Hospital Delirium

If you have an older parent or other family member, read this article in the New York Times.

The article is about hospital delirium, which sadly happens all too often to older adults in the hospital. About one third of all hospital patients over 70 develop delirium, which is frequently misdiagnosed. No one is exactly sure why so many patients develop delirium, but it can be caused by improper medication use. Sadly, many doctors do not understand that older people do not tolerate medication dosages that younger people tolerate, so they are given the typical dose, then, when delirium develops, they are restrained, and medicated, to deal with the agitated behaviors. Some other causes of delirium include lack of sleep (hospitals are noisy 24 hours a day, 7 days a week), not making the older person's glasses or hearing aides available, and changing rooms. I worked in one hospital where patients were moved from room to another constantly, which resulted in different nurses, different case managers, new roommates, and we wonder then why they become delirious.

Crazy?

I had an interesting experience last weekend, although not a unique experience. I have a friend and colleague who is a private professional guardian. She is the guardian for several people, and she gets appointed guardian in situations where the Ward does not have anyone to act as guardian.

One of her Wards is a woman I'll Mae. Mae has dementia, and according to my friend, Mae is not a pleasant person. Mae has children, but they don't want anything to do with her.

My friend called me last Saturday, asking a big favor. It seems that Mae was at a local hospital, having been sent there by her nursing home because she injured one of her caregivers. The hospital medicated her with her some pretty strong anti-psychotic medication, deemed her medically stable, and was putting her in the ambulance to return to the nursing home. The nursing home was refusing to allow Mae to come back without a private sitter in place, for the protection of their staff. And my friend was out of state at a wedding.

For those who are my facebook friends, that's why I spent Sunday afternoon at the psychiatric emergency room at John Peter Smith Hospital.

My friend was able to find a sitter who could stay with Mae Saturday, and she did return to the nursing home. My friend also engaged a private duty service to take over on Sunday, but by Sunday morning Mae had injured the Saturday sitter, and had continued to hurt nursing home staff. The nursing home was done, and insisted that she leave.

Again, long distance and over the phone, my friend arranged for law enforcement and emergency medical responders to take Mae to the psych. ER at JPS. She called me when she could not locate Mae anywhere in the hospital system.

We eventually found Mae in the regular ER, because she had complained of chest pain while on the way to the hospital. She was absolutely calm and non-threatening when I found her. She was mean, but not violent. I stayed with her until we got her admitted to the psychiatric unit.

My friend cut her trip short to come back to Fort Worth for a couple of days to get Mae situated in an Alzheimer's facility that I helped her locate, and she's leaving again today to finish the rest of her vacation. So I might yet be called out again to help with Mae.

Some of you reading this may identify with this situation. Our medical system has no good way to deal with those people with dementia who also have behavior issues, including violent and aggressive behaviors. There is something inherently wrong with having police take a frail, 76 year old woman to be involuntarily committed to a psychiatric unit. Regular hospitals are unable to provide the medication management required in a situation like this, and a guardian has no legal authority to admit a Ward to a psychiatric hospital. The nursing home clearly had no idea how to manage the behavior, and Alzheimer's units like the one Mae went to yesterday, where they do know how to manage the behavior are incredibly expensive (over $5000 a month). Mae is lucky she can afford to live there.

I don't know what the answer is, but we are going to have to find a better solution, because the numbers of people with dementia will only grow as the population continues to grow older. I'd love to hear any ideas.

What Happened?

OK, I know you're wondering what happened.

I got bored.

I am one of those people who changes wallpaper and screensavers on a regular basis. So when I saw that there were new template designs, and picture backgrounds, I just couldn't resist.

I would have preferred it if there had been a longhorn--you know, for Cowtown, but the powers that be at Google apparently don't see the charm in cattle; I guess they've never been to Texas.

So, I settled for rocks. Lest you think they aren't relevant, think again. The journey we are all on can be rocky and treacherous and beautiful. And I hope that some of what you learn here helps you along on that journey, so that you miss the more dangerous passages, but still experience the excitement and beauty.

Here's to the next leg of the journey--wherever it is!

Walking the Floors

Mobility. However you are mobile, it's important to do it safely.

Of course most people are familiar with canes and walkers, but not a lot of people ever get the proper training in how to use these devices. I worked with physical therapists long enough to know that those walkers with 4 wheels and hand-brakes that everyone seems to have in assisted living are not all that safe. If a person has trouble with memory, they might forget to lock the brakes, and if they have trouble with sequencing, they might not be able to use the brakes properly. Because they have 4 wheels, they move faster, so the person might not be able to keep up.

My best advice: see a physical therapist to find out what will work best for you, and to make sure you know how to use your equipment properly.

Other safety tips:

• Get rid of all the throw rugs. Even large rugs can be a problem, because we had one that would not stay in place, and this resulted in Mom's fall last Fall.
• Make sure cords of any ilk (extension, phone, cable, computer) are out of the way. If you can shorten them and attach them to the wall, even better.
• Promptly clean up spills, and pay special attention to greasy or slick spills. I had my own fall a couple of years ago when some greasy food was not properly cleaned up. The floor looked clean, but it was still very slick, and falling in front of 50 people was as bruising to the ego as it was to my knees.
• Make sure furniture is placed so that there are wide pathways to accommodate a walker if one is used. Remember that furniture walking is never a safe option.
  
• Nightlights are your friends. There are lots of varieties, so you should be able to find the right type for every location.
• Carry a phone with you, or even better, install an emergency response system ("I've fallen and I can't get up"), so you can get help if you do fall.

These are just a few ideas to make mobility safer.

Gotta Go, Gotta Go, Gotta Go Right Now

We're rounding out bathroom safety today. Obviously grab bars around the toilet are helpful, but some bathrooms are just not set up for that, if there's a tub on one side and a pedestal sink on the other side, so then what do you do?

You add something called a versa-frame. You can see here that this item is just an aluminum frame that fits to the existing toilet. The legs can be raised or lowered, and this provides arms the person can use to help push up from the toilet. This item costs around $50, but I've never seen them at a big box store. You'll have to order it online or get it at a medical equipment company.

Most toilets are low, sitting only about 15" from the floor, making it difficult to get up if you have a bum knee or hip. Replacing your toilet with a 17" model is one option, but an expensive option. You can get a toilet for around $115, but if you don't know how to install it yourself, you'll have to pay a plumber for the installation. One option is to add a toilet seat riser. This particular model locks (don't ask me how), and can also be purchased with arms. Not always the most stable option, and can be problematic if there's a man in the house. But at $50, it's less expensive than replacing the toilet.

For a lot of situations, a bedside commode is a solution. If a person can't walk to the bathroom, a bedside commode can be placed wherever the person needs it. The bucket is removable for ease of emptying. The bedside commode can also be used over the toilet. In this photo the bucket is removed, and the splash guard is left in place, so this could then be placed over the toilet. Then, if needed, the bucket can be replaced and the bedside commode placed by the bed at night. Bedside commodes come in wider widths than the one pictured here for wider people. There is still some Medicare coverage for bedside commodes, so be sure to check with your medical equipment provider for details. If you pay out of pocket, cost will be $150-200, depending on the type.

Raindrops Keep Fallin' On My Head

On to bathing safety!

If you're not able to safely get in the tub for a bath, or to stand to shower anymore, then you need to consider adjusting things to make showering safer. Grab bars are often the first line of defense in this instance, and the first thing I did in my house for my mother.

You can see that this grab bar is placed so Mom has something to hold onto as she is bending over to turn the water on. This is also the bar she uses when she actually lifts her legs over to get into the tub. Fortunately, the handyman who installed the grab bars was able to anchor this grab bar into the studs on both ends, so it is easily able to withstand a great deal of weight.

This bar is for stability while standing and showering. It is longer, allowing for something to hold onto from almost any point in the tub. Grab bars come in all shapes, sizes and finishes. I believe the ones I installed are 2 and 3 feet long, and are brushed nickel. They were fairly inexpensive, around $25 each.

You can get grab bars in white plastic, polished chrome, you can even find designer grab bars that match your fixtures, of course you'll pay more for these. Grab bars are readily available in stores like Lowe's or Home Depot, and you'll find them in the plumbing section. Medical equipment companies also carry them, and they are comparable in price to the big box stores. I was really fortunate to find a great handyman through the medical equipment company I used for some other things. He installed the grab bars in about 20 minutes, and it only cost $50.

There is a lot of variety when it comes to bath/shower chairs. This one is molded plastic. The legs snap in place, and they can be adjusted by turning them. There is an optional back, that we have chosen not to use. It's lightweight, but very durable, and can hold up to 400 pounds. Also note the tub mat in place, to provide a less slick surface for feet and chair legs.

When looking at a tub bench it is important to remember to measure your tub width. I knew my tub was on the narrow side, so I made sure to measure it, and I'm glad I did. The first bench I looked at, which was a little less expensive than this one was a little too wide to fit all four legs squarely and evenly on the bottom of the tub, which is crucial for safety. You want to make sure the legs aren't on the curve of the tub. And be sure to measure front and back legs, because the other bench I looked at had about a half inch difference in width from front to back.

Weight limit is another consideration. It does seem that most of the benches I looked at are now automatically super-sized, accommodating 300 pounds or higher. This was not always the case, because back when I worked in the hospital we usually had to specify when we needed something to accommodate more than 200 pounds.

When I priced the benches in the big box store, they were twice what I paid for this bench at the medical equipment company, and with nowhere near the selection of the medical equipment company.

The last item we got for the tub was the hand held shower. This type is inexpensive--only $18 at the big box hardware store, and even better, it just screws on to the existing pipe. No special tools, no plumber. It even came with a little aluminum tape. You can spend a lot more if you want, but if you think the need is only temporary, this is really all you need. It makes showering while sitting more pleasant, because you don't have to have the shower pounding in your face, and since you can't move to let the shower hit different body parts, the shower can do all the moving.

Hopefully this has given you some good pointers for making bathing a safe and still pleasurable experience. We'll tackle the rest of the bathroom next.

Can't Reach That

Thanks to Mom, who was discharged from rehab this week for inspiring this post.

After we left the hospital, we made a stop at an unnamed big box home improvement store so I could get a hand-held shower and to price a bath chair. Got the hand-held shower, but the bath chairs were more expensive than the ones I had seen online. As I was telling Mom this, she said, "You know, you should go to the Senior Centers and do talks about this. I know there are a lot of ladies at the Senior Center who need this kind of stuff, but they don't know about it."

So, since there's so much of this stuff, also known as adaptive equipment, out there, I'll probably break it down into several posts. Today we'll talk about a "hip kit", which pretty cool, although that's not why it's hip.

When folks have had hip replacement or surgery to repair a broken hip, they are often placed on hip precautions: no crossing the legs, bending more than 90 degrees, other things that I can't remember right now. The result is that you can't reach things on the floor, like things you've dropped, or your feet. That's where the hip kit comes in.

The item at the top is a reacher. Pretty self explanatory. One nifty feature, that's hard to see, is a magnetized pin near the tip, in case you drop a safety pin or some other small, metal object.

The next items are the yellow long-handled shoe horn and the long handled bath sponge. Pretty clear what those are for, and how to use them. The sponge makes a pretty good scratcher, too, as Mom has discovered since her incision itches.

The white cylinder looking thing is a sock-aide, and Mom loves hers. This one looks like a rigid one, made out of hard plastic, they also make soft ones out of fabric and probably cardboard or something. What you do is put your sock on the cylinder, then undo the straps (in this picture they're not fully extended) and hold one in each hand. Then you drop the cylinder on the floor, put your foot into it, and then pull the cylinder out with the cords, and oila! Your sock is on! (To my OT friend Denise, hard to describe in words only how this works).

The last item is called a dressing stick. I've never known many people who actually used them, but you can see that there are different types of hooks on each end, so useful for hooking things.

You can buy each item separately, but they are less expensive when you purchase them in the hip kit. They are readily available at multiple places online, and also at most medical equipment companies. Medicare will not pay for any of this, but a kit will cost anywhere from $30-40, depending on the store. My local medical equipment company charges a bit less than most of the ones I found online.

Next stop--the bathroom.