Long-Term Care for Seniors: Dr. Robert Kane Shares Insights

Categories: Active Senior Living,Aging Advocacy,Caring For Elderly,Grandparents,Hospitalization,In-Home Care,Medical,Uncategorized

In a recent article from the Star Tribune, reporter Warren Wolfe dug deep into the issues that can arise while caring for elderly loved ones. The article features Dr. Robert Kane, a physician who heads the U of M Center on Aging. Kane was so frustrated with the problems he and his sister faced after caring for their aging mom that he wrote a book about the long-term care system.

Advocate on Aging Deborah Dolan shared her thoughts on the article and Kane’s work. “Dr. Kane expresses beautifully from personal experience the essence of a geriatric care manager (GCM),” said Deborah.  “He speaks well of the advocacy a strong, knowledgeable GCM can provide to elders and their family.  Even in the best of circumstances when you are an adult child of an aging parent providing the daily love and support they need can be ‘grueling,’ and a geriatric care manager can help.”

Deborah had the privilege of meeting with Dr. Kane several years ago as she was growing her geriatric care management business, and he spoke of his experience with his mother.  He had formed the on-line support group and found that he had many colleagues in a similar position of caregiving as he and his sister.  Deborah was not sure if he was promoting his number one lesson just yet, but she is glad to know the importance of a GCM has found a prominent position on his list of lessons learned.

For Kane’s work, Deborah is appreciative. “Thank you, Dr. Kane, for your support both as a care manager and as a volunteer with the Senior Linkage Line.  An additional resource of the Minnesota Board on Aging is www.minnesotahelp.info, an online directory of services designed to help people in Minnesota find human services, information and referral, financial assistance, and other forms of help’ (taken from the website).  It is a wonderful point of beginning when families are ready to take the first step in finding help for their aging loved ones.”

Hospital Delirium: Real Danger from Hallucinations – Part II

Categories: Aging Advocacy,Caring For Elderly,Hospitalization

Hospitals and families alike are becoming more aware of the dangers of hospital delirium and are taking steps to reduce triggers.

Situations like being without eyeglasses, being in a dark room and being unaware of the day and time can trigger delirium. Hospital rooms should have clocks, calendars and adequate light, and nurses and doctors should make sure that patients have their glasses, hearing aids and dentures.

Family members can bring objects to help a patient stay oriented. Things like photos, a favorite blanket, or a familiar possession can be comforting.

Family members can also help by remaining calm and reassuring. Remind the patient where he or she is and why. Families should limit the length of visits and number of visitors to prevent patients from feeling overwhelmed, but they should also try to make sure the patient is rarely alone.

If the patient experiences an acute episode of delirium, relatives should try to arrange shifts so someone can be present around the clock. For more help and to ask questions, contact a qualified geriatric care manager before hospitalization to assist during the transitions.

Here are six questions to ask the hospital to help protect your elderly patients – thanks to the NY Times:

1. Do the nurses and doctors routinely screen for delirium or identify high-risk patients?

Older and younger patients who develop severe infections or heart, liver or kidney problems are at higher risk for delirium. But about 75 percent of delirium cases are missed when the hospital or its intensive care unit is not actively screening for it. While delirium can cause patients to become aggressive, disruptive or incoherent, it can also manifest itself in much less obvious ways, making a patient seem withdrawn or disconnected. Even with regular screening, family members are often the first to notice subtle changes. If you detect new signs that could indicate delirium — like  confusion, memory problems or personality changes — it is important to discuss these with the nurses or physicians as soon as you can.

2. How does the hospital deal with agitation or delirium in patients if it develops?

The longer the duration of the delirium, the greater the chances of poor consequences for the patient, so it should be addressed quickly. Experts say hospitals can treat delirium by helping patients sleep, making sure patients are hydrated, allowing family members to stay at patients’ bedsides to help them become reoriented, and getting patients up and walking when it is safe to do so. Family members should also inquire about hospital policies involving restraints for confused patients. Removing restraints is often recommended because they can cause patients to feel paranoid or trapped. Some hospitals use anti-psychotic medications like haloperidol, but some experts caution that these should be used in moderation and are not yet proven to work.

3. What does the hospital do to keep patients from becoming disoriented?

Situations like being without one’s eyeglasses, being in a darkened room and being unaware of the day and time can trigger delirium. Hospital rooms should have clocks, calendars and adequate light, and nurses and doctors should ensure that patients have their glasses, hearing aids and dentures. Family members should make sure the hospital staff knows if the patient needs these items. The family can also bring a few familiar objects from home to help a patient stay oriented. Things like family photos, a favorite blanket for the bed, a beloved book or relaxation tapes can be comforting for all patients. Family members can also help by speaking in a calm, reassuring tone of voice and reminding the patient where he or she is and why.  Massage can be soothing for some patients, and if it is all right with the medical staff, family members can walk with the patient in the hallways. Families should limit the length of visits and number of visitors to prevent patients from feeling overwhelmed, but they should also try to make sure the patient is rarely alone. If the patient experiences an acute episode of delirium, relatives should try to arrange shifts so someone can be present around the clock.

4. What policies are in place to make sure patients get adequate sleep?

Family members should find out if patients are able to sleep through the night or if they will be awakened for medical tests. Find out how the hospital controls noise and whether it offers any nondrug measures like back rubs or warm tea to promote sleep.

5. If my family member needs a urinary catheter or other bedside interventions, how does the hospital decide when to remove them?

A common procedure like a catheter insertion can spur anxiety in frail, vulnerable patients. Experts say it’s important to remove catheters, intravenous lines and other equipment whenever possible because they can make patients feel trapped, leading to delirium.

6. Will the physicians and pharmacy staff review my family member’s medications to identify medications that increase delirium risk?

Bring to the hospital a complete list of all medications and dose instructions, as well as over-the-counter medicines. It may help to bring the medication bottles as well. Prepare a “medical information sheet” listing all allergies, names and phone numbers of physicians, the name of the patient’s usual pharmacy and all known medical conditions. Also, be sure all pertinent medical records have been forwarded to the doctors who will be caring for the patient.

Hospital Delirium: Real Danger from Hallucinations – Part I

Categories: Aging Advocacy,Caring For Elderly,Hospitalization

Hospitalized older people often experience bizarre and disturbing hallucinations. Doctors are recognizing so-called “hospital delirium” and are developing ways to prevent or treat it.

Hospital delirium affects about one-third of patients over 70. The American Geriatrics Society finds that a greater percentage of intensive-care or post-surgical patients experience the episodes.

While the cause of delirium is unclear, there are many triggers: medications, infections, surgery, and pneumonia. Other triggers involve disruptive hospital procedures, such as sleep interrupted for tests, feelings of isolation, and changing rooms. Procedures like catheter insertions can create fear in frail, vulnerable patients.

Episodes of hospital delirium can mean setbacks for patients. It can extend hospitalizations, delay scheduled procedures, and require more time and attention from staff members. After an incident, patients are more likely to be placed in nursing homes or rehabilitation centers. Research from the Indiana University Center for Aging Research finds that elderly patients experiencing delirium were hospitalized six days longer, and placed in nursing homes 75 percent of the time, five times as often as those without delirium.

Furthermore, an episode of hospital delirium can have deadly consequences. Nearly ten per cent of elderly patients experiencing delirium died within a month. Experts say delirium can contribute to death by weakening patients or leading to complications like pneumonia or blood clots.

Watch on Thursday for Part II of the Real Danger from Hallucinations of Hospitalized Elderly!

Excuse me, Doctor, but I’m over here!

Categories: Aging Advocacy,Caring For Elderly,Hospitalization

Recently I accompanied an elder client to a doctor’s appointment.  Estelle was a new patient so we had no idea what to expect from this visit other than the doctor was a specialist in pain management, and Estelle had plenty of chronic pain.  What occurred is nothing like Estelle had ever experienced before; yet as a geriatric care manager for the past 8 years, what happened during the appointment is becoming too common and very unsettling.

Estelle’s daughter filled out form after form after form with Estelle’s medical history, current medications, and why she was seeing the doctor.  Yet when we walked into the examination room, the doctor was sitting behind a desk staring at a computer screen and a young woman was sitting behind him peering over his shoulder.  He apologized saying he was learning a new computer system and training a new office person at the same time as he was seeing Estelle.

For the next hour the physician, his eyes glued to the computer monitor, proceeded to ask a litany of questions barely waiting for an answer from Estelle or her daughter before he asked another.  Many of the questions were the same questions Estelle’s daughter had just answered on the myriad of forms.  Where does it hurt?  How long has it been hurting?  Did you do something to injure this area? On and on while seldom giving Estelle the common courtesy of eye contact or time to answer.  After an hour the doctor wrote Estelle a prescription for oxycodone, and asked Estelle’s daughter to make another appointment in a week; he would do an exam then.

This is just one example of a numerous doctors’ appointments where the physician failed to use common courtesies and effective communication skills.  In 1971 a study conducted by Albert Mehrabian concluded that 93% of communication is non-verbal:  55% of communication is body language, 38% is tone of voice and only 7% of what is being communicated is done so through words.  What did the doctor’s non-verbals say to Estelle?

My interpretation was:

• this computer is more important than you
• you are merely an interruption in my day
• you do not deserve my attention
• I don’t really care if I can help you or not

My role in a doctor’s appointment is to serve as an advocate for the elder patient.  Most often what I do is guide the physician toward effectively communicating with their patient.  I ask the physician to speak directly to the patient (not me); to slow down and give the elder person time to process an answer; to be patient; to use common courtesy; to give the respect that our elders have earned.

My recommendations for the doctor and others who see themselves in this scenario:

• make eye contact unless you know that it is a cultural negative to do so
• make small gestures such as touching the patient’s arm
• lean forward telling the patient you are listening
• nod in understanding
• wait for the patient to answer a question before you ask another

For the sake of quality care, I ask you to think about your communication style especially with your elder patients.  If you are a care partner for an elderly person, resolve to become an advocate for better communication between the physician and their elder patients.  Everyone benefits!

Advocacy is keeping the puzzle intact…

Categories: Aging Advocacy,Caring For Elderly,Hospitalization

I think of my role as advocate as the person who takes all the pieces of my client’s healthcare jigsaw puzzle and makes sure they fit together to create a cohesive and complete picture.  With so many health issues and sometimes so many physicians and caregivers involved, the pieces become scrambled, and it’s my job to put them back together.

Example:

Recently a client went to the hospital due to a fall.  After determining there were no broken bones or lacerations, the central concerns became her balance (since she’s complaining of being dizzy) and the neuropathy in her feet.  A hospitalist, a wonderful doctor with a compassionate bedside manner, sees my client for 10 minutes each of the next three days she is hospitalized – as an inpatient I might add.  Following the issue at hand, he looks for ways to decrease her falling risk, and something he can do immediately is “adjust” my client’s medication.

So the hospitalist takes away one of her blood pressure medications, adds on another drug to help with the neuropathy (although admits that one of the side effects is dizziness), and for some unknown reason, cuts her depression medication in half.  Three days later when this lovely ady arrives at transitional care, she is crying, upset and refusing therapy.  Thirty minutes with a doctor has just undone years of seeking a delicate balance of high blood pressure and depression.

My job as her advocate is to begin unraveling why her medications were changed, which changes do we keep and which do we undo.  Remember I’m non-medical; but my role requires me to become educated about the medications involved and then be willing to ask the questions of her medical caregivers to return the puzzle to a cohesive and complete picture.

Can Compassion Be Learned?

Categories: Aging Advocacy,Caring For Elderly,Hospitalization

Let me begin by saying that this is not a topic I have researched in depth.  Rather it is a question that has found its way into my thoughts and won’t depart since writing my thesis for a graduate degree in Gerontology.  The thesis topic was communication; specifically, communication between the physician and their elderly patients.  My research focused on the competencies of efficient and effective communication, and whether physicians are taught such skills in medical school.  With this thought came the question of what can be taught and, more precisely, what can be learned.

First, the words competency and compassion don’t seem to fit together.  From my perspective, “competency” belongs in the stiff corporate world of skills required to do a job while “compassion” belongs in the realm of human emotion.  In the professional world of medicine, can these two qualities be found in one person?  If not, can human emotion be taught?  Can human emotion be learned?

There are certain skills associated with communication that can be taught and learned.  Non-verbal affirmations such as head nodding, sitting and eye contact are behaviors which, with commitment and a desire to achieve, can be learned.  Then there are the innate characteristics that are inborn, a part of who we are from birth, that are central to the nature/nurture debate.  Thus the question – can human emotions such as compassion be learned?  Or must there be a predisposition for that characteristic lying dormant until such time as it is wakened through life experience or pure, simple desire?

Some behaviors, we want to believe, can be taught simply through modeling.  We strive to be good parents, children, citizens, employees, stewards in our personal lives.  But is the example enough to bring forth these qualities in others?  Or do we individually need that “gene.”  The simple answer – I don’t know.

Compassion is just one of several innate characteristics found in humans which provide the fertile soil necessary for positive growth.  Openness, warmth, honesty, a true understanding of another person’s circumstances are all traits which encourage trust.  With trust comes the opportunity for honest communication.  Being a skillful communicator requires behaviors which can be taught and learned — coupled with the quality of compassion.

My husband is the kind of guy who views his glass either half full or overflowing with goodness.  Thus, he believes in the goodness of people.  He adheres to the philosophy that people are born with a core of inner health waiting to be tapped into by life experience.  From his view, compassion is available to everyone as is honesty, empathy, love, trustworthiness and the other human characteristics that make us “good” people.

Nice.  It feels good to believe this.  I want to believe this!  I also want my doctor to demonstrate this quality when talking to me and my elderly clients.  But the question remains – can compassion be learned?  The answer isn’t clear, but I believe we should continue trying to model and teach the behavior that is a true gift to the others and especially the elderly.

Am I Here For Observation Or Am I A Patient?

Categories: Health Insurance,Hospitalization,Medicare,Medicare Part A,Medicare Part B,Medicare Part D

Does the following scenario sound familiar?

You have recently been hospitalized. After getting home you receive a bill for a lot more than you have ever been charged before. You call the hospital, the billing department gives you some explanation about not being an inpatient (what?!), that you were “probably” told at the time you arrived at the hospital (I don’t know! I was too busy being sick to listen intently!), that you “most likely” received a patient’s bill of rights or some other document telling you the difference between outpatient and observation admission, and that you have the right to appeal if you do not agree with this decision (good because I don’t agree with having to pay this bill!).

You look through your hospital papers, you call Medicare (and wait for an hour to talk to someone), and you are given the same information that the hospital’s billing department gave you. Now you are really confused as to what you should do, but you know you shouldn’t have to pay this hospital bill!

A client of mine experienced what I have just described and we decided to appeal. Following is the appeal I wrote on her behalf:

Click to see Medicare Letter

The appeal was denied.

The next time you or a loved one is sent to the hospital, listen carefully for the word “observation.” What this means is that Medicare Part A pays for the room and board, Medicare Part B pays for approved therapies and prescriptions (and very few drugs are covered under Medicare Part B). Some insurers will allow you to re-file your prescription charges under your Medicare Part D plan which leaves you liable only for deductibles and copays. But you must be aware of your rights and what you need to do to receive this additional coverage.

There’s more to this conundrum. I’ll blog about it in the near future.