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Monday, April 12, 2010


As a visiting doctor, watching the decline of people sent to nursing homes is painful. So often their behavior becomes an issue, resulting in the prescription of sedatives, which starts a spiral of decline. While such behavior problems are often attributed by nursing home staff to dementia, I have also seen behavioral problems among people who were not demented in the hospital prior to coming into a care facility, even when much sicker in the hospital.

While agitated behavior is often attributed to dementia, worsened by an unfamiliar environment, there are other causes in rehabilitation facilities and nursing homes. Often patients are relatively neglected compared to their prior home environment as well as the prior hospital environment. They cannot go to the bathroom alone, and need help with many things they want to do. Sometimes they do not have a means to call for help. However, when they do, staff cannot be everywhere at the same time, so even in the best of care facilities, people may feel neglected. No one likes neglect, so agitation or screaming can result. The feeling of completely social powerlessness leads to intense frustration which has little other outlet. Family members often notice that when they are present and responding to the person, the screaming or agitation stops. Intermittent positive reinforcement occurs, which results in the behavior becoming habitual.

Unfortunately, sedating people to manage their behavior has further terrible effects. Through being insufficiently helped to get up and exercise, and not being helped to the bathroom in a timely way, they lose continence, develop bedsores, and become weak through muscle atrophy. Excessive sedation also means they lose interest in their rehabilitation activities and are less aware of when they need to go to the bathroom etc, thus deteriorating even further. Delirium and confusion can be other consequences of too many drugs acting on the brain, especially in the frail elderly. This leads to more agitation and screaming, which leads to more drugs. Watching this can turn depressing quickly.

Staff requests for medications are understandable because screaming and agitated behavior can create a horrible environment for both staff and other residents.

The real solution lies in increased staffing and responsiveness by nursing home staff. Unfortunately, our society has not figured out how to care well for our elders. All of us should hope for the sake of our own lives to come, that the future will see a greater investment in making our elders comfortable instead of weakening them with under-staffing and over-sedation.

Home care is not feasible because most people are simply unable to care for a family member 24 hours in their homes, and cannot afford full time home care. This leaves working family members, those who find nursing very difficult, such as those too frail to lift a person, little choice but to put their loved one in a nursing home in such a situation. Family members find this decision extremely painful, and it signals an important turning point of decline.

Our society has a great need for better solutions for elder care. Your comments are welcome.

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