as Steve Shields, leader in the transformative nursing home movement has said publicly: the staffing is the same; the costs are distributed differently, but they are the same. Transformative nursing homes are budget neutral.

The story from Lincoln, Nebraska is heartening. There are not enough of these HOMES yet. We MUST liberate our elders from traditional nursing home and bring them HOME.

The transcript of this story from the Lehrer News Hour can be read at:
http://www.pbs.org/newshour/bb/health/jan-june08/nursing_01-23.html

TOO MUCH MEDICINE CAN MAKE YOU SICK

Part Two of Two
What Does All This Mean To YOU?


To quote from the last paragraph of Dr. Wolf’s article: “A serious problem exists because both doctors and patients do not realize that practically any symptom in older adults and in many younger adults can be caused or worsened by drugs. Some doctors and patients assume that what are actually adverse drug reactions are simply signs of aging.”

Be assured, my friends, that ageism in our medical system in the United States is alive and well. We must be advocates for ourselves AND for those we love who may, merely by chronological age, be potential victims of this vicious and insidious “ism.”

One practical note: if you are looking for a good nursing home and you learn that one of the disadvantages of the residents who live there is that each tends to be on nine or more medications, BEWARE! The federal government agency that oversees care in nursing homes has set “nine” as the cutoff number of medicines at which an individual may be at high risk for being inappropriately medicated. “Too much medicine can make you sick.”

Second practical note: when you get a prescription, ask questions about side effects. Ask about other possible approaches as alternatives to the recommended prescription. In other words, get enough information to assure that you are able to give informed consent to the primary care provider’s suggested treatment. Ask these questions too when you accompany an older adult to their primary care provider.

Third practical note: find a geriatrician for your primary care provider if you are over 60 years of age. There is a not-so-recent field of medicine, geriatrics that specializes in the care of adults 60 and older. These primary care providers have special training in gerontology and geriatric medicine. As we age, our bodies and even typical symptoms of various disorders do not fit the classic medical textbook description. Much like infants and children who, because they are in a unique developmental stage, are universally under the care of a pediatrician, we older adults are best served by those specialists who understand, through extensive training, the older body.

A physician may be a board-certified geriatrician. Or, a physician may obtain a Certificate of Added Qualifications (CAQ) in Geriatric Medicine or Geriatric Psychiatry. This CAQ is offered through medical certifying boards in family practice, internal medicine, osteopathic medicine and psychiatry for physicians who have completed a fellowship program in geriatrics.

TOO MUCH MEDICINE CAN MAKE YOU SICK

PART ONE OF TWO PARTS

Today’s entry is a ‘wake up and smell the coffee’ message. Older adults (that’s 60 and over) are generally overmedicated, suffer debilitating and sometimes irreversible side effects from sometimes inappropriate or wrong-dosage medications and are at the mercy of a healthcare system that is patently ageist.

The contents here are taken from a wonderful newsletter, WORST PILLS BEST PILLS (September, 2007 issue). It is edited by Sidney M. Wolfe, M.D. with Public Citizen, a national not-for-profit, public interest organization.

The front page article in this newsletter presents staggering figures about Drug-Induced Diseases among older Americans that occur each year in the United States.


ADVERSE DRUG REACTIONS
9.6 million older Americans suffer adverse drug reactions. At least 37% of these reactions are not reported to the primary care provider because the patient did not realize the reaction was drug-related. Dr. Wolfe believes this is a result of the primary care provider not explaining possible adverse effects to older adults when medicines are prescribed.

DRUG-RELATED AUTOMOBILE INJURIES
At least 16,000 injuries from auto crashes involving older adults are attributable to the use of psychoactive drugs, specifically benzodiazepines* and tricyclic antidepressants**

HIP FRACTURES AND SUBSEQUENT HIGH MORTALITY RATE
32,000 older adults suffer hip fractures that can be attributed to drug-induced falls. Of these, more than 1,500 will result in death. Drugs usually involved: sleeping pills, minor tranquilizers, antipsychotic drugs and antidepressants. Dr. Sidney M. Wolfe, editor, states that all of these categories of drugs are often prescribed unnecessarily, especially in older adults.

DRUG-INDUCED DEMENTIA
Approximately 163,000 older adults suffer from serious mental impairment (memory loss, dementia) either caused or worsened by drugs. These drugs may be minor tranquilizers or sleeping pills, drugs to treat high blood pressure or antipsychotic drugs.

DRUG-INDUCED TARDIVE DYSKINESIA
73,000 older Americans suffer this very serious and often irreversible side effect of prescribed antipsychotic drugs. This disorder is characterized by involuntary movements of the face, arms and legs. About 80% of older adults receiving antipsychotic drugs do not have schizophrenia or other conditions that justify the use of these powerful drugs.

DRUG-INDUCED PARKINSONISM
At least 61,000 older adults have developed this drug-induced disorder due to the use of antipsychotic drugs such as Haldol, Thorazine, Mellaril, Stelazine or Prolixin.

Other drugs prescribed for gastrointestinal problems can also cause this same drug-induced disorder: raglan, Compazine and Phenergan


*Short-acting benzodiazepines are generally used for patients with sleep-onset insomnia (difficulty falling asleep) without daytime anxiety. Shorter-acting benzodiazepines used to manage insomnia include estazolam (ProSom®), flurazepam (Dalmane®), temazepam (Restoril®), and triazolam (Halcion®). Midazolam (Versed®), a short-acting benzodiazepine, is utilized for sedation, anxiety, and amnesia in critical care settings and prior to anesthesia. It is available in the United States as an injectable preparation and as a syrup (primarily for pediatric patients).

Benzodiazepines with a longer duration of action are utilized to treat insomnia in patients with daytime anxiety. These benzodiazepines include alprazolam (Xanax®), chlordiazepoxide (librium®), clorazepate (Tranxene®), diazepam (Valium®, halazepam (Paxipam®), lorzepam (Ativan®), oxazepam (Serax®), prazepam (Centrax®), and quazepam (Doral®). Clonazepam (Klonopin®), diazepam, and clorazepate are also used as anticonvulsants.

**If you would like more information about drugs in this category, select the URL below and paste it into your Browser’s address box:

http://www.healthyplace.com/communities/depression/treatment/antidepressants/antidepressant_list.asp

A word – or Two – About Food

I know, I know, this is a blog about aging. But food, as an essential part of so much of our life, fits right in, I believe.

I’m engaged in a book now by Michael Pollan whose title is IN DEFENSE OF FOOD. I highly recommend it. His advice is this: Eat food. Not too much. Mostly plants.

A quote from page 8 of his book articulates well the long-held place of food in our individual, social and communal life:

"We forget that, historically, people have eaten for a great many reasons other than biological necessity. Food is also about pleasure, about community, about family and spirituality, about our relationship to the natural world, and about expressing our identity. As long as humans have been taking meals together, eating has been as much about culture as it has been about biology."

In many public retirement communities, an emphasis is placed on enhanced dining from a simple marketing perspective. The large dining rooms are often elegant in style with tablecloths and “real” napkins at every setting. Staff serve residents restaurant-style from a menu that contains choices. Nice! Regardless of the motive. Call it paying attention to consumer interests. Not a bad idea either.

I’ve been thinking much about food, health, quality of life, and the dining experience, particularly for people living in retirement settings in the context Pollan states on page 8 of his latest book.
Pleasure
Community
Family
Spirituality
Our relationship to the earth
Expressing our identity (cultural and ethnic food habits)

How can we enhance the expression of each of these deep human values in the retirement setting? It will vary by community, by location, by local circumstances. It’s worth looking into with serious intentionality.

I believe the most important ingredient in this holistic approach toward food and sharing meals together is cooking REAL FOOD from SCRATCH. The trucks that pull up to institutional kitchens carry processed food or food-like substances as Pollan calls them. The fuel connsumed in transporting foods in our industrial food culture (an average of 1500 miles) is ten times the energy of the food transported. As we call for care of the earth, can we stop the over-consumption of fuel, the overuse of the chemicals used in growing and processing these foods, which subsequently end up in our waterways, and buy locally? Buy REAL FOOD, fresh vegetables, fruit, nuts, eggs from our local farmers and beef, pork and poultry from local ranchers? Imagine the gastronomical delight in once again having home-cooked food, of savoring the marvelous sweet juiciness of fruits and melons grown nearby and served promptly after being harvested.

For those who tend to look at the pragmatic first --- Food budgets based on cooking ‘from scratch’ are a mere 1/3 of the budgets based on trucked-in, processed and frozen foods. And look at how we honor Mother Earth in the process! It’s also a win for the lucky people who are served this food, for the small local family farmer and rancher, as well as the kitchen staff who get to do something more creative than open boxes and heat up the oven!

More on Dementia and the Drugs to Treat It

I discovered that Dr. Bill Thomas (father of the Eden Alternative and Green House projects in long-term care) has a blog titled “Changing Aging.” The URL is this:
http://www.umbc.edu/blogs/changingaging/

In a post of January 15, titled “No Miracle Pill,” Dr. Thomas refers to 6 clinical studies examined by Italian researchers on the use of commonly prescribed drugs for mid-to-moderate Alzheimer’s. Aricept is the most common of those named. They found “that in none of six clinical trials they examined did using the drugs significantly reduce the rate of progression from MCI (mild cognitive impairment) to dementia.”

I have heard other respected geriatricians state this same result from their own professional reading and experience. In one case, the geriatrician told those of us in the audience, “I tell a family member, ‘if your mom enjoys eating at “Uncle Julio’s Fine Mexican Restaurant”, your money would be better spent giving her that simple pleasure once every few weeks.” He went on to say that the improvements in memory from using these drugs are “clinical” in nature. After a few months on the drug(s), a person with dementia might be able to remember a series of five words from a list of ten, over four words that s/he was able to remember before beginning to take the drug.

Dr. Thomas ends his short post with this: “The problem is that, outside of a small number of exceptional circumstances, the drugs listed above are largely ineffective and expose patients to substantial and sometimes dangerous side effects.” (Emphasis mine)

The original, short and easy-to-read article that Dr. Thomas refers to can be accessed here:
http://www.msnbc.msn.com/id/21990057/

Using Antipsychotic Drugs Off Label In Nursing Homes To “Manage” Behavior
© January 8, 2008 by Imelda Maurer, cdp

Once again a research study has affirmed the obvious: nursing home residents who are treated with antipsychotic drugs as a result of exhibiting “behavioral problems” do better when they are taken off these drugs. The New York Times in its January 4, 2008 issue described the study, conducted in England, Wales and Australia and its findings. In part the article reads, “The study sharply challenges standard medical practice in mental health clinics and nursing homes in the United States and around the world.”

First, a simple glossary:
Antipsychotic drugs. refer to those medications that were originally developed to treat psychosis. A diagnosis of psychosis includes conditions such as schizophrenia, bipolar disorder, mania and delusional disorder. Medications to treat these psychoses include Haldol; Risperdal; Abilify; Clozaril; Zyprexa; Symbyax; Seroquel; Geodon

Behavioral Problems. Terms like this or adjectives such as “combative,” “aggressive”, “uncooperative”, “resists care” are seen in nurses’ notes of typical nursing homes. Such descriptions are subjective, reflecting a bias on the part of the one charting. Good care givers, professional health care providers, know to look for the meaning in any behavior. All behavior has meaning. It is the task of the caregiver to find that meaning and address the issue the resident is attempting to communicate. Mary Lucero, a nationally known expert on dementia and dementia care notes, “Resistance to care is a message of distress. It is evidence of frustration and anxiety pushed to the last resort.” A person with dementia cannot act with the reasoned intent to cause harm. Aggressive or combative behavior is that person’s means to protect, to remove an obstacle or to stop an action seen as harmful to him/her.

Off label use of a drug. When a drug has been developed and approved by the FDA for a certain disease or disorder, but a health care provider prescribes it for a condition other than that covered by the drug’s FDA approval, the practice is called off label use. Physicians attending nursing home residents in far too many cases prescribe any of these antipsychotic drugs as all-purpose tranquilizers

Typical nursing home. Whenever I use that term in my blog, it describes any nursing home that is institutional in culture, where staff convenience determines a resident’s daily routine, where regulations may be duly adhered to but in a mechanistic, impersonal way, and where activities are generic and repetitive. As a consequence, morale is low among staff and residents. Turnover, especially among front line staff, the direct care givers, is very high. Unfortunately, the residents can only escape through death.

Back to the study! An editorial in the journal Lancet, in which the full study was described, advises against using these antipsychotic drugs to address behavioral issues at all. “We know that behavioral treatments can work very well with many patients.” Johnny Matson, professor of psychology at LSU in Baton Rouge writes.

Hooray for the authors of the study who conclude that the routine prescription of the drugs for aggression “should no longer be regarded as a satisfactory form of care.” Physicians in typical nursing homes may practice their craft primarily by prescription. It occurs, for example, when the director of nurses tells the attending physician that Resident X has been shouting out during the night, or is “combative” and “uncooperative” with care. An all-purpose tranquilizer --- read antipsychotic drug being used off label--- is prescribed. The resident’s behavior changes. His/her body may become rigid; the resident may become untalkative, unable to feed him/herself any longer, is no longer oriented to those around him/her, shows signs of depression, and may be one of the “slumpers” typically found around the nurses’ station.

I am reminded of Steve Shield’s words about culture change here. Steve, CEO of Meadowlark Hills, Manhattan, Kansas says, as I wrote in an earlier blog, that when he and his staff were exposed to the philosophy of culture change they all saw it as holy. “It is holy,” Steve explained to me, “because it liberates the elderly and returns hope to them.”

True culture change – the kind that results in transformative environments for residents and for staff – will reflect medical personnel and licensed staff who look for the meaning in resident behaviors and who try, in as many ways as it takes, to address the issue the resident is trying to communicate.

“GOING GRAY” and “I FEEL BAD ABOUT MY NECK AND OTHER THOUGHTS ABOUT BEING A WOMAN”

© January 2, 2008 by Imelda Maurer, cdp

Several weeks ago I heard author, Anne Kreamer, interviewed on one of San Francisco’s public radio stations. She had recently published a book titled, “Going Gray.” I checked it out of our neighborhood library. It’s sort of a pop culture kind of book. So is a recent book I read by Nora Ephrom, “I Feel Bad about My Neck and Other Thoughts about Being a Woman". Both books are easy-read reflections of issues aging women face in our American culture.

Anne details her experiences as a fifty-one year old woman who decides to no longer color her hair. She is going to ‘go gray.’ The author examines culturally accepted reasons for coloring one’s hair, stereotypical values and motivations affecting both men and women to color their hair, along with a simultaneous and often unarticulated search for authenticity.

Nora has a whole chapter on “maintenance” with details of time and costs, written in her typical observant and humorous style.

Anne cites two writers near the end of her book which go beyond the pop-culture and which I wish to share: Betty Friedan in her 1993 book, “The Fountain of Age” wrote that “an accurate realistic, active identification with one’s own aging – as opposed both to resignation to the stereotype of being ‘old’ and denial of age changes – seems an important key to vital aging, and even longevity.”

Anne’s comment on Friedan is this: “An active, realistic acceptance of age-related changes” – as opposed to denial of passive resignation – was thus the key to a continued vital involvement in life, a very different face of age than disengagement and decline. . . . Mindless conformity to the standards of youth can prohibit further development and that denial can become mindless conformity to the victim-decline model of age. It takes a conscious breaking out of youthful definitions, for a man or woman to free oneself for continued development in age.”

Women, our graying hair and our changing bodies are subjects of complex, convoluted issues in our society. Some of these unexamined values are hawked even by vendors who define themselves as religious or spiritual. Material presented in a widely advertised national program which grants certification in “Spiritual Gerontology”, for example, has a self-administered survey, “Ageless in the Lord,” which measures “how you are progressing in the 12 keys to agelessness.” (Clearly the implication is that aging is a negative, and that if we are really progressing we will be 'ageless.' Please, please, don't deny me my aging!)

On the other hand, Andrew Weil in” Healthy Aging” takes the better part of the first chapter of that book to conclude that “. . . aging is written into the laws of the universe,” and that “acceptance of it must be a prerequisite for doing it in a graceful way.”

Yes, aging is going to happen (unless we die young). Accept it? Just accept it? I think not. Cherish it. Honor it. It is where Providence has brought us.

In the final pages of her book Anne Kreamer draws that same conclusion as the worthy reason to go gray. By doing so, she says, she is ‘facing it (aging) squarely, accepting it incrementally. I think that each year as my hair becomes whiter, I will be a little more ready to celebrate the good things about my ‘here and now.’. . I’m proud of what I’ve done, the years I’ve lived, how far I’ve come. I’m happier going through each day – on the sidewalk, in stores and restaurants, at parties – being as honest as I can be about who I really am.”

What are your thoughts about your neck and about going gray?

When I began writing, my intent was to raise some thoughts about accepting and cherishing our aging. Now that I have finished writing, I realize that really, the focal issue is that of the ageist society in which we live.

So my final questions are, do you think ageism is the issue? Have we just accepted these societal norms and practised one of the worst 'isms' in our society? How does one consciously articulate and then fight this aspect of ageism?