Blog – Coleen P. Kenny

How would you respond to the following remarks made by elderly people with dementia?

1. “Honey, my clothes have been stolen and I think my purse has been too.”

a. Your clothes are in your room; you just don’t remember.
b. Oh, dear. I’ll let Security know, and they will talk to you later.

2. “Should I go across the street now? My mother is waiting for me.”

a. Honey, your mom’s been dead for 30 years; your room is over here now.
b. Let me call and see if she’s home yet; and let’s find some juice while we’re waiting.

3. “The porch rail is broken because men come every night and beat on it with hammers. I hear them!”

a. The porch has been broken for the last year, there are no men; just come in the house.
b. I see what you mean; I will call the police to patrol tonight and see if they can catch the men.

If you chose b for all 3, you chose wisely. If you chose a, we need to talk…

The old rule of thumb was to try to reorient folks to reality. All this does is upset them and make a bad situation worse. Imagine if you truly believed that your husband or mom was still alive and everyone was telling you he or she wasn’t. Imagine that every time someone told you your loved one was dead, it was brand new information. Brand new grief.

Imagine if you misplaced your purse, or maybe you donated it ten years ago, and now you believe it’s been stolen. Imagine believing it’s 1941 and that your children are still elementary age and everyone’s telling you it’s 2011… how terrifying to lose that much time.

But in dementia, the reality is that the brain’s failing. It’s losing its old memories and can’t create new ones. So trying to reorient someone with this disease process is like trying to get a two year old who’s hell bent on having a tantrum in the grocery store to stop.

Sometimes you just have to go with the flow. Meet the person where they are at.

“Therapeutic fibs” as nurse/speaker Brent Longtin calls them.

They don’t hurt anyone and they can prevent a world of distress.

Would love to hear your feedback or stories…
Coleen

“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

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

Marge’s room is covered with framed photos. Grands and great-grands. Graduations and christenings.

And my favorite: a sepia of herself in her wedding gown, her husband Mike smiling in his flyboy uniform.

World War II was roaring in full furor when they met in London. Marge, a local Brit and gorgeous gal, attended all the USO dances. Mike frequented those same dances until he was called to fly missions over Germany.

Placing a hand to her chest, Marge tells me how handsome Mike was in his uniform, and “Oh, could he dance.” He kept her dance card full, and when the hostile skies called, Mike proposed.

Marge refused.

She would consent to be neither war bride nor war widow.

With a smile and her British accent, Marge tells me she continued to dance. Never alone. But no one stood out like Mike.

When he returned to London, he sought her out. They danced. He proposed.

Marge accepted.

The pair married in London when the war ended, and a year later Marge was allowed to cross the Atlantic, newborn son in her arms. Mike drove her from the docks to the family farm in the Blue Ridges of Virginia. “I thought the driveway would never end.” She adjusted from the bright lights of London to the quaintness of rural farm life. They spent many years raising two children and growing old together.

A few years ago, each fell ill and ended up in a different nursing home. They talked on the phone twice a day and always said goodnight. Six months later a bed opened and Mike moved to Marge’s facility. A nursing assistant gets him dressed, and he spends all day in Marge’s room, sharing meals, watching TV, holding hands.

A true love for the ages…

One of my favorite long term care patients went to the hospital last week. Sally was quite ill and we weren’t sure she was going to pull through.

Her best friend was in tears; she compared the potential loss to losing her husband several years before.

The two are widows. They reside four doors apart, and they’ve shared three meals a day for the last five years. They attend Bingo and sing in the facility talent shows together. (Picture “They tried to make me go to rehab and I said No, no, no!” done with walkers and canes…) They raised money for Haiti tsunami victims and for a local family that would have gone without a Christmas. (You did not want to be the only one without a ticket to win that quilt!)

These women support one another in sickness and in health, through good times and bad. They fuss over one another and tell me when the other needs a visit from the Nurse Practitioner. And they’ve been at the home long enough to see lots of other folks pass on. They know the odds.

So when word came that Sally was returning from the hospital, word traveled faster than a cougar chasing a rabbit. Relief and excitement flowed. And when I entered Sally’s room to say “Welcome Home!” she gave me a wonderful smile.

I told her Jenny had missed her terribly.

Sally pointed to the dresser behind me…A half dozen long-stemmed stunning yellow roses stood tall in a glass vase. “I know.”

Friendships like one are precious and rare. So with Valentine’s Day on the horizon, consider who holds your heartstrings–Golden Lassos as I like to call them–and spread some gentle cheer…

Okay, this heartstring, aka Golden Lasso, tethers me to Mom. Engaged this fall and getting married Valentine’s Day, she called to ask how to get her soon-to-be-spouse to take his meds without being a nag.

Turns out an astute pharmacist had called to say his refills were overdue. Almost Hubby (AH) told mom he doesn’t take his blood pressure pills everyday to save money. AH, aka Cradle Robber, is 16 years older than mom, and mom wants to keep him around a while. They have fun together. He treats her wonderfully.

He needs to take his meds.

So I asked what she’s done so far. She’s filled a pill box and put it by the coffee pot. She made a blue triangular note card reading “Take your pills!” that stands on the table when he sits to breakfast.

I told her it sounds like a great first plan.

Medication noncompliance is a huge issue in this nation, especially among the elderly and frail elderly. If one skips blood pressure meds, the doc thinks the meds don’t work and increases them; next thing you know, someone’s fallen because the pressure is too low on the new dose.

Or someone decides to take medicines some days and not others…”I don’t want to spend all day in the ladies room” is one I hear often with fluid pills. Instead she spends a week in the hospital and six weeks in a nursing home because her heart failure got the best of her.

Noncompliance includes not taking medications at all; not finishing medications (such as antibiotics) as ordered; not taking medications as ordered, like AH taking his every other day instead of daily; sharing medications with friends and neighbors; and taking over-the-counter (OTC) meds the doc or Nurse Practitioner advised avoiding.

Mom called a few days later with AH’s current lab results…his kidney function could be better…IF he would take his meds as ordered….

More on promoting compliance in the next segment, Sweet Readers!

A recent patient was a retired nurse; old school; she knew how things should be done. And as she got to feeling better, she would daily crook her index finger at me and motion me over.

“They need to wait for me to move; they shouldn’t rush me.”

“They need to tell me what these pills are for.”
She was right, and as her conditioned improved, she’d add, “I was a nurse, ya know. And that makes me a pain in the ass.” This became a daily exchange, always capped off with a devilish smile that lit her eyes.

One day last week though she wasn’t smiling. She stopped at the nursing station where I was charting. “Am I the only one here who can walk?”

I looked around. Indeed we had several patients in wheelchairs. I wondered if she remembered that was her starting point as well.

“You do get around better than most,” I said.

“That’s a shame. I wish there was something I could do.” Her smile was subdued and didn’t reach her eyes as she said, “See ya later, kid” and ambled on her walker to her room.

She’s still an old nurse, ya know…

“I’m so glad you’re here honey; something is wrong and I need you.”

A pull-me-down-to-bed-level hug followed these words. My 90 year old patient released me but held my arm, stroking it like she might comfort an infant. She fingered the lapel of my blue lab coat and told me how pretty it looked. She pointed to her mouth while saying, “I always loved your beautiful teeth.”

After five minutes of sitting on the edge of her bed, she told me, “I feel better now; I trust you.”

So why do I do it? Why do I take care of the frailest elderly? Isn’t it depressing, or boring?

My heart slips into my throat as I answer that question. In nursing school, the over-seventy set snagged me with a golden lasso of heartstrings that even Wonder Woman would be jealous of. When my brain says it’s time to change careers, God helps me change a life.

Whether it’s prescribing cold medicine, pain medicine, or even end-of-life medicine, I can’t imagine a different career path. I can’t imagine not being hit on the bottom by a grinning 80 year old who knew just where he was aiming that beach ball. Or not having known the silver-haired gentleman who wrote me a love poem, his words still framed on my kitchen table.
I really can’t imagine not having been there this morning when my patient thought I was someone from her past who had given her a sense of security.

I also love coaching the nurses and aides how to provide quality bedside care, and teaching the Nurse Practitioner students how to assess and safely prescribe for this frail population , and guiding families how to cope with the caregiving.

And best of all, who else out there gets told how young you look all day?

So remember, sweet Reader, I do this because I love these folks, and I’m here if you need me!
—Coleen

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.