depression

To Walk or Not to Walk?

I often have families of patients express concern about how much mobility a person with dementia should be allowed. Elders with dementia often want to move in ways that seem excessive to the rest of us: They may wave their arms all the time. Or they may pound their feet on the floor. Most often, they want to walk.

I have had many patients who simply want to walk all the time: Up the hall. Down the hall. Around the garden. Around the garden again. Hour after hour. Day after day.

Invariably, this raises concerns, both for families and for caregivers. What if an elder has less than perfect balance? What if an elder doesn’t have an accurate assessment of risk? What if the elder falls? How should we balance the elder’s desire to move and walk with understandable concerns about safety?

If at all possible, I try to work with families to create an environment in which the elder can move around. Dementia patients often experience agitation and anxiety, moving around is one way that patients cope with those feelings. Walking, and other kinds of movement, not only relieve stress but tone muscles and strengthen bones.

As a geriatrician doing house calls around the San Francisco Bay Area, and as the medical director of an assisted living facility for dementia care, I do not use restraints. I find that there are almost always better, and kinder, options.

Instead of tying down a patient, I try to answer questions like these: Are there ways in which the elder’s physical environment can be changed to allow movement yet make falls less likely? For instance, are there obstacles that might be removed, or area rugs that might be pulled up? Would it be possible to install railings or handles that might steady an elder as they move? Is the elder taking medications—like sleeping pills—that might affect balance and increase the risk of a fall? If the patient wants the freedom to get out of bed, might it make sense to use a low bed and a mat, or perhaps, to put the patient’s mattress on the floor?

Of course, even with preparation and one-on-one supervision, there is no way to guarantee that an elder won’t fall. It’s important for each family to have an in-depth conversation with caregivers and the medical team. Each family will have different priorities, and of course, that should be respected.

But if at all possible, I try to help my patients keep on trucking. For one patient, that might mean walking. For another, it might mean just waving their arms, or perhaps twirling around. Elders are usually happier, and healthier, when they have the freedom to move.

Elizabeth Landsverk, MD

Board Certified in Internal Medicine, Geriatrics

and Palliative Care Medicine

Don’t Discount the Value of Exercise!

swimmers-225x133Earlier this month, a large study cast doubt on whether exercise can help nursing home residents with depression. The study, published in BMC Medicine, followed more than 1,000 residents in 78 “care homes” in the United Kingdom. It found that the number of elders who participated in exercise classes was low, only about half of the residents attended classes. And it found that only 36 percent attended an exercise class once a week, and that depressed patients attended exercise classes even less frequently than that. It concluded that perhaps nursing home patients are too frail, both physically and mentally, to exercise enough to ease symptoms of depression.

It’s clear that, in this study, exercise alone did not work to help patients suffering from depression.

But I would be very distressed if this study led families and caregivers to conclude that exercise just doesn’t work for depression. The authors of this study acknowledged that the culture of the nursing homes tended to emphasize safety, minimizing the risk of falls, over activity, such as the exercise classes. So perhaps, the problem wasn’t that exercise didn’t help, it was that the culture of the nursing homes didn’t encourage enough exercise to make a difference.

Actually, many recent studies have shown that exercise is one of the few things that can prevent, or delay the onset of dementia. It also seems to help with the symptoms of Parkinson’s disease.

However, the nursing home needs to have a culture that supports exercise, and also supports holistic treatment of depression. That may mean encouraging residents to go to movement classes. It may also mean recognizing that apathy is a symptom of dementia. So that may mean giving appropriate medications that help elders regain the motivation to do things.

Also, don’t ask an elder if he or she “wants” to exercise. Just say, in a cheerful tone of voice, “It’s time for exercise!” And give some ice cream, or another treat, as a reward after exercise class. It’s worked for many of my patients.

Elizabeth Landsverk MD Geriatrician, House calls doctor for Marin, Burlingame, San Francisco, San Jose, Walnut Creek -  On call 24/7, working to avoid trips to the ER - Working to reduce medications, and improve enjoyment of every day - See more at: http://elderconsult.com

 

Is Your Elder Neglecting Their Own Care?

A colleague recently forwarded me an essay from The New England Journal of Medicine about what we call in the field “elder self-neglect.”

The essay describes a patient who has piles and piles of paper in his home, rotting food in the kitchen, rat feces everywhere. It addresses what doctors and families might do in such a situation.

elder stress The authors of the journal essay suggest a few things:

1) Lowering our standards for safety and cleanliness, i.e. clearing paths through the clutter.

2) Making sure that the patient’s doctor works with the patient to identify goals and solutions.

3) Arranging for a home visit by the doctor, as one way of paving the way for a home care team.

4) Making “worst-case scenario” plans.

I’m glad that such a prestigious journal published this essay. As a society, we need to talk more about self-neglect. As the essay states, as many as one in ten older adults neglect their own care, and the rate is higher among poor and/or African American elders. We need to talk more about how we balance an elder’s right to make his or her own decisions against his or her safety.

The NEJM essay also makes these points, but then says that “many such people do not have moderate or severe dementia and so are not considered legally incompetent to make health care decisions.”

This is where I differ greatly from the authors. My feeling is that in rare cases, self-neglect may be a choice. Most of the time, as I do geriatric house calls around the San Francisco Bay Area, I find that self-neglect is a huge red flag.

A normally-functioning person simply does not want to live among rotting food, rat feces and piles of junk.

The first question to ask is, “Does this person have the mental capacity to make the choice to live this way?”

Caregivers, family and friends need to push for a full neuropsychological exam in a case like this. The “Mini Mental” exam, asking the person what day it is, or who the president is—that’s not enough to make an accurate judgment of their mental status. Plenty of elders I’ve met know what day it is, but also think they can talk to dead relatives or are happy to give out their bank account numbers to strangers.

Also, don’t forget that some medical conditions can create significant mental fallout: heart problems, cancer, Parkinson’s disease and many others. Ask your elder’s doctor to explore whether a medical problem could be behind the self-neglect.

If the person does have capacity, then all we can do is to set up a structure (caregiving agencies and so on) that can swoop in if and when the person eventually loses capacity. Families should consult an elder care attorney to know their options. They should try to talk to their elder and ask them what they would want done if they were in the hospital, or if they lost their capacity to make decisions. Sometimes, elders are more open to this kind of conversation when there’s a problem or a crisis.

But most of the time, I find that elder who’s severely neglecting his or her own care does have some kind of dementia or a medical problem.

The authors of the NEJM essay emphasize compromises and working with the patient. Of course, I’m all for that. But remember, it’s next to impossible to negotiate with someone who has dementia. If a person gets a proper psychiatric evaluation—and that’s a full neuropsychological exam—and then is found incompetent to make health decisions, then that person needs to be protected.

That doesn’t mean snatching a person from his or her home. I believe that elders’ wishes should always be honored if at all possible. If a person doesn’t want to take non-essential pills (like vitamins), or if a person wants to bathe just once a week, that’s fine. But it’s not OK for an elder to be living in a home filled with piles and piles of paper. That’s a fire hazard. Clearing paths through the mess is not enough. It’s not OK for an elder to be living surrounded by rat feces. That’s a health hazard.

Of course, all elders who are able should be able to make their own decisions. Just make sure that self-neglect really is a decision, and not the sign of a deeper problem.

Elizabeth Landsverk, MD Specialist in Geriatrics

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