Health Care in rural areas

For the many who retire in Muskoka, where I live - see the map, there are difficult issues not yet addressed in city-centric media: environment (noise & light pollution, wells and septic systems), social, tourism, employment, education, addictions, access to services, rural politics, access to health care, media, transportation peculiar to those NOT in a city.

In a study by Dr. Hsien Seow, he found that "patients living in rural areas used 20% less nursing and 7% less personal support hours/week, that those living in non-rural areas."
Do you suppose this is by choice? Or do we have access issues? Local papers constantly feature ads for nurses or PSWs. Most of my friends in the business of senior care state this concern.

In fact, what I believe is that since about 50% of us in, for example, the province of Ontario DO NOT live in the big cities and we have more in common with one another than we might expect.

The Ontario LHIN (gatekeepers of Ontarian health care dollars) has published,

May 2, 2006	North Simcoe Muskoka (NSM) Population Health Profile (PDF)
	--NSM LHIN's overall population health profile.

Interesting information: relative to the province, NSM has a higher

• annual average population growth rate
• proportion of older people, daily smokers,
  
• prevalence of activity limitations,arthritis/rheumatism
• age-standardized all-cause mortality and hospitalization rates.

We have a lower

• percentage of immigrants, visible minorities and Francophones
• percentage of the population who have had contact with a physician
• life expectancy at birth for both men and women
• low proportion of young adults.

Simcoe Muskoka health statistics are clear:

"The population in Simcoe Muskoka is aging, which is consistent with trends across Ontario and Canada. In Simcoe Muskoka the percentage of those 45- to 64-years-old increased to 27% of the total population in 2006 from 23% of the total population in 2001. The proportion of seniors (65+) also increased slightly to 14% in 2006 from 13% in 2001."

What seems clear is that we must concentrate as much on accessing health care in all regions of the province. With highly trained physicians, well-versed in issues pertaining to geriatric medicine: including palliative care, pain control and chronic diseases that befall those in the higher age brackets.

Phone-in shows do not take this into account. Summer visitors, and seasonal residents, complain about taxes, but when they drop of a heart attack in rural climes, they want roads and infrastructure that easily conveys them to a hospital.

Most of us succumb to circulatory system diseases or Neoplasms (tumours), resulting in hospital visits and Primary Care interventions. It behooves you to be prepared, and ensure that your health care plan takes into account long-term issues, and the ability to access treatment where and when you retire. Those who retire in northern, rural communities fail to realize the disparities between rural and urban delivery of services. Many require transportation to and from the city.
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Simcoe Muskoka swine flu count up to nine, including one in Alliston
New Tecumseth Free Press - Ontario, Canada
Ontario's acting Chief Medical Officer of Health reported this afternoon that there are 131 new confirmed cases of H1N1 flu virus since Wednesday, Posted May 29, 2009

Reference
Seow, H. (2008). The use of end-of-life homecare services in Ontario, Canada: Is it associated with using fewer acute care services? (hsienseow@gmail.com)

Retirement Homes vs. Long-Term Care

Firstly, we must establish the difference between LTC and retirement homes. The clientele is vastly different, and both are governed by a different Act. The former, the LTC Act, and the latter, the Landlord Tenant Act. The clients are incredibly different.

If you are putting a family member into LTC or a retirement residence there is lots to do.
If you are on a waiting list for LTC in Ontario, you only have 48 hours to complete the process, so be prepared. Plan ahead. See: moving your parent: a checklist.

There are many options to placing or choosing a place to live:

Home support Services to enable older adults to continue to live independently in the community (usually also available to individuals with disabilities).

Long term care facilities Long term accommodation for individuals who require more nursing or personal care than can be provided through home support agencies. Includes facilities formerly known as homes for the aged and nursing homes.

Retirement homes Housing options for older adults, usually with meals and some support services available but no on-site nursing care.

Seniors' apartments Apartments for individuals aged 55-60 years and over who are able to live independently, care for themselves and maintain their own units.

Transportation Public and specialized transportation services, particularly for older adults and people with disabilities.

There are risks in being in a retirement home. It is unregulated by the various health care agencies. Workers need not have any qualifications or special staff, such a Personal Support worker, geriatricians, activity directors with training, full-time nursing staff. What family members need to take into account, is that a senior should have a medical check up, with chronic diseases, such as Parkinson's, Sundowner's Syndrome, cardiovascular health issues, or diabetes, identified to ensure that the correct placement is made.

Another concern, is that many symptoms of senior frailty, such as dementia, should be diagnosed to ensure that the placement is a fit for both the senior and the caregiver and the institution. My father was placed in a retirement home, only to have to be moved in two months since his brain tumour came back and his health deteriorated to the point where more nursing care and supervision was required. His doctor did not tell us about the dementia symptoms he had had three years previously. An issue arose in 2008, regarding sprinkler systems in retirement homes -where frail seniors may be unable to get themselves out of a building without help.

Ontario's Retirement Homes are Failing to Care for Seniors
Canada NewsWire (press release) - Toronto,Ontario,Canada
Under Ontario law, retirement homes are only obligated to comply with the Residential Tenancies Act, which was never intended to regulate health care.

In Ontario, long-term care homes fall under 3 categories, governed under different pieces of legislation :

1. "Long-Term Care Homes" are homes governed under the Nursing Homes Act (NHA).
2. "Charitable Institutions" are homes governed under the Charitable Institutions Act (CIA).
3. "Homes for the Aged" are homes governed under the Homes for the Aged and Rest Homes Act (HARHA).

Beds in LTC vs. retirement homes

Here is one family's story.

My father has been gone for fifteen years. When my mom went to a retirement home the family knew she was cared for -meals cooked etc. but she had several falls (broke a wrist) then needed a walker and as her falls continued it was decided a wheelchair would be the next step.

At that point we toured nursing homes. All of us have full time jobs or other commitments so having her come to our house was not an option. A part of the process we chose and listed our preferences for placement and her name went on a waiting list. We only found three places we liked and listed a fourth as a poor choice.

Her name came up twice-once was so far geographically that we wouldn't see her so we turned it down. The next one was our fourth choice and we were told if we turned it down we would lose the place in line. Meanwhile the retirement home was working with her but hasn't got the staff to always be with her.

As a compromise we placed her at the last choice on our list and then asked if we could be notified of another place asap knowing that any move is stressful to an elderly person. Within two months she fell trying to get out of her new wheelchair and died as a result of a head injury. She would have been 85 in Feb.

She was fairly healthy and we were optimistic about her living longer. As a result of a coroner request the staff at the nursing home met with family and answered our questions about the accident. Now head injuries can be fatal. The answers we got were unsatisfying.

There was no clear reporting done as far as time and incident reports. They put her to bed with icepack and had someone sit with her and only when she vomited did they call an ambulance. This, even knowing that one medication was Cumiden. The staff people expressed their regrets but I left the meeting with the feeling that it was just another fall, another senior, another day. I understand this home has a lot of clients stay short periods of time until the "better place becomes available."

In short I just wonder how many people realize how the placement system works. Ask lots of questions-we didn't realize there is even options about restraints for wheelchairs. My sister was closest geographically to the retirement and nursing home and so most of the overseeing was done by her. This is time that she will never get back and I will always be grateful for all the things she did to make sure mom was cared for. I am glad you are dealing with these issues as it is not a topic that is much discussed until the situation arises and information is key!!!

~~~~~~~~~~~~~~

You can report specific incidents at the MOH & LTC website. See making a complaint.
That said, you can make a complaint about an individual nurse on duty, or a physician. The Dr. only in the LTC home once per week. The nurses busy doling out meds. When I complained about one of my late father's physicians, I was quite pleased with the intervention on the part of the College of Physicians. They came into the LTC home, spoke to the Dr., gave him some advice, spoke to nursing staff, and similarly checked them out.

Nurses in LTC act as Nurse Practitioners, and phone a Dr. to request a med, without the Dr. seeing them. It is a terrible situation.

This is not surprising and is a reportable issue.

Mike Wallace said, "The trouble with aging is you will not feel better tomorrow than you did today."

Accessing physicians - vision of the future

As a grandmother, with children and granddaughter 430 km away, we have been using Skype to speak to our family members free. This began 6 months ago, as you can see from photos on the left.

I heard an interesting discussion on CBC this morning on telehealth and video conferencing issues in health care. With an estimated 400,000 Canadians without a physician, Dr. Peter Lin spoke of the benefits of using this kind of technology to improve access.

I think it a fine thing. We really need to envision new strategies that incorporate technology into modern health care practices.

Our granddaughter was born 18 months ago. We keep in touch through Skype. It is wonderful. She is increasing her attention span immensley, and our free 'calls', while blurry (she moves so fast!) are really good. We can see her walk, hear her talking, and generally have a visual, interactive, two-dimensional visit in real-time.

This seems to be a great way to assist those in remote and rural areas in accessing information. It lessens the amount of time and energy of a patient in trying to make it to a health care appointment. Dr. Lin seems to feel that while physical contact with a doctor is necessary sometimes, often it only confirms an issue.

I recall, for example, my father's trip in an expensive ambulance two hours into the centre of the city, only to be told that he was palliative and that further treatment would be ineffective. I took time off work, drove in the ambulance. We wasted EMS crew time, and resources (they were late due to having an emergency call). In fact, in Muskoka, with 8 crews on during peak time, it is a collossal waste of resources.

The oncologist was 3 hours behind in her appointments, I heard another patient complain about this, having driven in from another town, as well.

Not only that, but Dad was incontinent, due to the effects of the radiation treatments my mother insisted he have. No one told us that we could expect infections, and Dad suffered for weeks with urinary incontinence. He was unable to use the pee bottle in the ambulance. It was humiliating for him and disheartening for me.

I would have appreciated having a video conference, to save all of us the stress of this trip to a major downtown hospital. On the way back we were drenched in a thunderstorm.

I am sure that there are issues around billing, but that could be fixed. We are short ambulances, due to the fact that some patients need an ambulance to simply visit a physician and they either lack the physical ability, they are drained by such appointments, or they lack transportation. This is evidenced by the various support groups (e.g., Altzeimer's Society, Cancer Society) who provide volunteer drivers.

I would hope that this possibility is explored by physicians who are concerned about their patients and interested in improving access to health care.

Senior Drivers in Ontario

In an Ministry of Transportation of Ontario PPT (Jan. 11, 2004), I read that Senior Drivers in Ontario over the age of 80 numbered 165,758 in 2001.

About 65,000 have a semi-annual licence renewal consisting of a vision, knowledge and road test. I recall my late mother studying for her test. She had not driven in more than 30 years, but had kept up her licence. Once Dad's brain tumour required his licence be taken away, she was the driver again. She had issues navigating their mini-van up and down the driveway, especially in snow. Sometimes she would ask a neighbour for help --information that I felt I should have been given, and with her doctor we could have made some better-informed decisions. She may have been a danger to others when she drove.

Stories abound of seniors driving when they were incapable of doing so safely. Jim Taylor, a Canadian writer/blogger, titles one 2004 blog, "Seniors becoming a scapegoat for social discontent." His stats, from Canadian sources, demonstrate the need to concern. Transport Canada warns of those in intersections being the most at risk. Current stats, in the recent Ontario move to more severely curtail teen drivers, reveals statistics that demonstrate seniors are more risky than newbie teen drivers:

• 6.4 % of fatal accidents caused by those less than 20 years of age
  
• 7.3 % caused by those over age 65 (with fewer km traveled).

• With 16 - 19 yr. olds have accident rates of 2.47 per 10,000
• Adults over the age of 65: 2.9 per 10,000
  

The American Safety Council has publicized these concerns. It is suggested that adult children drive with their parents to see what is going on. If they do not feel safe, then they are not only a danger to others but to themselves.

The Japan Automobile Association demonstrates similar concerns, as this problem is not limited to North America.

Helpguide.org gives some warning signs:

• watching for mobility issues, confusion, slow reaction times, drifting into other lanes, failure to use turn signals or missing exits.

Generally, if they have problems meeting their needs at home, it is likely that you will have to intervene and discuss your concerns. There is a duty on the part of Family Physicians to report to Ministry of Transportation of Ontario (MTO) medical conditions that may impair driving. Unfortunately, those who have dementia may be able to appear quite normal, and can cover up big problems they may have -such as getting lost, or may not realize function issues, such as remembering which is the gas, which the brake. I know that my father could no longer use basic technology (TV clicker and the phone) once his dementia was severe. Hidden dementia can affect some seniors and getting lost can compound driving errors. The Toronto Star says 20% with dementia are still on the roads.

There are three responses on the part of the MTO: immediate licence suspension, referral to Medical Advisory Committee, or further evaluation.

The Mayo Clinic empowers family members to take responsibility for their parents, in a very difficult role reversal they recommend reporting the senior to their physician, taking the car keys, disabling the car, assisting with alternate transportation such as those the Legion, senior centres, and volunteer groups may offer. Setting up an account with a taxi company can help, too. You must take responsibility, since those with TIA, or dementia, or other issues once they have progressed, cannot make the decisions necessary for the safe operation of a vehicle.

Warning signs of unsafe driving include:

• Forgetting how to locate familiar places
• Failing to observe traffic signals
• Making slow or poor decisions
• Problems with changing lanes or making turns
• Hitting the curb while driving
• Driving at an inappropriate speed
• Becoming angry and confused while driving
• Confusing the brake and gas pedal

There are senior driver improvement programs, such as 55 Alive, which are available through safety organizations and various driving schools. This helps seniors maintain their skills and adapt to changing physical abilities. There are 4 important issues: vision, hearing, movement and reaction times. Course content helps them adapt to new societal issues: adapting to new laws, technology, anticipate actions of other drivers (i.e., road rage), and to self identify health issues that assist them in determining when how often, and whether they should be driving.

Drivers make 8 - 12 decisions every km, with only seconds to respond in some cases.
There are physical issues of concern to seniors: checking blind spots, looking for traffic or pedestrians, merging, yielding, which can affect the ability of a senior to drive safely.
Hearing impairments mean that they cannot locate sirens, horns, and hear brakes; all clues to impending accidents.
Some are seeing less clearly: night vision or glare becomes an issue. They are more sensitive to light and dark levels.

Polypharmacy can cause drowsiness, dizziness, blurred vision, concentration, coordination, memory lapses, resulting in an inability to keeping a steady course. Road conditions in North America require different strategies in winter. Transport Canada offers a booklet in winter driving to provide valuable information.

Delirium is another issue, as well as dementia that puts drivers, and the cars and people around them, at risk. Be proactive and take responsibility for safety on the road.

Senior Driver Education offers some suggestions:

1. Introduction
2. Strengths of Older Drivers
3. The Effects of Getting Older
4. The Possible Effects of Drugs on Driving
5. Good Practices to Maintain Driving Fitness
6. Personal Action Plan
7. The Safety Driving Cycle
8. High Risk Situations
9. The Importance of Signs
10. Alternatives to Driving
11. Closing Reminders
12. More Information
13. Individual Notes

seniors and pain, caregivers and medical decisions

Interesting Toronto Star item:

HealthZone.ca - Your health - Law turns deaf ear when elderly beg ... A lawyer-member of the Human Rights Tribunal, Handelman says Ontario's Health Care Consent Act is clear: Except in an emergency, there is no treatment without consent. When the patient is not capable, the substitute decision maker consents – or not – to treatment

I found that in Long-Term Care (LTC) this is not an issue. Emergency rooms are reluctant to accept LTC residents. For that reason, many LTC homes require that residents, or Alternate Decision Makers, sign a form indicating the level of response to a resident. Home Care is not necessarily an easier situation, but it does make life much more comfortable for the patient. You have many more choices and options.

For example, when my late father entered the home, we knew he was palliative. We had a DNR order, to not resuscitate. There are several levels of orders like this. You can choose to DNR, and not send the resident to the hospital (with long waiting times in emergency), or within the LTC the client can receive any medications s/he needs. If you are there, and you are vigilant, you can advocate for them.

So often you see families making all sorts of incredible things happen to try and prolong a life that is less than comfortable. Caregivers know their loved ones/clients, yet health care professionals need to recognize that end-of-life and palliative care require different treatment options from no treatment, to utilising the full resources of the LTC and the nurse on duty.

For some, not eating is a crisis, yet at end-of-life your systems are shutting down, like the slowing down of a clock. One's body cannot process food. For those with pneumonia, to give IV fluids means that they are fighting with more fluids in their lungs. To feed by tube similarly weighs down a body that is preparing to shut down. We really must respect the patient, and many are simply not hungry yet we force them to eat.

My father was in pain and we had great difficulty accessing a physician. The nurses are the only contact, and the physicians are too busy to return calls, or go to the LTC home. Pain control, if it is neglected, is a form of elder abuse, in my mind. Seniors with dementia are unable to process 'pain' as an abstract concept. When asked, they cannot understand your request.

Care of terminally ill attacked: The standard of care of the terminally ill in the NHS in England has been criticised by MPs. Palliative care is becoming more complex, yet we are not giving any more training in geriatrics to those caring for palliative clients.

Reliable information

Here is a timely text. Stealing into print: Fraud, plagiarism, and misconduct in scientific publishing

Health care professionals, as in other professions (education, for example) rely on peer-reviewed, ethical, scientific journals, for current data to set standards, guide practices, and develop a dependable, reliable, valid and research-based treatment standards.

The editorial process is one that is independent of other influences. There are flaws, but this is the standard for the healing professions. Peers (qualified Ph.Ds, professors, nurses, doctors) read each other's research and determine if the research is valid, and was undertaken ethically and independent of, for example, pharmaceutical companies who may have paid for favourable research. There are disclosures in these journals about financial support, to determine if a drug does what it says it does, without unacceptable side effects. Unfortunately, in a rush to review research, due diligence may not happen. We know how busy these professionals continue to be.

In a news story, Elsevier unit failed to disclose journal sponsors - wtop.com 7 May 2009 ... The journal was in fact sponsored by drugmaker Merck.

"Those publications included one that heavily favored drugmaker Merck's osteoporosis drug Fosamax and the painkiller Vioxx."

I have found, however, on the WWW, many instance of this false information, some call it
hucksterism, as they take old, published data and transform them into Advertorials. Articles that not-so-subtly suggested you buy particular products.

Falsifying research data. Creative Writing foisted off on the public as truth. Shoplifting. Stealing. Cheating on taxes.Is there more of this? Or is it simply that with the WWW we hear more about it? As I said in a previous blog: I am increasingly appalled by the number, the extent and the range of advertising and propaganda, and blatant manipulation of seniors as businesses, and website managers, try to earn a buck. They take advantage of those who are ill, and frail.

Do not trust search engines to find information you trust. Ensure that they are affiliated with a trustworthy, professional association, such as an educational institution, or professional body whose reputation you can trust. Media and journalists are not the best source of information, either, as those who have even been quoted can attest. Be vigilant. Peruse, carefully, what you read. Check for your sources.

Long-Term Care and flu

Residents in a Long-Term Care (LTC) home are often frail seniors with comorbidities: several chronic diseases that put them at risk. They require extra personal care. Their needs are different, in that they need nursing care unavailable in a regular setting such as their home, or a retirement home.

The Ministry of Health and LTC keep up a website of reports. You can search and find complaints about these (primarily) for-profit agencies. In Ontario something like 530/640 homes are for-profit, with government subsidies.

Many in LTC have Alternate Decision Makers, often spouses or adult children who are making personal, financial or medical decisions for them. Caregivers are reluctant to put ailing loved ones in care, but do so out of a need to ensure they have the personal care they need. Most in LTC cannot take care of their own Activities of Daily Living (ADL).

There are many 'visitors' to LTC. Loved ones try their best to visit their family members. There are many volunteers (Hospice, spiritual advisors, Therapy Dogs), or service workers like massage therapists, and professionals who provide dental or foot care), or other people that have been hired to see to residents. Some drive long distances to see them, especially in Central Ontario. Friends, knowing their buddies are in LTC, make every attempt to visit. This is not always possible, since a LTC home could be closed due to various reasons. Flu is an obvious one with the recent Swine Flu, H1N1. Giving LTC residents a flu shot might help, but with the new bugs around we cannot be sure it prevents new strains from infiltrating a home.

And scabies is an infestation that closes a floor or a wing. An unseen pest, the symptoms are itchy rashes that become infected if not treated or identified by those unable to communicate their symtoms. Another issue: the Superbugs that are floating around the health care system: MRSA, C. Difficile (CDAD), VRE, VAP. It is crucial that we are more vigilant in Washing your hands (- tips).

What is my concern, is that no one knows if a home is closed until you turn up at the door for a visit. I have a friend I visit regularly and have found this to be a problem. Many family members attempts to visit their loved one as much as possible and provide extra care that cannot be delivered by busy staff.

There should be a place where building, floor or wing closures can be listed. In fact, these incidents need to be tracked. It was in 1999 that Flu was blamed for 20 deaths at nursing home, (Last Updated: Friday, Nov. 10, 2000) CBC News). Until the Health Department becomes involved, no data seems to be kept. What about the homes where seniors are ill, family members cannot visit, and no deaths occur? Having flu is horrible when you are young and able, when you are incontinent and unable to take care of your bodily needs it must be frightening.

Those working in LTC, travelling from home to home, and resident to resident must be the most vigilant. at risk are LTC residents who require hospitalization a few days, only to return bringing risky bacteria and viruses. I would call on the Ministry to keep data on this information.Track incidents and require LTC homes to be more vigilant with hand washing.

Reportable Infections in Ontario

• Clostridium Difficile Associated Disease (CDAD)
• Methicillin Resistant Staphylococcus Aureus (MRSA)
• Vancomycin Resistant Enterococcus (VRE)
• Hospital Standardized Mortality Ratio (HSMR)
• Central-Line Primary Blood Stream Infection (CLI)
• Ventilator-Associated Pneumonia (VAP)
• Surgical Site Infection Prevention
• Hand Hygiene Compliance

Spotting elder abuse

1. Physical abuse

Seniors can have fractures, dislocations, lacerations, abrasions, burns, injuries (head, scalp, face), bruises on upper arms (from shaking), wrists or ankles (from being tied down), bruises on the inside of thighs or arms.

The clue, however, is sudden evasive moves when you move suddenly. People instinctively protect their faces and heads from a possible attack. Look for PTSD-type fears: seeing the whites of their eyes when inappropriate.

2. Sexual abuse (non-consensual sexual contact).

Look for sexually transmitted diseases, pain, itching, bleeding, bruising in the genital area.
In young children they can exhibit inappropriate sexual behaviour that tells you something is wrong. I have had students in elementary school with too much information, using inappropriate sexual language.

For some, being in a position of authority and power leads them to this type of abuse. In addition, caregivers have been guilty of sexual misconduct as they try to assist the disabled in relieving sexual frustrations. If this is done by hired personnel: write down the details, take photos, take them to a doctor, contact the employing agency, and contact the police.

3. Psychological abuse

Look for signs of threats, intimidation, humiliation in a family member of client. A new movie, from the book Push, by Sapphire, is being made into a movie set to come out in the fall. It is called Precious. Check out the trailer of Mo'Nique's movie: Precious Movie Trailer - Oprah.com.

The impact of this abuse results in low self-esteem, anxiety, withdrawing, mood swings, depression, suicidal ideations or behavior, confusion, disorientation. (These are signs of dementia, and other organic issues. Be careful to get a proper diagnosis.)

Another good reference: one of those fictional stories that illuminate such as T is For Trespass, by Sue Grafton.

4. Financial abuse

Some family members find that their loved ones are spending money all over the place. Some come to adult children to borrow money. Adult parents can be tricked into lending money and enabling loved ones to misspend. Watch for changes in spending habits, canceling planned trips, or an empty refrigerator, a lack of food or medication.

5. Neglect

This issue is a difficult one. In order for an adult to be neglected, it must be proven that they are being refused help. I have found, in my travels, that some independent seniors refuse resources and other supports in a desperate bid to remain in their homes, and to be left alone.

My mother, for example, refused to accept such health care support. My attempts at caretaking were abject failures, and I have seen this in other family situations. I know of health care providers who enter a home, only to deny that they need help and refuse such care as Transfer Payment Agencies freely provide. Some dementia patients can cover up their illnesses, and lead apparently normal lives until disaster strikes in the form of an accident or trauma.

Indications of neglect may include poor personal hygiene, signs of over- and under-medication (polypharmacy), poorly dressed seniors (in soiled or dirty clothes), elders left alone and deprived of stimulation and affection, exhibiting signs of malnutrition. Adult Day Away programs, such as those offered in many communities, can help.

Vitamin D

Vitamins, supplements...natural is best.
An item of note this week. A study, reported by BBC.UK:
Elderly need more 'sun vitamin'
Spending more time in the sunshine could help older people cut their risk of developing heart disease and diabetes, say scientists.

We know that we should all get Vitamin D. By going out in the sun for 10 minutes, or so, we take in 10,000 IU. This is what a healthy adult needs. However, it would appear, from the research, that just as menopausal women have trouble absorbing calcium due to a lack of estrogen, 94% of the 3000 50 - 70-year-olds studied had a vitamin D deficiency.

A deficiency in vitamin D can mean metabolic syndrome, which puts seniors at risk for obesity, high blood sugar, high blood pressure and high cholesterol. This means such chronic disorders such as heart disease, stroke and diabetes.

SEE ALSO

• Vitamin D 'is mental health aid' 23 Jan 09
• Parkinson's linked to vitamin D 13 Oct 08
  
• Vitamin D could cut elderly falls 28 March 05
• Vitamin D 4 Mar 2009 ... There is growing evidence that vitamin D may reduce the risk of some types of cancer, ... You can get vitamin D from exposure to sunlight, ...
• Dr. Cannell Talks About Vitamin D
• Dr. Joe Prendergast on Vitamin D

who will profit?

The incredible disparities between those who have and those who have not will increase.

Agencies that that operate on a non-profit basis continue to struggle for government dollars, as they function as Transfer Payment Agencies.

Yet, private, for profit agencies are seeing an increase in business from adult children who have the means to pay for private care and keep seniors in their homes. Owner of Nurse Next Door Home Healthcare Services says their client base has increased by 25%.

Aging in place gets a boost
The Gazette (Montreal) - Quebec,Canada. March 5, 2009
By Shannon Proudfoot, Canwest News Service Gail Watson likes having the option of private health care as opposed to public care for her
The article says:

"Another provider, Home Instead Senior Care, says revenues increased by 24 per cent in 2008 and it projects similar growth for 2009 from 22 independently owned locations across Canada."

The reality is that adult children cannot afford to care for seniors in their homes and jeopardize their jobs. Some seniors would have relied on profits from selling their homes to pay for retirement homes, or home care, but the housing market isn't doing well.

This is a tricky situation, in that caregivers (primarily female) risk losing salaries, pay increases, hourly wages, and pensions, by giving seniors the type of care unavailable in the system. We relied on Red Cross workers in my father's retirement home to supplement his care suport. I was working full-time, and we could not meet his needs elsewhere as we waited for a long-term care placement.

Certainly, if a wife has to go into a nursing-type facility, with my parent's generation the husbands are often unable to meet their daily (ADL and IADL) needs. Some cannot drive, many cannot cook or clean. I worry about what will happen to these seniors without adequate care.

Health Care crimes & news

Swine Flu
It is amazing that viruses and superbugs exist everywhere: air, soil, toys, phones, coins, all handles (doors, shopping carts, in public and at home), and taps. Here is an Toronto, Ontario map of May 9, 2009, H1N1 incidents. Here is a WHO map of current stats.

Four Hospital Staff Workers in Toronto have H1N1
SourceL TheStar.com
Three of them work at Princess Margaret and contracted it from someone previously reported. They are 'mildly ill', but as previously written, they put frail seniors, and high-risk patients in an intolerable situation.

Therapy Dogs May Fetch Hospital Germs - Well Blog - NYTimes.com

Source: well.blogs.nytimes.com

Canadian researchers studied 26 therapy dogs who visited patients in hospitals or long-term care facilities. They found that they passed on MRSAs on their coats.

The answer: handwashing, patient advocates, and better infection prevention. (see my poster below)

And a conviction:

TheStar.com | Crime | Ex-health care worker jailed for elder abuse

Source: www.thestar.com

A former health care worker has been given 30 days in jail for striking an 84-year-old woman with a television remote control.

This is why groups like PSWCanada are fighting for better training, supervision, better staffing, and regulation. Bad apples that give all health care workers a bad name.

Supervision of ailing seniors:

Police search for missing Midland man - The Orillia Packet & Times ...
Mr. Desroches left a King Street health-care facility Friday morning, and failed to return that evening, then police were called. His body was found Monday afternoon in a wooded area. The 57-year old's death is not ruled suspicious, but they will do an autopsy, as he regularly visited local stores from his retirement home.

Retirement homes are regulated differently from Long-Term Care homes (formerly 'nursing homes' with few nurses). Residents of LTC fall under the LTC Act legislation, while residents of Retirement Homes are considered tenants, under the Landlord Tenant Act.

Seniors rally in Barrie to protest nursing homes costs
Source: Barrie Examiner: Posted By NICKI CRUICKSHANK
A month ago: 30 local seniors and members of the Service Employees International Union (SEIU) barged in an MPP's office.

What is interesting is that there is a difference between private (for profit) Retirement homes, and profit and non-profit LTC homes (where placements are paid for and/or subsized by the government). No one in Canada should be left on the street, but there is a difference between a senior with a chronic disease who needs less than a hospital placement and an Alternate Level of Care (i.e., nursing care in a Long-Term Care home) with a more precise level of care.

People misunderstand the difference, for example, in a private, for-profit business like Air Canada, that is NOT government run or subsidized. We have no rights to tell them how much to pay their staff, nor what they can charge us to fly with them.

New Ontario Health Care Legislation

Here we go. Magnificent improvements to health care! City news provided the earliest coverage. In a grandstand celebrating guidelines, the press is quite anticipatory. CBC quotes him: "McGuinty said 50 per cent of what a family doctors does can be done by someone else."

This is true. I know that improvements, over 30 years in the area of midwifery has improved the care provided to pregnant women pre and postpartum. My daughter's care was magnificent, with the midwife giving her tips, arranging for tests, test results, and providing excellent advice on breast feeding, for example. But this was about a year and a half ago!

CBC reports: Ontario Health Minister David Caplan called the new rules "momentous." They provide an intersting response from Doris Grinspun, the head of the Ontario Registered Nurses' Association.

Grinspun said the legislation lags behind what nurses can do in other jurisdictions in North America. That said, how many nurses are trained in senior health? We still fight this in the system: staff who fail to understand the needs of ailing seniors.

The act, they say, would also improve patient safety and strengthen the health care system by:

• Requiring health colleges develop common standards of knowledge, skill and judgment.
• Making team based care a key component.
• Requiring all regulated health professionals to have professional liability insurance.
• New drug prescribing powers: Pharmacists could soon renew prescriptions.
• Physiotherapists would be able to order X-rays.

They say that nurse practitioners, dieticians, midwives, respiratory therapists and dentists, will also be affected by the changes. I hope it will be for the good of all. But I am dubious.

From Ontario Health Care - for those over 50

My father was in pain for weeks. The doctor was unavailable. I could not convince the nurse in Long-Term Care that my father was in pain. There was little understanding and many myths around this topic. Without more education how will this improve?

We really have to stop calling them 'nursing homes'. There is little nursing done, mostly it is the PSWs who do the work. With a ratio of 1 nurse to perhaps 200 residents, and physicians who visit once a week we have people with polypharmacy. In my father's LTC home 90% of residents had power of attorney with alternate decision makers. These people cannot visit every day and see what is going on. It is crucial we train caregivers adequately.

They are untrained and many are ignorant of geriatric psychosocial issues. They are given no training in psychology. We expect more of our children's caregivers: in a nursery school they are required to have a two-year degree, not a simple certificate that a PSW in LTC or in retirement homes will now posses.

It is excellent legislating nurse practitioners, but we are short of those, too. We are short doctors with any geriatric training. Seniors are a very difficult complex case many with chronic disorders and multiple issues.

The abuse stories are appalling. It boils down to little or no training, insufficient staff, and ignorance around the issues of geriatric care. Elder Abuse is caused by poorly trained health care workers at all levels of the health care system: private or family caregivers, PSWs, nursing staff, physicians.

More news reports on this topic

• New legislation in Ont. will give health-care professionals wider ...
  CBC.ca
  
• Ontario Unleashes Potential In Health Care
  Government of Ontario News
• Ontario College of Pharmacists supports government's announcement
• Science Canada: New legislation in Ontario will give health-care ...

Research in health care

It has been a busy week. My volunteer work with Hospice Muskoka has consumed me, in a good way. Friday was the marvellous Butterfly Ball! I am happy to give back to my community. I truly believe, as I stated in my book, that every client/patient dealing with cancer needs a Patient Advocate. This is why I wrote about our desperate attempt to secure adequate health care for my mother and father. I think the issue is time. With too few professionals out there and the demands of reporting procedures, concerns about accountability and such, we are hard-pressed to do the things that are the most important.

My time I have spent reading about senior health issues, such as palliative care and pain management. I have Google alerts for these topics and happened upon a BBC News article on how pediatric cancer patients are dying from infections. In this world, we do much research, yet we ignore much of it, as well. We focus on our "To Do" lists, at the expense of quality care and continuity of care for patients. We do not focus on needs versus wants. We have pediatricians, yet very few geriatricians. Why is this? Seniors illnesses are complicated by infirmities and chronic comorbidities that require specialists and an intensive health network. Caregiver burnout is a debilitating issue.

I keep up on these issues, and like to reflect on what we really know, such as Best Practices Blogger, a terrific resource freely available, yet I have found in health care, as with education, we have proven research on what works well in a hospital (or classroom). This simple information on hand washing, pain management, can prevent the transmission of bacteria or viruses, such as Swine Flu. We know that viruses are mutating, partly due to drug-resistant superbugs such as MRSA, or C. Difficile. There are many barriers to good health and health care, being hospitalized or bedridden is one compounding factor. Case conferences are a good way for a family to ensure that we have treatment plans and assessment tools to determine the best course of action.

Is this just me or do others find this as they move through the world? We know a great deal but it is simply not applied to every day life. With an increasing number of people with chronic disease, and a limited number of health care practitioners (e.g., orphan patients), we will be even further disadvantaged. Caregivers must be assertive, sometimes aggressive, and ensure that health needs are being met.

Agitation or pain?

Whilst caring for my father (in 2007) I had a great deal of trouble getting him pain relief. having moved him from a retirement home to a Long-Term Care home - we were quite frustrated. In this day and age there is no reason that anyone should be in pain. Palliative care at home has many benefits, but other issues.

Quality End-of-Life Care: The Right of Every Canadian. This subcommittee made recommendations regarding palliative care, made in the 1995 report, Of Life and Death.

The report says, in part:

"Many witnesses repeatedly indicated that pain control techniques are not being adequately used and, often, sufficient medication to control pain is not being provided. Several witnesses suggested this is due to a lack of training and education of medical professionals in the area."

I found that it was the nurses around Dad that controlled the amount of pain medication he got. In Long-Term Care (LTC) the doctors only did regular rounds, and if I felt Dad had more pain the nurses would phone the physician and tell them what my father needed. Sight unseen. Extra visits were not made. No one, it seemed, understood about palliative care and the 'normal' progression of pain control.

It occurs to me that the agitation Dad had was significant. The message I got from the nurses was that he needed an anti-anxiety drug (which does not relieve pain). I now know that he was agitated BECAUSE HE WAS IN PAIN. Why would he NOT have been in pain? My father, with his arthritic knees was not mobile any more. His knees had probably seized up. He had bed sores that were raw. Likely, so the literature says, he had headaches from the tumour.

He was totally unable to articulate his pain. This was part of his delirium, and later his dementia. It is no wonder. I blogged about this last month but it needs to be said again. There is a disconnect between the centres of the brain that can identify pain and it comes out in other ways. As a family member you must advocate, since you know your loved one best.

Symptoms of pain
Loss of appetite, anxiety, bleeding, constipation, cough, confusion, dehydration, depression, diarrhea, dysphagia, dyspnea, hiccoughing, intolerance of sheets on their legs, sweating, nausea, vomiting, pruritis, insomnia, mouth pain, skin problems, seizures, urinary frequency, weakness.
Watch for changes in expression, a change in behaviour, physical, intellectual, emotional spiritual pain:

• being very quiet or moaning, rocking
• being friendly to now being combative
• from being cheerful to being sad
• eating well then refusing food
• sleeping well to insomnia
• gestures: wringing of the hands, fidgeting with clothes, "pleating", clenching fists, flinging arms about, reflexive jerking, rubbing a body part, rhythmic body movements (banging on a table)
  
• holding onto a chair for security
• tossing and turning in bed
• changes in body posture: slouching, slow shuffling, tense posture, rapid gait, tense sitting or lying positions
  

Be Aware
Be vigilant and take note of new symptoms: confusion, falls, loss of independence, incontinence, depression.

If patients have a history of delirium, then prolonged sedation, mechanical ventilation, and acute respiratory distress syndrome, they are at risk psychologically: comorbidities may include posttraumatic stress disorder (PTSD), anxiety disorder, and depression. Families and caregivers may also have depression and anxiety, as I well know.

There are two different categories of pain: acute and chronic. Chronic pain, from chronic diseases, last a long time (3 - 6 months or more) and results in sleep disturbances, anorexia, personality changes or work inhibition.

Causes of chronic pain: arthritis, stress fractures, diabetes, cardiovascular issues, muscle spasms, constipation, oral pain, bruises or skin tears (common in ailing seniors), lymphedema (swelling of limbs), shingles.

Acute pain has a definite pattern of onset, it last for a limited amount of time, e.g., during palliative care. It results in the fight or flight response, pupil dilation, increased sweating, respiratory rate, heart rate, as blood shifts from viscera (organs) to muscle.

Treatment needs to be addressed rapidly with a comprehensive management approach.
There are other types of pain:

• anticipatory pain - fear of the unknown, expected experience, causes fear and anxiety
  
• incident pain - when a patient is shifted in bed
  
• remembered pain - triggered at certain times of day by particular past events
  

Pain Thresholds
These can be lowered in a previously pain-tolerant person. When you have discomfort, insomnia, stress, fatigue, anxiety, sadness, depression, boredom, or social isolation. We can increase pain thresholds by dealing with and managing pain, and symptoms early and swiftly.

Barriers to pain management

• Failure of physicians to understand pain management
• Failure of nurses to understand individual signs of pain
• Lack of patient-centred care
  
• Poorly coordinated health care
• Red tape
• Lack of accountability of Primary Care Teams
• Misguided focus on a 'cure' rather than quality of life

Myths around pain

• personal, preconceived prejudices on the part of the patient, health care professionals (PSW, nurse, physician, institution), caregivers, family members
• pain is 'normal'
• dosages depend upon the individual "Pain is whatever the person says and occurs whenever the person says it does" (McCaffery, 1999)
  
• delivery of pain relief - oral vs. shots are best
  
• myths around addictions, dependence, tolerance of pain
  

Busting myths around pain

• We feel pain when asleep
• A palliative care patient will not become addicted and deserves pain management
  
• All seniors do not have pain
• There is no ceiling dose for pain -we need not wait exactly 4 hrs. for another dose, or remain at a particular dosage over time
• Anxiety is a sign of unmanaged pain
  

Such publications as The Fundamentals of Hospice Palliative Care (2007) speak of pain as a "complex biological event that affects the person, the family, the community, and society." When a loved one suffers, we all suffer. It is up to a family member to advocate for those who cannot speak for themselves. Sometimes deep pain, as affected by psychological, biological, sociological, spiritual or practical factors, can increase without interventions. We need to be assertive and advocate for loved one. Record pain symptoms in a medical diary and do not stop until you are satisfied that the pain is being managed. You cannot overmedicate and Tylenol will not do it for many folks.

Swine Flu: H1N1

Fighting and preventing infections
There are many places for information. MRSA, for example, is a web site with information on fighting this bacteria, which applies to all communicable diseases or viruses. You must protect yourself in day care, at school, at your gym, as well as in hospitals. These viruses and superbugs exist everywhere: air, soil, toys, phones, coins, all handles (doors, shopping carts, in public and at home), and taps. Here is an Ontario map of incidents. Here is a WHO map of current stats.

* People who have symptoms of respiratory illness should call their health care provider or call Telehealth at 1-866-797-0000, TTY 1-866-797-0007. Cases are increasing. Click here for an interactive (CBC-created) map of current incidents world-wide.

These Superbugs can exist on curtains, bed spreads, taps, and become airborne. If you cannot wash your hands use a sanitizer. Alcohol-based gels or sanitizer should contain between 60 and 70 % alcohol to be effective. You should wash your hands with anti-bacterial soap and water after 5 applications.

It is terribly important to protect yourself, your children, caregivers and seniors from the risk of contracting swine influenza (flu). The Center for Disease Control offers some more tips for family, as well as signs and symptoms.

They define Swine flu: "Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses. Outbreaks of swine flu happen regularly in pigs. People do not normally get swine flu, but human infections can and do happen. Most commonly, human cases of swine flu happen in people who are around pigs but it’s possible for swine flu viruses to spread from person to person also."

What happens is that the virus mutates and it is then passed on to humans. CBC's FAQ page says, "These cases occur in persons with direct exposure to pigs, such as children near pigs at a fair or workers in the swine industry."

The most frail depend upon many caregivers for their ADLs. Those in hospital, hospices or Long-Term Care see many PSWs, therapists, or volunteers in a day, as well as nursing staff. Each time a new person enters their room to bring them medications, water, snacks, change their bed, get them up out of bed, to transfer them to a wheelchair, they risk bringing bacteria with them. The US Government is tracking Swine Flu progress. BBC news is similarly tracking the flu. Canada has 55 cases as of Sat., May 2nd. A total of 28 cases of influenza A (H1N1) have been reported in seven European countries.

Symptoms
=> fever, lethargy, lack of appetite and coughing, runny nose, sore throat, nausea, vomiting and diarrhea.

Of course, contact your doctor. They suggest you not go to emergency. There are retrovirals, but likely, if you haven't been to Mexico, you have the 'regular' flu! Don't forget the BRAT diet: Bananas, Rice, Applesauce, Toast. Drink plenty of fluids.

Risk factors include:

• The very young or elderly
• Palliative care recipients
  
• Patients with chronic illnesses

Symptoms of typical superbugs (bacteria) can include anything from mild to severe abdominal cramps, high fever, severe diarrhea, leading to dehydration, inflammation of the colon and even death. This is the same with flu viruses, except the viruses can be air borne as a victims coughs and sneezes. This can happen through contact with a surface, and then using the contaminated hand to eat, rub an eye, or any other activity that allows the bacteria to enter the body. (Bleach is the only thing that kills a superbug.) Alcohol sanitizers don't kill superbugs.

Warning Signs
If your child experiences any of the following warning signs, seek emergency medical care:

• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Not waking up or not interacting
• Being so irritable that he or she does not want to be held
• Not urinating or no tears when crying
• Their symptoms improve but then return with fever and worse cough

What can you do about it?

At hospitalinfection.org there are many suggestions that might help. The Ministry of Health & LTC, has good suggestions. Unfortunately, for vulnerable seniors, they may be unable to advocate for themselves. The Center for Disease Control has some more information.

One trend in Canada is to suggest that you ask your Primary Care staff if they have washed their hands. Others include various preventative measures. One problem is that Primary Care deliverers do not change their scrubs or their protective gloves. Another issues involves items, such as door handles, surfaces, i.e., food trays, stethoscopes, blood pressure cuffs and bed rails, and even privacy curtains that are washed infrequently.

If you are at home and caregiving, you must be careful to thoroughly wash everything after any contact. Bedding needs to be washed in hot water, and dried on high heat, if possible. This includes clothing, and cloths. You can buy protective padding that will help cover mattresses. Surface disinfection is important: hand rails, cups, anything anyone touches can carry the virus.
With the first case in Sudbury, incidents will be on the rise on Central Ontario, too.

Visitors must be directed to practice safe visits.

• Social distancing - do not visit if you have signs and symptoms of colds, infections or flu
• Practice excellent hand hygiene - see below
• If you need to cough - cough into your elbow - not your hand which touches a surface and leaves the virus behind
  
• Wash your hands after a visit. Those who visit many clients can carry viruses or bacteria from patient to patient.
  
• Stay away from anyone for whom you might pose a risk
• Boost your immunity by getting adequate sleep, eating properly and taking 500 mg Vitamin C each day.
• A new study of pet therapy dogs shows just how easily hospital germs can be transmitted to visitors.

Why is hand washing important?

Hand washing, when done correctly, is the single most effective way to prevent the spread of communicable diseases. Good hand washing technique is easy to learn and can significantly reduce the spread of infectious diseases among both children and adults. Wash after you change rooms, before and after eating and preparing meals, and after going to the bathroom, or serving any of the needs of care recipients.
See this post for videos on hand washing. It is crucial you keep bacteria and germs away from frail seniors and young children.

A new study out:
Visiting pets, including Therapy Dogs who can pass on infections. A dog with MRSA on its fur had spent time in patients’ beds and was kissed by patients. The findings were reported in a letter published in The Journal of Hospital Infection.

This is an informative video that explains how infections are spread.

beware of abuse #2

In a horrible case of abuse, several teenagers in a nursing home in Minnesota* were charged with hitting, spitting, tormenting and neglecting seniors in their care. I posted previously about Elder Abuse. It occurs in Canada, but rates are difficult to pin point, since unreported cases are hidden. But estimates are between 4 and 10% of older adults in Canada.

This site provides signs of abuse. But I think such abuse can be prevented by only hiring regulated, trained workers, with a registry of workers who have proven themselves capable, trained and able. Working in health care is a priviledge. We need highly trained, monitored, educated and supervised adults to provide care to our frail elderly. With high turnover, poorly defined duties, workers who over step their duties by diagnosing and giving family members poor advice, we cannot rely on the industry to regulate itself.

The government continues to demand that TPAs regulate their own workers, but this is a fragile tower of cards. Workers who steal from residents, bully them, abuse them, have sex with them, and further exploit them will get away with what they are doing.

Family members must visit family members often, or seek professional opinions, early diagnosis of physical and mental health issues to prevent disabled and frail seniors from sinking into decline. Look for missing posessions, over- or undermedicated residents, changes in behaviour, monitor bank accounts, bed sores, unexplained bruising. Visit well and at different times of the day.

Sometimes a senior can be his/her worst enemy. They may not be able to manage their daily needs. You do them a favour by intervening and ensuring that they are well cared for. Be vigilant.

~~~~~~~~~~
*Read the full US article here: Nursing home elder abuse