Do You Remember Evelyn?

On my March 15th entry I recounted the story of Sharon and her siblings as they dealt with their mother Evelyn and her experience with medically induced dementia. Earlier this week one of her older siblings, whom I also taught, wrote to me. In that letter, Jack commented on that entry remarking that what I said was "right on the mark." With his permission I include the rest of his comments

"Mom now talks like she did 10 years ago. You are right. You can't give anyone that kind of mind affecting medication and expect them to cope. I wish health care providers would sometimes just take a step back and really think about the types and quantities of medications they are prescribing for the elderly. As you said the real tragedy is that many elderly people don't have a loved one to help. It really took a toll on Sharon as well as Mom. I'm glad it is over. Mom is physically healthy for her age (85). Now that she is "dried out" perhaps she can enjoy more of her remaining years."

I was moved to post this entry today after reading a story on cnn.com entitled, "Is Grandma Drugged Up?" The link to this story, both a video and a text story, is listed below, documenting what evidently happens all too frequently to elderly Americans. You can cut and paste this URL in the address box of your browser.

http://www.cnn.com/2008/HEALTH/conditions/05/28/ep.age.meds/index.html

We Are a Pilgrim People, We Are the Church of God

© May 20, 2008 by Imelda Maurer, cdp

On Pentecost Sunday my parish of Saint Agnes Church experienced a meaningful, moving Pentecost liturgy. The opening hymn had as its refrain, "We are a pilgrim people, we are the Church of God." As I sang, 'pilgrim' conjured up the reality that the nature of pilgrim and pilgrimage is that of moving toward a worthy goal as opposed to a permanent, stable position or condition. In that context I remembered my losses through death over the past year of significant others in my life, women with whom I had shared ministry and community life in significant ways years ago. These women have completed their pilgrimage. The rest of us continue on that path. As we do, we remember those whose faces we no longer see, but whose spirits live within us and within the community. Our Congregation has a beautiful and deeply symbolic ritual each summer, remembering those Sisters and Associates who have completed their pilgrimage and gone ahead since our last gathering. It is often poignant when a Sister's picture is flashed onto the media screen, particularly if her death was, by human judgment, too soon in her life or in her illness.

I experienced a similar poignant moment last December while I was on our university campus. I accompanied a lay university professor, the Dean of the School of Professional Studies, to an appointment; our way took us into the entrance of the Main Building. We had just shared a conversation in which she told me how she felt "so called" to be a part of our university primarily because of the high population of first generation Hispanic students and the university's efforts to empower them through a good education.

Of course I had been in that lobby and hallway more times than I can count. But that morning I saw things differently, perhaps because of our recent conversation. I saw again the framed photographs of our university's founding Sisters and of the university Presidents along with other items documenting our history and legacy. Tears welled up immediately with emotions of nostalgia, pride and gratitude. I was so conscious of the richness of my, of our, congregational heritage.

On Tuesday evening before Pentecost, that Main Building of Our Lady of the Lake University, burst into flame about 7:45 p.m., Texas time, the result of an electrical short in the attic above fourth floor. My first call came from a friend in San Antonio when she first saw it on the local TV station. My home phone and cell phone were busy over the next two hours. Calls coming in and going out. No one could grasp the enormity of the inferno, the significance of this loss. The same disbelief followed later as I watched TV website videos taken that evening and the following day.

The loss is a physical building. Like the Sisters who go ahead of us, there is a physical change, but the heritage of our university and its mission live on within us and within the larger community.

The gain is the opportunity for transformation. Fire is itself a symbol of transformation. Joan Chittister addresses the challenge when she reminds U.S. Sisters that though our numbers (Sisters, Sisters who actually are on the staff of our university) are decreasing, "it's not numbers we need. We each have at least as many strong women leaders as we had when we started."

And so we do! I ask the readers of this blog to keep our Sisters and our university in your prayers. We will rebuild. Let us pray that in the process of rebuilding that the mission is maintained --- no, strengthened, born anew through this potentially transforming event. Let us pray that our foremothers who provided this legacy are with us in spirit and grace throughout this task. Let us pray that the Sisters and staff at Our Lady of the Lake University and all CDPs can be engaged "in one great enterprise of fire and flame" (Chittister), that the leadership within all of us will "follow the lights . . . to the edge of tomorrow rather than the preservation of yesterday." (Chittister)

Another part of the refrain of our Pentecost gathering hymn speaks of the Spirit –sometimes represented as tongues of fire: "United in one spirit, ignited by the fire." And so may we all be.

A Mission Statement That Gets to the Heart of It All

Southwest Airlines is my airline of choice for reasons beyond its 'byte-sized' fares. I particularly appreciate and enjoy the unique spirit of customer-focused service that is evident throughout its system and the cheerful, friendly ambiance of its employees. Perhaps because of its customer focus, Southwest is the only airline in the United States that has made a profit every quarter since its first quarterly profit as a young start-up company in the early '70s. Even after 9-11. Southwest realized a profit before any receipt of the government subsidies that were provided during this time of crisis for the airlines.

Last week on a Southwest flight, I read with great interest, "Colleen's Corner", the regular column written by Colleen Barrett, President, in their Spirit magazine. Colleen, a part of Southwest since its inception in the early 70's, writes in the April issue about Southwest's Mission Statement.

Speaking for Southwest, Colleen notes that their Mission Statement deliberately never mentions flying airplanes, making a profit, or providing a return to shareholders. All airlines are alike in this regard, she says. "Instead, we use our Mission Statement to explain how we will accomplish these business goals."

Their short Mission Statement has two sections. One addresses their external customers; that's us, the passengers. The second section addresses its internal customers: its employees. Southwest states its commitment, promising job stability and personal and professional development. The company pledges to treat its internal customers the same way it asks them to treat its external customers. Colleen makes clear that Southwest knows that without employees the "Right Employees", there would be, at best, poor customer service. And with poor customer service, there would be no more customers.

For many frail elders, there is no or little choice in where they live their last years. In such cases, "poor customer service" does not mean no customers, unfortunately. For those who reside in retirement communities where the focus is on customer service, both external and internal customers, those elders undoubtedly experience a higher quality of life, and the staff experiences satisfaction in their work, a low turnover rate, and input into how the organization moves toward its goal. (I've just described transformative nursing homes!)

Some retirement communities may not have a written Mission Statement. But whether one exists or not, every organization operates according to some mission statement, a philosophy. The 'operative' Mission Statement is revealed in the values and attitudes that permeate the policies, programs and procedures of the community, and how the employees, from CEO to the newest hire, approach and carry out their work. The goal is always to work toward and to assure that, first, the written words are really what we believe and value, and, secondly, that they are made operable day to day for each elder in the community and each employee.


Colleen's column is available online at
http://www.spiritmag.com/2008_04/colleenscorner/index.php

Copy and paste the above address into the address box on your internet page

Here is the Mission Statement of Southwest Airlines, stated in its entirety, (84 words!) also on page 14:

The mission of Southwest Airlines is dedication to the highest quality of Customer Service delivered with a sense of warmth, friendliness, individual pride and Company Spirit.

We are committed to provide our Employees a stable work environment with equal opportunity for learning and personal growth. Creativity and innovation are encouraged for improving the effectiveness of Southwest airlines. Above all, Employees will be provided the same concern, respect, and caring attitude within the organization that they are expected to share externally with every Southwest Customer.

Dementia and Medications - A Personal View

Sharon was a freshman when I taught her in the late '60s. She lived with her other siblings in a nice home in a new part of town. Their dad was a successful businessman. I always experienced their mother, Evelyn, as a warm and delightful woman: devoted housewife and mother; active in church, PTA and school fundraising efforts; always gracious, hospitable, loving and with a great sense of humor.

Yesterday I had a call from Sharon. She was responding to a message I had left on her home phone when I had been unable to reach her mother who now lives in an assisted living community. My apprehensions had been well-founded. Over the past six months, Evelyn had been in and out of the hospital twice, in two nursing homes, in rehab, and finally back to where she has been living for the past several years.

Evelyn was discharged, at some point during this six-month ordeal, from the hospital to a nursing home for some rehab. Sharon is a devoted, faithful daughter. Her love for her mother is expressed not only by her presence, but by her strong and effective advocacy. (Mary Hunt, theologian, would call this "Fierce Tenderness".) Within a week of Evelyn being admitted to this nursing home, Sharon saw her mother decline from a woman who suffers from back and hip pain, to a woman restrained in her wheelchair, drooling, defecating on herself, unable to recognize her daughter, and physically unable to maneuver the simple task of taking a facial tissue out of its box.

"My mother does not have dementia," Sharon told the staff. She asked questions; she studied the nursing home medical chart; she discovered that when her mother would call out for help that the staff would medicate her and physically restrain her (!!). Sharon took the list of medications her mother had been put on to a pharmacist. That was the core problem: a mixture of almost a dozen medications for pain, and psychotropics. Sharon immediately moved Evelyn to another long-term care community where the doctor literally weaned Evelyn off her toxic regimen of medications.

Yes, Evelyn DID have dementia. It was MEDICALLY INDUCED DEMENTIA and therefore, thank God, reversible. (The tragic injustice is that it occurs in the first place.) Sharon says "we have her almost back to where she used to be. I'm just grateful that she does not remember what she went through."

It has been a difficult journey, not only for Evelyn, but for Sharon and her siblings who have companioned their mother during a very long and difficult time. Again, thank God that Evelyn has children who, out of filial love, will look after her best interests. How many residents in nursing homes do not have children who will look after their best interests? Let me say, as a Catholic Sister that would be 100% of us! We Sisters must be those advocates for our frail elderly Sisters now and the younger among us, for us when the need arises.

Childless or not, as I said at the end of my last post, "We will either change it or live it.


© Imelda Maurer, cdp 2008 All Rights Reserved. Permissions: ilmcdp@yahoo.com

Dancing with Rose -- the Book

The author of this book is Lauren Kessler, a journalist whose mother died of Alzheimer's. Eight years after her mother's death, Lauren wanted to learn more about the disease, to confront what she had been too frightened to confront at the time of her mother's illness. She admits that it was an attempt, in part, "to make up for being a lousy daughter."

Her avenue of learning was to take a position as a Resident Assistant at 'Maplewood', an Assisted Living facility which specializes in Alzheimer's Care. (I use the word 'facility' deliberately. As one reads the book, it is clear that despite the love and care of the caregivers, there is, as a result of the corporate model, an institutional approach to care. It is run by schedule; it is not person-centered. It is not a community; it is a facility.)

Undoubtedly the touching descriptions of her bonding with the residents ring true, and leave the reader with a sense of gratitude. Lauren loves those in her 'neighborhood' and she senses that same devotion among many of her peers. She reflects upon a funeral of one of the residents where at least nine staff people from Maplewood are present, some at no small cost. Resident Assistants (RAs) who were scheduled to work that shift have switched with another RA, and they will work a shift for that RA when requested.

One can only conclude that Lauren does not know that long-term care does not have to be in the institutional mode. The transformative power of culture change has not found its way to the corporate offices of the Maplewood chain. Thus, when Lauren reflects on the state of the "eldercare industry", she reflects what is found in the all-too-numerous 'traditional' retirement settings, not the transformative HOME of culture change. This is what she says:

She apologizes to a resident for his having to wait for so long after he told her he needed to go to the bathroom. His response was, "I guess that's my job now, to wait."

"I think about Larry's comment for the rest of the day. I think about the time old people spend waiting, not just in places like Maplewood but throughout the eldercare system – nursing homes, assisted living, rehab, any facility that houses those who are no longer able to take care of themselves. They lie in bed, wide awake at 5:00 a.m. waiting for a caregiver to help them get up and dressed. They sit at the table waiting for meals, the first ones wheeled in fifteen or twenty minutes early because it takes so much time to get everyone in their places. They wait, like Larry, to be taken to the bathroom. They wait for attention.

"The problem is understaffing. The problem is undertraining. The problem is high caregiver turnover. The problem is paying minimum wage. The problem is the eldercare industry. (I could go on and so I will: The problem is undervaluing the elderly. The problem is fear of aging. The problem is fear of dying.) Some problems can be easily fixed and others can't. Whatever the problems they are either ours to solve or, twenty or thirty or forty years from now, ours to live." (emphasis mine)

I hope that Lauren and every future long-term-care resident find a person-centered retirement community and then demand that operational philosophy from long-term care providers. We will either change it or live it.

What's in a Name

Recently a news story ran on one of the cable networks about the correlation between street names and the value of the houses on those streets. It seems that houses on streets with names like Massacre Lane or Poison Avenue don't sell well. Houses on such named streets go down in value. And who is surprised. I don't know how streets acquire such names except that perhaps 'Massacre' or 'Poison" were names of leading pioneer families. Over time that connection is lost and people only see the word in its most ordinary meaning.

Retirement centers – Nursing Homes – come up against the same issue. If you had to move from your home because you need more help day-to-day, and you had a choice of where to live, would you choose Brown's Nursing and Rehabilitation Center or Theresian House? Southfield Convalescent Center or Meadowlark Hills? The infirmary or St. Mary's Convent Community?

The first name in each of the three pairs defines those who live there by their physical frailties and limitations. The latter name is more normative of a residential complex or, in the case of Sisters, just another convent. There is no implication in the name that those who live there are in the least bit deficient.

Because words reflect and shape our concepts, names that point to a limited, negative defining of the people in that place, both the individuals who live there and those who care for them are subject to negative concepts about themselves or those they are there to serve. Given that truth, what are the consequences for the residents who receive care in such a frailty-defining environment?

Conversely, as words reflect and shape concepts, so do concepts reflect and shape the words we use. That's what's in a name.

Dancing with Rose

That is the title of a book that was recommended to me by a colleague and friend. I just started reading it late last night. More about the book later.

The title reminds me of an event I experienced as a volunteer ombudsman here in the San Francisco Bay Area several years ago. I was working full time but I also volunteered with the San Mateo Ombudsman Program to visit a nursing home in my neighborhood once a week.

The scene that I recall now is seeing a resident in this "typical" nursing home, a man, with some type of dementia go up to the Activities Director and ask if she would dance with him. Her response was one of duty. Of tasks to be completed as her primary goal and focus. She said, "I'm too busy." End of conversation. It was obvious to me then that she did not see responding to this request as a part of her job description.

What an opportunity lost! Here is a person with cognitive impairment TELLING the Activities Director what is important and meaningful to him. A gold mine for an individual who is attuned to person-centered care, who is attuned to the dignity and individuality of each resident. 'Oh, yes, Mr. Johnson, I will dance with joy with you now and I will see that there are always many opportunities for you to dance with others!'

The big question here is Who Are We Working For. Are we working for the administrator who wants to see tasks completed, who wants to see an activity room neat and clean, who wants to see 'big numbers' for all scheduled activities? Or, are we working for the resident and trying to discern what are his/her routines, his/her interests, his/her life-long patterns. Only when responses are made to these issues can we be enablers of life-long development, of quality of life, of individualized person-centered care. Only then are we actualizing the reality that this long-term care ministry is, in the words of Joanne Rader, "sacred."

Dictionary Takes Note of "Aging-in-Place"

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

Philosophical Values Underlying Transformative Nursing Homes

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

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

NOT on the structure of a hospital, and

NOT on sickness and disability.


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

“An environment worthy of older people,

an environment of intentional community vs. institutionalization.”

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

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

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

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

A Place Where Love Matters

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TOO MUCH MEDICINE CAN MAKE YOU SICK

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


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

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

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

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

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

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

TOO MUCH MEDICINE CAN MAKE YOU SICK

PART ONE OF TWO PARTS

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

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

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


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

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

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

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

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

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

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


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

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

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

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

A word – or Two – About Food

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

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

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

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

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

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

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

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

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

More on Dementia and the Drugs to Treat It

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© January 2, 2008 by Imelda Maurer, cdp

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

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

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

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

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

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

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

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

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

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

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

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

Culture Change: Let's Not Make it a Cliché

Wednesday, November 7, 2007

Reissued September 5, 2018

There is a wonderful revolution taking place in (albeit all too few) nursing homes across the country. As long as there are parents who say to their children, ‘Promise me you’ll never put me in a nursing home,” or any of us groan to think that we may spend our last days in a medical institution that is foreign to any feel or sense of “home” with all its deep and deeply personal implications, then there is need for this revolution – this transformation to spread.

It goes by several names: Culture Change; Transformative Nursing Homes: Resident-Centered Care; Person-Centered Care; Green House Model; Household  Model, Wellspring

What all these terms have in common is a philosophy that holds to the following values and attitudes:

• The resident is put back into the driver’s seat, making as many choices about his/her daily life as possible. One implication is that activities and care revolve around the resident as much as           possible, as contrasted with an institutional schedule and staff convenience.

• It is an environment that honors the culture of aging as life-affirming, satisfying, humane and meaningful.

• The place has the feel and look of HOME. Just two evidences of change in the environment:
            No medical carts rumbling down the hallways.
            No nurses' station.

Although the culture is not transformed by merely instituting programs, studies have shown that in communities where the culture has transformed to a resident-first culture, certain  practices/programs are present. That information can be used as somewhat of an evaluation of how far along on the journey of culture change a community has come.  It is accessible at this link:  http://www.artifactsofculturechange.org/ACCTool/  . Once on that site,scroll down to the,"Artifacts of Culture Change Downloadable Version".

Culture change is not about rearranging the furniture. Far from it. It is a deep, challenging transformation of attitudes and values which is dependent on strong, knowledgeable leadership. The leader must have a deep belief in these transformative values and the leadership ability to shape staff so that these values permeate every cell of their being. Anything short of this is not transformative change and the result will not be ‘culture change.’

The win-win part of culture change is that this transformative mode of operation costs no more than traditional, institutional care. In fact, there are many reasons why the cost is probably lower. That’s a topic for another day.

Steve Shields, CEO of a transformative community in Manhattan, KS speaks of what made it possible for him and his staff to move forward in their journey of transformative change. He is quoted in Beth Baker's book, Old Age in a New Age:  When Action Pact consultants first introduced the concepts of culture change, "The vision was painted so strongly and in front of everybody that it became holy. Truly."

I spoke with Steve about that quote and asked him what he meant by  saying that culture change is ‘holy.’ He said simply and straightforwardly, “It is holy because it liberates our elders and returns hope to them.”

CIRCLES

© April 5, 2005 by Imelda Maurer, cdp

It’s a wonderfully thrilling time to work in the field of aging. Each day brings exciting news of approaches to care and life in nursing homes and retirement centers that put HOME back into “nursing home.” This cultural transformation from the institutional, medical model of “living-every-day-by-a-schedule-that-someone-else-decides-for-me” to a model where the nursing home resident is truly the CENTER of all decisions, programs and activities goes by several names: Culture Change; Cultural Transformation; Person-Directed Care; Green House Project and similar terms. The common theme is that the resident is at the center of the program.

The graphic above is taken from the Internet at

http://www.pioneernetwork.net/news-and-events/Accord2.php The article from the newsletter of the Pioneer Network summarized focal points of its June 8 - 9 meeting in St. Louis.

"Marguerite McLaughlin of Quality Partners in Rhode Island (the QIO that supports all QIOs nationally) presented a framework for person-directed care to illustrate the need for elders to be at the center of

● transformative care practices (e.g., bathing frequency, time and method),
● transformative workplace practices (e.g., a culture of valuing and respecting caregivers and their needs), and
● transformative environmental practices (e.g., the creation of sanctuary, shelter and peace that provides a sense of community and safety, free of unwanted intrusions)."

Recently I was fortunate enough to visit a nursing home that pioneered this cultural transformation: Teresian House, a 300-bed nursing home in Albany, NY, owned and administered by the Carmelite Sisters for the Aged and Infirm. Sister Pauline Brecanier has been the administrator there since the late ‘80s. Sister Pauline believed even then that the nursing home “should look and function as any family home would" (from CULTURE CHANGE, Haworth Press).

Among the positive impacts resulting from transforming a “nursing home” into “HOME are these: obviously happier elders, happier, more content, longer retained employees, a full house since word of mouth about good customer care spreads quickly, and a neutral financial impact. In other words, this innovative, humane approach to life in a nursing home doesn’t cost any more than the way ‘traditional’ nursing homes operate.

My hunch is that medical costs, number of hospitalizations and visits to the Emergency Room are much lower than in a traditional nursing home. But I don’t know of any study that has looked at those factors.

My reason for visiting Teresian House was to visit with a Sisters’ Congregation, the Religious of the Sacred Heart, who has recently begun to depend on Teresian House to care for their frail elders who need nursing home care. The Sisters have done an outstanding, remarkable attentive, and thought-full job in planning for and implementing this transition, and are to be highly commended for that. (More on that in a later blog, I hope.)

The living proof that Teresian House is really HOME, and that the elders who live there feel at home, is evidenced by the following which is shared with you with Sister Mary’s permission.

Sister Mary Ranney is a 95-year-old Religious of the Sacred Heart. She moved from the convent retirement center, Kenwood, to Teresian House (located on Washington Ave), some months ago. She wrote the following which was included in the Sisters’ community-wide newsletter. (‘Bunny’ is the name of one of the Sisters who visit there weekly. There are, incidentally, Sisters there every day VISITING, HELPING, ADVOCATING, as a part of their job description.)


Teresian House: a Kenwood on Washington Ave!
“So much has been said of our new home, and so well expressed, that it is difficult to add to the picture. For me, one thing is different! Here, we walk in circles, no straight lines. Surprisingly, we get there! A circle to the chapel, He is in it; a circle to the dining room, friends await us; a circle to the front door, guests on hand; a circle to Bunny’s class and we get lost! I notice too, there is more light in circles, more love in circling hugs, more joy in enlarging our circle, more peace to have come full circle”

It seems to me that the Sisters and all the elders at Teresian House are experiencing ‘the hundredfold’ promised in Mark 10: 29 – 30. It is my hope and prayer that we will all be that lucky!

Blessings on you, Sister Pauline, and on all advocates and practitioners who are working to make nursing homes HOME!

I’m Not a Young Woman

© March 26, 2007 by Imelda Maurer, cdp

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?

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."