When Are Antipsychotic Medications Necessary?

The issue addressed in this article from the journal, Caring for theAges, carries important information in two areas of interest to anyone serving elders in a retirement setting: 1) the appropriate place of antipsychotic medications for elders who have no diagnosis of a mental disorder and 2) the role of  the family member, the medical power or attorney or the "decision maker" if the resident is not capable of making her own decisions. I will refer to these individuals by one common term, "advocate."

The issue of excessive, inappropriate prescribing of antipsychotic drugs -- in violation of state and federal regulations -- for persons living with dementia in nursing homes has been mainstream news for more than two years now. Luxenberg states clearly and simply what the State and Federal guidelines are in this regard.

The author goes on to state the standard of care when he names all those engaged with the resident in assuring appropriate planning and implementation of treatment for elders iu a nursing home. He says: the "prescriber", the facility (sic) and the family work together and communicate with one another in setting care goals. Gone are the days when "the doctor ordered" suffices to stifle all questions. Gone are the days when family members are viewed as intruders rather than the strongest allies in achieving the best outcomes for the resident physically, mentally and psychosocially.

Acknowledging the role of these advocates, Luxenberg poses four questions that the resident, or the person acting on her behalf should ask the physician when medications are prescribed.  Note: this article applies to antipsychotic medications, but the same questions should be asked and answered to the satisfaction of the resident or advocate for any medication or plan of treatment. If these conditions are not satisfied, "informed consent" for treatment has not been provided. No one of us, resident of a nursing home or not, should ever submit to treatment (medication, diet, surgery, therapy, psychological counseling) without giving our informed consent. Answers to the four questions posed will provide sufficient information to provide informed consent.

For advocates ( including medical power of attorney)  of nursing home residents who cannot speak for themselves, the responsibility the advocates bear in this role is to seek adequate information about any proposed plan of care so that he or she, the advocate, can give informed consent for the suggested course, or can deny that treatment according to the wishes of the resident as put forward in his or her advance directives.

Here is the article in its entirety

When Are Antipsychotic Medications Necessary?

In this first of a two-part series on dementia-related behaviors, Dr. Jay Luxenberg, chief medical officer at On Lok Lifeways in San Francisco, talks about antipsychotic medications (Caring for the Ages. August, 2012.  Vol. 13, No. 8.  Page 18)

Antipsychotic medications are Food and Drug Administration (FDA) approved and used mostly for psychotic illnesses such as schizophrenia and bipo¬lar disorder. While none of these drugs has been formally approved by the FDA to treat dementia-related behaviors, they sometimes can be helpful for this purpose. By talking with your physician, you can learn more about when these drugs can help and when other treatments are better choices.

Antipsychotic medications are Food and Drug Administration (FDA) approved and used mostly for psychotic illnesses such as schizophrenia and bipolar disorder. While none of these drugs has been formally approved by the FDA to treat dementia-related behaviors, they sometimes can be helpful for this purpose. By talking with your physician, you can learn more about when these drugs can help and when other treatments are better choices.

Federal nursing home regulations state that antipsychotics should be used for dementia patients only when the behaviors pose a risk to self or others or symptoms are bad enough to cause great and prolonged distress for the person or seriously hurt his or her ability to function. The regulations also say that these drugs can’t be used for behaviors that don’t put the person or others in danger or at risk of physical injury. These include wandering, crying out or yelling, poor self-care, memory problems, mild anxiety, insomnia, and nervousness.

In general, antipsychotics should only be used after trying other means of managing the problem behavior, only in the lowest dose needed, and only for the shortest possible time. The physician will work with the resident and his or her family, as well as facility caregivers and staff, to figure out what is causing the problem behavior and what nondrug treatments might help. When it is decided that an antipsychotic may be needed, risks, benefits, and treatment options should be discussed with the resident and his or her family to be sure they understand them (except in some emergency situations).

The prescriber and facility staff also will work with the resident and family to set care goals. For example, if the drugs are used to help a man who is delusional and is terrified of people he sees under his bed, the care goal might be to get his delusions under control so that he can relax, sleep well, and have a better quality of life. Facility staff will work with the physician to track the person’s progress and to watch for possible adverse drug reactions or other drug-related problems.

4 Questions to Ask Your Physician:
• What are the pros and cons of this medication in this situation?
• What if I don’t want antipsychotic drugs to be used? What are some drug and nondrug options?
• How long will this medication be used?
• How do we decide treatment/care goals?

4 What You Can Do:
• Make sure the physician and facility staff know as much as possible about your or your family member’s personality, background, likes and dislikes, favorite things, fears and phobias, hobbies, habits, and so on.
• Let the physician know if you or your family member has a history of mental illness.

For More Information:
• Antipsychotics in the Elderly: www.amda. com/consumers/antipsychotics.cfm

What's Wrong with this Picture?

One of my e-subscriptions is to a quarterly newsletter published by the Missouri Department of Health and Human Services. In their current issue, there is an article with the title, “Missouri Nursing Homes Have Happy Clients, MU Researchers Say”. I have been unable to successfully access the URL listed for the entire article, so I can’t critique the research as such. But so many red flags waved brazenly as I read the article. But my first response when I read the title of the article was WHAT?!!
The whole system of traditional long-term care is sick, dysfunctional and “lethal to both resident and staff” (quote is from Steve Shields, culture change leader). Those deficits are reflected in the newsletter article.

1. Who of us wants to be seen or to be considered a “client” if we are living in a nursing home? Do any of us consider those with whom we live “clients”?
2. The survey may well have been valid and reliable for what it tested, but consider these facts:

a. Residents and family members are usually extremely uninformed about the minimum standards of care in a nursing home. So if the resident sits at the table for 45 minutes before a meal is served, does she or the family even know to complain? If the resident is awakened each morning and prepared for bed each evening at the convenience of the staff, rather than at the time she chooses, does she know her rights are being violated? I could go on and on.

b. For the most part, family members can sense the good will among caregivers. Perhaps that is why they and the resident think life can’t be any better in a nursing home. That’s where hopelessness seeps in.

c. I can’t think of a single family member who would say, “I intentionally put my mom in a third-rate nursing home.” Rather, we so often hear, “Mom’s nursing home is the best one in town.”

d. Jude Rabig, Ph.D. did a fascinating study that I regret has not received more recognition. Rabig interviewed residents of a “good”, traditional nursing home about their perception of their quality of life. The residents rated the nursing home highly. This nursing home undertook new construction, providing the same number of beds but with the architectural environment of households. (Household model, public space and private space – person-directed – transformative culture change – global workers – etc.). Six months after these same residents had moved into the household nursing home, Rabig interviewed them again about their quality of life. It is not surprising that they rated their quality of life as very high. It is quite revealing, however, that from their new home (not homelike, folks, HOME!) they looked back on their life in the “good” traditional nursing home as a very negative experience. “Incarceration” was one term used to describe life in a “good” nursing home before culture change.

So for 90% of Missourians to say that things are good, may well reflect that there is no concept that life can be better in a nursing home. (Oh, how I’d love to talk to the 10% dissident population! Perhaps they are the dreamers who won’t accept the overhead call system, the restraint alarms going off constantly, the deadened “activity” schedule, the uncertainty of never knowing who your caregiver will be today.)

3. Roughly 95 – 97% of the nursing homes in the United States are still run by a schedule that reflects task-first, person-wherever-she-fits-in philosophy. This reality, as horrendous as it is, does not exist because caregivers are selfish or unfeeling. It exists because this is the “system” in which they were trained. It is this lethal system that is responsible for the extremely high turnover in nursing homes, especially among direct-care staff.

One of the researchers is quoted in the article: “Nursing home administrators have worked diligently throughout the past decade to improve the quality of care delivered to residents and to make care settings more homelike.” Undoubtedly, that is true. But two points:

1. As long as the work is to improve a system that is dysfunctional and lethal to all who are touched by it, the energy is misplaced. The system must be turned on its head! Everything must be seen through eyes focused on person-directed values. Every practice and policy must be evaluated in light of the analysis of, ‘how do we do this at home?’

2. The touchstone of life in a nursing home is NOT the care. I wish I could remember the source of this statement that I read during the past week: “How is it that even when the care is superb, nobody wants to go to a nursing home?” Of course clinical standards must be met. But it must be provided through the prism of person-first, not task-first.

The touchstone of life in a nursing home is honoring the individual, being there in service. There’s a world of difference between “caring for” and being “in service”. How do most of us respond if someone says, “I’m going to take care of you.” We don’t want to be taken care of. If we need services, we want those services provided in a dependable, compassionate and competent manner. But “taking care of” reflects a lot of things that are the topic of another post on this blog.

To read the entire article, visit: http://munews.missouri.edu/expert-comment

UNTIE THE ELDERLY AND DISENGAGE THAT ALARM

In the mid 1980s, a movement began mandating that caregivers “UNTIE THE ELDERLY”. The movement grew, and with the passage of the 1987 Nursing Home Reform Act, the use of physical restraints decreased. Before this movement, it was not uncommon to see any number of nursing home residents restrained in their wheelchairs during the day and in their beds at night.

I remember seeing my first grade teacher as a nursing home resident tied to her bed and also having her bed rails up. That’s called “double restraints.”

A woman obviously happy about being restrained. Picture provided by manufacturer

My own mother was restrained in a nursing home. I remember being shocked when I first saw her in that vest covering the entire front of her upper body. The vest ended in narrow strips of cloth that were tied in the back of her wheelchair. My mother’s response to my question of “why” was a resigned, hopeless shake of her head. The nurse told me it was “doctor’s orders” for her own safety. In those days I did not know better so I didn’t question “the doctor” or the nurse. I know better now and as Maya Angelou says: “We did the best we could. When we knew better, we did better.”

My mother's vest was the style shown in the figure below -- an older style -- than shown here.

Later in rural West Virginia, Ruby, a middle-aged adult child called me in the ombudsman’s office in a sense of panic. Her mother in a local nursing home had called her earlier that morning saying, “Ruby, they’ve got me tied like a dog.”

Some long-known facts about restraints:

Every system in the body is negatively affected through the imposed, prolonged immobility.

The psychological effects of being restrained are obvious to any observer who would put him/herself in the restrained person’s place.

Studies have shown that caregivers relate less frequently to residents who are restrained than to residents not restrained. Restraints, then, mean further isolation

And here’s the kicker: RESTRAINTS DON'TLESSEN INJURIES OR FALLS.

From a recent study: “Despite unambiguous legal regulation and evidence of a lack of effectiveness and safety, physical restraints remain frequently administered in nursing homes, with a recent survey reporting physical restraint rates of more than 20% for U.S. nursing homes, according to background information in the study, which appears in the May 23/30 issue of the Journal of the American Medical Association

One doesn’t see Posey Vests much anymore, though belts and “lap buddies” and things of that nature are too prevalent. The popular restraint used today is the position alarm. They don’t reduce injuries or falls; they don’t keep residents more safe; they have all the negative side effects of any physical restraint -- and then some.

The call today is not to untie our elderly, but to DISENGAGE THAT ALARM!! Tied up, hooked up, the end results are the same.

Transformative Culture Change proves once again that it facilitates happier, healthier outcomes

Fortunately, research continues, fortunately, around Alzheimer’s Disease: cause, cure, and preventative measures. The Chicago Tribune published an article in today’s paper entitled, ““Having Purpose In Life Helps Fight Alzheimer's, Study Finds”

In a nutshell, the research done by the prestigious Rush University Medical Center concludes that persons who have a purpose in life are better protected from health problems, including Alzheimer’s. Persons living with dementia who have purpose in life also maintain a higher cognitive function over time than others living with dementia.
The article includes the researchers’ definition of purpose in life: “the tendency to be intentional, to engage in behaviors that one wants to engage in and thinks are important”

Those behaviors or activities will vary greatly from individual to individual. One may find setting the table an aesthetic, pragmatic and enjoyable task. Another may look forward to feeding and petting the community cat, feeding the fish, walking the dog, caring for favorite potted plants, finishing a special cross stitch, peeling the potatoes for dinner, deciding what the menu for dinner will be, engaging in an evening game of dominos, watching major league baseball on TV,or listening to classical music. It may be in letter writing, or social calls to one’s neighbor, whether that is across the street or across the hall. For all, it is the ability to make choices and to act upon those choices.

The implications for life in retirement and for life in retirement settings is boldly clear. When individuals maintain control over as many choices as possible in their daily life, their life is made better and their brain health is strengthened. When individuals living in an institution continue to engage in their habitual routines, their chosen interests, their accustomed relationships, their life is made better and their brain health is strengthened.

These values stated above are at the core of transformative culture change. As consumers, or consumers-to-be, we should be demanding that this person-directed living be a given mode of operation in any long-term care setting we visit.

For those providing aging services, there is a moral obligation to provide the environment, programs and services that will provide the best practicable results. The amazingly good news is that this approach enhances the bottom line! All this also creates a workplace environment that is humane and healthy with a resulting decrease in employee turnover.

The brief article referenced in this post may be accessed at:

http://www.chicagotribune.com/health/ct-x-alzheimers-purpose-in-life-20120523,0,6856063.story

“Henry is restored to himself!”

NPR had an amazing segment on All Things Considered yesterday, April 18th. The online version includes a six minute video demonstrating the power of music for people living with Alzheimer’s disease. I recommend listening to the segment and watching the video. In the video, a nursing home resident is “awakened”’ by music. An observer made the comment that because of music, “Henry is restored to himself.”

Henry, who is featured in this short video, is seen sitting “inert”, restrained, in a wheelchair. He lives in an “Alzheimer’s Unit” of a nursing home. Henry is depressed and non-responsive. Henry’s non-responsiveness reflects a moving into one’s own world, seeking relief from the barren, impersonal institutional environment that one lives in.
As you watch the video, note the environment Henry has lived in for ten years. You see people in wheelchairs lined up along the side of a hallway. Two women placed, one in front of the other, in total solitude in a depersonalized institutional environment. You see lines of people sitting in wheelchairs in a section of a large room, totally unengaged and uninvolved. You will see what is referred to as a “slumper”. This is an all-too-familiar sight in institutional nursing homes: an elder literally slumped in his/her wheelchair, many times with his/her head bent at a 90 degree angle.

Is it any wonder that people “check out” and become slumpers in such barren, impersonal environments? Is it any wonder that absenteeism and staff turnover in such institutions is incredibly high? To quote Steve Shields, these institutional environments are “lethal” to the spirit of residents and of staff. One’s living environment can easily and does lead to depression and withdrawal. There are multiple consequences for such individuals physically, socially and psychologically.

The Picker Institute has, commendably, funded the “Music and Memory” project which will undoubtedly enhance the quality of life for countless nursing home residents. Fortunately, Henry is one of them. If Dan Cohen, Project Director, had not come into Henry’s nursing home, would that institution has ever known that Henry loved music? Luckily, the staff did gain this important information – after Henry had been their resident for ten years!

The good news for nursing home residents today is the requirement for licensed nursing homes to complete a recently revised comprehensive assessment for each resident. That assessment is referred to as MDS 3.0 (Minimum Data Set [of information] version 3.0). This instrument is an excellent tool for getting to really know the resident. All care and services in the nursing home should then flow from that assessment. If Henry were just moving into the nursing home now, under the requirements of MDS 3.0, his daughter and other family members would be interviewed in order to learn much about Henry’s likes, habits, hobbies, preferences, strengths, abilities, needs, etc. Chelly could have told the nursing home staff what she says in the video: Dad “was fun-loving, every occasion he would come out with a song . . . .He was always into music” How sad that Henry had to wait ten years before this vital part of his life and personality was known to the staff and acknowledged by appropriate services.

What about persons who live in unlicensed nursing homes? Many sisters, brothers and priests live in their own convent or seminary headquarters and receive nursing home care there, legally, and without the requirement to be licensed.

There is no obligation – from a legal standpoint – for such centers to utilize the MDS 3.0. However, the staff leadership in these unlicensed communities should look into the advantages of completing an MDS on every brother, sister or priest in their care. There is no better tool available to assure that the staff knows – really knows – the resident.

For those of us who are not (yet) living in a nursing home, it behooves us to look to those we love who are, to those sisters or brothers whom we have known and with whom we have shared community and ministry for decades. It behooves us to advocate for them by making sure the staff does know each individual resident – as an individual – so that care and services appropriately build on that person’s habits, abilities, hobbies, strengths, preferences, habits and needs.

Staff persons who want to do the best they can for each resident will welcome this added information. Staff, in completing the MDS 3.0, will actively seek information from family members and friends, seeing these individuals as strong allies in their service to their residents..

Keeping our elder safe --- at what cost?

We really want to “take care of” those elders in our life who are important to us. Those elders may well be our parents, or may be elder members of our religious congregation. The response of “wanting to take care of” comes from a sincere “caring about” the elder(s) in our life.

Too often this well-intentioned mindset is tainted with the ageism that is so embedded in our society that we are totally unconscious of it; we don’t recognize it. Two examples of this come to mind immediately. In one case, a widow in her early 80s lives in a rural area but drives the short distance into the small adjacent town as needed and desired. Recently her vehicle of many years became unusable. Her only child chooses not to help his mother shop for another vehicle because he worries about her driving. Now this woman has had no accidents, no fender-benders or traffic violations. She uses good judgment about when and where to drive. However, her adult child worries about her mother. “Something might happen.”

A second example is of an elder Sister who wanted to make arrangements to spend Easter with her family who lived some 70 miles from her motherhouse. The Sister appointed to act as “superior”/family member” suggested to the Sister that she not make this trip. “Sister, you know you fall sometimes. I’m afraid if you make that visit you may fall while you are there.” The Sister, of course, didn’t visit her family.

Dr. Judah Ronch tells us that such actions result in “surplus safety.” In the name of caring for an elder because we care about them, we prohibit them from taking risks that are inherent in life. When all risks are negated, there is no quality of life. Every day every one of us take risks – a flight from one part of the country to another – driving a car – and on and on. We take risks because we judge the benefdits to outweigh the risks.

When elders are prohibited from taking similar risks because we want to keep them safe, usually ageism, exhibited as paternalism is involved. A valid question to ask when one is tempted to prohibit an elder’s action in order to keep him/her safe is this: “Would I be inclined to make this same decision for a person who is thirty years younger?” If the answer is no, examine whether a paternalistic/maternalistic (read patronizing) mindset is what drives our decision.

For more information,Google “surplus safety” and “Judah Ronch”

Alzheimers -- Living in the Moment

Often when aging and aging services are discussed, the focus becomes, intentionally or not, pathological aging, such as is experienced by any elder who is living with dementia. It is true that as one’s age advances the risk of dementia increases – until we’re 95 according to Dr. Snowden of the Nun’s Study, and then the risk for dementia decreases to almost ‘it’s not going to happen.’ However, aging and living with dementia are not interchangeable terms.
There is a very thought-provoking article in today’s New York Times entitled, “Finding Joy in Alzheimer’s.” The author believes that we should “reassess our thinking about the elderly and old age dementia” – that an important change in perspective is called for in how we view the changes that are going on in the affected elder.

The comments that follow the column enhance the already informed and perspective-rich article. I offer the link here for your convenience.

http://well.blogs.nytimes.com/2012/02/16/finding-joy-in-alzheimers/?ref=health

Death doula: A midwife for the end of life

This brief article from today’s L.A. Times describes an advocate’s perspective on companioning another during his/her dying. This one sentence reflects the nobility and sacredness of the task Ana takes on as a death doula: “If I'm assisting in a death passing, what I'm really doing is assisting the soul to birth its new life. And that's such an honorable, necessary thing." Ana Blechschmidt

The entire article can be accessed at this link: http://www.latimes.com/news/nationworld/nation/la-na-death-doula-20111227,0,1874185.story

But my bathroom has always been steps away from the foot of my bed!"

A week ago I moved to a new (for me) home in a new city in a new State along with fellow community member, Sister Bernie Galvin. Three days after arriving, I commented to Sister Bernie on how puzzled I was that in going from the kitchen to the basement, I automatically headed for the door which is a closet, instead of the door on the other side of the room which leads to the basement. I visualized the previous house I had lived in and realized the path I instinctively took WOULD have led me to the basement in the "old"house. When I shared that revelation with Bernie, she told me that she had a similar experience. In leaving her bedroom to go to the bathroom in this new location, she instinctively attempted a left turn into the hallway which was the “route” in the previous house.

Patterns and routines run deep. We both have adjusted pretty well to learning new patterns, but this reality of following learned routines rather spontaneously caused me to think of consequences for elders when they are hospitalized, or when they first move to a nursing home.

That same pattern of following a familiar “path” to the bathroom, the first few nights that an elder is in the hospital or is new to a nursing home often results in falls. These falls can have serious and sometimes fatal consequences.

Hospitals are taking more notice of falls because Medicare no longer reimburses the cost of care due to an in-hospital fall-related injury. The “solution” to preventing falls, whether in hospitals or nursing homes is NOT the use of physical restraints or those ever-increasingly-used but proven-to-be ineffective chair alarms. Evidence of this is not only common sense, but ongoing research.

Lack of mobility adversely affects every ---- every --- system in the body. When one doesn’t move, one loses muscle strength and balance – just for starters.

An article in “Medical News Today” describes an in-hospital study which concludes that falls are not related to activity (number of steps taken). An analysis of in-hospital falls during this study found that all of the falls took place at night, and that 60% of these falls were related to visits to the bathroom.

Patterns and routines run deep.

To read this short article, click on the link below.


http://www.medicalnewstoday.com/releases/236797.php

Real Food VS. Oral Nutritional Supplements

Michael Pollan is a journalist who, in doing some investigative journalism work about our food supply and the way we Americans eat, has written some very good books. In fact, Pollan is recognized as a foremost authority in the conversation about real food and what he calls “food-like” food. The latter he defines as processed and pre-prepared foods.

I wish Michael had been with me at a conference session (Aging in America) that I attended last week. Two national organizations focusing on aging cosponsored their national conference here in San Francisco so I took advantage of what I had judged to be worthwhile sessions. This one was entitled something about the role of malnutrition in older adults in loss of independence.

Without going into their entire presentation, I present this brief summary: A fine doctor (internist, geriatrician, certified medical director at two teaching nursing homes, and researcher) presented data showing how older adults are at risk for malnutrition and all the ills that can result from malnutrition.

Then two registered dietitians (RD) took over the rest of the session. In the interests of full disclosure, they both stated that they were consultants for Nestle Nutrition Institute. (Oooohhhhh!) I hate it when I get caught in a corporate “paid programming” session especially when it happens at a conference that advertises itself as a professional conference.

Now the first purpose of any corporation that intends to stay in existence is to make money. Good capitalistic principle. Not an evil concept when the reach for profit is kept in its place.

So these RDs showed us many charts with all the good results reflecting the benefits for a person who is malnourished or is at risk for being malnourished when s/he is provided oral nutritional supplements (ONS). I don’t question their results.

This is what I questioned at the session: Are there studies that reflect that when real food is provided to elders (Meals on Wheels, Senior Centers, PACE Centers, retirement settings and nursing homes) that the need for ONSs decreases? Are there studies that indicate that when residents of nursing homes are allowed to come to the dining room (or kitchen in a household nursing home) for meals when they are ready to eat, that the need for ONSs decreases? Believe it or not, not even the doctor was aware of any such studies.

I also had to explain what I meant by “real food.” When food is prepared for any of the congregate settings mentioned above, the typical approach is to buy foods from an institutional food service. The food is already seasoned (high in sodium) and cooked. All that is required of the staff is to open and heat. Even the cakes and other desserts are all pre-cooked and just have to be thawed and served. By and large that is what elders who do not live at home, or who live at home and can no longer prepare their meals, are subject too.

In fact the studies I asked about have been done. And in every study, the need for ONSs decreased; there was less wasted food within the institution and the outcome was an increase of weight for the elders who were malnourished or at risk for being malnourished.

There’s also the whole world of smells when food is “cooked from scratch.” Don’t we all know that experience of the simultaneous sense of aroma from the kitchen and a sense of, “I want to eat!” Let’s not deprive our elders of that experience – the pleasure of eating “real food” and all the healthy benefits it provides.

Michael Pollan summarizes a healthy diet in his book: “In Defense of Food” this way: Eat real food, not too much, mostly plants." I say let’s provide that for our elders!

P.S. I know there are situations in which only ONSs will provide the needed results. But those ONSs should be tried only after there is no response to “real food” provided in an environment of HOME.

Quality of life, Falls and Vitamin D

When researchers examine the quality of life that residents of nursing homes experience, one of the questions in determining a good or poor quality of life is, “How often do you get outdoors?” We certainly don’t need esoteric research to convince us that getting outdoors is a good thing. Our experience tells us that. Perhaps it is that first walk in the morning around the yard to see what has appeared since yesterday. Or it may be that cherished walk in the early morning or late afternoon that is a ritual for us, after which we feel a new energy in our steps. What can compare with the brush of a soft spring breeze on our cheek? What delight do we not experience at the sight and sound of a bird winging its way with obvious delight, also, in the new day?

If a person is not living independently at home, that access to the outdoors may be totally dependent on her caregivers. How many retirement settings have priorities and stated programmatic policies about assuring that residents in their retirement community get outdoors when the weather permits? Are activities ever planned that involve an outdoor experience? Are spaces intentionally developed that invite elders outdoors?

Now apart from the gift to the soul that being outdoors provides, there is also an aspect of physical health. We all know that exposure to sunlight produces Vitamin D in our bodies. Amazing, isn’t it! Twenty minutes outdoors when the UV index is 3 or greater will do it!

Here’s what a noted doctor says about Vitamin D and older adults:

According to Elizabeth Sykes, MD, vice chief of clinical pathology at Beaumont Hospital in Royal Oak, Mich., older adults with vitamin D deficiency also have an increased risk of muscle weakness and bone diseases such as osteomalacia (softening of the bones) or osteoporosis (reduced bone density) as well as an increased risk of rheumatoid arthritis and type 1 diabetes (http://www.agingwellmag.com/news/ex_012511_02.shtml accessed April 20, 2011)

Falls among elders are serious matters. One in three persons over the age of 65 experiences a fall over the course of a year. These falls can lead to hospitalization, admission to a long-term care setting, or even death.

Studies of elders show a relationship between falls and Vitamin D levels in the body. Vitamin D is needed by the body to improve muscle strength and contraction.

Medical professionals encourage Vitamin D supplements among elders if needed when exposure to sunlight is not sufficient, or if their diet does not provide this vitamin adequately. So in those climates and at those times of the year when our friends and/or family members living in retirement settings can get outdoors, let’s get them outdoors! When sunlight exposure is not practical because of the weather, a healthy diet and, if needed, the Vitamin D supplements should be used.

Oh, and one other thing: an analysis at Rush University Medical Center of several studies among older adults with Alzheimer’s showed a relationship between the presence of this dreaded disorder and “a constricted life space.” That constricted life space was defined in the study as: “Specifically, those with a life space restricted to their immediate home environment.” Older adults in a “constricted life space” were twice as likely to develop Alzheimer’s as elders whose life space extended beyond this immediate home environment.

Anybody for a walk – for its gift to the body, mind and spirit?

Avoiding Falls in Our Later Years

© September 16, 2010 by Imelda Maurer, cdp

Corporations bag billions in profits each year with “anti-aging” solutions – creams, oils, supplements, surgery , books – successfully playing to American’s fear and denial of aging.

While we cannot avoid aging, and while there are no true “anti aging “ solutions, an article in the New York Times describes how the skill of balance CAN BE ENHANCED with appropriate exercise! Why is this so important?

“Unintentional falls among those 65 and older are responsible for more than 18,000 deaths and nearly 450,000 hospitalizations annually in the United States, according to the Centers for Disease Control and Prevention in Atlanta. Most of these falls are caused by a decline in that complex and multidimensional human skill known as balance.

To remain upright and sure-footed, explained Dr. David Thurman, a neurologist with the center and a spokesman for the American Academy of Neurology, “there are several components of the nervous system, as well as motor or movement functions that need to be intact.” These include the vestibular system of the inner ear, vision and proprioception, the ability to sense where one’s arms, legs or other parts of the body are without looking at them, as well as the strength and flexibility of bones and soft tissue.

“All of these,” Dr. Thurman said, “tend to degrade with age, particularly as people move into their seventh and eighth decades.”

Yet, unlike many effects of aging, balance can be improved, and the age-related declines can be delayed or minimized with proper training.

“The preponderance of evidence,” Dr. Thurman said, “shows fairly convincingly that strength and balance training can reduce the rate of falls by up to about 50 percent.”
To read about the types of exercise that can enhance the skill of balance without hiring a personal trainer, go to the NY Times article by clicking on the title of the blog entry.

Making it OK to Sleep Late

© September 14, 2010 by Imelda Maurer, cdp

My sister and her husband have, for the last few years, enjoyed socializing at a neighborhood senior center. Their custom is to go once or twice a week. Not long ago during a telephone visit, I asked my sister if they enjoyed lunch at the center. “No,” she said, “they serve lunch at 11:30. We are late sleepers and when we get up and take our time in the mornings, we don’t usually make it in time for lunch.”

Nothing unusual in that remark. After many years of hard work, this retired couple can now manage their daily schedule according to their own likes. They share long evenings, get to bed late and like to sleep late in the morning. Fair enough. They deserve it!

In too many nursing homes, for those adults who have to live in one, there is a schedule: breakfast served at particular time as is lunch and dinner. That means that staff members are required to have the residents up and dressed in order to be “on time” for the institutionally scheduled breakfast time.

Lots of problems with this kind of living for years on end. It’s institutional. It’s NOT home. For elders with even minimal cognitive impairment, being awakened and helped with dressing and grooming before they are ready to do so may result in notes in that elder’s chart claiming there was “combative behavior” or that the resident “was uncooperative with a.m. care.” That’s a topic for another entry.

However, the good news in all this is that THE TIMES THEY ARE A CHANGIN’! Progressive nursing homes are “making it ok to sleep late.” An article in The Chicago Tribune highlights a nursing home which is making the move from institution to home.

Note the advantages that are evident: quality of life for the residents; enhanced employee satisfaction; lower costs for the provider.

“Nursing homes that embrace the new philosophy are letting residents decide when to bathe, eat and sleep; allowing them to organize their own activities; and redesigning nursing units into small "households."

Advocates say residents in such homes are happier and healthier; the employees have more job satisfaction; and giving care this way even costs less.”

The administrator is quoted as saying that she doesn’t even like to speak of “allowing” residents to sleep late. "It's not for us to give them that freedom," she said. "They should have it."

There is an important corollary to this story: consumers -- that’s US, the nursing home residents of the future -- must demand this kind of environment and person-centered living. The movement of transformative culture change in nursing homes is a fast-growing ripple. We advocates and consumers must change the ripples into waves!

GO, MAKE WAVES!

Click on the title of this post at the top of this page to be linked to the article from The Chicago Tribune. It is a short, enjoyable and informative piece

I Never Saw Your Wrinkles

Another one of my favorites -- posted some time ago!

Friday, March 2, 2007
I Never Saw Your Wrinkles
© March 2 2007 by Imelda Maurer, cdp

Several years ago I fell in love with gardening. It was a kind of surprising transformation following a farm-life childhood, where the work seemed only drudgery. So averse was I to having to go on Saturday mornings to hoe the weeds out of the long rows in the grape vineyard or from around the young corn plants, or to pick the field peas, that I cultivated the habit of praying for rain every weekend.

When I was in my mid-30s, I found myself living in rural southern Louisiana with an ample yard of beautiful, dark, delta soil beneath the lawn. I decided to attempt a small organic vegetable garden and cultivated a patch that was probably 20 feet by 12 feet. I was astounded at the delight I took in seeing the small seedlings take hold and flourish, at the beauty of the different shades of green against the dark, black soil. I looked forward to the time I would be able to spend in my garden, a time that became richly reflective and meditative, as well as emotionally fulfilling.

As that first spring progressed, the tomato plants grew almost shoulder height, producing tomatoes for me and many of my neighbors. After the growing season, I removed the dead plants and added them to the compost pile where, during the still winter season, they turned into rich dirt. That compost, added to the garden, nourished the next season's young plants. I had an experiential awareness of the universal cycle of life, death and subsequent new life, as I had observed my garden plants mature, provide fruit and later yield to death.

There is a distinct beauty in a young, maturing plant. A pepper plant, for example grows so straight with wondrous, dark, shiny, green leaves. Its stems strengthen and become almost woody, enabling it to support the proliferation of beautiful, glossy, waxy peppers. In doing so, the plant loses its youthful appearance and gains the beauty of maturity.

I began to understand not only that the appearance of the pepper plants in each stage of growth and development held its own beauty, but that there was a certain rightness and appropriateness in the beauty of each stage of that pepper plant's life. The reflective time in the garden provided the recognition of a connection between the stages of life in the plants I loved and nurtured and the stages in my own life. I recognized in a new and profound way that there is a beauty, a rightness, an appropriateness in who we are and how we appear at whatever age.

I've believed for many years that as we age our beauty deepens. The face and eyes of older persons reflect the richness of their life experiences and the wisdom that comes from their life's journey of intermingled pain and joy. It is this inner self, wonderfully manifested in some way in our physical being, that is who we really are. Robert Redford alluded to this perspective in an interview in which he spoke of a personal rejection of having plastic surgery because he believes that in that process, "something of your soul in your face goes away."
We all know at some level that, when we look at someone, or when we call a person's image to mind, that we are seeing the person as he or she really is -- something of the inner self. This was exquisitely voiced by a woman in a news story that ran recently on "Good Morning America.” The story cited growing numbers of adults older than 65 who are choosing plastic surgery. Featured was an 80-year-old woman who had recently had a face lift, tummy tuck and breast augmentation. She was shown sitting around a table with women of her own age group, obviously friends and acquaintances. One in the group asked why she underwent plastic surgery. The subject of the interview answered, touching her smooth, wrinkle-free face: "Look how smooth my face is. Don't you remember how wrinkled it was?" To which her friend replied in a soft-spoken voice, "I never saw your wrinkles."
Posted by Imelda Maurer, cdp at 8:14 AM

I'm Not A Young Woman

© March 26, 2007 by Imelda Maurer, cdp

This is one of my first entries on my blog, which you can tell from the date. However, it's one of my favorites. I want to share it again.

Lowe’s had a large selection of vacuum cleaners, and I needed one. I had just moved to begin a new ministry and was shopping that Saturday afternoon for some basics for the small house I was renting. The salesman was helping another woman when I walked up. I was there only a moment or two before he looked at me and said, “I’ll be with you in a minute, young woman.” To which I responded politely, “I’m not a young woman.” The woman he was helping was probably embarrassed at my apparent lack of social sensitivity to this well-meaning salesman. She turned to me and said, “He’s trying to make you feel good.” “I know,” I said, “but I’ve lived 63 years to look like this, and I don’t want any of those years or experiences disregarded.”

How many of us have not had that experience at least once since we passed 55 or 60 years of age? How did we really feel about such a remark? A good feeling because maybe we really don’t look as old as we really are? Maybe ‘they’ really think I am still young. And am I happy that I am seen as still young?

Our western society is so terribly ageist. The state of youthfulness is worshipped and sought after to the tune of billions of dollars raked in by the cosmetic and anti-aging industry here in the United States alone. On the other hand, birthday cards for anyone 30 or older make degrading joke after degrading joke about one’s age. What a shame.

Dr. Andrew Weil, in his recent book, HEALTHY AGING addresses this concept of our society’s abhorrence of aging. He concludes by saying that no matter how much we spend on hormonal supplements, plastic surgery or anti-aging cosmetics, we cannot stop the aging process, and we should “accept” our aging. No, Dr. Weil, we should not “accept” our aging, we should CHERISH and HONOR our aging. It is a sacred part of our life journey.

For me as a Sister of Divine Providence, it is another wonderful and good aspect of God’s Providential love and care. For me, aging is an adventure. I’ve never been this old before! Who will I be as an old(er) person? How will the experiences of my life, both inner and outer experiences, show themselves in my face, in my body?

Aging can hold much pain for some of us. I don’t deny that. Many older adults suffer complex health problems. But that is not a universal experience. Each of us has some control over how our older years will be lived based on our inherited genes and by the way we live each day now: healthy diet, at least a 30-minute walk, positive attitudes, and informed, regular care of body, mind and spirit.

If we each fought ageism every time we encountered it, whether it is public policy or a well-meaning sales clerk, wouldn’t we individually be a lot more psychologically healthier? Wouldn’t our entire society be a lot healthier?

Can you look at yourself in the mirror and smile with gratitude for the life’s journey that has been yours so far, and that reveals itself in that face you see in the mirror?

"When I Grow Up . . . "

© by Imelda Maurer, cdp July 26, 2010

AARP has an ad that I believe is absolutely wonderful and absolutely on target. The message seeks ultimately to recruit members to their organization. But the line used over and over again by the middle aged actors in the ad is this: "When I grow up . . . " It ends with a voiceover saying, "At AARP we believe you're never done growing." What an attitude toward aging! And it's true! We have the potential for growth and development until we draw our dying breath.

The ad is on the web and you can access it by clicking on the title of this post. It's only 30 seconds long. Enjoy it!

http://homadge.blogspot.com/2010/04/aarp-when-i-grow-up.html

The Real Story of Aging: As Experienced and as Ministry To the Other

The following letter was sent earlier this week to all members of the American Association of Homes and Services for the Aging (AAHSA) by Larry Minnix, our AAHSA President, who is also a Methodist minister. Larry can talk the statistical, bottom line, give a surpass-the-competition kind of talk with a valid and assured competence. Larry also “gets it” about the real mission of serving our elders, and always communicates that mission in messages such as these to the membership.
In this letter, Larry writes about a woman who, incidentally, lived and died at a Continuing Care Retirement Center here in San Francisco: The Sequoias, a Presbyterian-sponsored ministry.

The letter is worthy of broad distribution for these reasons:
Larry dismisses the myths of aging often portrayed in the public media; he also rejects the botox-using, aging-denying efforts all too prevalent in our American society.

He shows how Jean Wright and those of her ilk, lived her life to the fullest. She embraced her aging as part of the “fulfilling process of the life cycle.”
Larry observed that Jean “lived fully until she died. She trusted in the grace of it all. She reminded us that our mission together is about the people we serve.”
I share this letter with the hope that it will stir reflections among each of us about honoring our own aging and those among us, that it will draw us to a deeper consciousness of the sacredness of this “Third Act” -- our own and those we love -- and the profound implications therein.

Jean Wright: The Real Story of Aging
By Larry Minnix
May is dedicated to older Americans. Maybe it's because I'm becoming one. Maybe it's because a great one, Jean Wright of The Sequoias, recently passed. But lately I have been giving a lot of thought to the real story of aging in our society.

Older Americans Month is a great opportunity to reflect on aging and role models of successful aging. Throughout May (Yes, I'm starting early), I plan to present role models I have known.

The media often portrays aging as either comedic characters who can get away with edgy comments because of age or, more recently, the once beautiful or handsome movie star who has been retreaded with botox and cosmetic surgical work to become the “70 year old who’s the new 40” kind of image.

Don’t get me wrong, I like edgy "senior" comedy. There is an outrageous quality about some of it that I find fun, and I think Raquel Welch was gorgeous at 29 and looks good at 69. No value judgment about either.

It’s just that, well, those role models are not the real story of aging. But Jean Wright is. And I do not believe our society and culture will ever fully embrace aging as a part of the fulfilling process of the life cycle until we understand and appreciate people like Jean.
On Feb. 7, 2010, at the age of 86, Jean died at The Sequoias, a storied AAHSA member, where she lived with her husband for 28 years. Jean’s daughter, Deborah, said Jean was “…surrounded in death by her husband and children.” Reminds me of Abraham and Sarah’s passing in the Old Testament. They died “a good old age.”

Jean was a “powerful lady,” says Ramona Davies, a friend of Jean and a Northern California Presbyterian Homes and Services leader. Jean was elected to the Aging Services of California board, the AAHSA House of Delegates, and was the first resident to serve on AAHSA’s Board of Directors.

Ramona stated it well: In every session Jean attended, she would remind providers and residents alike who we are supposed to be serving. She could make us uncomfortable in doing so, but you always knew that Jean was one of our biggest fans.

I admired her tenacity as her body steadily betrayed her. She rarely missed our AAHSA board meeting, traveling across country to attend. On two occasions, we had to call 911 because she had fallen at a hotel event. She didn’t like the fuss and didn’t miss the meetings.

There were special intangibles about Jean. She exuded integrity, hope, disciplined thought, and principles. She inspired confidence and trust. One time, my wife and I hosted an informal dinner for the AAHSA board at our home. We had a skittish border collie mix named Bear. Bear really only loved his family and barked at other people. Jean came into our home, sat on our couch, and Bear immediately bonded with her. Jean faithfully asked about Bear when we’d correspond.

Deborah, Jean's daughter, referred to Jean’s Sequoias/ASC/AAHSA years as “Act Three” of Jean’s life. What a concept! In the latter days of Act Three, Jean taught us one of the most valuable lessons that can be taught: How to recognize the near end of life and how to accept the inevitability of it.

After steady deterioration of body, Jean asked to be part of “Comfort Care” status. She had “…long been an advocate of compassionate choices related to end-of-life care,” wrote Deborah. Jean “graciously accepts the path she has chosen.”

O, death, where is thy sting?

Deborah asked Jean what message she wanted us to receive from her. Teacher and purveyor of wisdom to the very end, Jean replied, “Tell them that I’ve had a good, good life and that I am grateful for the role each of them has played in that life. No regrets!”
Jean Wright‘s life, dying, and death are the real story of aging in a healthy way. She lived fully until she died. She trusted in the grace of it all.

She reminded us that our mission together is about the people we serve, and that, like the Sequoias obviously knows, you and I are in the “No regrets” business during the “Act Three” of people’s lives.

People like Jean give all of us confidence about the life cycle. We trusted her. We can trust beyond ourselves. Even Bear, my mistrusting dog, sensed it. Jean, we already miss you!

Let’s celebrate people like Jean in May.

Catholic Sisters: Strong, courageous, nurturing compassion

© Imelda Maurer, cdp March 23, 2010

On September 10, 1950 our family was on our way to 7:30 a.m. Sunday Mass. Within blocks of church a woman ran a red light and hit us broadside. My younger sister and oldest sister sustained serious injuries which resulted in a week’s stay in the hospital for each of them. My oldest sister was knocked unconscious and was also bleeding profusely from the neck. My mother feared an artery had been severed and applied pressure at the laceration – not taking time to remove her Sunday gloves.

After the ambulance arrived and the paramedics had provided emergency First Aid, my mother, of course, accompanied my sisters in the ambulance to the hospital. Mother told the ambulance driver to take her to St. Paul’s Hospital. This request came from my mother’s deep love for the Church and her trust that the Sisters in a Catholic hospital would provide the best physical and spiritual care possible. The ambulance driver told her that St. Paul's Emergency Room was not open on Sunday; he was going to the county hospital. My mother’s response to this was to beat on his shoulder – bloodied gloves ---- and tell him: "You take me to St. Paul’s. The Sisters will let me in.”

The driver pulled up to the front entrance of St. Paul’s hospital. This was well before 8:00 on a Sunday morning. My mother dashed to the staired front entrance leading to the administrative offices. She had gone no more than two or three steps when she saw a Daughter of Charity of St. Vincent DePaul rushing toward her down the steps. arms open and embracing her when they met. Sister’s response to my mother’s reporting that she was told the Emergency Room was not open on Sunday was, “Of course we’re here for you.”

No matter how many times I remember that story, it is still a very emotional experience for me: recalling my mother’s unquestioning trust in and love for everything connected with the Church, and the human, immediate, effective compassion that wonderful Daughter of Charity showed my mother. (How many hospital administrators are in their office at 8:00 on a Sunday morning?) The story is true in fact and deeply symbolic of the commitment and compassion Sisters have shown those in need throughout our more than 200 years in this country. Sisters nurtured the orphans, taught poor immigrant children, nursed soldiers from the North and the South during the Civil War. All this was often done without pay and at times under oppressive conditions within the hierarchical Catholic Church Institution. Sisters marched in Selma. Sisters have worked for women’s rights. Today Sisters are found beyond the hospital and classroom, though there too. Sisters are answering unmet needs – in metropolitan areas, in hamlets and in inner cities – needs that would continue to go unmet without the involvement of Sisters.

Most recently Sisters acted with strong, courageous, nurturing compassion, this time publicly and corporately. Prominent women religious leaders concluded after a careful study of the pending health care bill that “the reform law does not allow federal funding of abortion and that it keeps in place important conscience protections for caregivers and institutions alike. We are also pleased that the bill includes $250 million to fund counseling, education, job training and housing for vulnerable women who are pregnant or parenting.” (Sister Carol Keehan, CEO of CHA)

On March 15, Sister Carol Keehan, A Daughter of Charity of St. Vincent de Paul and CEO of the Catholic Health Association issued a statement of support for the pending health care bill. The statement reflected that the bill goes beyond the requirements of the Hyde amendment and said “the time is now for health reform.”

Two days later, Network, (www.networklobby.org) a national Catholic Social Justice Lobby, sent a letter to every member of the House of Representatives saying: “We write to urge you to cast a life-affirming yes vote when the Senate health care bill (H.R. 3590) comes to the floor of the House for a vote.” The letter was signed by Sister Marlene Weisenbeck, FSPA, President of the Leadership Conference of Women Religious. That organization represents 95% of Catholic Sisters in our country. Sister Marlene signed a second time as President of her Congregation, along with more than 50 other Sisters in various capacities of elected leadership within their congregations. I have every certainty that many more congregations would have been represented in that letter had it not been for the necessity of a very close deadline.

In these public actions, I believe, Catholic Sisters were caring in ways we have cared since our beginnings in this country. In the words of Senator Bob Casey of Pennsylvania, “They care for the least, the last and the lost.”

This public, corporate stance for those most marginalized in our society is a source of great pride for me. This is “us” at our best! Strong, nurturing, courageous, passionate! What a gift to be within this circle of women!

"A story is difficult, if not impossible to read in an electronic medical record."

© Imelda Maurer, cdp January 25, 2010

Today's mail included the current issue of the publication, "Caring for the Ages." It is a journal of the American Medical Directors Association. Medical directors are physicians who, in addition to possibly attending some of the residents in a nursing home, are responsible for developing and implementing medical care policies and procedures that are based on current standards of practice. The Medical Director is also responsible, if requested by the nursing home, for supervising the care other physicians in the nursing home provide their residents to see that all medical care policies are implemented.

I was excited to see the debut of a column by Dr. Jerald Winakur and skipped quickly to that page. Dr. Winakur is a practicing geriatrician and a faculty member of the University of Texas Health Sciences Center in San Antonio,TX. About this time last year he published a remarkable, moving memoir, "Memory Lessons", in which he tells his life story through the narrative of his father's stages of dementia and finally death. Each chapter is a well-told story wrapped in his professional and humanitarian understanding of the aging process and his manner of honoring that process in each of his patients and in his dad.

In this column, Dr. Winakur relates his experiences as a practitioner in the context of stories. Each person, he relates, brings a story. The doctor's task is to listen to that story. Winakur has learned to ask a few questions, he says. He believes that the "forged ability to listen" is the 'art' of medicine. "By listening to our patients' stories, good doctors glean most of the information they need not only to treat ailing bodies but also to care for our fellow humans as unique beings. He continues, "It is not necessarily what patients tell me but what they don't tell me -- what I observe from years of being alert to nonverbal cues -- that is often even more important than words."

The intent of his initial column is to highlight the relational aspect of 'doctoring.' He chides those physicians who become "mere technicians" in our procedure-oriented world." Referring to the current health care 'debate,' Winakur pleads that people making public policy set in place policies that will provide reimbursement for both narrative and statistics. Otherwise, he says, "if the oft-tortured thread of a story is absent in the debate of policy makers . . . . our health care system will be sterile, unresponsive, bureaucratic, inflexible and undignified for patient and practitioner alike."

While reading this column, I was again reminded of how fortunate Dr. Winakur's patients are to have him as their primary care provider. I have a few friends in San Antonio who fit that description, and not one of them expresses less than a huge, grateful smile when this relationship is mentioned.

I was also reminded of a recent telephone conversation with my sister who lives in another city. In response to a question about her health, she told me that she and my brother-in-law are just fine. "We've changed doctors." Their previous, doctor, in their estimation, had gotten to the point that "he thought he knew more about us then we did." In other words, this 'other doctor' didn't listen to their stories. He didn't honor their narratives. My response was totally supportive. "You go, girl!"

If your primary care provider isn't listening to your verbal and nonverbal messages, is too rushed to listen or to question, writes a prescription at the first mention of a symptom --- maybe a change should be in store in your future!

Aging, Wisdom, Companioning, Spirituality

© Imelda Maurer, cdp October 8, 2009

Harry Moody publishes an e-newsletter on Human Values in Aging. His latest issue included poetry about aging.

The first poem is entitled “Alzheimer’s Patient.” Reading it we see some of the anguish of Alzheimer’s. We also see the call for those of us who know such individuals to companion them, to know that they are “ill and not insane.”

ALZHEIMER’S PATIENT
Oh, how can this be?

You and I are losing me

Some day soon

May be morning

May be noon

I will no longer be the me

You and I know as me,

And the answer seems to be

Words, and thoughts, frequently scramble

And my conversations seem to ramble.
Oh, how can this be?

You and I are losing me.

What do I see when I look into your eyes?

And neighbors come just to pry?

Confusion, hurt, pity, and pain?

For I am ill and not insane.
Oh, how can this be?

You and I are losing me?

Oh, help me pray,

"Lord, please come to me and take me Home with you for all eternity.

"What can we do to keep from losing me?

"Nothing," say the experts.
Oh, how can this be?

You and I are losing me?

But in my confused and foggy state,

To You I plea,"Love me--Remember me--Help meTo be--

For as long as I can be

The me we know as me."

“The Journey” is a plea from the Alzheimer’s patient for ongoing recognition of his/her dignity and a plea that we identify them in terms of their strengths instead of their losses.

THE JOURNEY
My journey began as a child

I was told what to do"GO TO BED""DRINK YOUR MILK"

I was learning to maneuver my broad wings

Trying to soar over the world below

Dependent for my life

My journey continued through adult life

I as doing as I wanted to do

FLYING

FLYING

I was in control of my wings

Independent. Living my life.

Now my journey begins as an aged woman

I still feel I can do as I wish

But now you tell me what to do

"YOU NEED YOUR REST"

"DRINK YOUR FLUIDS"

My feathers are being plucked, slowly.

One by one

You limit my flight day by day.

Look upon me carefully

See me living

See my wings spread wider than ever before

Do not end my journey

It is not time

"I CAN FLY"

"I CAN FLY"

“Oak Tree" speaks so eloquently of the deep need for companionship, relationships, even among those who can no longer relate as they used to. At some deep, unarticulate-able level, this companioning tells them, with great joy, that they are not alone.

OAK TREE
I stand Alone

A strong Oak Tree

My Sturdy Limbs spread Wide

My leaves are Steadily Falling

A Child comes to Climb

Happiness

I am no longer Alone

What Nursing Home Residents Talk About With Their Therapists

© Imelda Maurer, cdp September 29, 2009
The following is taken from a blog: http://www.mybetternursinghome.blogspot.com/ and was posted on September 10, 2009. The blogger is a psychotherapist.

What struck me about these topics shared with a therapist is that these topics are the stuff of ordinary life. Do nursing home residents need a therapist because they have no one else to talk with? Is there any intent anywhere within the nursing home organizational structure to create community? Carter Catlett Williams, noted advocate and social worker, tells us in her book “The Red Book”: relationships are not only the heart of long-term care, they are the heart of life. And life ought to continue, wherever we live.

Directly from the article:
Have you ever wondered what nursing home residents discuss with their shrinks behind closed doors? Here I solve the mystery, revealing the types of conversations I've had with residents over the years.

-- Feelings about leaving home and being ill.

-- Issues around loss of control and being dependent on other people, with a focus on gaining control     over what they can.

-- Ways to work with the staff to get their needs met.

-- Roommates, and how to cope with them.

-- The reaction of family members to their placement and illness, including ways to help adult            children understand that Mom or Dad can't be there for them in the same way because Mom or Dad    is sick and needs help themselves, and ways to help adult children understand that just because      Mom or Dad is sick, it doesn't mean they can't go off campus every once in a while.

-- Issues around dying, including concerns about the afterlife and worries about how the family will    get along without them.

-- Ways of making the most of the time they have left, including getting more involved in nursing    home activities and the life of the nursing home community.

-- Their lives, choices, accomplishments, and regrets.

-- Stuff that interests them that they don't get to talk about with anyone else, just to be their regular   selves again instead of being a patient.

Personal P.S.
Words reflect our concepts and form our concepts.  In the case of this author, the use of the word "patient" to describe elders living in nursing homes. Defining a person as a patient, defines him/her solely in terms of physical illness or limitation. If physical needs are the only concerns being dealt with in a nursing home, it will be a dreadful experience for the resident and for the staff.

An analysis of the Five Star Nursing Home Rating System

© Imelda Maurer, cdp September 28, 2009

When a nursing home touts its five-star rating, it may mean something positive – or not. A five star rating may indicate that the nursing home really is a place where the residents are provided good holistic care, live in a home environment, experience person-centered care, make choices about significant issues in their day and in their care – when they get up and when they go to bed, when and how they are bathed, etc. -- and where staff are empowered and happy in their work.

That same five star rating may not reflect the reality of perhaps, institutionalization with its depersonalization of residents and staff, high turnover with its implications for continuity of good care, poor staff morale with implications for residents, etc.

The government website itself states the limitations of the rating system. (http://www.medicare.gov/NHCompare/static/tabHelp.asp?activeTab=6) noting that the information is for one point in time (snap shot ), that it is self-reported and that the Quality Measures and Quality Indicators measure only a few of the many aspects of care.

An article in today’s Los Angeles Times states, “Although the Centers for Medicare and Medicaid Services created a website called Nursing Home Compare in 1998 . . . the site's usefulness has been criticized since its inception. “
The entire article can be read at: http://www.latimes.com/features/health/la-he-nursing-homes28-2009sep28,0,5321203.story

Nationally, this article reports, 40% of persons over the age of 65 can expect to spend some time in a nursing home. Our own self-interest pushes us to learn more about these issues and to advocate for those living in nursing homes and --- for ourselves.

Drugs and Dementia Care: Unnecessary, Ineffective and Costly

© Imelda Maurer, cdp September 25, 2009

Isn’t it amazing how often compassion and common sense aren’t validated until there is an official study or series of studies that address the issue involved.

Within the past year or so there has been one news report after another indicating the prevalence of nursing home residents with dementia being prescribed anti-psychotics. This exists in the face of Black Box Warnings by the FDA indicating that elderly residents with dementia are at an increased risk of death when certain anti-psychotics (Seroquel is a big one) are part of the drug regimen.

Recent Research
A study in Australia was reported in the September issue of Caring for the Ages. The residents in that study all had progressive dementia “with persistent behaviors that made it difficult for staff to care for them.” One group of caregivers was provided two-day training in person-centered care with dementia residents. The residents were tested with scientifically valid check lists to indicate their level of agitation at the beginning of the study and then at four and at eight months after the beginning of the study.

Results
After four months, those residents with dementia receiving “usual care” showed an increase of agitation of almost 9 points on the scales that were used. By contrast, those residents who were cared for in the person-centered care model, showed a decrease of 9 points on the same agitation scale.

So there’s the scientific proof --- medical professionals refer to it as “evidence-based” approach to care –

Drugs prescribed for patients with dementia are not always unnecessary. But it is clear that reaching for a prescription pad the moment a symptom is noted is not good medicine even though it is a prevalent practice in too many nursing homes. Dr. Al Power is a geriatrician and certified medical director who practiced at St. John’s Home in Rochester, NY. He has a book that will be published in the early part of 2010 on this very topic of non-pharmacological approach to dementia care. In his own nursing home practice, Dr. Power told me, an average of 6% of his dementia patients at St. John’s were on anti-psychotics. That’s a wonderful contrast to the national average among nursing home residents with dementia of 28%

The call to liberate our elders
When this evidence-based, person-centered approach is used, these elderly residents have been set free from the shackles of unnecessary drugs. Let the work go on!

News from the Front: Culture Change in Action

© Imelda Maurer, cdp August 10, 2009
ilmcdp@yahoo.com

My work day started on a great note and I want to provide you the same delight.

Across the country Coalitions on Culture Change are deepening and broadening the involvement of nursing homes in transformational culture change within their State. The link I’m sharing this morning is from the Louisiana Coalition Newsletter, Leader.

KaraLe Causey, President of LEADER (Louisiana Enhancing Aging with Dignity Through Empowerment and Respect) writes on page 1 about the place and importance of choice in her life and how this translates to elders in long-term care settings. You will find the article stimulating and motivating. KaraLe would be as great a novelist as she is administrator. You'll enjoy the article!

On page 2, a Certified Medical Director writes about meaningful and effective activities with residents with dementia.

Page 3 includes descriptions of how some nursing home communities honor the death and dying experience of a resident and the resident’s family by particular practices and rituals. One ritual noted includes leaving a single rose on the bed for 24 hours following the death of a resident. How touching that is, in contrast to the traditional, institutional model in which the bed and room are stripped as soon as the body is removed.

Full disclosure: I have been gifted to know KaraLe since August, 2005 when I volunteered time in her nursing home following Katrina. KaraLe opened a vacant wing at Haven Nursing Center to receive 44 residents from a nursing home in New Orleans. Many of these residents lived at Haven for three or more months before they were able to return to their nursing home in New Orleans.

Thanks, KaraLe, for the wonderful work you and the Louisiana Coalition are doing! See you soon at the Pioneer Network Conference!

Here’s the link. Enjoy!

http://laculturechangecoalition.org/userfiles/Newsletters/2009%20August.pdf

"I am richer being able to be with them and serve them."

© Imelda Maurer, cdp July 15, 2009
ilmcdp@yahoo.com

Yesterday I wrote to Sister Mary Lou Mitchell, President of the Sisters of St. Joseph, Rochester, NY regarding the July 9th article in The New York Times featuring their Sisters living in their retirement setting. Below is the response I received from Sister Mary Lou, printed here with her permission.

Dear Sr. Imelda,

Thanks for your note and the wonderful piece you did on your blog. This has truly been a humbling experience for me and for the Congregation. Health promotion across the life span and gerontology has been a passion of mine for many years and I am grateful that the community has allowed me to work on improving the quality of care for our elders. They are such wonderful beautiful women and I am richer being able to be with them and serve them in this fashion.

Let us pray that together we can continue to help our culture know that our elderly are a gift to us and not a burden.

In peace,
Mary Lou

Indeed, we are all and always gift to one another. That reality does not become invalid because of chronological age and/or frailty. All of us who are care-ers for others, through a formal workplace position or from the relationship of sisterhood or friendship can validate Sister Mary Lou’s experience of being “richer” because we are “able to be with them and serve them.”

To all those who, by your conscious and intentional actions, honor our aging members by your care and service – blessings to you. You are the joyfully visible sign of God’s Providential love for all of creation.

New York Times July 9 2009

© Imelda Maurer, cdp July 14, 2009
ilmcdp@yahoo.com

On July 9th there was a lead article in the New York Times by Jane Gross entitled, “Sisters Face Death with Dignity and Reverence.” I have attempted a blog entry about this outstanding article twice since I read the article but the writing has always fallen flat.

Immediately after reading the article online, I called the Sisters of St. Joseph of Rochester, New York to express my gratitude to Sister Mary Lou Mitchell, President, who was quoted in the article. In addition to the print article, there is a slide show on the website which shows in the course of its own story Sister Mary Lou in a couple of pictures expressing warmth, affection and compassion to her elderly Sisters. I did not sense that this woman in congregational leadership was ‘panning for the camera.’ I sensed a woman familiar with and comfortable with expressing those human emotions with her own. A gift to her Sisters and to the world.

This morning I sent an e-mail to another Sister and I included the URL to that July 9th article. When I remembered a quotation from the article of one of the Sisters living in the retirement center, tears came to my eyes. I thought then: “This is what I should write about.”

This is the quotation: Sister Marie, a 77-year-old Sister who lives at the retirement center and who visits the community nursing home frequently is quoted as saying, “We won’t let anyone go alone on the last journey.”

These Sisters of St. Joseph companion their Sisters. These Sisters honor death as a part of living, as the doorway to the fullness of life. They live out the words of Bill Moyer: “Death must be witnessed and attended to.”

Integral to this faith-based vision is the reality that this earthly life is a gift, a precious gift. In the context of these faith values, namely, that life is a gift and that this physical life is for a limited time only, the Sisters of St. Joseph have intentionally provided an environment where life could be lived to the fullest, where appropriate services could be provided, and where these Sisters would “die with dignity and die well.” These values are expressed in an environment which intentionally promotes the services the Sisters want for their frail elderly. It is expressed in recruiting and hiring well-qualified personnel – a geriatrician-physician as the primary care provider for many of the Sisters, and a nurse practitioner on staff in the nursing home. By definition, these are professionals with pertinent and excellent knowledge and skills related to aging and the care of the aging.

A nationally known social worker, Carter Catlett Williams, in speaking of typical nursing homes, reminds us that all too often we absorb the values of our culture. Not so with these Sisters. They have consciously chosen the environment and the services which will result in a higher quality of life for their own and which will allow them a “good death” in the end, in the company of their Sisters.

I am reminded of a piece of poetry/prose that I share with the readers of this blog:


"I will not die an unlived life. I will not live in fear of falling or catching fire.

I choose to inhabit my days, to allow my living to open me, to make me less afraid, more accessible, to loosen my heart until it becomes a wing, a torch, a promise.

I choose to risk my significance; to live so that which comes to me as seed goes to the next as blossom and that which comes to me as blossom, goes on as fruit."

Dawna Markova
Author of Open Mind.

To read Jane Gross’ article, go to:

http://www.nytimes.com/2009/07/09/health/09sisters.html

There’s no place like home

© Imelda Maurer, cdp July 6, 2009
ilmcdp@yahoo.com

Bill Thomas, M.D. has patented a particular approach to culture change in long-term care. The name given to facilities that follow Thomas’ guidelines is “Green House.”

This particular approach is only one way in which culture change is being implemented in long-term care. There are other models. What they hold in common is that they center on the same values and principles: resident-directed environment. Such approaches result in: HOME as opposed to INSTITUTION; autonomy, dignity, individuality, spontaneity in a nursing home resident’s day; more positive outcomes for nursing home residents; and higher morale and lower turnover among nursing home staff. The whole thing, according to well documented research is budget-neutral, though I suspect, in light of greater resident AND employee satisfaction that there is an overall savings in employee training and in medical costs when a nursing home is HOME and not an INSTITUTION.

The Rochester, NY daily newspaper carried an article on July 6th about one such nursing home in that city. You can access it by clicking on the URL below.

Some particularly pertinent statements from the article include these:

It is imperative that there is a change in the organization’s culture if the “model” is to work, if there is to be real change.

“The movement is also prodded by recognition that people treated like parts on an assembly line fail to thrive.”

“Cottage Grove administrator Cathy Allen, a registered nurse who lives in Honeoye Falls, appreciates the close relationships that can form between staff and residents. Allen recently took Chambers (a nursing home resident with some dementia) to buy prizes for games. On the short trip, Chambers repeatedly asked Allen how she had slept and how her day had been, and Allen said she answered cheerfully, again and again. Then at one point Chambers said, "I like being with you."”


http://www.democratandchronicle.com/article/20090706/NEWS01/907060321/1002/NEWS

Is Your Loved One in a Long Term Care Facility at Risk for the H1N1 Flu?

The following article is taken directly from the April 30th issue of the weekly e-newsletter of the American Medical Directors Association: "Weekly Round Up."

The H1N1 Flu (first called the Swine flu), is spreading throughout the United States, Canada and Europe. There is lots of talk about this moving into a pandemic—an epidemic of an infectious disease—in the U.S. Daily, the government’s Centers for Disease Control and Prevention is reporting increasing numbers of cases of this flu. As of April 28th, it is confirmed in 10 states in this country, in Canada and several areas in Europe, with Germany as the latest site.

Of course, it is natural to worry about your loved one in a long term care (LTC) facility. LTC facilities have processes in place to try to keep infectious diseases such as flu from coming in and making patients/residents sick. For example, they will request that employees or visitors who have a fever or other signs of illness stay home. Also, they will monitor that staff is washing their hands, not touching or breathing on food, and wearing masks and gloves around someone who is sick. Normally the facility will make sure those patients/residents who are well enough get flu shots and other preventive care. However, there is no flu shot at this time to prevent H1N1 flu.

What are the signs of H1N1 flu? People with the condition usually have the same complaints as people with any flu-like virus, except some people with the H1N1 virus are reporting some nausea and diarrhea. Suspect that someone has H1N1 if he/she has respiratory illness with fever within seven days of close contact with a person who has the illness or within seven days of travel to someplace where people have the H1N1 illness; or they live in a community (like a LTC facility) where people have been proven to have H1N1. Like seasonal flu, H1N1 flu may cause other medical problems to get worse.

Eating pork products does not cause the illness (although it is best to avoid exposure to pigs from Mexico), so you don’t have to worry if the facility is serving ham for lunch.

The medical director makes sure that the facility has flu control practices and policies that go beyond a vaccination program. Such a program is the first step in preventing flu outbreaks, but other steps are needed; and the medical director and his team will make sure that these steps are taken. Facilities have ways to prevent flu illness from spreading if someone gets it. This is often called infection control or outbreak control measures. The facility’s first goal is to protect your loved one and keep him/her safe. So take heart. Doctors, nurses, and others are on alert when there is flu like this going around, and they take steps to try to prevent everyone from getting sick.

Your physician can tell you what you can do to prevent bringing an illness into the facility and how to keep from getting sick if you visit a loved one in a facility where people have or have had the flu. In the meantime, fighting illnesses like H1N1 flu starts with common sense. If you don’t have to go somewhere, don’t—especially if you are sick. Avoid close contact with people who are sick, and wash your hands several times during the day.

Questions to Ask Your Physician:
• What will happen if there is an outbreak in the facility? What outbreak control means will be used?
• How will family members be notified if there is a case or outbreak of H1N1 flu at the facility?
• How will my loved one be treated if he/she gets H1N1 flu? Will he/she have to go to the hospital?
• How will my loved one be protected from getting H1N1 flu if others in the facility have it?
• How can I help prevent the spread of H1N1 flu?
• What will happen if there is a pandemic? Will the facility be closed to the public?
• If a vaccination for H1N1 flu becomes available, will my loved one get this?
• What else will the facility do to prevent patients/residents from getting the flu?

What You Can Do:
• Don’t visit your loved one if you are sick or feel like you are getting sick.
• Wash your hands often.
• Cover your face if you cough or sneeze and then wash your hands.
• Don’t bring small children to visit your loved one if they have been exposed to the flu at school or in the community.
• Let the facility know if you recently visited a country (such as Mexico) connected with a flu outbreak or outbreak of other infectious illness.
• Urge your loved one to tell a nurse if he/she has any signs of the flu.
• Urge your loved one to avoid close contact with others during flu season or outbreaks.

How much did the Smithfield Easter Ham Really Cost?

© Imelda Maurer, cdp April 28, 2009

For several weeks I’ve wanted to use my blog to write about food. It’s an issue that, for the last couple of years, has stayed with me and it won’t let go. Since the original purpose of this blog included reflections on healthy aging and quality of life in later years, the topic of food is quite apt. The issue goes far beyond issues of the individual, however, because our food choices also impact the animals raised as commodities on factory farms, the environment, the economy, the viability of family farmers, and public health.

Last week I finished listening to the audio version of the book, “The Way We Eat: Why Our Food Choices Matter” by Peter Springer and Jim Mason. Just a few days later, news of the swine flu and its potential to become a pandemic hit the airwaves.

The mainstream media has only addressed the number and location of diagnosed cases of swine flu, number of deaths, the actions of public health officials, etc. None has addressed the cause. Web sites such as The Huffington Post, The Environmentalist, Farmers Weekly, Marion Nestle, however, do clearly make the connection between this global wave of swine flu and factory hog farming. Specifically, Smithfield Foods is mentioned as being the source.

Smithfield, an American-owned meat producer, owns confined animal feeding operations ‘CAFOs’ in Veracruz, México where the swine flu outbreak originated.

We Americans are accustomed to low-priced food. The hidden cost of our grocery bill is in subsidies to the factory farm owners --- corporations such as Smithfield, ConAgra, ADM, Cargill, etc.

One of the ways in which Smithfield is subsidized is by the fact that --- even here in the United States --- there are scant regulations directing the treatment of animal excrement in these CAFOs. A single farm may house (very inhumanely) tens of thousands of hogs. Their excrement far exceeds that produced by humans living in a city of up to 400,000 people. Human excrement is regulated and there is no environmental degradation as a result. On factory farms, excrement is held in ‘manure lagoons’. It is possible, according to several reports that I have read, that the carrier of the swine flu is a fly that reproduces in pig excrement. The fly can infect people by biting.

Smithfield does not have to pay for treating millions of tons of animal excrement. The result is an increase in air and water pollution, respiratory and other health problems of employees, early disability and shortened life spans of these underpaid workers. Think of the costs to city, state and federal agencies in this all-out effort to contain the spread of swine flu. Smithfield gets the break, the bigger corporate profits.

What was the REAL cost of that Easter ham?

What can each of us do to support sustainable farming, individuals and groups who practice humane and healthy farming methods?

When It Comes to Dementia, Forget the Drugs

This article appeared in the Los Angeles Times, March 19, 2009


As Alzheimer's and similar diseases affect growing numbers of people, billions of dollars are being spent on the medications that offer marginal benefits. Instead, let's invest in the human touch.
By Ira Rosofsky
March 19, 2009

Pete Townshend of The Who concluded his baby boomer anthem, "My Generation," with these words: "I hope I die before I get old." And my boomer generation may well still wish for that.

I am 62 -- old enough to cash in my 401(k), too young for Medicare -- and standing with my peers on the edge of a dementia precipice.
Alzheimer's and other forms of dementia afflict up to 5 million people in the United States and about 26 million people worldwide. By 2050, there could be 13 million cases of Alzheimer's alone among U.S. baby boomers and the aging Generations X and Y, according to the National Institutes of Health. Some reports have the global prevalence of Alzheimer's growing to as many as 100 million people by midcentury. The U.S. comptroller general estimates that annual long-term care costs for the elderly -- which includes treatment for dementia -- could quadruple by 2050 to $379 billion.

How should President Obama and his healthcare policymakers, who are working to overhaul our system, prepare for my generation's future? Based on my experience, they can begin by finding a way to end the over-dependence on drugs in treating dementia.

As a psychologist who works in nursing homes, I am intimately aware of the large number of residents who take one or both of two FDA-approved drugs for dementia -- known generically as donepezil and memantine, which together account for more than 90% of the anti-dementia drug market. The most popular brand-name versions, Aricept and Namenda, make up 75% of the market.
I'm also aware of the huge and growing expenditures for these medications -- close to $3 billion annually worldwide for Aricept and more than $500 million for Namenda. Big Pharma spends as many billions of dollars on promotion as it does on research and development.

Examine the documents supporting the Food and Drug Administration's approval of Aricept, and you will see upon what a slim reed this drug's empire was built. Those taking the drug scored, on average, three points better on a 70-item cognitive assessment scale. That's about a 4% difference, mostly reflecting a slower decline rather than positive improvement. And the differences disappear when the drug is discontinued -- indicating that the drugs "do not represent a change in the underlying disease." At best, these effects may be only marginally more effective against dementia than garlic was against the Black Death in the 14th century.

What we do know today, from studies and observation, is that donepezil, memantine and drugs like them fall short on cure and comfort.

Even on Aricept's website, the claims are sketchy on the drug's effectiveness when it comes to cognition: "People who took Aricept did better on thinking tests than those who took a sugar pill."

How much better? The company doesn't say.

Many studies of the effects of drugs for dementia also speak about statistical significance, but statistical significance can be highly overrated if the differences aren't meaningful. Take my extremely nearsighted wife, for example. Suppose a drug enabled her to read the giant E at the top of an eye chart without her glasses, but none of the smaller letters. Her eyesight would show statistically significant enhancement, but -- despite her being a much better driver than me -- I'd still refuse to ride in a car she was driving if she wasn't wearing her glasses.

There are similar effects at play with anti-dementia drugs.

In 2004, Richard Gray of the University of Birmingham in Britain compared hundreds of patients with mild to moderate dementia who were taking Aricept or a placebo. The drug did improve mental functioning, but at disappointingly small levels -- about one point on a 60-point scale. More important, there was no delay in the dementia's progression or the rate of patients' institutionalization. And there were no significant differences in mood, behavior or cost of care.

Based on results such as these, the British National Institute for Clinical Excellence -- the functional equivalent of our FDA -- recommended in 2005 that Britain's National Health Service greatly restrict the use of drugs for dementia. Donepezil can be prescribed only by a psychiatrist or a neurologist, and its use is restricted to cases of mild to moderate -- not severe -- dementia. And memantine is restricted to clinical trials.

Could the thousands of dollars spent annually per patient and the billions overall be better directed?

Yes, says Gray: "Doctors and healthcare funders need to question whether it would be better to invest in more doctors and nurses and better social support rather than spending huge sums of money prescribing these expensive drugs."

A survey released in 2002 by the Kaiser Foundation found that the staffs in a typical nursing home spend a total of about two hours and 20 minutes a day with each resident. For the remaining 21 hours and 40 minutes, residents are left to their own -- mostly medicated -- devices.

Where is the comfort in that?

Some proponents of drug therapy argue that despite some disappointing results, the drugs do slow the worsening of symptoms for some people. But in our medicalized institutions for the frail and elderly, drugs are the first recourse for most problems. And often the second and third recourse.

In the United States, those over 65 consume 30% of the prescription drugs, according to a 2004 report. Dementia sufferers in nursing homes are not only taking donepezil and memantine but other similarly questionable drugs for depression, anxiety, psychosis or for simply being ornery. Many of those without dementia are also on a variety of mind- and mood-altering drugs.



It's easier to medicate than to engage. And when the chemical restraints don't work, nursing homes return to a time before modern psychotropics and use physical restraints.

But why not admit the failure of medication and instead spend some of those billions of dollars on more staff to hold the hands of both patients and their families? Beyond nurturance, much of the savings from giving up on cost-ineffective medications could be diverted to basic research that might yield not only statistically significant but meaningful and large improvements -- even a cure.

There is some comfort in believing, as our medieval ancestors did, that a tangible nostrum -- like a pearl-hued donepezil tablet -- will do some good, but it may be more comforting simply to comfort.



Instead of drugs, I'd bet many patients are wishing someone would just say the words of another ancient rock anthem: I want to hold your hand.

Ira Rosofsky is a psychologist and the author of "Nasty, Brutish, and Long: Adventures in Old Age and the World of Eldercare."