A Resiliency Solution to Eliminating Those Things That Cause Elders Difficulty and Drive Up The Cost of Care

Seeing Things in a New Way

The Southeast Advocacy Center for Elder Rights

Chattanooga, TN

 

 

 

 

What Gets Elders in Trouble and Drives up the Cost of Care?

And…

How the Development of Resiliency Could Improve the Lives and Outcomes and Reduce the Costs of Care for Elders Everywhere

 

The way services are provided to elders contributes to limiting their ability to live out their lives with meaning and purpose, being functionally independent and paying their own way.  The development of Resilience as the foundation for Culture Change in Elder Care provides the foundation needed to solve many of the problems.

 

1.       There is a cultural assumption that older people are just going to deteriorate and need to become “patients” at the end of their life which results in:

 

·         Failure to implement strategies that will help the elder bounce back from infirmities;

·         Failure to implement strategies that will help prevent debilitation if an elder is ill;

·         An assumption that older people who are confused or having trouble thinking have progressive dementia of some type and simply must be locked up;

·         An approach that looks at elders primarily as a worn out body and surrounds them with medical monitors, rather than looking at them as a whole person;

·         Failure to successfully recognize and address psychological, cognitive, and spiritual issues that have a substantial impact on physical health as well as overall well-being.

 

If Resiliency were adopted, there would be a more optimistic handling of the current circumstances, looking for the best possible outcome; “care plans” would look at the whole picture of the elder’s life and how to maintain it in a way to assure meaning and purpose; More creativity would be used in figuring out how to help elders avoid infirmities or bounce back from them. 

 

2.       There is disengagement from life among elders that brings with it a host of medical problems because there is:

 

·         No system to help elders retain or regain a sense of meaning and purpose for their lives;

·         An erroneous cultural belief that an older person no longer has anything to offer;

·         Limited resources to help elders develop and maintain resiliency in the light of life   changes that may be occurring;

·         Limited spiritual resources to help elders continue to grow and contribute to the lives of others, sharing wisdom they have developed over a life time;

·         A lack of recognition that disengagement is a psycho/spiritual problem that needs an intervention, not the normal final step in living;

·         Failure to develop treatment protocols for “demoralization” as a significant psychological diagnosis different from depression (largely because there is no “pill” for it).

 

If a Resiliency model were in place, the elder’s limitations would be seen with an understanding of the problems but optimism about how to work around them to continue to maximize the person’s contribution to life and ongoing growth; creativity would be consistently used to help keep elders in the game of Life.

 

3.       Elders fail to move around, adopting a largely sedentary life style because:

 

·         The elder thinks they are too old for “exercise” or it is too hard;

·         Elder women were not led to value exercise as young adult females;

·         There is a limited understanding of other ways to get exercise and the desirability of getting it in ways that do not seem like exercise (e.g. sweeping floor, grocery shopping, gardening, etc.);

·         Elders are not aware of easy exercises that are simple and safe to do;

·         There is a need for more ways to make exercise and movement easy and fun for elders;

·         Physical therapy to get elders moving is underutilized but vital in overall medical care.

 

A Resiliency approach leads to professionals and elders all recognizing that even if debilitated, they can regain functioning; there would be a commitment to maintaining or regaining the movement needed to continue to live a life of meaning and purpose; there would be more creative approaches to stimulate and facilitate movement and regaining of function on the part of elders.

 

4.       Elders quit doing Activities of Daily Living for themselves, losing the ability to ever do it in the process because:

 

·         Care assistants that help them are trained to “do for”, rather than to help elders “do for themselves”;

·         Care givers use “custodial” care approaches rather than “rehabilitation” approaches, often adding to the problems the elder is having;

·         Elders do not have adaptations that keep them doing as much as possible for themselves (ranging from pill dispensers to tub transfer benches to Velcro fasteners on clothing, etc.);

·         Those helping elders often think they are doing a good job when instead they are contributing to debilitation;

·         Facilities sell “help” that actually makes elders more infirm due to both a misunderstanding of the importance of “how” help is delivered and a false belief that it makes more money (which is only short term);

·         Care assistants are under trained and think it is easier to “do for”, so don’t bother to provide care in a way that promotes independence;

·         Elders can be led to think it is ideal to have someone “do for” them, not realizing the problem it creates for them long-term;

·         The way care assistance is delivered, negates the value of physical and occupational therapy being delivered,  preventing the elder from reaching their potential to bounce back;

·         There is inadequate utilization of occupational therapy to improve Activities of Daily Living due to the belief that the elder can’t improve or because third party payers will not cover because they make more money if the elder does not bounce back and is moved into long-term care.

 

Resilience recognizes that the elder may have current limitations, but with the right kind of help can regain functioning; Creativity will develop ways to help the elder compensate for limitations they cannot regain, and all will work together to be certain there is adequate function to do all those things that historically have made this elder’s life feel worth living.

 

5.       Falls cause significant impairment and high costs in elders and often occur because:

 

·         Wrong assumptions are used as to how to prevent falls encouraging less movement when more is actually indicated;

·         Elders are placed in wheelchairs instead of getting strengthening of muscles and improvement of balance through therapy;

·         Elders are “alarmed” and not allowed to move instead of trying to maximize movement;

·         Staff does not understand that what increases the risk of falls is inactivity and loss of muscle strength and balance;

·         There is inadequate utilization of physical therapy because of the belief that an elder cannot improve or because third party payers do not have a commitment to the elder being able to bounce back, preferring their placement in a long term care facility where their financial obligation ceases;

·         An erroneous assumption by some physicians and even physical therapists that someone with dementia cannot benefit from therapy, when, in fact, they can benefit a great deal;

·         Elders wearing shoes that are not stabile for ambulation due to other foot problems that have not been addressed;

·         Inadequate transfer skills, walking skills, etc. on the part of care staff, resulting in poorer elder outcomes and greater risk of caregiver injuries;

·         Failure to look for causes of falls other than old age or lack of use (e.g. medications, infections, etc.).

 


 

Resilience recognizes that falls are not a normal part of life for elders and with some appropriate interventions can be prevented in ways that improve the elder’s overall functioning and enable him or her to remain engaged in those things that matter; Creativity nurtures approaches that may be unusual but successful to help the elder reduce the risk of falls while fully living life.

 

6.       Elders with cognitive impairment are not treated in ways to maximize their potential:

 

·         Elders are labeled as having “dementia” or even Alzheimer’s using “Diagnostic” approaches that are almost always superficial and inconsistent with scientific knowledge of dementia, yet are widely used for their convenience;

·         At times neuro-imaging is used to label dementia, yet results do not correlate with  functioning on many occasions, but this difference is not considered;

·         Other, more likely causes of cognitive impairment are ignored (medications, infections, depression, etc.);

·         There is an erroneous belief that people with dementia aimlessly wander so must be locked up; this is further encouraged because “locked dementia units” bring in more revenue and are thus promoted by facilities;

·         There is an erroneous belief that people with dementia cannot learn, so services to help them bounce back are denied them;

·         Specialized “Memory Units” are usually staffed with people with very limited extra training and often “manage” behavior with drugs only and care is “custodial” not “therapeutic”;

·         There are very limited “therapeutic” programs to help people retain or regain cognitive functioning, yet they are capable of doing so but are denied this opportunity.

 

A Resiliency approach recognizes that even in the presence of some cognitive difficulty, much can be done to regain and retain cognitive functioning in a way that facilitates active participation in life. Maintaining a normal life style instead of becoming progressively demoralized and withdrawn from life will be recognized as vital for those with dementia. Creative approaches to care can make it possible to develop more effective living settings and improve therapeutic results.

 

7.       Wrong medication or too many medications taken together cause unnecessary impairments in elders because they are used widely and minimally monitored:

 

·         Medications that cause cognitive impairments are often unrecognized and could be changed to a medication with fewer side-effects, but because the person is old the assumption is made that the symptoms are simply due to old age;

·         Medications have rarely been tested in elders, therefore the side-effects are under documented;

·         Poly-pharmacy is common in elders and the impact of numerous drugs in combination has not been researched at all;

·         Drug Cascade, in which new drugs are prescribed to counteract side-effects of other drugs is very common, adding to impairments, but often missed as the cause of the problems   because of Ageist expectations of infirmity;

·         Alternatives to medications that are equal to or even more effective are underutilized because they are unknown, considered “out there” or because they are too much trouble (meditation, engagement, yoga, relaxation exercises, massage, exercise, etc.).

 

A model of Resilience will seek solutions to problems caused by medications, assuring that they are fixed rather than ignored and attributed to old age; Understanding what the elder needs to maintain their total life functioning will drive prescription drug use, avoiding, if at all possible, any medication that robs the elder of a normal life; Creative strategies for improving pain, lowering blood pressure, or other problems will be developed to substitute for those medications that prevent elders fully living life.

 

8.        Depression is underdiagnosed and often inappropriately treated in elders:

 

·         Ageist assumptions hold that old people are down in the dumps, so symptoms of depression are often ignored as what can be expected as one ages;

·         Treatment of depression is largely limited to antidepressant medications that often have side-effects and have been found to be largely ineffective except in cases of severe depression;

·         Psychotherapy is rarely prescribed, especially if a person has some memory problems and due to an erroneous belief that older people cannot change;

·         There is an erroneous belief that elders with some cognitive problems cannot benefit from psychotherapy;

·         Strategies that have been found to effectively combat depression by producing endorphins, the body’s natural antidepressant, are not widely recognized or utilized (exercise, humor, thankfulness, helping others, etc.);

A model of resilience recognizes that depression in elders is quite treatable and vital in helping preserve their life in a meaningful way; In addition to professional psychotherapeutic intervention, creative strategies will be developed for providing therapeutic opportunities for elders in churches, community groups, or other settings.  These types of opportunities are valuable in general and even more so when payment for professional psychotherapy is not available.

9.        Medical problems are not identified and treated early, resulting in unnecessary hospitalizations:

 

·         New cognitive impairment is ignored because it is seen as part of normal aging instead of recognizing that it can be a symptom of a medical problem (urinary tract infection, medication side-effect, dehydration, depression, Vitamin B-12 deficiency, oxygen deprivation, transient ischemic attack, etc.);

·         Falls are looked at as a normal element of aging instead of suspecting a treatable medical condition (infection, medication side-effect, over-medicated, need for regular exercise or perhaps physical therapy to reverse the debility related to a prolonged sedentary life style, etc.);

·         Withdrawal, sleeping constantly, missing activities are seen as “just getting older” instead of recognizing a treatable medical problem (disengagement, depression, over-medicated, etc.);

·         Respiratory Distress may be ignored as simply age related deconditioning instead of recognizing it as a treatable medical problem (respiratory infection, failure to take medications, failure to use prescribed oxygen, need for rebuilding endurance, etc.).

A model of Resilience recognizes that elders can avoid debilitating problems when symptoms are caught early; that it is important to be sure an elder’s physical well-being is maintained to help preserve their psychological, cognitive, social, and spiritual well-being; Creative strategies make sure elders can get what they need in a minimalist way to avoid more serious problems.

10.    Hospitalizations can easily create problems that drive up costs and prevent the elder from ever being able to return to home by:

 

·         Overprescribing sedating and cognitive impairing medications that hastens deconditioning;

·         Use of a catheter for convenience that then becomes permanent;

·         Failure to get the elder  up and moving and allowing them to lay in bed (or not doing range of motion exercises) resulting in both debilitation and increasing the likelihood of decubitus ulcers or other medical complications;

·         Failure to have an accurate preadmission baseline of cognitive functioning to know what impact current medications are having on cognition;

·         Failure to use extreme care in anesthesia with older adults, resulting in serious cognitive impairment that could have been prevented;

·         Failure to develop the discharge plan from the first day in a way that targets the necessary function needed to return to normal life (rather than just discharging to long term care as a matter of routine).

·         Failure to coordinate with long term care settings to get medications, therapy, etc. in place from the first hours of return.

 

A Resilient approach among hospitals will assume that elders must be discharged to home to reclaim and continue their life as they have known it; Creative strategies are developed to make sure that occurs rather than simply dumping the person into a nursing home as the easiest discharge.

 

11.   Assisted Living settings can actually deteriorate elders, making them unnecessarily debilitated and driving them into more expensive nursing home care by:

 

 

·         Failing to look at the whole person and provide programs to help them thrive, not just survive;

·         Failure to have prevention and early intervention systems to avoid medical problems and disability;

·         Failure to provide help in a way that  retains and helps regain functioning, instead contributing to deterioration;

·         Failure to coordinate closely with medical system, leaving that totally to elder and family which results in much poorer outcomes;

·         A lack of skills in integrating people with dementia into a normal setting to maximize their retained abilities, instead shifting anyone with cognitive problems into a locked memory loss unit;

·         Emphasizing their “fine hotel” approach that quickly sends residents with impairments to nursing homes because they no longer “fit in” there.

A Resiliency approach to Assisted Living recognizes that most elders have the ability to age in place and to bounce back from any infirmities; There is the recognition that every effort needs to be made to maintain a whole life for the elder, psychologically, socially, cognitively, spiritually as well as physically; Creative approaches to care delivery and service models maximize elder potential in that setting.

12.    Medical care fails to try to understand an elder-focused approach to care consequently physicians, nurse practitioners, nurses, therapists, and others:

 

·         Have  a “body as machine” approach to care;

·         Over prescribe medications without really being able to monitor serious side-effects;

·         Assume medication side-effects are instead the effects of advanced age so miss the  opportunity to prevent more serious problems;

·         Have an “elders belong in a nursing home” mind-set that misses bounce back opportunities;

·         Have little understanding of the person psychologically, cognitively, socially, and spiritually but still make life changing recommendations based only on physical functioning;

·         Have the same Ageist attitudes as rest of the population which unnecessarily limits elder’s potential;

·         Due to limited time spent with the elder patient, uses medication as treatment of choice instead of exploring other, more creative possibilities. 

Resilience results in seeing the highest possibilities for elders and always working to achieve that result; it is passionate about seeing the person as a whole being – not just a broken body; Creative strategizing develops new options for elders where they can truly thrive, not just survive.

 

Antidote for Current State of Dealing with Elders:

Develop Resilience in Not Only Elders, but Also in Health Care Providers and Family Member Advocates.

Resilience = Reality with Optimism

Resilience = An Understanding and Focus on the Bigger Meaning and Purpose of Life

Resilience = The Creative Ability to Improvise and Find Multiple Strategies That Could Work

1. Reality with Optimism – Self talk that considers the current circumstances accurately and then envisions a hopeful and positive outcome;

Constructive self-talk is rooted in:

·         Seeing the current situation as a single problem to be address (not generalized to “usually” or “always”); and not seeing it as attacking you, personally but merely as the present circumstances;

·         Recognizing that the current problem can be satisfactorily addressed and resolved.

  Requires:

·         Commitment - Staying engaged in the current situation and committing to successfully ride it out.  Avoid denial of the issues or bailing out;

·         Agency – retaining an “I can do this” attitude which leads to effective action;

·         Challenge – Seeing the current issues as a challenge that can be addressed and solved successfully in a life affirming manner.

2. Bigger Meaning and Purpose for Life

First step is Being Wise Selfish (the Dalai Lama’s term)

·         Getting out of yourself;

·         Helping others;

·         Developing altruism.

Focusing on the big picture of life and what it is all about:

·         Recognizing your gifts;

·         Sharing them with others.

Understanding that current challenges need to be considered in light of:

·          What gives meaning and purpose to your life;

·          What you feel passionate about;

·          How you are contributing to the bigger picture of Life

·          How you are continuing to grow;

·          What keeps you interested and engaged in living.

3. The Creative Ability to Improvise and Find Multiple Strategies That Could Work

Starts with recognizing there are multiple answers:

·         Being open to “out-of-the-box ideas”

·         Being flexible, letting go of “should's” and “have-to's

·         Enjoying the creative problem solving process.

Determine the basic elements that must be addressed to achieve your goal(s), and recognize that there are many ways that it can be done:

·         Look for 20 legitimate strategies;

·         Brainstorm, stretching your imagination;

·         Ask what others have done that is creative or interesting;

·         Consider if there were no limits, what could be done.

Analyze possible strategies, asking “How could we do this?” rather than discounting the possibility:

·         Consider how you could do each approach;

·         Determine resources you would need and creative ways to obtain them;

·         Determine likely results of each strategy;

·         Select the best three;

·         Develop a feasible action plan;

·         Try one; knowing you have two others waiting in the wings if that doesn’t work.

 

 

          

A Resiliency Solution to Eliminating Those Things That Cause Elders Difficulty and Drive up The Cost of Care

Seeing Things in a New Way

The Southeast Advocacy Center for Elder Rights

Chattanooga, TN