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!

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

Pain management is one of the most challenging yet most rewarding tasks I tackle as a Nurse Practitioner. The keys to good pain management are 1. Assess thoroughly, and B. Make no assumptions!

Yesterday three patients brought this point home.

Dave, age 80, has had pain all over for three weeks. One of his diagnoses is bone cancer, so the hospital prescribed Dilaudid, an excellent medication for that type of pain. But it wasn’t touching the pain; “it’s a10 out of 10 and I’ve been crying this morning.”

I pulled up a chair and opened my ears. Dave didn’t describe bone pain. He described what sounded like gout. His exam increased the suspicion, then Dave told me his gout medication had been stopped due to cost… three weeks ago. I hit Dave with some Prednisone followed by his gout medicine. Today, Dave says the pain is 5/10 and he was able to do physical therapy, and with a smile was working on his tuna on rye.

Jenny, age 72, told the nurses she had Restless Leg Syndrome. It was keeping her awake every night. The staff wanted me to order some of that RLS medicine we see on TV. When I talked to Jenny, she said her knee hurts when she goes to bed. She moves her leg around trying to get comfortable. “It’s not RLS,” I told her. An exam revealed arthritis, not unusual in this age group. Jenny hates pills, so I ordered Voltaren gel. It started last night. She slept.

Then Sarah… only 64 and waiting to finish therapy to move to an Assisted Living Facility. Seen for a routine visit (there is no such thing in Geriatrics), Sarah says she has pain all over all the time, and Tylenol doesn’t touch it. I asked about Vicodin, and she said she’d used it with great relief, but a doctor had told her she’d get addicted. So she’s been “living with the pain.”

Sarah and I talked about addiction and dependence and appropriate use of narcotic pain killers. Tylenol is great, but if it isn’t working, and another agent does, we will prescribe safely. Sarah said she had no trouble stopping the Vicodin last time, and was willing to try it at a low dose three times a day.

I look forward to following up with Sarah…

I look forward to blogging more on pain management in the next week; feel free to contact me with questions!

–Coleen
www.cpkenny.com
coleen@cpkenny.com
(names changed to protect privacy)

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…

As I posted last: Mom asked how (without being a nag) to get her fiance to take his medications correctly.

Medication noncompliance is a huge issue. Skipping blood pressure meds makes the doc thinks they don’t work so he increases the dose; next thing, someone’s fallen because their pressure is too low.

Or a woman skips her fluid pills some days: “I don’t want to spend all day in the ladies room.” 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; not finishing the full course; not taking the ordered frequency, such as every other day instead of daily; sharing medications with friends and neighbors; and taking over-the-counter (OTC) medications or supplements the doc or Nurse Practitioner advised avoiding.

Noncompliance in the elderly is magnified. Eyesight issues impact reading labels, and insulin needle markings are tiny so overdose is easy. Memory issues cause missed or duplicated doses. Changes in metabolism heighten side effects so someone stops their medication without telling the prescriber. Income and insurance coverage are limited so items aren’t filled. Multiple providers complicate the mix.

So how do we get folks to take their medications correctly?

1. Pill boxes are available with several time slots for a week. Family or a friend (or a hired person) can fill it once a week and check to make sure everything is used.
2. Automatic pill dispensers come with multiple options, including pulling the pill back if not taken within a certain time. Google search reveals multiple models, including http://www.epill.com/md2.html (I have no experience with nor do I endorse this model)
3. Alarms are available reminding people to take their pills, a good option if the person stays nearby and is able to hear.
4. Pre-filled insulin syringes can be requested, but insurance won’t usually cover them. Fill them ahead and tag them with day and time labels for your elder.
5. Discard expired meds and put inactive pill bottles in a plastic baggy out of sight. It’s too easy to grab the wrong bottle…
6. The elder can “brown bag” their meds for appointments (including over the counter and supplements!!) A family member or friend can keep a complete list of the medications in an electronic device such as a cell phone.
7. Be sure everyone knows everyone else who’s prescribing and make sure they’re sharing notes. Family members have handed me typed lists with all the providers and their phone numbers…very helpful!!
8. Get everything filled at the same pharmacy! People chase the $4 dream, but an alert pharmacist can catch interactions and call the prescriber before filling the script.

This is just a short list, but please let me know if you have questions or suggestions!

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!