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Recently, the Wall Street Journal published several articles about the maintenance of physical health through old age. One article, published in the “Health Matters” column discusses how to stay healthy even through old age. The article specifies middle age as the critical time to prevent physical decline. Although it may be apparent that exercise is a key factor in staying healthy, specialists emphasize that it is important to modify daily exercise routines in order to minimize injury. Studies have shown that many middle age adults eventually injure themselves from exercise routines, and consequently stop exercising altogether. It is important to address any pain that is experienced with a physician, as this may be a precursor to more serious problems that will eventually lead to physical decline.

The Wall Street Journal’s “Health Blog” featured a related article titled “Preventing Physical Decline in Middle Age Helps Preserve Good Health Later in Life.” This article was inspired by a study that is currently being conducted by the Center for Medicare and Medicaid Services and the Bloomberg School of Public Health at Johns Hopkins University. The study is called the National Health and Aging Trends Study (NHATS) and observes the dependency of elderly adults upon others for assistance in activities of daily living. Such activities include walking, showering, dressing, and getting out of bed. The study hopes that its findings will help to improve quality of life for elderly adults in the future. Statistics today actually show that trends of disability levels among the elderly are declining. These optimistic results can be attributed to the many studies that have focused on improving the physical health of the elderly.

For example, the development of a new exercise regime called resistance training has led to a range of benefits, both mental and physical, for elderly adults. Resistance training involves exercises that are performed against an external, opposing force that increases as muscle strength improves. Various studies have proven that physical therapy can also have many unexpected benefits, including improvements in incontinence and mental well-being.

While skilled nursing facilities should be implementing these physical exercises into their residents’ daily routines, many homes, unfortunately, are so understaffed that they are unable to supervise such activities. Instead, many resort to the use of physical restraints, which has actually been linked to a decline in mobility in elderly adults. Not only is the use of physical restraints harmful to your loved one, however, but it is a direct violation of his or her rights as a patient if not used properly, such as when its done for the convenience of the nursing staff, and not the benefit of the patient.

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A recent article titled “Caring for elders: the role of registered nurses in nursing homes” emphasized the great importance of staffing a sufficient amount of registered nurses (RNs) in nursing homes. The article refers to RNs as the “linchpin” of nursing homes as they are expected to organize innovative activities, exercise clinical judgment, and deal with ethical dilemmas while linking together different departments. The study discussed in the article conducted various interviews with RNs from different nursing homes. The conclusion was that the responsibilities of RNs are absolutely crucial to nursing homes, but many factors such as understaffing and a lack of communication often stand in their way of doing their job properly which in turn leads to a lower quality of care.

While RNs may also do office work and other administrative tasks, these tasks can be delegated to other staff as the skill set of an RN can be better utilized elsewhere. The article stresses that RNs should really be focusing on direct patient care, such as maintaining a good relationship with their residents and exercising clinical judgment. If RNs maintain a good relationship with their residents, they will in a better position to direct other administrative tasks to other staff to ensure that the nursing home is providing the best quality of care.

An RN is becomes tied down with office work usually when the facility is understaffed and do not have enough staff to delegate the proper responsibilities. An RN complained about this understaffing and incorrect delegation of duties saying, “Handling invitations to tender, equipment and resident inventory, billing, and drafting quality control documents could be delegated to others. We actually spend little time building a relationship and communicating (with the resident).” When RNs do not have time to maintain a good relationship with their residents due to understaffing, it becomes nearly impossible to carry out individual care plans for their residents, which is extremely important for ensuring safety of residents and preventing falls.

Previous studies have shown the staffing levels of RNs and the amount of RN direct care time are correlated with avoidable nursing home injuries such as pressure sores, urinary tract infections, and falls. Because of this, it becomes increasingly important that nursing homes both hire enough RNs and allow RNs to carry out their proper responsibilities. Undervaluing the role of an RN could seriously compromise the quality of care. Unfortunately, as this article has shown, many nursing homes do ignore the importance of a proper caregiver-patient relationship, and disregard the importance of staffing nursing homes properly.

When choosing a nursing home, it is important to ensure that the well-being of their residents and the human element of care is one of the most important priorities for the facility. While this may seem obvious, many nursing homes do not have their resident’s health as a first priority. This is both inexcusable and a violation of a patient’s rights.

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Medication is intended to improve the quality of a patient’s life by reducing uncomfortable symptoms or by curing a disease. However, taking more medication does not equal to receiving more benefits. In fact, the consequences of using too many medications at once, or polypharmacy, can be extremely harmful and counterproductive. An article published by Hovstadius and Petersson looks at the different factors that lead to excessive polypharmacy and discusses the alarming finding that polypharmacy is most lethal and occurs most commonly in adults aged over 65 in nursing homes.

The article says that one of the most common risk factors for excessive polypharmacy is age. As the prevalence of disease increases with age, the amount of medication prescribed also increases. The prevalence of polypharmacy has also been increasing as new medications and technology are being discovered. In the entire national population, the prevalence of polypharmacy in the age group 80 to 89 years is 75.1%, and the percentage continues to rise as age increases. Elderly adults also often forget to take certain medications as they already have so many types of medications to keep track of, which is another reason why polypharmacy can be so dangerous.

Another factor associated with polypharmacy other than age is poor self-perceived health, poor life satisfaction, declining ability to function and declining cognitive capacity. Many nursing home residents who suffer from dementia also suffer from depression. This depression can usually be treated by non-pharmacological methods, such as daily social activities, simple exercises, and independence tasks. Unfortunately, many nursing homes do very little to ensure that their residents have a good quality of and good outlook on life as many nursing homes do not have these options of activities available for their residents. Rather than treating patients with non-pharmacological methods, nursing homes often use drug treatments or chemical restraints,which in turn leads to a higher likelihood of polypharmacy occurring.

Perhaps the most common consequence of polypharmacy is harmful drug-drug interactions. The effect of one medication can be influenced by another medication, and result in a harmful side effect. The risk for drug-drug interactions increase greatly as a patient is taking more medications. For example, a patient on 10 different drugs has 45 possible one-to-one drug interactions. Even more harmful is a disease-drug interaction, which occurs when a disease is worsened by a drug prescribed for a reason other than to treat the disease. This is highly common in nursing homes because many nursing home residents have diseases such as Alzheimer’s, but are also given unrelated medications such as nutritional supplements or urinary tract infection antibiotics.

Due to the severe consequences of polypharmacy, it is important to be aware of the risk factors that lead to polypharmacy and ensure that you or your loved one are not being prescribed unnecessary medications. Unfortunately, as many nursing homes are understaffed, instead of providing the proper care and treatment, unnecessary drugs such as chemical restraints are often improperly used.

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Depressive symptoms are common in patients suffering from dementia. Because of this, many patients are given anti-depressants, or selective serotonin uptake inhibitors (SSRIs). Research has shown that increased use of SSRIs is associated with an increased amount of falls in the elderly population, however details are still lacking on the exact relationship in the specific population of nursing home residents. A recent study published by the British Journal of Clinical Pharmacology shed light on the issue by looking specifically at the details of the relationship between SSRIs and injurious falls in the nursing home population. The study found that higher doses of SSRIs increase the risk of falls by three-fold. As falls are becoming increasingly common in nursing homes, it is important to understand all the risk factors that contribute to falls.

The study analyzed daily drug use and monitored falls over a two year period for residents who were able to walk independently (with or without a walking aid). All 248 patients studied met the criteria for dementia. To emphasize the huge effect drugs had on the rate of falls, the study cited one example from one of the patients they studied. An 85 year old female resident, who was on no SSRIs, hypnotics, or sedatives, had a risk of an injurious fall (per day) of 0.12%. After placing her on a dosage of SSRIs, her risk of an injurious fall (per day) jumped up to 31%. What is even more shocking is that her dosage was only 0.25DDD (Defined Daily Dose), whereas the average dosage given to nursing home residents is 1.00DDD. This means that the risk of an injurious fall increases by 198% when you place a patient on SSRIs or other various forms of drugs.

The study also points out the dangerous cycle of drugs and falls. Many nursing homes argue that drugs not only alleviate symptoms but also prevent falls when in fact the opposite is true. Behavioral disturbances like agitation and aggressive behavior (for which SSRIs are often recommended) often lead to an increased fall risk, which in turn lead to a higher drug dosage. Also, increased dosage of SSRIs has not even been shown to be more effective on depressive symptoms. In fact, there is very weak support for the idea that SSRIs are an effective treatment for patients with depression and dementia. Due to these reasons, the study urges clinicians and nursing home staff to prescribe SSRIs to their patients with due caution as to not increase the risk factor for falling.

Despite the consequences of SSRIs, the use of SSRIs and other drugs is quite common in nursing homes. In fact, a huge problem nursing homes often have is that many residents are on too many drugs at once. In previous studies, polypharmacy has already proven to be extremely detrimental to patients, but as this study has shown, the use of drugs can also greatly increase the incidence rate of falls. Many studies have offered more effective alternative treatments for dementia symptoms, but these alternative treatments require an adequate amount of staff to carry out the treatment. Unfortunately, many nursing homes are understaffed which is ultimately the reason why polypharmacy and easily avoidable falls occur.

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Dementia is a degenerative disease that can cause many behavioral and psychological symptoms that make patients difficult to care for. Although medications for these symptoms exist, not many studies have been able to provide conclusive evidence that medications such as acetylcholinesterase inhibitors are actually directly involved in relieving symptoms of dementia. As a result, many studies are now looking at non-pharmacological treatments that involve social interaction, simple physical activities, and other daily activities.

A study published in 2012 tested a treatment known by the acronym “MAKS”: “M” for motor stimulation, “A” for activities of daily living, “K for cognitive stimulation (German word is kognitiv), and “S” for a short introductory phase or a spiritual element (discussing topics such as happiness or singing a song). The results were very positive; the MAKS treatment significantly reduced symptoms of dementia for the 146 residents that participated in the study. Two therapists and one aide conducted the MAKS therapy for 6 months (6 days a week, 2 hours a day). Each 2 hour session started with the introductory phase in which a simple group activity was conducted to make everyone feel included. Then, 30 minutes was allotted to motor exercises, such as bowling, croquet, or balancing a tennis ball on a Frisbee and passing it to one’s neighbor. Another 30 minutes was spent on cognitive tasks, and then the last 40 minutes were spent on an individual activity such as preparing a snack or crafting with wood or paper.

After 6 months, participants in the study were less likely to exhibit challenging behavior such as running away and being aggressive and were generally happier. This improved social behavior, decrease in challenging behavior, and improvement in mood was most evident in residents with mild dementia. This study successfully showed that the MAKS therapy can greatly slow down the progression of dementia at an early stage.

Additionally, the study found that not only did the MAKS treatment work, but it also resulted in more long-term results than drug treatments. The MAKS treatment also had no side effects, as opposed to the side effects of drug treatments. The study implies that due to the overall advantage of the MAKS treatment, it is important that nursing homes treat their patients using similar non-pharmacological treatments whenever possible. The MAKS treatment and non-pharmacological treatments similar to it are much cheaper in price compared to the price of drugs, but call for an adequate amount of staff at hand to conduct group activities and to properly supervise each and every resident. Unfortunately, many nursing homes are understaffed, which is why drug treatments are used in place of other more effective and safe treatments.

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Many couples nowadays work simultaneously and take care of both their aging parents and their children. Coined the “sandwich generation”, these couples may experience a burnout as they have to focus on their job, care for their children, their marriage and the health of their aging parents. A study published in the Social Psychology Quarterly looked at what factors attributed to these burnouts and coping methods for successful couples. In interviews from the study, one of the most frequently mentioned stress factor was caring for aging parents, which was reported to be even more difficult than caring for young children.

The couples who were interviewed pointed out that much of the stress that comes from taking care of elderly parents comes from watching their decline in health each visit, and that having the support from their partner helped them immensely. The study found that lower rates of couple burnout correlated with lower rates of job burnout, and that one of the most important coping methods associated with reducing couple burnout was visiting their parents together. Visiting their parents together therefore strengthened their marriage, and reduced the stress of seeing their loved ones in a compromising situation.

Coping with the difficult task of watching the health of your loved ones decline is only one of the many stresses that families have to deal with. Families that decide to choose a nursing home for their parents are presented with a whole new array of stresses. With the wide array of choices, it becomes difficult to decide which facility will provide the best care with the most convenient location. As the article suggests, an important part of making the decision is making it together. It is also important, before making the decision, to visit the facility together to ensure that the facility has all the needs of your loved one, and staff that will offer professional care.

If you or your loved one is seeking a nursing home, the main issue to keep in mind is ensuring that the nursing home is not understaffed. In order to provide the proper care, one of the most basic requirements is that the nursing home has enough staff to give attention to each resident. Understaffing can lead to a wide array of problems, including malnutrition at mealtimes, an increased amount of falls, increased likelihood of pressure ulcers, and possible misuse of physical restraints.

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According to the American Geriatrics Society Foundation for Health in Aging, approximately half of nursing home residents experience falls each year. Because falls are such a common accident, it is important that nursing homes understand how to handle the situation immediately after a fall, and the best ways to prevent falls. An article by the Assisted Living Column emphasizes that falls not only cause physical injury, but also psychological damage that may lead to more falls in the future. The article also stresses the importance of caregivers at nursing homes to be educated about the nature and impact of falls.

The psychological impact of falls is important as it almost always leads to more falls. After falling once, older adults become fearful of falling again, and so engage in less physical activity. This reduction of physical activity results in reduced mobility, which is a risk factor for a second fall. In a long-term residential facility such as a nursing home where residents are unfortunately at a risk of experiencing falls, staff should be trained on preventative measures.

The article emphasizes the importance of proper prevention methods. The staff at the nursing home should be aware of all the risk factors and work to eliminate as many of these risk factors as possible. Many of the risk factors for falls are environmental factors; the floor may be too smooth or slippery, rooms and hallways may have inadequate lighting, or furniture placement might be dangerous. All of these factors are things that can be easily fixed with an observant and knowledgeable staff. Unfortunately, a problem in many nursing homes is that the nurses often give a lack of direct care. Direct care involves physical and psychological treatment of the patients, while indirect care mostly involves administrative tasks. If there is a lack of direct care for the residents, it becomes increasingly difficult for staff to take notice of the environmental hazards that the nursing home may have.

Another major risk factor is the type and amount of medication that the patient is on. A study done by the Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) found that those who were on psychoactive medications were more likely to experience a fall due to the medication’s side effects. Unfortunately, psychoactive drugs are one of the most frequently used drugs in nursing homes. Nursing homes often find it more convenient to use psychoactive drugs to prevent episodes of agitation. However, rather than using psychoactive drugs, nursing homes should provide more direct care and should not be using chemical restraints to subdue their residents as this is a direct violation of the Patients’ Bill of Rights.

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A study published by The Gerontologist found that nursing homes that focused on creating a culture of patient safety which involves using less physical restraints, resulted in lower mortality rates, lower rates of failure to rescue, decreased chances of medical errors, and more days between serious safety events. A culture of patient safety involves ensuring that the nursing home or hospital is engineered both physically and systematically to enhance the safety of the patients and residents. It also involves a blame-free environment in which individuals are able to report errors with fear of punishment. Lack of a culture of patient safety can lead to staff that is afraid of reporting mistakes, which leads to the increased use of physical restraints.

Physical restraints are a controversial care process used on individuals with difficulties transferring and with behavioral disorders. Nursing homes often resort to the simple method of using physical restraints to limit falls rather than attempting to fix the underlying problems in management that lead to these falls in the first place. In reality, physical restraints do not prevent falls. In fact, the study found that nursing homes that use less physical restraints report less falls per year. Physical restraints have also been shown to increase the likelihood of death, injuries, and functional decline. Nursing homes often resort to physical restraints because they are uneducated about better safety methods. Staff should be trained in teamwork, documentation, and reporting and discussing safety issues. Each resident has different health needs, and so a specific care plan should be adopted for each individual to prevent falls, rather than resorting to the use of physical restraints.

The study also found that the nursing homes that heavily rely on physical restraints and less on a patient safety culture also tend to be understaffed. Unfortunately, understaffing is a problem in most nursing homes, and so many nursing homes are not providing the proper quality of care for their residents to ensure their safety from falls and critical errors made by staff. The use of physical restraints due to understaffing is also a direct violation of a patient’s rights, and is simply inexcusable.

The results from this study show that there needs to be an obvious push in nursing homes towards building and the importance of adopting a proper patient safety culture and hiring enough properly trained staff to give quality care to the residents. A nursing home should not only provide resident autonomy, and a comfortable living environment, but also a safe culture to ensure that its residents are kept at the highest level of physical and mental well-being as possible.

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The March 2012 issue of the Journal of Clinical Nursing studies trends in pressure ulcer prevention in skilled nursing facilities in its article titled “Registered Nurses’ Attention to and Perceptions of Pressure Ulcer Prevention in Hospital Settings.” Pressure ulcers continue to be a major problem in nursing homes and yet, many facilities fail to prioritize the prevention of these wounds, although they are one of the greatest sources of unnecessary suffering among the elderly. The study reaffirms this problem and observes that Registered Nurses (RNs) typically undervalued the importance of pressure ulcer prevention techniques.

Before reporting the actual procedures and results of the study, however, the article first discusses important prevention techniques that it would be considering when observing nursing homes and their ability to effectively prevent pressure ulcers. First off, pressure ulcer prevention must be administered from an early stage. The study reports that identifying and treating the problem early on can actually decrease the chances of the development of a pressure ulcer by 50%. Some common and effective prevention methods include repositioning and usage of support surfaces, such as foam or air mattresses. Nutrition was also found to be important. Patients who took nutritional supplements were able to successfully lower their chances of developing pressure ulcers.

The study consisted of two parts. The first portion involved an interview with the RNs. Highlights of these interviews reveal a heavy reliance of RNs upon their assistant nurses. Instead of providing direct care themselves, RNs delegated many duties to assistant nurses, admitting that they did not have time to implement or supervise these activities themselves. This confession presents the widespread issue of understaffing in skilled nursing facilities. Even when staff as a whole is sufficient in numbers, nursing homes are often lacking in their employment of RNs. Previous studies have confirmed that direct care from RNs specifically is especially important in the prevention of pressure ulcers, as well as many other health complications that are encountered in nursing homes. With regard to quality of staffing, the truth of the matter is that assistant nurses are much more prevalent and highly staffed than RNs in skilled nursing facilities. This reality makes it especially important for you to ensure that these nurses are well-educated and trained to provide your loved one with the care that he or she needs.

In addition to being knowledgeable of pressure ulcers, and other health-related issues that the elderly may encounter, nurses must also possess basic administrative, organizational, and communication skills in order to allow for the smooth operation of a skilled nursing facility. Many nurses who participated in the study admitted that they felt that the documentation of procedures and treatments was an unnecessary, cumbersome step in the caretaking process. RNs trusted that their assistant nurses were implementing prevention techniques, even if there was no documentation of them. However, careful and accurate documentation of medications, treatments, and health problems is absolutely necessary in optimizing the quality of care that a patient receives. By keeping a patient’s medical files organized, physicians and other third parties can more easily assess the condition of the patient, and thus prescribe the most effective treatments.

Proper documentation also contributes to the formation of an effective care plan. Nurses who participated in the study, however, claimed that no specific care plans were necessary in caring for patients suffering from or at high risk for pressure ulcers. RNs said that pressure relief was done automatically and that no specific policy was necessary because the nursing staff already knew what to do. If a patient showed signs of a pressure ulcer, then assistant nurses were simply to reposition the patient often and report the pressure ulcer to RNs. Such a mentality truly undermines the individual needs of each patient. No two patients are exactly alike. Therefore, it is absolutely necessary that each patient has a care plan that has been specifically tailored to suit his or her needs.
From its observations, the study concluded that prevention techniques were typically undervalued on an RN’s list of priorities. It also concludes that assistant nurses were unable to recognize risk factors or diagnose the stages of a pressure ulcer as accurately as RNs. This fact further attests to the importance of direct care from RNs. If your loved one’s nursing home is not providing your loved one with proper preventative measures for pressure ulcers, as a result of staffing issues, he or she may be a victim of nursing home neglect.

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A recent article titled, “Comparative Safety of Antipsychotic Medications in Nursing Home Residents” was published by the Journal of American Geriatrics Society. As reported by the article, an entire third of nursing home patients are prescribed antipsychotics at some point during their residence. Because such a large population of nursing home patients take these drugs, it is important to understand the risks associated with antipsychotic medications. This study breaks down the two types of antipsychotics and compares the risks associated with using each one. Typical antipsychotics, also commonly known as conventional antipsychotics, were developed in the 1950s. A second generation of antipsychotic drugs was later developed, and today these medications are called atypical antipsychotics.

The study concluded that in general, the use of atypical antipsychotics is more dangerous, as it was more often associated with negative side effects. These included an increase in cardiac problems, infections, and hip fractures. However, an exception to this was found with cerebrovascular issues, in which case, atypical antipsychotics appeared to pose less of a risk. We hope that your loved one never finds the use of antipsychotic medications necessary, but if he or she does, it is important to understand risks and side effects, in order to do an educated cost-benefit analysis of taking such drugs.

The study also notes that the effectiveness of antipsychotics in Alzheimer’s patients is outweighed by the risks. Although symptoms for various cognitive diseases may appear to be similar, effective treatments for each one are often very different. Inaccurately diagnosing and treating a cognitive disease can be very dangerous, and even lead to death of a patient. Because there are so many fine details that must be understood and considered prior to beginning an antipsychotic drug regimen, it is important that the nursing home staff is trained and knowledgeable in such matters. As many nursing homes are, unfortunately, extremely understaffed, it is common to find nurses who are unable to properly and accurately diagnose and treat various medical problems. It is important that you are aware of this widespread problem, so that you and your loved one can hopefully avoid its many consequences.

One such consequence is the use of chemical restraints. Because the nurses in understaffed facilities are usually pressed for time, they will often automatically resort to the use of drugs, instead of first assessing the patient and considering other treatments that may be safer and more effective. This is especially important in dementia patients. In 2005, the FDA issued a warning of excess mortalities associated with antipsychotic use in adults with dementia. Since then, many studies have been conducted on the various uses of antipsychotics and their overall effect on quality of life in patients who suffer from dementia. The results have all suggested that behavioral therapies are the most effective treatment for dementia patients. In fact, the use of antipsychotics has actually been proven to worsen symptoms of dementia, such as agitation. It is important that you consider the many alternative methods that exist for treating dementia before resorting to the use of antipsychotic medications.

The study concludes by emphasizing the importance of monitoring a patient’s dosage of medications. Close and careful monitoring can prevent consequences of polypharmacy from occurring. The most efficient way to monitor drug use and antipsychotic treatments is to maintain organized and detailed medical records. Studies have actually proven that improper documentation of antipsychotic drug usage leads to a higher rate of death in skilled nursing facilities.

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