What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Tuesday, May 09, 2006

The Sunset of Your Life.

In the spirit of being constructive and not just criticizing the present day care of our elderly, I thought I would consider some aspects of long term institutional care for the elderly that could be considered ideal and doable. To do this we will have to look at the needs of the elderly based on their known common problems, and modalities and approaches that have been shown to be effective.
1) Exercise: This is probably one of the greatest short-comings in our present day long term care institutions. I recall a study done that took elderly nursing home residents that were confined to wheel chairs, and had them do five minutes of upper body exercises three times a day. The particular study was designed to look at the effect of exercise on bowel function, but at the end of two years the group on this simple exercise protocol not only did better in respect to bowel function, but also appetite, sleeping, behavior and other parameters. This protocol was not implemented in the nursing home as an ongoing practice because of staff shortages. Many nursing homes have access to a physiotherapist, and this is useful, but for the most part the physiotherapist is asked to address specific issues. Recreational therapy is also often available, but many of our seniors are not accustomed to the “ideology” of recreational therapy. Walking is an almost universal form of exercise for our seniors. Unfortunately with our long icy seasons in Canada, outside walking is prohibitive and dangerous many months of the year. One of my 90+ year old nursing home residences walked outside in the parking lot even with snow blowing and freezing temperatures, and in spite of the fact that she was legally blind. I admonished the staff for not accompanying her and they informed me that they simply did not have the staff for one to one activities such as outside walking. Needless to say, this particular nursing home had nothing but hallways (lined with wheel chair patients) to accommodate her walking indoors. For those seniors that have problems precluding walking, hydrotherapy is very effective. Walking in water holding onto rails takes weight off of the weight bearing joints such as knees, feet and hips, and the water offers resistance that increases the work load. Unfortunately, this also requires personnel and supervision.
In summary, an ideal facility should have an area that is reasonably pleasant and safe for patients to walk, a recreational program, a physiotherapist, a hydrotherapy pool, a walking pool, and sufficient staff to meet safety criteria (the staff need to be capable but not necessarily highly trained). I find it interesting that the newer hospitals (where early discharge is the imperative) have open spaces for patients to walk, but in our nursing homes where patients will spend the rest of their lives, our elderly have to walk in crowded wheel chair areas or parking lots.
2) Socialization: The mind is similar to the body; if you don’t use it, you lose it. Although group socialization for some patients is helpful, many patients, because of problems such as decreased vision, hearing, or social skills, find group socialization stressful and are unable to benefit from groups. However, one to one socialization is a benefit to all. This is an area where staff can be extremely helpful. Interaction between the patients and all members of the staff is extremely important. The people cleaning, preparing meals, nurses, etc, should always take an interactive role with the residents. Asking about relatives, the day of the week, the weather, any kind of interaction, has been shown to help delay dementias, prevent aberrant behavior, prevent depression, and be therapeutic. Since hearing is frequently a problem with the elderly, speaking slowly and clearly, face to face is best. Because once again this is an area where staff shortages play a role, an active volunteer program would be great. Ideally, other healthy aging people are best, although I have seen elderly patients respond dramatically to High School and University students as well. One elderly lady who was actively visited over a long period of time by two young college students, decided to help them financially complete their studies. Perhaps programs could be set up in schools where as part of a health-science program, students could spend a period of time with institutionalized seniors and write a report on their experience for study credits. So let’s add a very active recruiting program, and community integration programs, to our ideal nursing home. Unfortunately, at present, most interaction occurs in a group setting (lack of staff and cost effectiveness).
3) Professional Staff: There has been a continual downgrading of professional staff in our long term care facilities. Not only have there been inadequate staff-to-patient ratios, but there has been an ongoing trend to replace R.N.s with L.P.N.s. The chronically ill elderly are the most vulnerable in our society. They are often on many medications and need close and careful monitoring. Yet, during some shifts in large nursing homes, only one R.N. may be on duty and be responsible for the L.P.N.s, any physician communication or orders, critical nursing assessments, etc. A clear understanding during conversations when a physician is receiving information and giving orders to deal with this fragile group of patients is vital, yet it is not unusual for the nurse supervisor and other care givers to have English as a second (and weak) language.
So we will add, not only increasing numbers of care givers to our ideal facility, but increasing numbers of R.N.s with a special interest and training in geriatrics.
I will close today’s blog for now and complete my “ideal nursing home” wish tomorrow.

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