II. Practice Strategies Return to the Beginning
How can you, as a practitioner, make these interactions work for the better health of your older patient? Here are some suggestions:
A. Giving Patients Information for Healthy Decisions
The information given you in this course will be most valuable if it is shared with your patients. Almost everything that those who live long and healthy lives have in common is in the power of your patients to do for themselves. Improving diet, being more physically active, taking care of emotions and accentuating the positive, being with people, stimulating their minds, or paying attention to their spiritual well being are all actions that have been shown to be good for you. You can provide the motivation and information to make these changes by offering what you have just learned to your older patients. When doing so, think about the following:
1. “Prescribe” Healthful Habits for Your Patients
Some of your elder patients may believe that they are too old for healthy practices to make a difference in their health or length of life. Now you have proof that you can give to your patients that this is not true. Besides reminding your patients of the importance of diet and exercise, let them know about why they should make the effort to get out and be with others, take the bus to the library to find some interesting books to read, or mend a family relationship.
2. Remind Them that They Are Not Their Parents
A patient whose parents died young may be convinced that his or her own early death is inevitable. Perhaps you can anticipate your patient’s concern and point out the many ways that they can improve chances of living longer. After all, environment and good health habits are responsible for 70% or more of how long and healthfully they will live (Perls & Terry, 2003).
3. Reassure Them that Long Life Need Not Be Full of Disability
Your elderly patients may be dreading the coming years, assuming that they will be filled with nothing but an inevitable decline into physical decay and dementia. This image of the future is not one to inspire the healthy habits and go-get-‘em attitude that can add years to life. Telling them about those who are still going strong into their 90s and 100s may be the inspiration they need to look to the future with hope and make the efforts to make sure their later life is healthy and happy.
4. The Mind-Body Connection and CAM
Some complementary and alternative therapies have been shown to have positive mind-body health effects. Many of these therapies are not invasive or harmful and do not add yet another medication to a patient’s pillbox. The National Institute of Health’s Center for Complementary and Alternative Medicine offers information about those therapies which show promise. You may find out the latest research results on their website at www.hccam.nih.gov/health/bytreatment.htm . According to the site, relaxation, hypnosis and biofeedback all have beneficial effects on age-related conditions like insomnia. Other studies have shown that aromatherapy massage had a calming effect on those with dementia (Smallwood, Brown, Coulter, Irvine, & Copland, 2001) while massage, reflexology and music therapy seemed to benefit hospice patients (Demmer & Sauer, 2002).
5. If Your Patient Is Concerned About Cognitive Functioning
Your older patients may be concerned about losing cognitive function even if they have no more than normal memory loss. Why not tell them about some of the research we’ve discussed so that they can begin “healthy brain” habits? Reading, doing puzzles, taking a class, starting a new career, or learning to paint or sculpt are all not only fun, but also good for the brain. Those patients who never went to college may be interested in some of the new college programs especially for seniors. The fitness classes that are so beneficial to the body and social life are also good medicine for the brain.
6. Protecting Your Patients from Scams
The downside of all this interest in anti-aging is that many, many unproven, expensive, and potentially harmful anti-aging treatments are being sold to unsuspecting elders. In fact, a group of researchers has recently stated that “there is as yet no convincing evidence that administration of any specific compound, natural or artificial, can globally slow aging in people, or even mice or rats” (International Longevity Center, 2001). Advise your older patients to be very cautious before they spend time and money on anything that says it will keep them young or return their youth. And, if you do find out that a patient is taking some unproven anti-aging remedy, this is a good time to discuss those healthy habits and behaviors that really do improve the length and quality of life.
B. Encourage Health in Many Aspects of Life
Just as many aspects of life affect health, health problems can make other areas of life more difficult. These can then, in turn, make maintaining and improving health more challenging. You can help break this cycle by finding out from your patients what is affecting their mental and emotional, social, and spiritual lives and addressing those health issues even if they are not what may seem most important to you. You can also offer care in a way that is sensitive to your patients’ life circumstance.
1. Offer Help for What May Not Threaten Life, But Which Affects Social Life
What is keeping your elderly patients from having a full social life, from getting to religious services, from doing activities they enjoy? Is incontinence keeping them inside the house out of fear of embarrassing themselves? Do hearing or vision problems prevent them from talking with friends and family? Have you ever asked about sexual problems? Addressing these kinds of health problems may help the social, spiritual, and mental health of your elderly patients, and thus lead to better overall health.
2. Making It Easier for Caregivers and Receivers
Can you find out what tasks are most difficult for the caregivers of your elderly patients and help with those, even if your patient originally came in for something else? Also, can you ask your elderly patients who have caregivers how they feel about that? Perhaps by helping your patients to become more independent you can improve their mental outlook and self esteem. You might also wish to become familiar with the services that can provide respite for caregivers and the many, many new technologies that can make those with disabilities more independent.
3.You Can’t Change the Past, But You Can Be Aware
You may need to make a special effort to establish trust with patients who may have had bad experiences with the health care system in decades past due to minority status, income, or something else. Perhaps you will need to make a special effort to form a personal rapport with a patient or even just acknowledge that previous experiences may have been unjustly difficult. Spending a few moments listening to a patient whose ideas about his or her health have been dismissed by other practitioners can help ensure your patient will also listen to you.
C. Use Inter-relationships to Benefit Your Patients
Sometimes you may not be able to address a health problem directly due to a patient’s reluctance to seek or accept help, financial concerns, or other reasons. In that case, consider creative ways to improve the situation using other areas of your patient’s life.
1. Roundabout Mental Health Services
Does an elderly patient seem a little down but won’t go to counseling? Of course, mental health problems require professional services. However, you may be able to improve the mood of an elder whose problem has been properly evaluated and is not that severe by other means. Exercise has been shown to reduce depression. Can you suggest a fitness class if they will accept nothing else? What about a support group at a community center? Or could you refer them to a men’s group or other activity that may bring them into contact with others who share their problem?
2. Meeting Fitness and Social Needs at the Same Time
Many fitness programs for elders combine exercise with socialization. Walking Clubs, in which groups of elders walk together regularly, senior aerobics and water aerobics classes, senior bowling leagues, and many others can fill two needs at once. If you have concern about the social isolation of a patient who would never acknowledge loneliness, why not recommend they lose a few pounds through one of these activities? Or, similarly, if you have a patient who simply cannot become motivated to exercise alone, maybe a group activity would be just the thing.
3. Appeal to the “Do-Gooder” in Everyone
If your elder patient just won’t become physically and mentally active for themselves, what about encouraging them to volunteer in such a way that they get some exercise as well as improve their social life? Delivering meals to homebound elders requires walking, lifting, and interacting with others. Raising food for the homeless in a community garden is great exercise and a way to meet new friends. Most senior centers have volunteer programs that are as much for the benefit of the elder as the senior center and may be able to give you suggestions.
4. Motivate Your Patients through the Personal Touch
As we have seen, later life can be a time of great loneliness, especially if an elder is homebound. You are in a special position of trust to people who may have lost almost all of their family and friends and who depend on you to help them maintain their independence. Use this special gift to motivate your older patients to take up those healthy habits that we have seen are so important. If you are in a practice in which you see the same patients over and over, how can you form a connection in order to create the trust that may motivate them to take your advice? Could you note down in the record a spouse’s name in order to ask about them? What about mentioning some small fact about the patient’s life, like unusual military service or a special accomplishment?
5. Don’t Forget about the Importance of Spirituality
Even those patients who may not wish to go to a formal religious service still have spiritual needs, especially when they become seriously ill. What can you recommend for patients who spiritual loneliness is affecting their health? With the new HIPPA regulations many hospitals will only provide information about patients to clergy if the patient lists a religious denomination. Let patients know that they can receive a clergy visit but that they must fill out the right forms. Also, many senior centers have non-denominational programs about spirituality led by psychologists or nurses. Other programs that may not at first seem to be spiritual provide an opportunity for discussions about the meaning of life that are so important to elders. Examples include reminiscence projects, support and discussion groups, and memoir and art classes, all available at senior centers.
6. Use the Family Connection
What elders won’t do for themselves they will sometimes do for family. For example, elder abuse victims, who many times feel great concern for their abuser, will often not agree to receive help unless help is also offered to the abusing family member (Brandl & Cook-Daniels, 2002c). Many elders are concerned about becoming a burden to their adult children or not entering a nursing home in order to preserve an estate for their adult children. Can you suggest that they take up behaviors that promote health by reminding them of the effect of their disability on family members?
D. Your Local Elder Service Agency is a Resource for the Whole Elder
The elder services network – including senior centers, home care corporations, councils on aging, and the like – should be your partner in helping your patients meet their overall health goals. For over 40 years, these agencies have been dedicated to serving the “whole elder” and are experts at creating programs that encourage overall well being and matching individual seniors with just the right service or activity. One of the best ways you can meet the various needs of your elderly patients is by making sure that they are taking advantage of what is available to them in their community. The two primary agencies are:
Senior centers, which are public or private community centers frequently offering both activities for independent elders as well as care or case management for homebound elders; and Home care corporations, which are federally-funded agencies designated by your state’s agency on aging to provide a wide variety of services, mainly for homebound seniors.
How can you make sure your patients are using their local elder service agencies? First, send your older patients to elder service agencies for the kinds of social, spiritual, and mental health-enhancing activities that we have seen can improve physical health. This would include almost all activities and services, but especially:
Fitness classes Support groups Discussion groups about spirituality Activities to stimulate the mind Social and recreational programs Nutritional programs such as congregate lunches and home-delivered meals
You might want to make suggestions to your patients of specific activities as well as have resource guides available in your office for patients to browse through.
Second, if you want a homebound patient to spend more time with people, eat better, or have other kinds of non-medical help, start communicating with his or her care or case manager. A care or case manager is the person who evaluates an elder’s needs and arranges and monitors in-home services, such as friendly visitors or home-delivered meals. This person may be a staff person in a senior center or home care corporation, a private geriatric case manager who is privately paid by the hour, or someone else. The best way to find out if a homebound elder has a care or case manager is to ask. Because the elder may not know the terms “care manager” or “case manager,” you might wish to ask questions like “Who arranges for your in-home services?” or “Who do you call if you have a problem?” If an elder patient does not have a care or case manager, you could be doing their health a big favor by referring them to a senior center or home care corporation so that they may find one. Any communications about individual patients must, of course, follow all legal and ethical privacy guidelines.
How can you find out about the elder services in your area? A good place to start is the Eldercare Locator. This is a national hotline of the federal government that can refer you to your home care corporation based on the name of the community or zip code. Their number is 1-800-677-1116. You may also get information through their website, www.eldercare.gov. Home care corporations have comprehensive information and referral services that can tell you exactly what is available in your community. Many senior centers also provide extensive information and referral and, since they generally serve a smaller area, may have more detailed information.
What Do Senior Centers Offer?
Senior centers can be public or private, large or small, with many services or with just a few. However even those in small towns may provide:
a range of fitness classes, including aerobics, weight strengthening, walk clubs, Tai Chi and yoga, and other exercise opportunities health clinics individual help with financial, legal, tax, and insurance problems informational programs on health, legal, financial and other issues support and discussion groups classes teaching art, crafts, and many other topics; trips social and recreational activities volunteer opportunities spirituality programs congregate lunch programs and home-delivered meals “friendly visitor” programs medical transportation care and case management information and referral counseling for elders and family caregivers and many others.
What Do Home Care Corporations Offer?
Home care corporations offer a wide variety of services. Like senior centers, they may be public or private. Many services are the same in all home care corporations because they are federally funded, while others may be special initiatives of the agency supported by state and local or private dollars.
case management of individual elders information and referral to other elder services agencies direct care such as chore, personal care, or homemaker services protective services for abused elders money management for those who are no longer able to pay bills caregiver training and respite community education and many others.
Other Services for Elders that Have Recently Been Created
A variety of services have come into being over the past couple of decades to serve elders and their caregivers. Among those that might be of use to your patients are:
Social and medical day care centers, which offer care and activities to elders who need supervision and socialization but who still live in the community Private geriatric care managers who evaluate an individual’s needs and arrange and monitor services for an hourly fee Respite care, including both in-home care providers and short-term nursing home or assisted living stays, in order to give caregivers a rest Private organizations or universities that offer travel and educational opportunities for seniors Private membership organizations that offer many services similar to those provided by senior centers and home care corporations Elder legal service providers who offer no or low-cost legal services on aging-related issues such as health benefits
