Little Old Ladies from Little Old Towns

I worked at the GreatRep today, where I was unsurprised to find out that one of my residents is in the process of dying. This is a woman who's lived at the GreatRep for about half of my life. When I was in high school, she moved in. She's been there longer than any other resident, longer than the current Director of Nursing, longer than anyone else who's worked there. Pretty amazing.

The entire time I've known her, she's been almost like a living doll. She doesn't speak, rarely makes noises, and doesn't initiate movement barely ever. We move her from chair, to wheelchair, to bed. We feed her with a spoon and hold a cup up to her lips to drink. We use a mechanical lift to put her on the toilet and change her briefs.

I've heard she used to be quite a spitfire back in the day, and would scream at people. There was one caregiver whose voice she just hated and this woman would have a cataclysmic reaction if that caregiver attempted to do anything for her.

Now this woman is ready to go, and she let us know that the way most of them do; by stopping to eat or drink. She'd simply hold it in her mouth or let it roll back out, whatever you put in there.

Her sister stopped by to say goodbye to her today, brought by a younger and more oriented family member. I never would have thought I'd laugh about what someone said to a loved one on their death bed, but this is the cutest and silliest little thing; you would have had to excuse yourself from the room too!

Little Miss Clara marched right up to her dying sister, telling us "I have to go see Sister! We had a violent disagreement a few days ago, and I've just got to make things right!"

Rememeber, Sister hasn't said so much as a word in years.

Miss Clara whipped out a sheet of paper where she had painstakingly written out her speech to Sister. She stepped right up, and gave Sister's arm a good shake, saying "Sister, wake up! It's me, Clara! Nurse, don't you think she oughta wake up?"

The nurse gently replied that no, sister would probably not be waking up and that Miss Clara might want to say her goodbyes.

"Oh, then. All right."

Miss Clara began to read from her paper.

"Sister, first of all, you were always prettier than me."

I wish mightily I could have known what all was on that paper, but it's hard to beat an opening like that!

I'm in like Flynn

Had my first day of med tech/med aide training today, and I think I'm going to love it. I like getting to learn how to read the MAR's, new charting, getting familiar with all the medications and what they do, and really getting to use my brain at work for the first time in a while. Caregiving is more social intelligence and brute strength combined, and this is more being meticulous, some critical thinking, and a ton of new things to learn.

The shifts are longer (10 hours instead of 8) so that is tiring, but I'm delighted to be getting done at a time when normal people get done with work now too. I'll be working med aide 3 days a week, and caregiving in between in order to keep me at full-time.

It felt really good to have my coworkers congratulating me today as they noticed that I was wearing regular scrubs instead of the caregiving uniform ones, and I love that in this role, I get to see the whole building and almost all the residents, rather than just the one hallway at a time.

Walking around there today was like seeing a new place; the people were all the same but my focus was very different. It's kind of like when you go back and visit your elementary school and can't believe how little the desks are. Familiar, but different enough to be disconcerting and charming at the same time.

Hopefully tomorrow I'll get my book learning session in with the DON and I think I may even be working the cart on my own (!) this weekend - yikes/hooray!

Antipsychotic Drugs and Chemical Restraints

At the GreatRep, and pretty much all long term care or memory care facilities, there is a Bill of Rights list for all the residents posted prominently around the building. One of these rights is "to be free of all restraints, including chemical restraints". Logical, right?

As an aide, I have very little to do with the residents' medications. I report symptoms to the charge nurse, who then decides what to do from there. A few of the residents are on frequent doses of the same medications for certain behaviors or symptoms and so we all know what they will probably get in response to our reports of their symptoms. Lillian has severe pain and it's very obvious when it's not being controlled well, so when she hurts we all know she needs her Morphine. LuLu repetitively hits herself, which lets us know it's time for more Haldol or Ativan for her.


A lot of science news articles state that the use of antipsychotic drugs for dementia is a bad practice. It's not intuitive, because if you look at the list of symptoms of say, schizophrenia:
"They include disorganized thought processes and disorganized behavior as well as delusions and hallucinations. The disorganized thought processes are seen primarily in speech such as rambling and 'word salad'. The patient may babble about various different topics one after another, which to the normal person, do not appear to be connected in any way. The phrase 'word salad' describes a patient’s incoherent speech, which lacks correct grammar and any obvious purpose. Disorganized behavior will be discussed in a following section. Hallucinations are false perceptions; patients believe they can hear voices others can’t and sometimes see or feel things others don’t. Delusions are misinterpretations of events and their purpose such as when patients believe the CIA is plotting against them or that their psychiatrist is involved in an assignation attempt against them. Schizophrenics cannot be reasoned with over their delusions; reasoning and discussion leads to the patient’s mistrust and anger." (1)

All of that is very typical of dementia patients as well. You'd think since the symptoms are so similar that the treatments can be as well. But apparently not, since the use of antipsychotics in dementia patients increases their death risk, for reasons unknown(2).

To be clear, it seems like Doctors are warning against antipsychotics to control behavior that is merely "annoying" for caregivers such as wandering, agitation, uncooperativenesss, etc. For behavior that is truly dangerous for the patients or everyone around them (self-injury, extreme combativeness that can physically injure both caregivers and the patient, etc) I think it can still be merited.

Which is why when I read articles like this one, "Alzheimer's Therapy Focuses on Care: Giving Alzheimer's Patients their Way, Even Chocolate"(3) part of me gets really frustrated. It seems like outsiders and the media tend to think that some of the interventions we routinely do on our patients are for our own convenience, and therefore wrong. I loved that it explained about emotional states lasting longer than the patient's ability to recall or explain the reason for the emotion; however I would have liked to have seen a few more realistic examples of how this can be implemented. Things like when one of my widowed residents becomes anxious, thinking her husband is injured and missing, it's more productive to let her talk about that briefly, then steer the topic to her children, who are all alive and well. She calms down and gets happier as she tells us about what they were like when they were little, and shows us the quilt her daughter made her. That way, when the conversation ends, it ends on a happier note, which is more likely to stop her anxiety cycle about her husband. And of course there are the more conventional redirections like trying to get her involved in an activity or focused on something else.

I just hate the idea that we're somehow failing LuLu because sometimes medication is the only way to get her to stop hitting herself. You can redirect her, feed her, hold her hands gently, all sorts of things, but if she's in that mood she will not be deterred and it's not safe for her.

Patients have the right to refuse care, for example. But an incontinent person who refuses to be changed for 8+ hours isn't making a reasonable choice and is endangering themselves by hugely increasing their risk for a pressure ulcer. So sometimes we just have to force someone to let us perform very basic hygeine on them. And it sucks. And sometimes the only way to do that without anyone ending up seriously hurt is to premedicate them, and sometimes even that doesn't work. I wish there were a magic wand to make combative people cooperate when you're trying to help them.

But for all the caregivers and family members who read that article, I want to tell them that baby dolls and chocolate are a part of the answer, and can be good tools, but we need more solutions. And that even as a profession, caregiving is rarely "convenient"; that's not why we do this work. So please give your facility the benefit of the doubt and ask first before assuming they're chemically restraining people for no good reason. It's a last resort, but sometimes it's the only way.

And I don't know if it really belongs on any patient's Bill of Rights. Because the truth is, they do have the right not to be restrained unless they're hurting themselves or others and nothing else will stop them.


1. About schizophrenia http://healthpsych.psy.vanderbilt.edu/AntiPsychoticMeds.htm
2. Antipsychotics and death risk increase http://www.webmd.com/alzheimers/news/20080616/antipsychotics-for-dementia-up-death-risk
3. Giving Alzheimer's Patients Their Way http://www.nytimes.com/2011/01/01/health/01care.html?_r=2&pagewanted=1

What a Winkle

I absolutely love the weird conversations I have with my dementia residents, and there's one that pretty much always takes the cake. "Cookie" hallucinates and can be very difficult to deal with, but she's often very focused on wanting to see a doctor and wanting every person she sees to be a healthcare professional. So I usually address her as Ms. Oven instead of Cookie, and emphasize that I'm a nursing assistant rather than a caregiver in order to get her cooperation. I once had to wrestle a wet incontinence brief away from Cookie, who gave it up only when I told her I needed the sample for the Doctor. Gross.

Anyway, over the weeks, Cookie has come up with some good ones; telling me the Borg are trying to get her when I go to wake her up in the morning, hitting on the life-size dancing Santa that we had up at Christmas, telling my female coworker what a "gorgeous guy" she is.

The other day I went to get Cookie up out of her armchair to go use the bathroom, and she had a little stuffed animal sitting on her walker. "Look at my Baby!" she said, as I approached her, "Isn't he cute? What should I name him?"

Her stuffed animal was a little moose, so I said "How about Bullwinkle?"

Cookie blinked at me for a long moment, then said "He's from . . . where? He's a Winkle, you say? Is he a Winkle?"

I answered "I think he might be, what do you think?"

"Yes, probably. A Winkle."

Oh, Cookie!

Matching Game

Here's a little game I like to call "I found what...WHERE?"

I'll tell you what I found, and you guess where I found it. It's a little like "find the saltine" on Scrubs except so far I haven't found any saltines anywhere unusual.

Let's play!

1. I found a flashlight.
a) In a cupboard.
b) In a garage.
c) In someone's underpants.

2. I found a pair of dentures.
a) In someone's mouth.
b) soaking in the appropriate cup with lid, labeled.
c) wrapped in a sock and in someone's pocket.
d) shoved down into a recliner.

3. I found a missing resident:
a) Sleeping in someone else's bed.
b) In the furnace control room.
c) trying to open the locked gate outside saying "Damn it!".

4. I found poop.
a) In someone's underwear.
b) Trailing from someone's bathroom to their bed.
c) On the shower floor.
d) Under someone's fingernails
e) In someone's mouth.

5. I found toothpaste.
a) on a toothbrush.
b) on the bathroom counter.
c) in someone's hair.

Keep in mind, this game is extra tricky because for some of these, every single option is true! My world is never boring. Or clean for very long.

Happy New Year!

We Heart Volunteers

We get a fair amount of volunteerism at the GreatRep. There are people that bring in dogs to visit with the residents, people that come read aloud to everyone, people that do crafts, people that put on musical performances. You'd think that all our volunteers would be pretty normal, but they're not. They're often just as weird as the rest of us in there (staff and residents both). There's the guy that comes to sing and play guitar almost every week, who's incredibly tone-deaf. There are people whose ideas of "activities" are so half-baked that I really worry they're going to get scared and leave. There are people who set off the exit alarm every. single. time. they come and go.

My favorite are the well-meaning oddballs. We've gotten lots of them lately, it being holiday season and all.

Yesterday was extra awesome because the musical volunteer of the day looked a lot like If Wayne Newton Dressed Like Merle Haggard. He had a special synthesizer-thingie that made his backup music, and a microphone and everything. He set up in the dining room, so we brought anyone who was willing in to listen to him while we passed out snack.

First of all, you've gotta have balls to show up and sing to a room full of people with dementia; they're not your typical audience and they won't be shy to let you know if they dislike what you're doing. And if they do like it, they may not show that at all. So I give the guy credit for that, plus he really did have a very nice voice. He sang Christmas songs for the most part, and did it well.

The part that really made him the December Standout in my book is that he'd stop between songs to do a little patter as if this were a nightclub. So after a rousing rendition of Rudolph, here's what we were treated to:

"So a few years back, my wife and I were driving home from cutting our Christmas tree and she looks out the window and sees some reindeer in the field we're passing by. She's shocked because she didn't know that reindeer were a real animal! So we pull over, and walk around the truck, and go up to the fence and look at the reindeer. About now I decide it's time to play a little joke on my wife. So I says to her 'Honey, what you might also not know about reindeer is that if you talk to 'em, they'll talk back to you.' She looks at me skeptically, but I'm insisting here, 'No baby, really, go up to one, and say niff and it'll say niff right back to you!' She told me I was full of it. So I tells her again 'Just say niff niff to them, it'll work! They'll say niff back to you.' "

(he went on like that for a while repeating "niff" a few more times to make sure we all knew he was trying to get his wife to say "niff" to the reindeer)

"I said really, I know it's strange, but you just go right up to them and say niff..."

which is when LeeLee (resident) decided she's heard "niff" enough times and interjected "What the hell is that?" which then made me laugh hard and silently.

Her reaction was way funnier than the climax to his story, which was that he came around the side of the truck and heard his wife whispering niff to the reindeer to see if it was true, and he laughed at her.

LeeLee knows what's up. "Niff"??? Really. What the hell IS that?

Eeek.

Sometimes I want to hate doctors for no reason. Sometimes I probably wouldn't hate them for whatever if I actually understood what their reasoning is for things. This is probably one of those times. There must be a perfectly good reason for requiring a clean-catch urine sample to diagnose a UTI even if the patient has had UTI's in the past and the care staff can easily recognize the signs. Even if the nurse could do a dip on a regular sample or send that out to the lab for verification.

(note: UTI = urinary tract infection; little old ladies get these a lot and they can cause pain, low-grade fever and increased confusion. They're fixable with antibiotics.)

But it seems stupid and mean to me, the lowly caregiver, that we have to hold still a really sweet lady with dementia, and the nurse has to put in a catheter for a few seconds so we can get that elusive clean-catch urine sample. We were all almost in tears at the end of it; I held one hand and food, a coworker held the other two, the nurse did the cath, and another caregiver held the light for the nurse so she could do it as fast and accurately as possible. Our poor resident was upset, we were upset, and I thought the Doctor Is Stupid. We got our resident cleaned up and into jammies and tucked into bed, and then she was okay.

I hope there's some good reason for this though. Or if not, that we don't have to do this to my poor resident again.

Why Dementia?

I was thinking about this last night, and then talked about it with a friend (hi Annie!) on the phone today; not everyone likes being around people with dementia and taking care of them, so why do I?

First of all, I don't always like all my residents. There are a few who really only react to anyone with physical aggression - no matter what you do, they're hell bent on hitting, scratching, spitting on, and choking you. Those few, I figure I just missed the window where they were able to get through their disease enough to react better, and now all I can do is provide the minimum care needed to keep them safe without either of us getting hurt. I don't get all fancy and try to put makeup on them or anything, because I know they won't enjoy it. And I don't have to like them, I just need to do my job and take care of them, so I do.

That's a very small percentage though. The rest have their quirks and behaviors for sure, but I genuinely really like them and enjoy taking care of them, even as they get further into their diseases.

It's hard to explain exactly why it doesn't really occur to me to think that watching someones dementia progress is depressing. The best I can liken it to is that my husband used to be a special ed. teacher, and would get all kinds of idiotic comments when he told people what he did for a living. "That's so sad! I would cry every day because those kids aren't fixable" or "That must be so HARD" or "You must be really special to be able to handle THAT all day". He'd always get mad because he didn't view his students as broken or worthless or burdens any more than any other kid. The kids don't hate their lives; they don't know any different, and have always been who they are. And sure sometimes they were pains, but every kid is sometimes. And sometimes they were very funny and fun and loving, just like any other kid.

I feel pretty similarly about my residents. I didn't know them before they got sick so I don't know any better than to expect them to be however they happen to be right now. And I pretty much like them how they are right now. And will still like them even as they decline. Knowing them when they're only somewhat confused makes the end/rageful stage (not everyone does this) easier to handle.

I think it's pleasanter to take care of someone who is in the permanently-combative stage if you know a little more about who they used to be. I always appreciate when I step out of the bathroom after getting a beat-down, my hair all askew, nametag crooked, covered in sweat and disinfecting myself like mad, one of my coworkers says "You know, Lily never used to be like that. When she first came here, she used to play the piano and try to tuck the other residents in at night. She was a cool lady." It makes it easier to go back in and face the Lily that's kicking me, if I can hold that picture in my mind and be trying to care for that past Lily even though she's gone already.

It's sad when someone is in the self-aware stage of the disease, and knows they're losing their memory and is powerless to stop it. It's sad because they're sad. But once they pass that phase and are living in the moment, they're often pretty content, and if not, then I can help them feel better usually. So that's not sad anymore.

With the rare residents/clients that I knew before they got so confused, it's more sad to me. Mainly just because I miss them, and I know that if they were aware of the whole situation, they'd be upset that they were missing out on so much. And I do understand that's where most family members are coming from, and it's really hard on them. It's easier for me because I usually get to live in the moment with my residents without mourning the past.

I think my favorite thing about working with people with dementia is the immediacy. I don't have to spend a lot of time building a relationship with a resident before they will trust me. If they like the way I interact with them, they'll probably go ahead and help me do what we need to do. If they like me, I get kisses right then. It's great, and very clear. And if they don't like me? I can go away, come back, and try again with a clean slate.

That probably sounds really lazy on my part. But it's true - I like the simplicity of my relationships with my residents. Affection flows freely and quickly, and anger vanishes fast, for the most part. Who wouldn't find that personality type easier to care for than someone who bickers and holds grudges? Right?

Confessions

One of my bigger peeves about working in Long Term Care is that my coworkers tend to be unreliable as far as showing up for shifts on time. Or at all. In general, I don't call in unless I absolutely have to, because I know how much it sucks to be the one that shows up when no one else does. The workload doesn't decrease just because the workforce has; the same number of residents still need the same amount of care that they do every day, no matter how many hands there are to give it to them.

Which is why, just yesterday, I was smugly thinking to myself how glad I was I'd made it in during the snow we recently had, and that I should pick out something fun to get for myself with my "perfect attendance" monthly bonus that I'm sure to get.

And then I fell down my damn stairs on the way out the door this morning at 5:45 am. And landed on wet, cold concrete. I dragged myself back into my apartment, intending to put on dry scrubs and head right back out the door, until the pain hit me and I realized that 8 hours of walking, lifting, and standing were probably not going to make my knee and hip feel any better.

So I sucked up the embarrassment and picked up the phone, and called, teling the charge nurse what had happened and that I wasn't going to make it today, but would do whatever I needed to in order to be there tomorrow. And me and my ice pack hit the couch and took a 4 hour nap.

And here's the confession part: It was awesome.

I'm only mildly sore and bruised-up now, which makes me think maybe I should have gone ahead and toughed it out.

But an unexpected day off like this is actually really, really nice. Oops. Guess I should remember this next time I'm cursing my "slacker" coworkers who don't show up. Turns out I've got a slacker side too, it just took a wet stairway and gravity to show it to me.

Dementia in Groups

The GreatRep (where I work) is an Alzheimer's and Dementia care facility. It's secure, which means in order to get outside, you must know the keycode and enter it to get the doors to open. Well, there are secure courtyards outside that anyone can go into whenever they like, but this time of year they don't get much use. Although one of my coworkers did build a tiny snowman outside the window and then took each resident to the window to see it and look at it and talk about the snow for a while, which was cute.

My friend Annie just wrote a post on her blog about her first visit to see her Mom at a facility much like the one I work at. Go read it, she's great, her Mom is great, and her Dad is too! http://tinyurl.com/28tgzbf

What cracked me up about it is that we give graham crackers out every day at 10am at my job! And what made me think is when Annie said "In my head I guess I wanted to imagine that, while we don't understand her in her disease, once she got around other people who had the same disease they could somehow find each other out there in that place where Alzheimer's takes them. But I guess it just takes everyone somewhere different."

I think it's pretty fascinating to watch the ways my residents interact with one another. We have one set of roomates that we refer to as "the twins" even though they aren't related, because these ladies can often be found strolling around together, or in their room reorganizing the closets for the zillionth time, or reading aloud to one another. One of the younger residents there strolls around all the time, patting the hands of whomever she comes across, or just sitting with someone for a while. She doesn't often strike up conversations, but she seems to really like the companionship of just sitting next to someone on the couch.

We've got a few married couples that room together, one of whom hardly talk to each other (or talk much at all anymore) but every day after breakfast we put them next to each other on the couch, and the wife leans over and falls asleep resting her head on her husband. They don't sleep together in the same bed anymore (that sadly doesn't work out very well when there's catheters and memory loss involved) but they're in the room together and they doze next to one another on the couch. The other ones still walk and talk, and they bicker bicker bicker just the way I bet they've always done.

On the more acute wing, mostly the residents don't really talk to one another very much. They're far gone enough that if you want their attention, you need to address them by their name, try to make eye contact or hold their hand, and speak up pretty loudly. So obviously since they all need that, none of them can really do that for one another. There are a few exceptions, of course. One of my favorite people there, Bonnie, is also on the younger end and has excellent hearing. When I'm feeding her lunch, she'll quietly respond to what someone on the other side of the dining room says, so if a coworker way over yonder says "Is Maxine ready for dessert?" Bonnie will say, so only I can hear her "Yep, she sure is". Bonnie is the one who says really cute things sometimes, like when a coworker told her "Oh, Bonnie, you are something else!" after she'd cracked us up, Bonnie answered "No I'm not I'm always just a Bonnie".

With dementia, it seems like those little moments mean a lot to those of us on the outside. Little peeks into the universe our loved ones are living in right then. And when they connect with each other, and I'm watching, it can make me so glad to have been there. I love walking away after settling someone at the table and overhearing two of my little old ladies that I see every day go "I don't know who that is, but she sure is a nice girl" and another reply "I don't know either but I think she's very sweet". I even got happy when one of my most confused ladies gave me a kiss on the cheek and told me "You're a nice boy".

I know some of the people with dementia feel lonely a lot, because they don't know that you've just spent 20 minutes holding their hand and talking to them; if you're not doing it right then, it doesn't count. But I think a lot of them have some pretty rich inner lives, given the stuff that will occasionally come through in those moments of clarity. I just wonder if they value those moments any differently than all the rest of their time. I know us outsiders do, because those are the moments we feel like we really connected with them.

But today I worked West 1 again (remember how I got my ass kicked all day last time?) and when I went to get Genivieve up, her daughter was sitting, watching her sleep, and holding her hand. Her daughter kissed her Mama goodbye and chatted with me for a few minutes, then headed out so I could start getting Genvieve ready for the day. And you know what? Genvieve was shockingly gentle and relaxed for me. She didn't hit, bite, scratch or spit. She let me help her, and even gently patted my hands. Even though she was asleep while her daughter was with her, I wonder if that didn't make a difference for Genvieve. Maybe it was a coincidence, but maybe not.

This is what death looks like

Ever since I started working in long term care, I've been worried about the first time one of my residents dies. I've had a few that did die, but never while I was there. I'd hear they'd passed a few days later, or months later (former home care clients) and it was sad, but not surprising. Walking in and finding that someone has passed away remains one of my bigger fears, although after the experience I had this week, it's a lot less scary of an idea than it used to be.

Yesterday, after my shift ended, one of my residents passed away. Phyllis was very old and frail, and when I started training at the GreatRep, had recently stopped walking and become wheelchair and oxygen dependent. Her sight was failing, and she had very little appetite. Phyllis began to constantly, under her breath, chant things like "Oh God help me, I can't see, I'm so afraid I'm going to fall, Oh god won't somebody help me why is this happening to me, Lord, why?". No amount of reassuring, hugs, gentleness or anything would soothe her for very long.

Then around 3 days ago, Phyllis began refusing to eat. She started looking more frail, the little veins by her temple becoming more visible like they are on a baby. She seemed less afraid, but more tired. We switched her to a fully pureed diet, but she had difficulty with even that, even though we fed her.

Day before yesterday, Phyllis was put on comfort measures only for her care. We knew that her time was almost over. The night shift caregiver cleaned her room, picked a bouquet of flowers and greenery for her to look at, and set up chairs for her family at the bedside. Phyllis' son came and sat with her all day.

Phyllis is the one who taught me what it looks like when someone is dying; she couldn't drink from a straw anymore, so when she was thirsty, I gave her Ensure by dipping the straw in her cup, holding my finger over the end, and dropping in tiny sips at a time with an eyedropper. Her mouth was very dry, and needed frequent swabbing to keep it clean so she could be comfortable and breathe as well as possible. I did that with little sponges attached to lollipop sticks that were invented for that purpose. Dying people don't go to the bathroom anymore, at least not if they aren't taking in anything. Their circulation slows, so their extremities start to get dark, and look bruised. The last time I saw Phyllis, she was in bed, her son reading in the chair next to her. I wiped her lips, gave her a sip of water, and kissed her temple. Her hair was soft and fine like a baby's. She dozed on and off.

I don't know what the last thing she said or saw was, but her son was in the room with her when she went.

As far as death goes, it was much softer and sweeter than I would have imagined. Elderly people can often remind me in some ways of infants, but Phyllis didn't until right before she died. I wonder if that's common, and if it's the helplessness or the inward focus or what that made her seem so much more like a baby then. I can't think of any right word to describe it other than softness. Phyllis was very soft before she went.

And seeing that made death a whole lot less scary for this bystander. I hope that all my old people get to go as gently as she did.

...And then I come home crying

Even good jobs can give you bad days. Very, very bad days.

My current facility (the GreatRep) is divided loosely into two wings, East and West. Residents can circulate freely from one wing to the other, but the West Wing is more acute, and is where anyone who needs mechanical lifts to be moved, or consistently must be fed at meals lives. As you can imagine, the more demented people get, the more likely they are to be combative. And there is one little stretch of the West Wing that we may as well nickname Witch Wing or something else that rhymes with it, because there are 4 women there that will slap, spit, scratch and pull the hair of anyone who dares to try to toilet, feed, or bathe them.

I have no idea why the administrators decided that some lucky soul would get ALL of these women at once (plus a couple of pleasant residents) and put them all on one run.

So when I went to sign in and saw my name written next to the dreaded West 1 run, I got nervous.

The morning started out well enough that I was lulled into a false sense of security. Madge simply curled into the fetal position and refused to unclench the entire time I dressed her (while she lay in bed) and put her into her wheelchair, and cleaned her face and inserted her dentures. Lillian tried to slap me while I toileted and dressed her, but she was too tired for much and was easy to dodge. The others mostly cooperated.

Then it came time for the after-lunch rush to get EVERYONE out of the dining room, toileted or changed, into bed or a regular chair (no wheelchairs) and into clean clothes if they got food all over them. This didn't go as smoothly. Lillian grabbed a huge chunk of my hair and yanked, yelling "you said mashed potatoes! YOU SAID MASHED POTATOES! YOU SAID THAT!" and kicking me as I put clean pants on her. She also managed to slap me across the face while I tried to stand her up from the toilet. Madge was no longer content to curl into the fetal position and instead lost her damn mind when I had to pull down her pants to check if she needed a new disposable brief. Lots of kicking, plus another slap for good measure. Thanks, Madge.

I held it together, finished doing what I had to do, charted, and drove home. Walked in the door of my apartment and burst into tears like the giant baby I felt like being all day.

Days like that make me grateful for two things:
1. I will only have West Run 1 occasionally, and I'll know what to expect next time.
2. I'm married.

How horrible would it be to have a day from hell like that and then come home to a completely empty apartment? I couldn't handle it. I know lots of people like to live alone, but I will always want a roomate, a child, a family member, a spouse, or even a pet around when I have the worst day of my life like that.

As it was, I burst into tears, changed my clothes entirely (I was covered in pureed food after trying to clean the witches of West 1 after lunch) and got into bed. My husband fixed me up with ibuprofen, an ace bandage, a bowl of cereal and soymilk, and an episode or 3 of Jeopardy.

I survived, but I sure as hell didn't do it alone!

Oh, another thing I'm grateful for? They make halidol in cream form. That way when someone is totally freaking out, if they have orders for it, the nurse can rub some cream on them to get them to calm down. If I ever meet the person who figured that one out (and had the common sense to know that pills and injections are a Bad Plan for anyone who needs the halidol that badly) I owe them a medal or a plaque.

Shift Reports: Take it to the next level

Even though we use shift reports to communicate among nursing staff about what our residents have been up to, sometimes a resident will misbehave so outrageously or so consistently that management decides ALL the employees should know about it and be on the lookout. This usually comes down to the people who keep trying to escape (ie "flight risk") and those who really, really, REALLY don't want to be on any kind of diet.

You wouldn't think those two things would be on par with one another in terms of inconvenience, but you've never seen an octogenerian ranting and raving in the dining room about having to eat "grass" at every meal (salads) or about not being able to get a second dessert. They can get loud!

So when someone takes it up to that next level, management prints up a flyer or 10 and leaves them in employee-only areas: kitchen, break room, nursing station, and by all employee exits. That way, when the teenage boys from the dish pit are headed out back to smoke, they know that if they hear someone on the other side of the fenced courtyard saying "Open the gate, let me out!" that they shouldn't. For example. Or when the waitstaff sees Mr. Whomever sitting there for an hour waiting for shift change so he can order a second lunch, they need to call an aide (like me) to convince him to move it along and wait until dinner time.

My favorite thing about these flyers is how much they look like Wanted posters at the post office. I like to imagine the "flight risk" residents strolling away from the building in slow motion, with Bon Jovi's Wanted Dead or Alive playing in the background. Who says that the "steel horse I ride" can't be a walker or mobility scooter instead of a motorcycle?

Add to that the complete awkwardness of most of the photos used in the flyers, and you end up with something like this:

RESIDENT NAME: Mrs. Ballyhoo
[followed by an awkward photo of said resident, such as this one I found by googling "Grandma"]

ATTN: FLIGHT RISK
DETAILS: Resident has Alzheimer's and is a flight risk. If you see resident unattended, please escort her back to the memory care unit. Under no circumstances should you open a door for this resident.

or something more benign, like:

RESIDENT NAME: Mrs. WhoDat
[another google result for Grandma]

ATTN: Diabetic
DETAILS: Resident is noncompliant with diabetic diet. Offer her the "special" pie and do not say it's sugar free. Resident will stay at table and order multiple lunches. Call nursing staff if this happens. Small portions only.

For whatever reason, these fliers crack me up. Especially when a lot of people have been rebelling and the walls are practically plastered with them. The kitchen always has a lot, saying who needs thickened liquids (ew) and who needs their food mechanically softened. But when the back door to the facility starts getting filled up, you know it's been a long week!

Dignity

There are different buzzwords that you hear a lot when you start learning about the world of senior care. "Aging in place" refers to someone staying in their own home. "Cognitive impairment" is the newer polite alternative to saying someone is confused, demented, brain-damaged by stroke, or senile. And any discussion about where/how/who will care for old people is bound to include opinions about how to "preserve dignity."

It's an emotional topic for families. They are used to seeing Grandma or Mom as a capable woman, and know that she worked for years as a nurse, or teacher, or Air Force pilot, or whatever it is she did. And even though she may not really be that same woman anymore in many ways, they want to have the stage set as if she still is the same as ever, as much as possible. Some families are against the use of mechanical lifts for that reason, because they think they are "dehumanizing." Some dislike certain terms; I have one client whose daughter doesn't like me to call myself her father's Caregiver. She prefers the term "escort" which I hate because my job is this:

and is NOT:


All in all, I'm not very sensitive about dignity. The truth is, getting old isn't a dignified experience. You lose abilities you used to have, and rely on others more. Your body is deteriorating. But you know what? It happens to EVERYONE who lives long enough. So there's no point being embarrassed about it. I think we may as well just be practical and do things the way that's the easiest for the old person. It's more comfortable and safer for them to be transferred with a mechanical lift? Use one. They need to be wearing diapers/briefs? Get some. The dickering about what to call someone's caregiver or whether or not Grandpa should wear a life alert pendant is more about the families than the person, lots of times.

But this week, at my job, I turned into the one saying "That's not dignified!" And it surprised me. What finally pushed me into that camp?

My facility's new policy that when we change someone's disposable brief, we must write the date, time, and our name ON THEIR ACTUAL BRIEF. Now that's impractical enough, but add to that the fact that if I check their brief, and it's clean, I must cross out the previous time and add the new one. Seriously. Which means that instead of a 2 minute trip to the bathroom to check, I need to decide if I want to be the jerk that writes on someone's butt while they're wearing the brief, the jerk that makes them take it off so I can write on it and put it back on, or the jerk who avoids the first two options by throwing away a perfectly fine one so that I can write on a new one in the other room where they aren't watching me autograph their underwear and then put that one on them.

Ugh.

I agree that not changing people when you're supposed to is horrible and can lead to health problems. But a small chart in their bathroom for staff to initial? Dignified. Writing on someone's underwear every 2 hours? Not.