This Is My “Now”

Some days dealing with dementia patients can be either challenging yet rewarding, or downright difficult. I often tell family members to “stay in the moment” with their loved one, focusing on the topic regardless of how outlandish or far-fetched as it may seem. It seems to me that most dementia residents  focus on ” going home”, when they last ate (3 days is the standard comment ), “taking care of the babies” and going to the bus stop.  I encourage staff and family to use Naomi Feil’s validation methods of reassuring the resident that all is okay, and validating what they are saying.  Arguing with a dementia patient is truly a moot point.  I highly recommend reading some of the research on the Feil Method and applying  it when dealing with dementia patients. For more information ,  go to the website :  .

I made a huge mistake last week, using the validation method…..let me explain.

Sarah is a new resident, but does not have dementia.She has terminal brain cancer. The progression of the disease process has taken from her the ability to communicate effectively; often losing the word she meant to say before it is verbalized. She may mean to say, “ I need to go to the bathroom” but it comes out ” I need red elephants.”      So to provide care to her, the staff have to use the process of elimination  : “Do you need a drink?  Do you need your pain pills? Do you need to go to the bathroom?”    Once the need has been identified, it is met …it just may take a few minutes to arrive at the right answer.    It can be a frustrating process for her and for those providing care.

Here is the thing.          Sarah at times, can speak clearly, with intent and purpose, saying exactly what she means to say. Her move to the facility was not a very happy moment for her and she had no problem expressing her dislike for being here or for those of us who helped with the process.  She had no trouble finding choice words to describe exactly how she felt about being in a place with a bunch of  “old people”. ( Sarah is only 59 years old.). She was extremely critical of every component of the facility. The building was not clean enough; the food was horrible; the staff was stupid, stupid stupid and the old people were OLD.   Her list of reasons not to stay in such a place would take days for me to transcribe or even begin explaining.   After about an hour of  listening to her and knowing that she had some neurological deficits, I contributed her complaints to the brain tumor as opposed to her true feelings.

” Sarah, I understand what you are saying and I am going to have someone come in and clean your room again and have the kitchen send you up something else to eat. I personally will see to your needs and try to make you feel comfortable as we can. It is going to be okay  Sarah, everything is going to be okay.”    

Without blinking an eye, Sarah stood up, looked me directly in the eye and said ” I call bull sh**.  How in the hell is everything okay when I am dying of brain cancer and you, YOU, don’t understand anything about me. You wrote up some papers, my family signed them and here I am in this place to die with a bunch of strangers and you tell me everything is okay? Bullsh**.  Why don’t you try living my life and see how you like it? Before this happened, I had my own life and didn’t bother anybody and now I am in this hell-hole waiting to die and you tell me  it’s okay. You know what? This is my NOW and I hate it and I hate you.   Now go get me my zebras because you have made my friggin head pound. I have brain cancer you know, so do you think I can get some relief ? Get out of my room.”                                         Talk about being put in my place.

My interaction with Sarah has made me think about how we interact with dementia patients over-all and how we respond to them.  When someone is looking for their wife of 60 years and we know she has passed away, we offer an excuse to the resident. ” Oh she is at the beauty parlor”, which in turn, calms the resident and redirects his thoughts from searching for her.  But what if, just what if he wanted to talk about his wife and grieve his loss? What if he already knows, deep inside, that she has died and is simply wanting to recount a memory about her?     Sometimes it is difficult to discern what the underlying meaning is when spoken by a person who has cognitive deficits.  Trying to figure out what is being said, is what is meant and is what is inferred and implied, is as confusing as this sentence is!

I learned a lot from Sarah during  that single interaction. I now know that everything is not going to be okay, just because I said so.    Human beings whether cognitively impaired or not, still have emotional outpourings that are real, not imagined, nor a figment of their imaginations.   Their ” now” should not dismiss who they were, how the feel or have felt, or what they are saying to us and wish to have understood.

Think about it, right now where you are. How will your ” now” moment be interpreted should you one day lose the ability to express yourself verbally?     WordOfTheYearNOW

Guarding The Front Door

Every occupation has certain expected risk associated with it. Look at how many convenience stores employees are harmed in a robbery gone bad; or how many police officers are shot in the line of duty….or how many construction workers sustain major injury while on the job.    Even the friendly mailman risks being bitten by a dog….but what risks is associated with being a long-term health care administrator?   What is the worst possible thing that could go wrong?

Well, to answer that, let me share  what happened on Monday in my building and how something very bad could have happened………

My office is located at the front door. I see  and greet every visitor, family member, guest and employee that comes and goes. Due to the volume of guests that frequent the facility, I may not always know who ” belongs” to which resident, but for the most part, I have a general idea.  I do at times, get thrown off when the” great-grandchild on Uncle Harry’s side twice removed and related by marriage” visits, but other than that, I know who’s who.

Monday. Let’s talk about what happened Monday.

While sitting at my desk, I see Bonnie  and Sandy  pass through the door. They greet me with the normal ” howdy-do” to which I exchange with a “hey ya’ll.”. Suddenly I hear a voice, coming from the doorway.

Glancing up, I see a woman…an oddly dressed, disheveled and very loud woman, standing in my doorway. A large Minnie Pearl style floppy hat, dark sunglasses, a trench coat and “jail issued slides” were the first thing that caught my attention.

Well hey! Are you interested in pornographic Bibles? I have a ton of pornographic Bibles that I am handing out. Do you like my shoes? I call them my jail slippers. I think they are nice for jail slippers. Do you like my hat? “  Before I could remotely gather my thoughts, stand up, or whip out my concealed carry sidearm…..she caught the attention of one of the male residents. .. ” Do you want to by my boyfriend? I need a boyfriend to string up. I am here to spread joy and cheer and visit”.  With that, she turned and walked with purpose toward one of the dining rooms as if she had done this a million times before.

Jennifer,the  Director of Nursing, had been in the office as all of this was taking place. I quickly whispered, “Which family does she belong to? Could it be one of the recent move in folks and we just don’t know her?   Without hesitation , she replied, ” I don’t know but she is nutty as a fruit cake. Pornographic BIBLES...really????”

Without second thoughts Jen and I sprung into action.  Well, not really.    I was still not sure if  this lady was a relative of a resident that I just hadn’t met and the last thing I wanted to do was call the police on an actual guest!  I had to be sure.          Jennifer and I ” tailed” her into the dining room, watching as she sat down with a group of ladies who had just finished lunch.    We observed from the Charge Nurse’s Desk, safely behind a glass window.

” Did you ladies just have lunch? Did you have golosh? ( I have no idea how to spell golosh, nor do I know what it is, nor do I intend on ever eating it, but hopefully you know what it is and will overlook my inability to spell it).

” I love these types of homes. I enjoy being full of cheer. Oh look, a kitty cat. What a pretty kitty cat. Nice kitty cat. Did you eat golosh today? I love golosh. My aunt Maddy made the best chicken………”

By now, I think or am fairly sure that this lady is a few french fries short of a Happy Meal. but I am not positive, so I enlist the Charge Nurse to go investigate further. ” Go introduce yourself, ask if you can help her and ask who she is here to see” I whisper .

” Hi, my name is Donna and I am the Charge Nurse. Who are you seeing today?” she asked.

The lady, engaged immediately with Donna. ” I am here to spread cheer. My aunt Maddy was in a place like this. You know what happened to her? She died. She made the most fabulous fried chicken. You know how she did it? She browned it…..”

Donna was clearly in my line of view and I could tell that she was not too happy with me for sending her into a crazy conversation. She was smiling and nodding along with  the crazy lady as she rambled on about Maddy’s fried chicken.

Jennifer is pretty no-nonsense and had heard enough. She loudly exclaimed…” Jessi, this chick is mental and I recommend you call the authorities.”.   Before I could agree, crazy lady jumped up from the dining room chair, waved goodbye…stopping briefly at the desk to say ” Goodbye my new friends” .       Off she went, back out the front door, leaving us  standing there, looking at one another as if to say, “what just happened?”

We chuckled at the insanity of the moment and quickly scattered , returning to our duties. Hours passed.  People came by and left the facility without incident. Pet therapy dogs stopped in, the Library on Wheels dropped off new books….family members came and went.

Just a few minutes after 4pm, Jennifer appeared in  the doorway announcing she  knew much more about  the “crazy-lady”.       Apparently, the Library on Wheels folks knew of and about her. She is indeed ” off her medication”, attends any AA, NA or other organized meeting that provides food, simply to enjoy the feast of donuts and coffee, and  she lives in her car.  She wears a variety of costumes/outfits including Bunny outfits, Top Hat and Trench coats and  often wears doctor’s scrubs and lab coats.      Okay, the bunny ears and floppy hats made me laugh, but there is nothing funny about wearing scrubs…or masquerading as a medical person. To me that is scary. 

Think about the size of your local hospital. When you walk in, normally, if you look like you know where you are going, no one stops you. You have the whole hospital to explore without question.  Nursing homes and assisted living facilities are no different. We are public places, yet private. Not just any Joe blow should get past the front desk….nor be able to wander through the facility. It is the obligation and duty of the person sitting at the front door, whether it be a receptionist, security guard, administrator or head nurse to insure the safety and well-being of those inside.

Let us never forget Carthage, North Carolina, March 29, 2009. A gunman walked through the nursing home opening fire on anyone he saw, killing 8 innocent people. Remember, most of those killed that day ,were elderly residents.  Granted that incident was spurred by domestic violence, the gunman was looking for his wife who was on  locked unit………but it could have happened anywhere, any time…to any one of us.

I dodged a bullet on Monday with  the crazy lady. My slow response to stopping her and the second guessing of myself as to who she was, could have  spiraled out of control.  Guarding the front door and protecting those in my care and the employees is not only my duty, but my obligation as well simply because of my title.    The lesson we can all learn from Monday, is to know who is who, and rather than second guessing, simply ask the person in question.   If she can walk into my facility, she can walk into yours……..




ICD vs DSM: More Than Codes

Times are changing in long term health care.  Typically, the average age of a resident is somewhere between 70- 100 years of age.  Their diagnosis is always along the same lines: dementia, forgetfulness related to aging, CVA, Heart disease,  lung disease, paralysis, mini-strokes….on and on the list goes.  Recently, the trend has changed to a younger , more complicated group of incoming residents : those with  Traumatic Brain Injuries (TBI), medication- managed schizophrenia, early onset dementia, ETOH induced dementia,  clinical depression and numerous psychotic disorders that are medication managed.

What I see happening now in Virginia, is  the mental health system weeding out the long term “dwellers” and finding placement  in assisted living  facilities and nursing homes across the state.  The question I pose is this ; Are such facilities prepared for a younger, more diversified group of residents with complex psychological issues?    Let’s face it.  A 92 year old dementia resident has different needs than a 32 year old schizophrenic resident.   The mechanism of action of dementia  and psychotropic  medications certainly  stand a world apart from medications meant to maintain those suffering from delusional disorders.

Let’s look at it this way. Grandma is 95 years old,  fraile, partially blind, extremely hard of hearing and wheelchair bound.  John is 37, paranoid schizophrenic, and was found not guilty by reason of insanity due to his mental health issues.  How comfortable are you with Grandma living down the hall from him?  Would you worry about her well-being and safety?

Another angle to think about: Mary is a 19 year old caregiver who has completed dementia training. She has been a CNA for only 2 years and is a great caregiver to the elderly in her care.  She sees John and becomes fearful and intimidated by his ” constant staring”. John can walk, talk, meet most of his own personal care needs….but John needs someone to insure he stays on the correct medications.   Should Mary quit her job because of her fear?

Don’t get me wrong, I personally enjoy working with psych patients. I started my career many moons ago working in psych hospitals and found it to be my “calling”.  But as a very young professional, I found myself cornered by a patient that  turned violent quickly.  The textbook learning and clinical rotations had not taught me everything I needed to know , including the part about never turning your back on a patient who is having a loud discussion with himself.  Thankfully, I was only battered and bruised and walked away from the incident.  The next day, I quit my job because I was scared it would happen again….and  the next time, it could be a lot worse.     So, I left the field of mental health and entered the world of long term health care- tada– and I’m still here!  

Now.….the two areas of practice are merging, and I have mixed feelings about it.  I understand that mental health beds are needed by those in immediate crisis and the long term patients need somewhere to live, someone to manage their care and some type of structure to insure their well-being.  But is mixing these two populations the right fit?

A unique characteristic in most dementia patients is that they are unpredictable. They may be fine and dandy one minute and aggressive and combative the next. One of the reasons for the shift in their behavior is the progressive deterioration of brain cells. Frustration or even physical pain/ailments that can not be expressed is also another reason why some turn aggressive.. The dementia patient has very little, if any, control of their behaviors.

Menalzheimer_braintal health patients have such a plethora of possible disorders, that it is difficult to judge which DSM 5 code is the one staff need to focus on. How do we as caregivers know exactly what to expect when a long term mental health patient has been admitted into a nursing home or assisted living facility?  There must be a reason the patient has not mainstreamed back into society…….Mental Health professionals consider those with inappropriate behaviors  to be manage by medications, but the patient must be willing to  comply with the treatment plan.      Hmmm. This is a wee bit different than the treatment plan of a dementia patient. 

So, what are we to do? Mix the two populations and hope the staff can adapt to the needs of both populations?    Hope the two populations can share communal living without incident?  schizophrnic

Long term care is just what it says. “Long term care” for those who can no longer care for themselves safely independently.  Hopefully the field can expand  and meet the needs of those suffering from both conditions in the ICD-10 and the DSM-5.



Successfully Connected

The world has become so advanced with how we communicate with one another, I think we often forget how to communicate. We text, FB, Tweet, Viber, Instagram and Snapchat our way through the day, interacting with those around us….. We share our lives openly by posting pictures on social media, storing precious pictures of life events on a memory stick and on  in cloud libraries. Advanced and high tech would certainly describe our society in a nutshell.

But you know, I think we have forgotten how to sit down with someone and talk face to face , without interruption of a ding, bling, chime or musical melody. It is like we need the distraction of an electronic device in our hand to even engage in a social encounter.  Follow me here:

One of the places that I love to meet people is airports. I strike up a convo with any nearby stranger and trade stories of where we are going, what the weather is like or going to be at our destination and on and on.  Once on the aircraft, I engage with my seatmate about airports, air jams, the beauty of a sunset from our view…

Leaving on my last flight out of DC, I took my seat in the middle of the airport waiting to board. I looked around to see who I could spend a few minutes with .Suddenly I found myself outnumbered by cell phones, ipads, tablets, kindles and some devices I could not identify.  Not one person looked up from their devices to acknowledge my asking “ Is this seat taken? ”   After a few minutes of feeling displaced, I went over to the  food court only to find tall tables with ipads as the center-piece to place your food order, surf the net while you eat and read your email.  I scanned the crowds, looking at the countless number of people, all looking down at the device; lost in their own world, unaware of those around them. But they are all communicating with someone…somewhere. Communicating.cellphone


Once onboard the plane, I took the window seat as usual. I love to watch the clouds float gingerly by on a beautiful day. For me, flying is a peaceful event; freeing me from phones, ipads, computers and any other device. my seatmates seemed like they would be interesting conversationalist…one appeared to be Middle Eastern and the other, possibly a Greek National.   After a few minutes of ” Hi, how are you? Mind if I scoot my bag under the seat”  chat, we are airborne.

Within ten minutes the flight attendant announces: ” Welcome aboard, the Captain has turned the seatbelt sign off, so you may move freely in the cabin and you may now use any FAA approved electronic devices. This flight offers WIFI, so feel free to connect  and enjoy the internet for this 6 hour gate to gate flight…….. ”      

INTERNET? WIFI??  What happened to the peace and serenity of flying? I looked over at my seatmates to discover they both had successfully connected to the www. of life.   Connected…..   Connected…. Successfully Connected.   Hmmmmmmm.

As I sit at my desk today, I listen to a daughter talking to her mother as they go through an old photo album together. “ Mom, this is you and dad, and me and Bobby. It was taken at the old cabin beside grandmas. Do you remember mom?  Without expecting an answer, the daughter moved on. “Look at this picture mom. Remember how we vacationed in Big Bear at the lake? Look at this one mom, it’s you and dad at Lake Arrowhead. Look at Bobby  in those red pants! Remember mom?   Oh here is one of Bobby and I at the church banquet when I was maybe 8. Look at how handsome dad was in that blue suit. You were so beautiful mom in that dress.   Here is a picture of Bobby’s graduation from high school; look you and Bobby, Dad and Bobby…..Look mom, here is your and dad’s 50th wedding anniversary picture…..There is Mr. and Mrs. Moore, Mr. and Mrs. Emerson, Mr. and Mrs. Oglen……

Sitting there eavesdropping on the conversation, I realized that it was THAT generation that was truly connected.   Just by listening to the daughter identify the pictures to her mother, I could tell that this was a family that spent time together, loved one another and captured their memories in a worn out photo album.

What will our generation have?  Cell phone cloud memories?  Facebook images?  Will we have any captured moments at all since we are so busy snapchatting , vibing, texting and hanging on social media?   We never look up long enough  and glance away from the electronics to notice the dawn sunrise, the evening sunset or the people around us.   Yet the generations before us were more connected than we will ever be. Their memories may not be digitized, tagged and have a thumbs up logo, but what they do have  is an everlasting remembrance to a different time and place.  A time of fireside chat radio, face to face family visits and time well spent.     I call that successfully connected.



The Cycle

Dementia is a unique and interesting thing. It may affect one person one way, and another, the complete opposite. Some days in our line of work, it is impossible to determine if dementia is the culprit to a certain behavior, or was the individual always this way.   I understand that not every single 90 year old was not always a sweet, cute ball of happiness , but geez, can there be so many vicious, mean ones?

Let me tell you about Shirley to give you an idea of what I am referring to when I say “mean.”     Wow. Shirley is a full packed pistol.     This morning as  I was walking through the facility, I encountered her or should I say, heard her.

” All of you can go to the pits of hell. All of you belong in jail. I am going to kill you all. You all are Godless heathens who need to go to jail and never get out. Let me get up from this chair and you will find out what kind of person I am. I don’t mess around. I mean it. I will kill you all. You hear me? Answer me!!!!!!   Fine, don’t answer. But I tell you one thing, when I get my hands on you, you better get running and hope I don’t catch you….”      Shirley continued on and on, and seemed to be working herself up, so i felt the need to visit with her for a while and see if I could redirect her and reduce her anxiety.

” Hey Shirley, how are you this morning?”  ( Okay, that was a dumb  question. )

“How am I doing? I will tell you how I am doing. You are a heathen. You hear me? I hate you. You are stupid, stupid, stupid, stupid. You belong in the jail. No you don’t. You belong under the jail. you dumb dumb. I wouldn’t feed you a scrap from my table. I will give it to the cow before I give it to you. You hear me? Huh?” Stand there looking dumb ‘cuz that what you are. Dumb.”

Well, goodness. I wonder what re-directional technique would work? Hmmm. Certainly with all of me experience and education I can calm her, right?

Kneeling down beside her, I tried to adjust the volume of my voice to hopefully have her match mine….

” Ms. Shirley, what has you so riled up today? Is there anything I can do to help you……”  Before I could finish, Shirley drew back to throw a right hook punch, aiming for my nose.  I quickly moved out of the fire.

” Anyone ever tell you how ugly you are? Ugly. You are ugly, ugly ugly.I bet you aren’t even married. Nobody would be stupid enough to marry an ugly thing like you……”         She continued on and on with her insults, carefully crafting her next plan of attack.

Without hesitation, Shirley changed gears.  ” Who did you say was getting married? Tommy? Well I hope he finally found somebody. He may be son, but he is one useless man. He ain’t worth the dirt he drags in on his shoes. Nothing worse than a useless man. Wonder who is marrying him? I hope it ain’t Patty’s daughter. That girl ain’t got good sense. Maybe they will make  a fine pair, useless pair………   She continued for 15 minutes discussing Tommy and his  lack of use..

It never ceases to amaze me at how dementia creates a whole new personality that differs dramatically from the who the individual use to be.       Shirley, prior to the onset of dementia, was an elementary school  teacher.   Now, we all know the patience needed to be a teacher, especially an elementary teacher!       So how did Shirley go from that person to the one screaming hateful words today?

The brain is a mysterious thing, yet carefully studied by the greatest minds of all times, yet some questions will always remain unanswered. The best any of us can do is to simply try to understand, reassure and comfort.

The key being try. All of the sweet talk in the world is not going to redirect someone who has lost the emotionally connect. The medial section of the brain may shut down, causing a loss for impulse actions as well an emotional balance……… who really knows?

Shirley continued to vent, rant and rave….eventually calming down after the nurse gave her her morning meds.   After a few hours, the meds will wear off and she will once again return to her previous state……..until it is time for her afternoon meds……..and the cycle continues.

People who do not advocate the use of psychotrophic meds have never seen the results of an unmedicated dementia resident who has absolutely no impulse control.    The purpose to medication is not to sedate or create a zombie, but rather to decrease anxiety, promote a sense of well being and overall sense of peacefulness.

Shirley is sleeping now…….all is well for the moment, and that is a all that matters…….for now.