Managing Stress

Set Worries Down

The instructor of a stress management class walked into the room holding out a half glass of water. Everyone in the class thought they knew what was coming: “Is the glass half full or half empty?”

But the instructor surprised the students by asking with a smile, “How heavy do you think this glass of water is?”  People called out answers ranging from 6 ounces to 20 ounces.

The teacher replied, “It changes.  It depends on how long I hold it—the absolute weight doesn’t matter.  If I hold it a minute, it is light.  If I hold it an hour, it is heavy and I will have an ache in my arm.  If I hold it for a day, it will be too heavy to lift and I will drop it. 

“It seems the longer I hold it, the heavier it becomes.  If, however, I set it down when it feels heavy and rest a while, I have the strength to hold it again.

“It is the same way with stress,” she said.  “If we carry our burdens all the time, sooner or later, the burden becomes too heavy and we won’t be able to carry on.

“Just like with the glass of water, you have to put down your burdens for a while and rest before shouldering them again.  When you are refreshed, you will be able to take up the burden, stronger again.”

So, put aside your burdens whenever you can; they will still be there after you have rested and you will be able to carry on as strong as ever.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Old Person Smell

Is there really such a thing as “old people smell,” or is it in your imagination when you visit seniors who look right at home among their antiques?  A recent study says young people really can identify such a smell, and old men smell the best.

Research

Just how do you go about proving this?  Johan Lundström and his colleagues at the Monell Chemical Sense Center in Philadelphia collected the underarm scents of people in three age groups: 20-30 years old, 45-55 years old and people 75-95 years old.  Then they had other young people (ages 20-30) sniff the armpit pads.

Collecting Scents

The researchers had the participants wear the same T-shirt to bed for five nights.  The shirts and sheets had been washed with scent-free detergent and the participants washed with scent-free soap every night.  They also agreed not to smoke, drink alcohol or eat foods that are known to cause body odors. Special pads were sewn into the underarms of the T-shirts to collect their body’s scent.

Ratings

The people doing the sniffing rated the pads on pleasantness and intensity and had to guess which of two odors came from older participants.  Then they were instructed to label all of the armpit pads by age category. 

Although they had trouble distinguishing between the young and middle aged people’s pads, they were able to correctly determine which came from old people more often than would be randomly expected.  Evaluators used words such as “earthy” and “mild, like stale water” to describe the odors of older people.

“These elderly odors were very distinct and easy to group together,” says Lundström.  The study found that the armpit pads from old men were rated the most pleasant, especially compared with middle-aged men, although the odors from old women were rated behind those of middle-aged women.

Lundström and his colleagues concluded that if you associate the scent of old people with something negative, it is likely to have more to do with context than the actual odor.

The study was reported online May 30, 2012 in PLoS ONE.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Managing Agitation in People with Dementia

Agitation in dementia has many possible causes.  It can be a result of degeneration of the nervous system which may lessen a person’s ability to cope.  Another huge factor is that the resident is unable to communicate a need.

Six Triggers
Researchers have identified six main causes of agitation in dementia.  As caregivers, it is our job to do the detective work to find out what the cause might be.  We need to imagine ourselves in his or her shoes to help figure out the trigger.  If at first you don’t succeed…be persistent, keep digging!  And always consider a combination of factors.

Fatigue: Most of us tend to be more irritable when tired and people with dementia are no exception.  Did the resident get enough sleep last night?  Has he had more activity than usual today?  You can ask, “Would you like to rest now?” 

Change: People with dementia usually like routine—everything done the same way, at the same time, every day.  What’s different today?  Think of anything new: maybe a new caregiver, clothes, holiday decorations or a change in lunch time or bath time.

Perception of loss: If the resident is reliving a loss such as the death of a loved one, empathy followed by distraction may work to divert the person’s attention.  If the loss is the perception that something has been taken, help the resident to look for it.  If the loss centers around money, it may help the resident if the family will bring in some loose change to keep in the resident’s pocket so he can be reassured that he has his money or his wallet.

Stimulus levels: Consider the environment.  What is going on around the resident?  Some people react negatively when there is too much noise, too many people or too much activity.  Others may tolerate this normally, but react badly when they are more tired.  This might be a time to walk the resident to a quiet area or his or her room where they have a chance to feel calmer.

Is it possible the resident is under-stimulated?  Could he be bored or restless?   Perhaps he or she needs physical activity such as a walk outside.  Could she be lonely?  You can ask family members to make a video of themselves doing routine activities for the resident to watch when she misses them.

Excessive demands: With dementia comes the loss of the ability to process multiple thoughts at one time.  People with dementia can’t multi-task or multi-think.  So we need to be careful in our communications that we only make one brief request of them at a time.  Saying “Brush your teeth, then you can get into your pajamas and ready for bed” may simply be too many concepts.  You may be more successful breaking it into bite-sized chunks: “Now it’s time to brush your teeth.”  When that is accomplished: “Now it’s time to put on your pajamas.”

Physical stressors: Rule out pain: it could be a headache, a pebble in the shoe, a stomach ache, a urinary tract infection or clothes that are too tight.  Look for signs of injury: red spots or bruises, limping, a bump on the head or holding a body part.  Look for signs of infections such as a rash, redness, runny nose or strong smelling urine.  Could the resident feel cold or hot and unable to tell you?  Is he or she uncomfortable due to wet briefs?

Communication

One of the greatest frustrations of having dementia is not being able to clearly communicate your wants and needs.  But we can do a lot to facilitate better communication.  First we need to make sure the resident is ready to communicate: are his glasses clean?  Is her hearing aide in, turned on and does it have a good battery?

Now the resident may be ready to communicate, but are YOU?  You should identify yourself every day, sometimes more than once a day.  Don’t assume the resident will remember you just because he knew you last week. 

Key Principles

It is essential that you know what the person’s limitations are.  If he or she has had a stroke it is important to know what parts of speech and thinking were affected.  Sometimes a stroke leaves the person unable to understand speech, other times he understands but cannot get the right words out.

Remember that agitation is a symptom that means something else is wrong.  It is the job of caregivers to figure out what the real cause is.  So when the resident is agitated, put on your detective hat and see if you can’t solve the mystery at the bottom of the behavior.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Cultural Sensitivity in Caregiving

One definition of culture:  "The constellation of values, norms and behavior guidelines that are shared by a group of individuals."  -Reflections on Nursing Leadership, 1st Qtr 2001

American medicine applies certain bio-ethical principles, such as autonomy and truth-telling, that can be at odds with the values of some of the many cultures found in the Bay Area.
 
These Western bio-ethical principles are based on Anglo-European values, which are also reflected in American law.  People from other cultures, whether caregivers, patients or families, may bristle when healthcare providers attempt to adhere to these values.

Withholding from patients information needed to make informed treatment decisions is illegal. Yet in many cultures telling patients negative information about their health condition is harmful to the patient.  Talking to the patient instead of the oldest child may also be seen as an infringement on the proper role of the family.
 
Distrust of the system

Significant distrust of the healthcare system exists.  In a group of culturally mixed elders in New York City researchers found: 

• Many equated less aggressive treatment with abandonment.
• Many thought having an advance directive was harmful, especially if it burdened one person.
• Most were reluctant to name anyone but a family member as a proxy or agent. 

Another example would be the African-American history of slavery and exploitation as test subjects.   African-Americans are half as likely as Anglos to opt for treatment to improve quality of life at the expense of length of life, even if pain will be constant. 

People that are poorer or socially disadvantaged expect to be denied care and often regard advance directives as legal devices of the health care system to deny care.  Some close-knit families feel that advance directives are destructive, and are incredulous on learning about laws that conflict with family decision-making.

One pattern seems to transcend almost all cultures: the elderly tend to have and prefer a passive voice in decision-making (e.g. “Doctors do the best they can”). 

Cultural multiplicity

In one culture illness may be seen as a test of faith and withdrawing treatment may be construed as interfering with God’s will, while in another using extraordinary treatments may be considered interfering with God’s will.

Pacific Island cultures may feel dying outside the home will leave the departed wandering without a place to rest while in another Asian culture, Chinese, death may be seen as a harbinger of more bad luck for the family of the deceased, so the patient may want to avoid dying at home. 

In many cultures, language and thought shape reality.  Talking about death must be avoided in places as diverse as Greece, China, Italy, Mexico, Korea, and countries in the Horn of Africa.

Can’t Know All Cultures

Clearly, we cannot know all cultures.  So how do we go about being culturally sensitive?  Proceed with caution.  Here are some things to bear in mind when working with a culturally diverse population:

• Not all members of a particular culture share the same beliefs.
• Find out how much the resident wants to know.
• Ask who the patient would like to be informed about health issues.
• Ask who to discuss treatments and outcomes with.

Above all, leave your cultural beliefs at the door when you go to work.  Deciding what the patient should or should not know is a form of paternalism.  It is also a distortion of the healthcare provider’s role as a patient advocate.

Consider taking a “values history.”  Find out:

• The patient’s perception of roles of caregivers and physician.
• The importance of self-sufficiency to patient.
• His or her attitude toward life (what brings enjoyment).
• What the patient fears most.
• What would be important to the person when dying?
• What is their religious background and belief system?

Although we want to avoid stereotyping, generalities can be useful: “I know that in some families of your culture we see [                   ].  Is this true in your family also?”

In a nutshell

Cultural sensitivity can be reduced to a few simple concepts:

• Leave your own cultural beliefs and biases at the door.
• Ask questions, then listen.  

Bio-Ethical Principles

• Autonomy: individual rights trump all
• Truth-telling: patients have a right to full disclosure
• Justice: resources should be equitably allocated.
• Confidentiality: Patients have a right to privacy
• Beneficence: act in the best interest of the patient
• Non-malfeasance: do no harm
• Responsibility: agree and adhere to regimen

At Pathways...

Early during the admission visit, the nurse asks the patient how much information about their health condition they would like to know, and whether they want to make their own healthcare decisions.

If they do not want to be the decision maker or know about their condition, we ask who they would like us to speak to.

If the patient does not speak and understand English very clearly, the nurse calls the AT&T language line and asks these questions via a translator. At subsequent visits a family member may translate.

Documenting this exchange meets the ethical principles of autonomy and truth-telling while respecting the patient’s cultural beliefs.

Dental Hygiene Related to Heart Disease

New Evidence

You may not be a dentist, but get those patients to brush their teeth! People who brush their teeth less than twice a day run a higher risk of heart disease. These are the findings of a recent study published in the British Medical Journal.*

This is the first study of its kind and confirms the established fact that inflammation in the body (including mouth and gums) plays a significant role in the formation of atherosclerosis. Researchers analyzed health data from 11,000+ adults. After adjustment for established risk factors, the study found those with poor oral hygiene also had increased levels of C-reactive protein and fibrinogen. 

Personal Care Services at Pathways 

Pathways Private Duty provides care to assist older adults and the chronically ill in their activities of daily living, as well as with meal preparation, exercises and medication reminders.  Our caregivers can also help with personal care such as bathing, grooming, and oral hygiene.  

When it's time for care in your home, Pathways is here to help.  Give us a call today at 1.888.600.2273 to arrange for an evaluation and assessment of your needs.

*Published online May 27, 2010 in BMJ; corresponding author is Prof Richard Watt (University College London, UK.)

When It Comes to Hospice, What's In It for Families?

We Know What Patients Get

The multiple advantages of hospice for the family are often lost in our natural concern for the patient.  We know the patient gets to stay at home with expert pain and symptom control as well as spiritual and emotional support.  We know they have volunteers for companionship and the safety and energy conservation provided when a home health aide assists with personal care.  And of course, there are the extras like massage with aromatherapy and music therapy.

“Unit of Care”

But how does the family benefit?  In the very unusual insurance benefit that is hospice, Medicare defines the “unit of care” as the patient and family—and family is loosely defined to include close personal friends and significant others.

Relief from Caregiving

One of the pluses caregivers love most is relief from being the caregiver.  It may be a couple of hours at the bank and beauty shop while a volunteer sits with the patient; it may be a 5-day paid respite stay in a skilled nursing while the caregiver recharges her metaphorical batteries; it may be a home health aide to do the physical care of bathing, dressing, shaving and linen changes several times a week; or it could even be a volunteer to grocery shop, run errands or walk the dog.

Emotional and Spiritual Support

A family at odds about healthcare goals may have a conference facilitated by a hospice social worker.  There is some financial relief as hospice assumes the cost of medications, equipment and supplies related to the terminal illness—even over-the-counter products and disposable briefs.  Then there is the assistance with funeral plans or insurance issues from skilled medical social workers—and sometimes a spiritual care counselor to preside over a memorial service or to pray with family members.

Easing the “Burden”

Those approaching the end of life often express regret over their perception of being a burden.  It is a relief to them to find out that family members can call hospice 24 hours a day to talk to a nurse or arrange a visit if needed, and that their families can have the same spiritual and emotional support that they get.  Patients are also comforted to know their family will have 13 months of support in their bereavement.

Time

And perhaps most important of all, because people who opt for hospice often live longer, patients and families have a few more cherished days or weeks to share this precious finale to life.

And Benefits for the Physician?

• Physicians get fewer calls at night and on weekends
• They have extra eyes and ears in the home. 
• Doctors get to be the heroes by giving patients and families better quality, and often quantity, of life.
• Physicians have hospice medical directors with whom they can consult on complicated symptoms.