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Division of Aging and DHHS Divisions Eldercare Locator
Age with Dignity East Arkansas Western Arkansas
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This
column appears in the August 2005 edition of Aging Arkansas,
July 2005 might turn out to be a tipping point in care for older Americans. Congress didn’t pass landmark legislation, the Supreme Court didn’t make a headline grabbing ruling, nor did any other major events happen effecting the care of the elderly. What did happen is Newsweek, the Washington Post, the New England Journal of Medicine and Health Affairs all carried July articles on care for seniors. Maybe it is a tipping point. Malcolm Gladwell argues in The Tipping Point: How Little Things Can Make a Big Difference that when small numbers of people start behaving differently, that behavior can ripple outward until a critical mass or "tipping point" is reached. Let’s hope the appearance of these “small” stories in respected national publications does indicate a critical mass is forming to improve care for older Americans. The current system needs help. If you haven’t learned though personal experience what it is like to care for a loved one read Jerald Winakur’s article What are We Going to do With Dad? It can be found in the July/August issue of Health Affairs online at: http://content.healthaffairs.org/cgi/content/full/24/4/1064 Dr. Winakur writes: “Three years ago my father, a longtime heart patient, had trouble breathing and complained of chest pain. He was admitted into the hospital with congestive heart failure. This is the hospital in which I have made rounds almost every day for the past three decades. Many of the nurses and therapists and I call each other by our first names. The CEO is my friend and patient. "My father’s physician is one of my young associates, well-trained and eager. I was confident that my father would receive the best medical care he could get in America today. Yet I would not leave him alone in his hospital room. During the day, if I or my brother or mother could not be there, I had a hired sitter by his bed. It’s rarely talked about, but acute hospitalizations are the most dangerous times for the elderly. "Even if they have never before manifested any signs of confusion or disorientation, it is in the hospital—in a new and strange and threatening environment, under the influence of anesthetics, pain pills, antiemetics, and soporifics—where the elderly (competent or not) will meet their match. "Add to this the iatrogenic mishaps (caused by the “normally expected” side effects and complications of standard medical procedures) and the human errors (mistakes in drug dosing, the right medication given to the wrong patient)—now multiplying in our modern hospitals like germs in a Petri dish—and it is almost a miracle that any elderly patient gets out of the hospital today relatively unscathed. "I stayed with my father every night; I slept in the reclining chair by his bed. I got up when he did; ran interference with bedrails, side tables, and IV poles; guarded his every move to the bathroom; looked at every medication that was handed to him and every fluid-filled bag plugged into his arm. I was not afraid to question the nurse or even call his physician. Each day my father descended deeper and deeper into paranoid confusion. He couldn’t rest, he was intermittently unsure of who I was. At first I could calm him with my voice, talking about the old days, reminding him of our fishing trips on the Chesapeake Bay when I was young. Then finally, so that he could get some rest, I got in the bed with him and held him, comforting him as he once—in a long-ago life—did for me. "After four days and nights in the hospital, I knew I had to get my father out of there. His doctor came by and told me that his heart failure was better and that his dementia evaluation did not show a treatable or reversible cause. But he didn’t like the way my father looked—he was agitated and sleep-deprived and deconditioned, a perfect candidate for some time in the Skilled Nursing Unit. And, after all, here I was, his senior associate, the medical director of the SNU. Surely my dad would get good care there. I took my father home. I knew if I didn’t get him home at that moment, he would never come home again. The Skilled Nursing Uuit for my dad would have been only a way station to a custodial nursing home.” Dr. Winakur took his dad home with the assistance of in-home care. If the Green House movement featured in the Newsweek article turns out to be as promising as it sounds, Dr. Winakur and others may decide to give nursing homes a second look. Newsweek: It seems so obvious: let people age the way they have lived. Today, finally, it's beginning to happen. From upscale residences in California to family-size nursing homes in Mississippi, living facilities for the elderly are undergoing an architectural and cultural makeover: big, sterile institutions are out, small, homey environments in. "We have to completely transform the system," says Rose Marie Fagan of the Pioneer Network, an umbrella group for innovative aging programs. Nursing homes are at the top of the list. Many of the nation's 17,000 institutions are decades old and operate on an impersonal hospital model—lackluster corridors, shared bedrooms, strict sleeping hours. Enter Dr. Bill Thomas, a 45-year-old geriatrician at SUNY Upstate Medical Center, who's on a mission to revolutionize long-term care. In the 1990s, Thomas launched the "Eden Alternative," which called for humanizing big facilities by removing nurses' stations, adding plants and pets, and focusing on the staff-elder relationship. Eden was just the beginning. Today his baby is the National Green House Project, a radical shift away from large institutions to homes with no more than 10 residents each. The advantages: cozy living, privacy (individual bedrooms and baths) and time for caregivers to get to know residents—not just their medical needs, but their life stories, too. The July 12 th issue of the Washington Post highlights another option: When, in 2003, it became clear that Rebecca Lewis's 76-year-old mother could no longer live on her own, Lewis decided to take on the role of her full-time caregiver. But mom Minnie Covington's transition from North Carolina to Lewis's Northern Virginia home wasn't a smooth one. Suffering from Alzheimer's disease, Covington would "pack all of her clothes in a suitcase as many as six times a day, and say, 'I want to go home,' " reports Lewis. She was agitated and had trouble sleeping at night. Within months, Lewis, then 52, was frustrated and emotionally drained. "I was totally exhausted," she says. "I told my husband, 'I have to do something.' "Still, with her mother relatively young and physically healthy, a nursing home didn't seem the right option. "She just needed guidance and stimulation," says Lewis. Through a local Alzheimer's association, Lewis and her husband, Kevin, found their way to Mount Vernon Adult Day Health Care Center, one of five facilities run by the Fairfax County Health Department to provide day care for elderly and disabled adults. "When I first heard of it, I'm thinking 'day care.' I'm thinking, 'They'll treat them like children,' " admits Lewis. "And I wanted so much for her to do something that would stimulate her." But Lewis says her mother enjoyed the facility from the start. She, too, saw an immediate benefit. "It allows me to do things for myself and not always concentrate on how I'm going to keep her busy," says Lewis, a stay-at-home mom. "Really, it's my lifeline and I feel like it's my mom's, too." The article in the New England Journal of Medicine makes the case for modernizing Medicare. When Medicare began in the 1960’s it focused on treating acute, episodic illness. Its design on treating these illnesses is out of date with today’s reality. Medicare must be retooled and recognize that 83 percent of Medicare beneficiaries, like Dr. Winakur’s dad, have chronic conditions. As the Journal says, “Any policymaker who is considering the modernization of Medicare must recognize that 23 percent of beneficiaries with five or more chronic conditions account for 68 percent of the program’s spending.” Medicare needs to provide good acute care, but it also needs to provide care to keep people like Dr. Winakur’s dad in the community. Home care, adult day care, assisted living--individualized to meet the specific needs of older Americans with multiple conditions must become the norm—not the exception. Maybe enough of us baby boomers will acknowledge this reality to tip the system in that direction.
Division of Aging and Adult Services |
