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How Can We Help Our Elders?

By Edward D. Miller, M.D. and Sue Donaldson, Ph.D., R.N.

Hopkins Medicine Dean/CEO Edward D. Miller, M.D. JHU School of Nursing Dean Sue Donaldson, Ph.D., R.N.

In September Ed Miller's mother-in-law Mary Louise Engelhart lost her long battle with lymphoma. She left behind her 90-year-old husband, Lawton, still vigorous and living independently in the elegant South Carolina retirement community where he had recently moved.

Then, in January, Lawton Engelhart developed diverticulitis. When he failed to answer the phone, Ed's wife, Lynne, learned that her stepfather had fallen in the bathroom, injured his hip and been lying on the floor unable to move. Engelhart was put in the nursing facility at the residence, lost 10 pounds, became incontinent and spent his days slumped in a wheelchair. The staff physician believed he'd need electroshock therapy to treat his depression.

At the urging of Sue Donaldson, dean of the School of Nursing, the Millers brought Engelhart to Roland Park Place, an assisted-living facility in Baltimore. Donaldson felt this step was crucial because the Millers had been rebuffed by the South Carolina facility when they tried to become involved in Engelhart's care. Hopkins internist Bill Schlott examined Engelhart and took him off all medication, and almost immediately, he started eating. In three days he gained five pounds and began responding to the world. Today, Engelhart reads the newspaper, revels in watching Tiger Woods on TV and is using a walker.

Miller's experience with his father-in-law inspired the dean/CEO to invite Donaldson to talk about the problems we face in caring for an aging population.

Ed Miller: What struck me most about what we went through is that I know the system and have the resources and I still was asking for help. What happens to people who don't have resources and want to put a loved one in a good facility?
Sue Donaldson: Nursing has been training geriatric nurse practitioners to work with families on these problems. They help evaluate the resources, look at the person and determine what will make them happiest. But nursing is not going to meet all of those medical needs. There must be a partnership between medicine and nursing.
EM: What I keep thinking about is that my father-in-law would have been dead in two weeks if he'd stayed down there. He was living a maintenance existence. And no one was interested in listening to anything that we, the family, had to say.
SD: If a facility that bills itself as assisted living or a nursing home makes you feel like you have to beg for information about your loved one's status, then something is wrong. Good facilities welcome families. You want and need them as a part of the team.
EM: The thing that surprised me most is that it's called "assisted living." Lawton didn't need to be in a hospital; he needed a lifestyle that would help him return to some of the independence that he had before.
SD: What you experienced with your father-in-law was a status change. You saw an abrupt shift in his functioning, and clearly his caretakers at the time did not help him come back up to his previous level. When something happens like that, a broken hip say, it's often to an elderly person who has been living successfully on their own, and it takes away their independence. Most falls occur in the bathroom, by the way. We discharge elders from the hospital very quickly now, but studies show that if they receive transitional services at home for a week or two they begin to improve. Without those services, they usually go into a nursing home and rarely exit.
EM: It seems to me that before that's necessary an advanced nurse could simply coordinate a range of services to help this older person regain independence. It's the simple things that count most, like getting the person up out of a chair to walk. Making them feel safe.
SD: The name of the game is not to lose too much during these transitions—to recover. You need someone to come to the house perhaps daily to do a short evaluation, to help with bathing, to make sure the person is eating and able to get around. Literally assisting them with personal hygiene. You couldn't afford to continue such intense services for a long time, but in the short term it allows an older person to reorient.
EM: The other thing that would be helpful is to instruct the family in how to use their time most valuably when they have someone in assisted living. One of the things we are facing now is knowing how often we should visit Lawton. I told my wife that I would try to see him three or four times a week for 45 minutes. But it would be nice to have someone tell me if it might be more effective if I came in a few more hours on Saturday and skipped during the week.
SD: Every elder needs an advocate. That's the best health management. I think, Ed, that you've intuited what needs to happen exactly right. Short, more frequent, visits work very well.
EM: It seems to me that we should be advocating to put systems in place, perhaps require more graded levels of care for the elderly. It makes sense economically as well as medically. If you save somebody through prevention or early intervention, you cut back on the number of admissions to the hospital.
SD: We need legislation and also education. There are some questions that everyone should ask in choosing an assisted living facility with transition into a nursing home: Who makes the decision whether or not I can live independently? If I go into a bed at a nursing facility, do I immediately lose my unit so I can never go back? So many things can happen to an older person during these transition stages that can be so disruptive in terms of who they are, who they relate to. It's a cruel world.
EM: What I've learned is that this is an area that needs more research, measurement of outcomes, on how to do it better. This, I believe, is the contribution the School of Medicine in collaboration with the School of Nursing can make.