Useful And Fantastic: Care Of The Elderly
Of all the nursing homes I have visited, the ones where residents live longest and healthiest and happiest are those where the staff say straight out, ‘We don’t bother with trying to cure, or even forcing them to keep fit. We just want them to have fun.’
Val Yule brings a host of practical suggestions to improve the lives of older folk who need full-time care.
In the months before my father’s death, I visited many special accommodation homes and nursing homes for the elderly when it was clear I could not care for him alone any longer. From these experiences, and from his hospitalisation, I could see the differences between the marvellous places and the less marvellous, and how easily the latter could be improved. So many of the problems were a matter of practical thinking, rather than money. So much unnecessary physical and psychological suffering can be eliminated.
In my professional career I worked in hospitals and institutions in Melbourne, Cambridge and Aberdeen, so that many comments come from ‘inside’ as well. I hope the following notes can be useful.
•Continence and bowels. I put this first, undignified as it may seem. It is the most important factor in an old person’s freedom and dignity. While it is essential for a professional to make your own diagnoses when patients come in to an institution, the reports and treatment regimens that come in with them should be given careful attention too. With older patients, this is especially important regarding bowel regulation. Once this gets disturbed, their lives can become horrible. In schools it is my observation that education really begins in the school lavatory. In care for the old, it is the management of elimination that can make all the difference between dignity and abandonment of self-respect. It was the unnecessary mess that was made of my father’s bowel management in his last month of life that led to his final giving up in despair and precipitated his death. Most old people have more elimination trouble than when they were younger. Research is needed to work out ways that all elderly patients, in both acute and chronic wards, can have elimination attention when they need it, which may include giving them the means to direct that attention, even if they over-use it. For staff this may be a minor nuisance - for the patients it is the difference between hell and normal life. When patients are physically incontinent, nursing care should include showing them such respect and kindness that the patients can still feel they retain their dignity.
• Of all the nursing homes I have visited, the ones where residents live longest and healthiest and happiest are those where the staff say straight out, ‘We don’t bother with trying to cure, or even forcing them to keep fit. We just want them to have fun.’
• I think there should be a public call for inventions that enable old people -when they reach a certain stage - to have as much bed rest as they want, without getting pressure sores, and making toileting easier. Wearying exercise may help to keep them ‘alive’ but to what point? It can be a tragic sight to see weary old people sitting around walls in nursing homes in plastic chairs after they have lost in interest in everyone, even their closest relatives, and in everything that could be provided to interest them. That is, we need improved ways of caring for the very old and weary, so that they can rest in bed if they want to, even if it does 'shorten their days'. There's nothing I like myself more sometimes than a 'good lie down'. I am petrified that in my old age I could be kept sitting up bored and weary and uncomfortable and chilly all day. At home I felt I had to insist that my father get up daily for an assisted wash, a sitting-up meal with us and an assisted walk down the passage, but otherwise he had the freedom to do what he wanted. It is the loss of freedom that is the very worst thing for the non-demented aged about leaving home.
• Photos and cards where patients can see them.
• A photo of the patient in his prime is I think a good thing to remind staff, visitors and the patient himself of who he still is. This should be in a prominent position for them to see it too.
• Underestimating patients is so easy and can push them into the state they are supposed to be. I learnt from experience always to behave as if a person in a coma can hear, and to give physical contact to the dying even if they are supposed to be unconscious. Weariness, despair and drug effects are not the same as dementia. And few old people, sane or not, need to know what day it is anyway. It is a silly question to ask. And staff may not see when they have put a patient at a physical disadvantage, how alert and with it that person is in normal circumstances. And even the demented have a person suffering within.
• Names. In a hospital or any residential setting, calling residents older than the staff -member by first name on first meeting can at once establish or build up a Parent-Child relationship that demeans and infantilises the patient. Older people hang on to their self-respect - it is often all they have left. It is a much nicer gesture on the second time of meeting to ask a patient what he likes to be called. The second meeting indicates that a relationship is being established - it is not just a casual attention by someone never to be seen again. He can then say, ‘Call me Reg’ but if he says ‘Anything you like’ or something similar, that means usually he would prefer to be given his formal name. He can call the staff member by first name, and the friendliness in that is sufficient. First-name calling between people of roughly the same age can establish friendliness, but when young staff first-name the elderly before given permission, it can increase the effect of declaring 'second childhood' and the lower status of the patient. Both the nurse and the patient are more liable to lapse into parent-baby relationship. “Come on now Reggie, drink this up for me ...” should never be heard.
• Meetings have a primary value for staff morale. However, much time in them is wasted as personnel wait for cases relevant to them to be discussed. I used to do routine paperwork during that time, and in some hospitals could also be interrupted for patient or relative attention during meetings. Someone at the door simply silently held up a card with my number. Some research could also look at what goes on in staff meetings and how they could be more efficiently and therapeutically run. I know meetings help protect staff by giving a break away from patients, but they can be overdone. In one hospital, if I had attended all the meetings I should have, I could have spent 40% of my time at meetings.
• Sometimes nursing staff in nursing homes as well as in hospitals object to old people having personal reminders of their lives with them, because 'they're a nuisance to the cleaner'. If they do have photographs and cards, often they are put on the wall behind the bed where the patient cannot see them. Yet the happiest people I saw in nursing homes did have mementos of their lives around them. We recognise that when Everyman dies, he can take nothing with him, he is stripped of all - except, some say, Good Deeds - but why should he be stripped of his identity while he is still alive?
• To have at each bed a photograph of the old person when they were in their youth, so that young staff can always see in that old person, whatever their present shell, what they really were, and respond to that image, of another human being like themselves, inside the shell they see.
• Stability of staff. Some great new invention is needed so that patients are not cared for by seemingly dozens of different and anonymous people, constantly changing, each with a separate piecemeal role. In industry it is being found that overspecialisation can be a mistake, and for some processes flow-through work by one person can be more efficient and also personally satisfying. Union and training problems may need solution in hospitals - and of course short-staffed institutions have greatest problems. But the more each patient is basically cared for by one identifiable person on each shift, the better that care can be. Of course it is impractical for one person to do everything, I am not suggesting that. And some staff not allocated to direct patient care will have to be available as ‘fillers’. Unpredictable rosters help neither staff nor residents. Rapid turnovers need to be avoided. A good staffing system allocates one staff member on each shift to be the chief personal carer for particular patients, to prevent patients feeling like some sort of handball being chucked around anonymously. Another point is that a major point of record-keeping is so that when a staff member is temporarily absent, necessary action that others could follow-up is not held up until their return because nobody knows what to do or what is going on.
• Other functions of research are to improve the welfare and work-satisfaction of the nurses and cleaners and social workers and medical staff and students, and administrators, so they too feel cared for and can enjoy their work and their responsibility and use their own commonsense and imagination. This, too, means attending to the 'horse-shoe-nails' whose absence loses battles and makes people unnecessarily miserable and ineffective.
• Some social workers have a tendency/reputation to put chatting and case-meetings ahead of getting arrangements made. They should be aware of priorities. Writing reports should come third, and these can always be in note form, to be quicker. All social workers talk to relatives and patients nicely. But some can be incommunicado in lots of meetings, and delay giving priority to enabling paperwork and phone calls that would have taken five minutes, to really help patients and families. A good deal of busy time can be taken up in answering calls that are just repeating the same unfulfilled requests, and receiving the same unfulfilled promises of immediate action. If they were done them earlier, it would save their owns and others’ time and trouble.
• Uniforms. With older patients - and many others - uniforms help - they know it is someone they can turn to, and it helps them to recognise their roles. Faces and manner are what is important for friendliness. Street clothes can introduce interfering factors of differing social class, sexuality, age and mores, and old people often cannot distinguish staff from other residents’ visitors etc. Uniforms, even if just a jacket or scarf, give a stability to recognition while street clothes are always changing. The value of function-identifing clothing for staff is a boon to both patients and their relatives. They need not all be white coats, or make them look like garbage-disposers. Social workers often try to dress to be more ‘friendly-looking’, but since fashions are affected by age and social class, their personal outfits can actually be offputting for the elderly. (In one psychiatric hospital in Cambridge that discarded uniforms, some patients started playing ‘doctor’ with other patients.)
• Someone who is now obviously extremely old and weary - and people age at different rates - and not just sick, should be spared much testing and wheeling hither and thither and physiotherapy unless they brighten up at this attention. CAT scans and stripping naked can be felt as indignities and weary trials. Hospital expense here can be reduced. Relatives and patients attitudes can be ascertained on this. Perhaps some want heroic measures - others may be upset at antibiotics for pneumonia.
• Collecting personal belongings after a death. Some hospitals let relatives take these home, if they would like to, with staff putting them together at the time, with anything in the laundry collectable later. This could prevent the ‘disappearance’ problem.
• High on the priorities for any medical and social research, something needs to be done about the increasing bind placed on institutions, hospitals and staff by the fear of litigation, which is increasing the trend to test for everything and to behave defensively rather than sensibly. This is a complex subject, and does require multidisciplinary research. High insurance premiums are not the answer. Some form of protective legislation plus some form of public education about Doctor is not God perhaps. The American precedent is frightening. Australia could well give a lead in solving the dilemma of really protecting against malpractice and also being free to act in the best interests of the patient without fear. The elderly should not be wheeled off for tests and treatment that will not actually solve anything but are playing safe or training students, unless they welcome the diversion or have everything explained and they are cheerful about it.
• To train all the staff on how to put the most important things for the patient ahead of the rituals and the tests and even the meetings - important as the meetings are for the staff's needs. This does not need expensive courses. It should need a one-half-day inclusion in all training for new staff, and inclusion in a manual of patient practice.
• Finally, in assessing a patient as suffering from dementia, staff should take relatives’ opinions into account, since any old person can quickly appear demented under strain, and brain scans do not show how much some people can apply in the way of intelligence when even a great deal appears to have gone. Depression is often the major determinant of apparently senile behaviour.
The following recommendations are not in order of priority.
•. To take seriously the records the patient brings, and what the relatives say, rather than take the very common tinge-of-pride attitude of 'starting diagnosis from scratch' and ignoring the past. Put both old records and new findings together.
• To put a high priority on the dignity of the old person - and
that means more attention to bowels and bladder than to clever tests to help train medical students. Even into the 1960s elderly patients at Kew were lined up on concrete and hosed down, but still today there are many places where nursing staff find it easier to chuck filthy linen down the chute than to attend to patients’ elimination when they need it.
• Prevention. Many illnesses and troubles of the elderly are preventable earlier. We are very aware now of preventing typical problems of age by avoiding smoking, obesity, and alcoholism, and becoming aware of osteoporosis. There are other great troubles that most people are not aware may be ahead of them, e.g.
Varicose veins turning into ulcers. e.g. most women with varicose veins/ hemorrhoids have them because their doctors did not warn them immediately they were pregnant or before against constipation and recommend bran in the diet rather than laxatives.
Jawbone deterioration because teeth do not meet. Dentists should be more attentive to preventing this.
Increasing senility by being treated as stupid or unwanted.
Deafness through too much exposure to loud music
Later visual problems through too much exposure to electronic screens?
Mental deterioration through rust. (I am interested in this area as a psychologist.)