Blog – Coleen P. Kenny

“I was ready for to deal with mom’s physical aging…I was never ready for this.” –words spoken by a Caregiver Daughter in my Dementia and Delirium talk today…

Deep emotion charged her words as she shared her struggles to reason with Mom and make Mom happy. Themes resonated through the room as others told of being accused of stealing misplaced items and of stories being created to cover for missing memories.

So I used an analogy I developed to explain Alzheimer’s type dementia: a cassette tape erasing as it unwinds…

We enter this world then breathe and eat and drink to survive. We learn to toddle then toilet train. Mom lets us dress ourselves (at times to her embarrassment), and we learn to bathe ourselves and do simple chores. Mom and Dad send us off to school and we learn to read and write and think, reason, and learn. Eventually, if Mom and Dad are lucky, we leave the nest. We make appointments and house payments. We buy groceries and balance our checkbooks and drive.

In Alzheimer’s Dementia (one type of dementia), the tape is erased. Money and time and cars and homes become unmanageable. The ability to bathe and dress is lost, not to laziness, but to inability to figure out very complex tasks we take for granted. Standing and walking, one foot in front of another in proper sequence and lift and balance, is compromised as the brain loses communication with the body. Toilet training is lost to incontinence. Swallowing is impaired leading to pneumonia. Appetite and weight are lost to the end stage of the illness.

But also lost is the ability to reason. To figure out new things. To cope with the fear of losing one’s purse or keys or home or mind. To communicate needs and thoughts and feelings.

And so the Caregivers are left to cope with these.

I told the daughter today that mom isn’t trying to drive her crazy on purpose. Breathe deep and step back and sometimes just nod and smile and say, “Okay, I’ll look into that” when the neighbor’s accused of stealing a pocketbook not seen for years. Because the person with the dementia believes it to be true.

And no manner of arguing, cajoling, bribing, yelling, huffing, or puffing will change that.

So this note is to you Caregivers…When you’re called to honor your mother who has dementia, remember you are not alone. And she’s doing the best she can, and that’s all you can do too…

My heart sighs for each one of you, and I will post more info on Dementia soon–please feel free to contact me if you have specific questions!

Driving the hour south from mom’s house to mine, thoughts on Easter, Passover, and their relationship to Aging flooded my heart, mind, and eyes…

Bette Davis said, “Old age is no place for sissies.” The challenges my patients face daily–the loss of loved ones, function, freedom, etc–take great doses of courage to manage.

I am in awe of the ones who treat each day like Easter, waking up to face their burdens and move forward. Doing their best to put aside the pieces of their past–physical, mental, emotional, spiritual–and making the most of the time remaining. Sharing love and wisdom and hugs with their Nurse Practitioner. Accepting the gifts of a cherished spouse’s smile or a faithful daughter’s visit.

And what about Passover and aging? I’m thinking of a Facebook friend who did not want to turn 40 even though several people encouraged her that the best is yet to come. I would also encourage her to count the blessings in her life, not only for what she has, but for what may have passed over her threshold, leaving her untouched, blessed, and moving beautifully into an awesome new decade.

I’m waxing philosophical instead of practical tonight, but these holydays instill great reverence and reflection. I encourage you to consider how you face your future (yes, I mean aging). Will you engage it like Easter, daily developing new skills and wisdom to deal with the setbacks? Will you be mindful of the blessings that enter your life and thankful for the burdens that pass you by? Remember, these practices can set you on a path of happier, healthier, more hopeful aging!

Happy Passover and a blessed Easter to you all…
–Coleen

So let’s start talking about types of pain and their management.

Foremost, I see a lot of arthritis pain. Even this needs to be broken down. Osteoarthritis (OA) is from “wear and tear” on the joints and affects us all. Rheumatoid Arthritis (RA) is caused by inflammation in the body and impacts the whole body, not just the joints. I’ll cover RA later.

OA—“oh my aching back/knees/hips/shoulders/etc” is the most common reason for pain. Due to repetitive use, misuse, poor alignment/posture or body mechanics, overweight, or even underuse, joints lose their protective glide. And pain happens.

In OA, the pain is chronic, stiff, and achy; redness, heat, and swelling are not common. The achy/stiff is usually worst in the morning, improves as you move, and returns later as joints fatigue.

The worst thing you can do is to stop moving! Sitting still increases the stiffness.

The best things you can do:

1. Lose weight; every little bit counts. Our hips and knees are designed to carry a weight specific to our body structure. Extra stresses the machine.
2. Put your pocketbook on a diet. Slinging a heavy purse, tote or book bag over one shoulder is a recipe for poor posture and shoulder strain and pain.
3. Move! Yoga is excellent for keeping the joints gliding and working on posture and mechanics. Walking is great for keeping us limber and fit. Whatever you can do helps.
4. Try heat or ice or IcyHot or Ben Gay; you may need to try a few.
5. Tylenol. Great medication, BUT just because you can buy it with your soda and toothpaste doesn’t make it totally safe. Don’t use it if you drink alcohol (both are processed by the liver), and don’t use more than 3000mg/day; that’s 6 Extra Strength. And be careful of the “acetaminophen” in cold or sleep medications; count those toward your 3000/day total.
6. Avoid NSAIDs (Ibuprofen, Aleve, Motrin, Advil). OA is not inflammatory and that’s what these are made for. They can cause blood pressure to rise or a bleeding ulcer.
7. If your insurance will cover, a Physical or Occupational Therapy consult helps a great deal with body mechanics and strengthening.

1-7 apply to all of us, not just the older folks I care for. Their joints are beyond Tylenol, and often we prescribe a low dose narcotic, such as Vicodin. Families get concerned about addiction, but we’re very careful about how much we use and monitor the effect. And I refer families to the complications of not treating the pain (See post #10).

Joint injections by a qualified physician are an option, as is joint replacement, but I will not cover those here. Let me know if you have any questions, comments, or concerns!

As I’ve said, pain management is one of the most challenging yet most rewarding tasks I tackle as a Nurse Practitioner. Last week I provided a tool for the assessment of pain. Today I want to talk about why pain management is important and why treatment isn’t always adequate.

First, why is pain management essential in the elderly? Well, you may say, no one wants to hurt. True. Quality of life is essential. And most people with pain report depression, insomnia, and anxiety. In turn, depression and insomnia exacerbate pain. The cycle can be vicious.

But it’s not just about feeling good. A person with cognitive changes may not be able to say “I hurt.” They may just act out with wandering, combativeness, resisting care, or rocking back and forth. As I tell my students, “If I hurt and can’t tell you, and you try to get me dressed or out of bed, I will slug you.”

Unfortunately, if a cause for the behavior is not found, the person may end up being sedated. They’re quiet and compliant, but still hurt.

If the pain is great enough, the person may stay very still which leads to skin breakdown (pressure ulcers). As the person holds a position, often rigidly, the muscles tighten leading to contractures and weaken leading to falls and possible fractures. Pain interferes with therapy after an injury. Appetite decreases and so does weight.

So why don’t we do a better job treating pain in the elderly?

Sometimes people don’t tell us they hurt; “Oh, it’s just part of aging”…I do my best to set that record straight. Sometimes no one asks. If the person can’t communicate, like I said above, the cues are missed and mistreated. Or maybe the last time pain was treated, it didn’t work and the person doesn’t want to try again.

Time is a huge issue; some providers see a patient every 7 minutes—how well can pain be assessed? Medication costs, side effects, and drug interactions factor in. Provider knowledge isn’t always up to date on the many treatments are available.

Families don’t always believe that mom or dad is in pain even when the person says so. I’ve had people tell me to discontinue pain medications because they were afraid the parent or spouse would get addicted.

But as my coworkers would tell you, I treat pain as aggressively as a Cardiologist treats a heart attack. So I assess and I treat, and I reassess, and I educate. (And I speak!)

Next time, I will cover some specific treatments for different types of pain. Feel free to contact me with any questions you have!
–Coleen Kenny
Nurse Practitioner/Speaker/Geriatric Expert

(Golden Lassos refers to heartstrings of gold stronger than any lasso Wonder Woman ever owned which bind me to my elderly patients.)

As I said last week, pain management is one of the most challenging yet most rewarding tasks I tackle as a Nurse Practitioner. The absolute must behind improved pain control, no matter the patient: Assess thoroughly!

Today I’m going to share how I assess pain so when you (or a little or an aging loved one) experience pain, you can make some notes that will help your Health Care Provider (HCP) treat you successfully!

The system I learned many years ago from a forgotten source is PQRST. Though not an intuitive order, the letters help me not miss anything important.

P: Palliative or Provocative. What makes the pain better or worse? What are you doing when the pain occurs or worsens? Movement, rest, not putting weight on it, heat, ice, medication, Ben Gay, or anything else you’ve tried or noted.

Q: Quality. What does it feel like? Sharp, dull, burning, stabbing, shooting, electric, aching, throbbing. Sometimes pain can be hard to describe, but let this list help you; it will help your provider!

R: Region. Where does it hurt? Does it travel anywhere else? Also, are you having different types of pain in different places? Like Dave in last week’s blog had bone cancer pain in his neck, the gout in his elbows and knees was the real culprit.

Radiation. Where does the pain go? To your jaw or shoulder? Down the back of your leg? Wrap around your rib cage? These are important details to note.

S: Severity. Most providers use the 1-10 scale; 1 is minimal, 10 is the worst ever. “My ears are going to bleed from this headache” as a friend described. Not everyone can communicate or understand the scale though, so try a face chart with smiling to grimacing. Be sure to describe how the pain is impacting your function. “I can’t stand from the chair without help anymore.” Does it interfere with appetite or sleep?

T: Timing. When does it hurt? How long does it last? Does it hurt in the morning then get better then worse at night? The pattern of symptoms can make all the difference!

As you note the details, put them on paper. If you do need a health care provider’s assistance, the “Pain Journal” will be a true asset!

Be well, Readers, and contact me with your questions and comments!

Coleen Kenny
Nurse Practitioner/Speaker
Geriatric Expert
www.cpkenny.com

WOW! Gray’s Anatomy just began with a scene of two physicians debating end-of-life care… One opting for comfort care and morphine… the other accusing the first of “killing” the patient…

As a Nurse Practitioner who prescribes morphine for end of life care and the management of symptoms, I experienced a variety of feelings (responses):

Proud of “Gray’s Anatomy” for addressing a very tough issue; a very real world tough issue. Dying. and Death.

Proud of the job I do on a daily basis…educating and counseling patients and families and helping them work through these tough choices.

Proud of the nurses I work with who carry out the orders to keep the patients comfortable.

Proud of the Hospice staff who come into the nursing homes and provide “extra eyes and ears” so these folks are kept as comfortable as possible.

This is never an easy topic. And there are no easy answers. But when you, and/or your loved one, are ready to let go, I pray there will be compassionate and knowledgeable providers available to help you make those decisions.

And remember, I’m always here as well.