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Wednesday, November 13, 2013

Non-Optimal Elder Care

We are the product of civilization, yet we live a highly nomadic existence.  We do not leave our elderly and infirm in valleys with a few days of food and supplies like our ancestors did.  We do entrust our family members to institutions when our employers or life circumstances call us away.  We trust the social machine and its human elements will provide love and compassion.  We assure ourselves that there are standards and regulations which govern these medical facilities.

Have we ever considered that some of the regulations are ill advised?  Take the depression/mental health screening which is mandatory in nursing homes.  For a middle aged man in rehab, perhaps it is appropriate.  For an elderly dementia patient who keys in on someone's words and obsesses over them, it is the beginning of a nightmare.   The young social worker comes in and administers the questionnaire.  The very last question is: "How often do you think of death and dying?" 
Now if engaged in activities and a steady routine with plenty of rest, this individual may not think of an abstract concept like death very often.  But someone asked a question and the brain works to respond.

        "Oh, every now and then I guess."
Every now and then isn't one of the choices on the questionnaire.  
So the naïve social worker tries to get a more accurate response.  

"How often is every now and then?"
"How often do you think about dying?"
        "Well, it's going to happen!"
"Yes, but I need to know if you think about it a lot.  Do you want to die?"
        "Who wants to die?"
"Some people want to die."
        "Should I want to die?"
"You tell me.  What do you think?"

The dementia patient doesn't respond but that's ok.  The social worker is able to write on the form "does not answer question, avoids eye contact, hunched forward with head on hand" and leaves to perform other duties.  Meanwhile the dementia patient is sitting there, unable to redirect herself with the idea of 'death'; 'some people want to die' & 'should I want to die?' rolling around in her defenseless mind.  

When a family member walks in the patient cries, 
"Get out!  The blond girl talks to me about dying and I won't!"

The social worker hasn't been properly educated, even if she has met every standard the state and facility sets.  She was taught depression is a disease diagnosed with a questionnaire.  She knows nothing about memes and contagious ideas.  She is unaware she set the patient into an emotional crash which the staff will bear the brunt of later.  When the nurse manager approaches her about the patient's disturbing behavior and the possible need of antipsychotics, the social worker will nod slowly and agree, "Yes.   She seemed depressed at her last interview."  

The wording and timing of questions can trigger changes in thoughts and mood, altering the final results of an assessment.  We need to consider that even though someone retains the ability to communicate with words, assessment strategies must change as a person looses their ability to protect themselves from the unintentional influence of others.  Until we integrate meme theory to our understanding of mental health, we will still be living in the dark ages.

Antipsychotics and antidepressants in elder care mask problems, suppress expression and prevent communication, impeding appropriate care.  The drugs reduce behaviors that upset observers, acting as chemical restraints.  One alternative to drugging the elderly is identifying structural violence which stresses an individual.  Important questions to ask are:  Do they need more time to sleep?  Is something painful?  Is there an infection? Do they need more (or less) human interaction? 

There are some innovative ideas in elder care including The Eden Alternative and the book Dementia Beyond Drugs: Changing the Culture of Care.  These alternatives focus on moving from a "dose" approach on interaction (patient received 5 minutes of 1-to-1 interaction with the nurse on second shift) to integrated, productive activities built into the daily routine.

But these innovations are not being encouraged by drug reps or encouraged by regulatory agencies which worry: "How will they document and verify this and how will compliance affect state funding?"  It will have to be individuals, families and the wider society applying selective pressures which will cause an evolution in the memeplex of elder care.

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