mental health

Dementia: a shortened good-bye

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Dementia and Suicide.

The attached article, written by a blogger in the UK, is straight-forward and thought provoking – it should be.

I live in Washington state, and I am glad that Death with Dignity is a legal option assuming all the legal requirements are met.  This is a very personal subject matter, as is the choice that individuals will make to seize the opportunity, or to reject the opportunity.  There is definitely a separate element of this option when the law is utilized for those with dementia. When is someone still capable of making the decision?

A non-profit in my state, Compassion & Choices of Washington, is an excellent resource for materials and information. They have even developed an Alzheimer’s Disease and Dementia Mental Health Directive – a first-of-its-kind directive that allows people – while still competent – to document their wishes related to who will provide their care, where care will be provided, how it will be financed, how to deal with difficult behaviors that may arise, and many other matters that both caregiver and patient face.  Bless all of you who face this horrific disease that has no effective treatment, and certainly no cure.

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Adjustment disorder: a long-term care facility side-effect.

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Duct-tape Moving Van

Think of a moving/relocating experience you’ve had with all of its inherent tasks of purging of items, packing what remains, and leaving all that is familiar as you move into uncharted territory.  In your new neighborhood you’re starting all over again to find: new friends;  a new supermarket with the best deals; perhaps the best school(s) for your children; a new church; and new ties to the community.  Not exactly an enjoyable experience.  It took you some time to adjust to your new community and feel that you fit in, didn’t it?

Now imagine doing the same thing as someone who is at least 70 years old with failing health, no family nearby, and perhaps with a compromised cognition level.  Vulnerable adults move into a long-term care (LTC) housing environment because of a condition, or combination of conditions, that make living independently no longer an optionBecause of this disruptive move, another disorder – adjustment disorder – makes their move a perilous one.

A loss of context in a new environment.  In my work as an advocate for vulnerable adults, I had the privilege of hearing a wonderful speaker, George Dicks.  At the time, Mr. Dicks supervised the Geriatric Psychiatry Service clinic at Harborview Medical Center in Seattle, WA.  He was also a contracted instructor for the University of Washington, teaching courses on Gerontology, Psychiatric Consultation, and Mental Health.  He emphasized that residents living in nursing homes and assisted living facilities struggle to look for context within their new environment.  For example, context is hard to come by when your daily bath occurs at 2:00 in the afternoon instead of in the morning or evening as was the case prior to the move.  And forget about finding comfort in routine because the demands on LTC staff are such that caring for numerous residents on their shift can’t possibly assure a routine on which the residents can rely.

Just providing care doesn’t mean that a staff person is caring.  Everyone who moves into a long-term care facility will have difficulties, but those who are cognitively impaired face an especially arduous adjustment.  As I previously mentioned, staff are hard pressed to provide individual care to their residents, and oftentimes are poorly prepared to handle the disorders that walk through the door.  Just getting through their daily shift is troublesome so trying to learn the habits and routines that are so vital for quality of life of the resident with dementia is a very time-consuming task.

a hand holding unidentified white pills
(Photo credit: Wikipedia)

Quite frequently, the only contact a staff person has with a resident is when they are making demands of that resident: “time to take your medicines Mrs. Jones;” “let’s get that soiled clothing changed Mr. Smith;” “open your mouth Mrs. Clark so I can feed you.”  Providing for  basic needs is not providing care.  Why?   Because the staff are requiring something of the resident.  There is no connection.  When a staff person interacts with a resident, absent a provision of care, that’s a better definition of care.

How to lessen the effects of adjustment disorder.  Those living in a long-term care housing situation oftentimes feel as though they left all their power, and all of their basic human rights, at the door.  They are constantly surrounded with reminders of their condition – all those other residents who look as lost and helpless as they do – and it seems that the only time anyone pays attention to them is when someone is demanding something of them in the form of providing some sort of assistance with their care needs.  If every staff person spent just five minutes of non-task-oriented time with each resident during their shift, those residents just might start feeling better about themselves.

  • Walk with a resident for a few minutes by simply accompanying them in the hallway and reassuring them along the way.
  • Play music the residents like in the common areas and in their rooms – and don’t assume that you know what they like to hear.  Take the time to find out what gets their feet tapping.
  • When you walk past a resident, greet them, smile at them, just as you would if you were in a social environment instead of a clinical environment.  Again, do so even when you’re not providing a care service.  Your friendly, heart-felt greeting may just make their day.
  • Start a dialogue with residents that allows them to open up to you about who they are; what their lives were like prior to arriving at the facility.  If you need to jot down some of their stories so you’ll remember them later, do so and continue the dialogue the next time you see them.  Wouldn’t it be a pleasant surprise to a resident when you asked them, “Tell me more about your grandson Charlie.  He seems like a real character!”  Wow – you were actually listening, and it shows.  Now you’re connecting with the resident.

If you are a staff person in a long-term care facility, can you put your grandma or grandpa’s face on your patients/residents faces thereby having a greater incentive to connect with those receiving your care?  Or if that doesn’t work for you, do what you must in order to add an element of care to those you serve.  Just because you’re helping the resident perform a task, doesn’t mean that you’re providing the care that they really need.

Alzheimer’s and other dementia: Advance Directives

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Most people don’t want to talk about end-of-life issues but all of us know it’s a topic requiring early discussion and appropriate timing to be of any use when emotional, and sometimes emergent, decisions must be made.

Auguste Deter. Alois Alzheimer's patient in No...
Image via Wikipedia of a patient for whom Dr. Alzheimer provided care. This patient became the model for diagnosing Alzheimer's dementia.

My siblings and I benefited from my parents’ end-of-life documents that dictated their wishes should we need to become involved.  My mother died in her sleep in 1994 so no active involvement was necessary but my father, suffering with Alzheimer’s for five years by the time he died in 2007, gave us a gift by spelling out in detail his end-of-life wishes set in place at least a decade before he died.  Think of an Advanced Directive or Living Will as a gift to your loved ones.  It certainly was a gift to my siblings and me.

An organization in Washington state, Compassion & Choices, worked with Seattle University Clinical Law Professor, Lisa Brodoff, to create a new advance directive for people with Alzheimer’s and other dementia.  This same law professor was instrumental in the passage of legislation in Washington State creating the Mental Health Advance Directive for people with mental illness.  This statute is considered to be model legislation for other states wanting to expand the rights and planning options for people with mental illness.  Bravo Washington State!!!

Although not yet available, the new Alzheimer’s/Dementia Advance Directive will be based on one created by Professor Brodoff for a 2009 Elder Law Journal article titled (excerpt attached): Planning for Alzheimer’s Disease with Mental Health Directives.  The new Alzheimer’s/Dementia advance directive is not intended to replace existing end-of-life documents such as a Living Will and/or Durable Power of Attorney for Health Care, but is designed to work in concert with those documents to ensure that any issues important to the patient with dementia that are not addressed in standard advance directives are honored as much as possible.

What additional issues are addressed in the new advance directive for those with Alzheimer’s or other dementia?

Potential issues that might be addressed are preferences regarding:

  • care in and outside of the home;
  • financing of said care;
  • caregiver choices;
  • involuntary commitment;
  • consent to participation in drug trials;
  • suspension of driving privileges; and
  • any future intimate relationships.

To get on the mailing list in Washington state to receive a copy of the new advance directive contact Compassion Washington: by email, info@CompassionWA.org or by calling their office at: 206.256.1636 or Toll free: 1-877-222-2816.  At the very least, regardless of where you live, using their model as a guide when creating your own Advance Directive may be helpful when such Directive affects the life of a loved one with dementia.  Being prepared for the unexpected, or even what you indeed suspect might be a future health issue, provide peace of mind for the patient and for his or her caregiver. 

That’s a priceless gift to be sure.