Friday, April 22, 2011

5 Things to Look For in Long-term Care

5 Things to Look For in Long-term Care
by Molly Edmonds
When we're looking for our dream home, we usually have a list of must-have features in mind. Some people can't live without walk-in closets, natural light and built-in bookcases, while others require two-car garages and big backyards. When it comes to long-term care options for ourselves or a loved one, however, we often don't know exactly what we're looking for. And because the decision that an aging adult needs long-term care can already be difficult in and of itself, we may let emotions get in the way of an objective search.
As it turns out, we can consider long-term care facilities with the same critical eye we bring to crown molding or skylights. First, there are some basic decisions to be made regarding the level of care and supervision needed, the financial resources available to pay for the care -- and location, location, location. Once you have a list of places that fit those criteria, how do you pick? Take a look at the five things on this list for some must-have features in long-term care.
5: Your First Impression
Feel free to trust your first impression when you walk into the doors of a long-term care facility. Use all your senses -- does the place smell pleasant, or is there an industrial or unpleasant odor in the air? Is it well-lit and pleasingly decorated? Is there a television blaring, serving as a babysitter for residents, or are there spaces for quiet and for conversation?
As you walk through the facility, you should get a sense that this is a home, not an institution. It's important to see the rooms to determine if the layout, lighting and sense of security are adequate. Privacy is important to many people, so find out if there are single rooms or if sharing will be required. Do residents live in long, anonymous rows of rooms, or are they grouped into small households or living units? Will there be opportunities for residents to make their spaces their own, such as bringing in their own furniture and decoration? What rules regarding noise and visiting are in place?
While people tend to focus on their own rooms, take time to visit common areas as well. You might inquire if there are outside areas where residents congregate, or in which activity rooms residents tend to spend a lot of time. Evaluate these areas for homeyness and cleanliness.
You'll also want to get a sense of the eating facilities -- more information on that can be found on the next page.

4: The Food
When you're touring a nursing home or assisted living facility, you'll likely be provided with a long list of social activities available to residents -- everything from bingo to swim classes. And while a long list of activities is a good way to pick a summer camp, there's no guarantee that the aging adult in question will want to spend a Tuesday afternoon making lanyards. That's why it's more important to focus on the one social engagement on everyone's calendar: meals.
Even if assisted living residents insist on spending all of their free time parked in front of the television, they're usually required to show up for meals. Since meals are often the primary activity of the day, take time to visit the dining areas and have a meal there. Consider whether the food is tasty enough to eat every day, and request a week's worth of menus to see if there's a variety of options.
Two other things to check are how dietary restrictions and preferences, such as keeping kosher, are handled, and whether a resident can get extra food or a snack throughout the day. These last two considerations will give you a clue as to whether the facility sees its residents as numbered mouths to feed or as distinct individuals with their own needs and desires. If the residents are given special attention when it comes to meals, then that standard of care usually carries over into other spheres as well.
3: Staff-to-patient Ratio
Most long-term care facilities strive to maintain residents' independence and autonomy as much as possible. However, that doesn't mean that residents should be deprived of care and help when they need it. For that reason, it's important to consider the staff-to-patient ratio of any care facility. In particular, you'll want to investigate the number of personal care aides, as they provide the bulk of resident care; a good ratio would be one aide to every five or six residents during the day and 1-to-15 at night [source: Matthews].
Good patient care is more than just numbers, though. Residents aren't likely to feel comfortable if they never see the same person twice, and if caregiving is merely a revolving door of who's available. A resident's transition into a long-term care facility will likely be made smoother by receiving individualized care from a trusted caregiver. Ideally, as you tour a long-term care facility, you'd observe positive interactions between caregivers and residents, such as staff greeting residents by name and staff quickly and cheerfully responding to residents' needs and requests.
We're not done judging other people yet -- on the next page we'll do some more spying.

2: The Other People
While scoping out the environment of the long-term care facility is important, so too ­is observing how people fit into that environment. That means taking a look at the current residents to see if they seem happy and engaged. They should look clean and well-groomed, because this will indicate that someone has taken care of them recently. Are there people moving around, taking part in activities, or are most people staying in their rooms by themselves?
To truly get the vibe of other people, you should visit more than once. Your formal visit, with the facility's tour guide, will obviously be the residence's attempt to show you the best of the best. Stop by at least twice more, unannounced, to see how people behave when tours aren't going on. By checking into common rooms and dining areas at different points in the day, you'll get a sense of what a full 24-hour period might be like in the home.
1: Report Card
While visiting a residence can give you a sense of all that goes well there, you may have to do some digging to find out what goes poorly there. If a facility receives Medicare or Medicaid funding, it is inspected every 15 months by a state surveyor. The surveyor's most recent findings are required to be kept onhand and shown to anyone who asks to see them. On this report, you'll learn what violations have been reported, such as physical abuse or health violations. Some of the violations may be minor, and no facility has a perfect record, but by asking staff members about these shortcomings, you might get a sense of whether they take complaints seriously or whether complaints are routinely blown off.
Another good resource is your state's long-term care ombudsman (some communities also have local ombudsmen). The ombudsman acts as an advocate for long-term care residents and their families and visits facilities regularly. He or she will have a good idea of the issues and problems at certain facilities, as well as a sense of what residences might particularly suit a certain type of person. The ombudsman's services are provided for free.

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Friday, April 15, 2011

For Elderly Diabetics, Questions About Aggressive Care

By PAULA SPAN

The more I talk to researchers about caring for older people, the more a couple of themes emerge. Namely:
a) Sometimes less really is more. Overtreatment can create big problems, as a recent post on prescribing antibiotics for common urinary tract infectionsreported, and it happens frequently.
b) Older bodies respond differently from younger ones, a reality health care providers don't always take into consideration. A routine that includes a few late-day cocktails, to take one of many examples, can be a pleasure for a 40-year-old but a danger for an 80-year-old.
The latest conversation I've had along those lines, with Dr. Sei J. Lee, a geriatrician at San Francisco's V.A. Medical Center, concerned diabetes, a huge health issue for seniors. More than a quarter of adults over 65 have diabetes, according to the American Diabetes Association.
Should the elderly respond to Type 2 diabetes in the same way as younger patients? Maybe not, Dr. Lee suggested in a recent commentary in The Journal of the American Medical Association.
People with Type 2 diabetes hear a lot about "glycemic control," keeping their blood sugar levels down through diet and exercise and, when necessary, medications. The target number, for most adults under most guidelines, is 7 percent on the commonly used A1C hemoglobin test.
"For younger patients, if we can get them down to near-normal levels, then over the long term — 10 or 20 years — the risk of severe complications, like the need for kidney dialysis, are lower," Dr. Lee explained. Lower blood sugar substantially reduces the odds of diabetics' developing blindness and kidney disease, research shows; it also appears to help ward off heart attacks, strokes and amputations, though that's less well documented.
Maintaining that number — what's called "tight glycemic control" — can be an arduous undertaking, Dr. Lee acknowledged, but "for someone who's 30, we expect many years of life, so it's absolutely worth doing."
However, it takes years of tight glycemic control — at least eight, probably closer to 10 — to produce those benefits. For frail old people, Dr. Lee believes the risk-benefit equation works out differently.
"They have so many other health conditions that the chances they will survive long enough to benefit from these reductions are very low," Dr. Lee said. "The average life span of people in nursing homes is less than three years, which reflects how sick they are."
Moreover, stringent adherence to glycemic guidelines may prove quite difficult for frail elders. If their blood sugar levels slip too low, for example, they can sink into hypoglycemia, more dangerous for them than for younger diabetics. Seizures, coma and brain damage are among the scarier consequences.
But even if that doesn't happen, "tight control imposes a major burden on how people live their lives," Dr. Lee said. "We have to resort to stronger medicines and more monitoring" — finger sticks several times a day, perhaps insulin injections at least daily, dietary restrictions for people who may already not be eating well.
"In nursing homes, patients tell me, 'I used to enjoy so many things that I can't do anymore. Food is one of the few pleasures I still have, and now you're going to take that away from me?'" Dr. Lee said. "Some patients don't care, but some care a lot."
A tough regimen for lots of older patients, tight control can be particularly problematic for those with dementia, who have a terminal disease and who may not be able to understand the reason behind all the needles and constraints.
"Let's be a bit more balanced," Dr. Lee suggested. "In the frail elderly, trying to get to near-normal blood sugar levels doesn't make sense."
Frail elders can still benefit from treatment, he hastened to add. Uncontrolled diabetes can exacerbate incontinence, for instance, and it can increase falls.
Moreover, age itself is not the criterion. "If your parent is 70 and playing tennis three times a week, he or she should be treated like a younger patient," Dr. Lee said. Someone that healthy and active might well survive long enough to reap the benefits of a stringent approach to lowering blood sugar.
But for someone who is 85 and frail, has other chronic diseases and already takes lots of medications, who lives in a nursing home or needs that level of care, aggressive treatment for diabetes is unlikely to pay off in better health, Dr. Lee said. Looser glycemic goals might serve better.
"The focus should be less on long-term outcomes, more on what's important for each person," Dr. Lee said. That would involve deeper discussions between physicians and patients, he acknowledged, rather than doctors' reflexively urging patients to maintain a number more logical for 40-year-olds.
But he suspects that many doctors already see that the push for lower blood sugar levels can prove troublesome for their older patients. "I wrote the commentary," he said, "to give them a rational reason to do what they already felt, in their guts, is right."

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