Challenges for the aged entering residential care
7 MINUTE READ
from Luke’s Journal 2020 | Ageing Gracefully | Vol.25 No.3
Ageing people come into Residential Aged Care Facilities (RACF) with – and sometimes because of – some established disabilities.
Their admission often adds one or more unintended disabilities. Their new residence is usually foreign, with unfamiliar nurses and doctors providing care now. They are often transferred via an unfamiliar hospital because of a recent acute event, such as a stroke, fracture or worsening of chronic illness like dementia.
Consider the following list of possible disabilities accompanying a new resident into a Residential Aged Care Facility:
- Change – whether in location, food, neighbours, noises
- Pain – secondary to arthritis, recent trauma, angina, constipation
- Breathing difficulty – due to chronic COPD, asthma, recent pneumonia
- Impaired vision – necessitating the importance of keeping glasses clean and in place
- Impaired hearing – managed with the appropriate use of hearing aids, clearing the wax from the ear canal
- Deteriorating mobility – impacting transport for specialist or hospital follow-up
- Impaired speech
- Disturbed sleep
- Chronic tiredness – contributed by decreased exercise, burden of disease such as anaemia, hypothyroidism, drug effects
- Tremor – Parkinsonian or otherwise, or simply a general deterioration in fine or gross motor function
- Constipation – secondary to diet, fluid intake, reduced physical activity, drug effects
- Polypharmacy – Most of us doctors are relatively capable of and comfortable with starting medications, but we are not good at knowing when we should stop. Hence, with each new problem detected or a different doctor consulted, patients and nurses are burdened by yet another drug addition to their already long list of medications. We need to have good reasons for all our prescribing and need to keep clear records of the medications, indications and directions.
- Social isolation – Many Aged Care residents feel forgotten. They may forget that their daughter had already visited earlier that day. Or they may suffer the perception or reality of family, doctor, nurse, carer or allied health professional not visiting as promised or expected.
- Malnutrition – caused by dental problems or poor appetite
- Mental health issues – depression and anxiety
- Loss of independence
A welcomed or enjoyable priority?
Few doctors see nursing home residents as an interesting or enjoyable priority in their clinical practice. A senior geriatrician from the UK related his involvement in a regional team of about 14 geriatricians, of whom only two saw nursing home involvement as an enjoyable or important part of their practice. When I withdrew from involvement in wider areas of General Practice to focus on nursing homes, a couple of fellow GPs made comments such as, “Does that mean that I can dump all my nursing home patients on you?” GP involvement in caring for nursing home residents can be more time-consuming and less lucrative than seeing only patients who come to the doctor’s rooms.
Verbal communication is important
Because of geographic change, the aged resident is often new to the GP and vice versa, and likewise for families, nurses and carers. Family conferences involving doctor, resident, family and nurses can be enormously helpful, preferably as soon as possible after the resident’s admission. They help to build relationships and establish mutually realistic expectations.
Written communication is also important
Sourcing the health history of a resident is a perennial problem. One doctor may prepare the hospital discharge summaries (sometimes a day before discharge), but another doctor may make additional medication changes without knowledge of the first. The copy of their hospital drug chart does not always arrive at the same time as the resident. Occasionally several pages of hospital record may arrive on time, but with some pages lacking dates or even names of the patient. All potentially disastrous if another new resident arrives from the same hospital at a similar time! We all need to take great care to legibly name and date every page of health records.
“The nursing and care staff need access to good records from the GP, and vice versa.”
The nursing and care staff need access to good records from the GP, and vice versa. Over time it is possible to develop excellent mutually helpful relationships between GP and nurses. The GP can build a mental record of which staff members in the nursing home provide the most accurate and helpful information. This also facilitates the possibility of good telehealth advice after hours. A brief conversation with the relevant carer can often provide vital insight into the resident’s needs. Site Director, Clinical Nurse, Registered Nurse, hands-on Carer, Domestic and Cleaning staff all have vital roles to play, as well as the GP. None should be discounted.
Asking questions that matter, gaining answers through stories
The elderly love to talk.
My own father spent his final years in a local RACF. If I asked him a general question such as “How are you today?” he would often launch into a lengthy description of his bowel habits. However, if I said, “Hi Dad, can you remember more about the uncle who used to ride his motorcycle from Melbourne to Adelaide?” he would expound all kinds of interesting family details.
My mother-in-law often asked for more fruit, mainly figs, for her bowels. The nursing staff said she always answered in the affirmative when asked if she had had her bowels open today. Her records indicated that she had “as required” orders for laxatives but never accepted or asked for them.
When I asked what her bowel actions were like, she said, “Like passing a brick.” With further questions she admitted that she opened her bowels with considerable discomfort and difficulty, and only about once a week!
My father asked me to put new batteries in his torch.
“Why?” I asked.
“So I can read the clock in the night.” He had had 5 timepieces in his room, but sometimes could see none of them because of low light or because someone had moved a clock or put another object in front of it!
Residents’ stories are amazingly varied and informative and often repetitive, but also very interesting. Helpful therapeutic decisions sometimes arise from listening to long-winded stories!
Dealing with the acute on chronic
New or acute events can still be expected in those whose life and health are already dominated by chronic illness. For some diseases we can do very little but encourage patient and family acceptance of the chronicity. Fairly often we can do useful things to relieve symptoms.
“For some diseases we can do very little but encourage patient and family acceptance of the chronicity. Fairly often we can do useful things to relieve symptoms”.
A more severe example is the man with a long history of advanced prostatic carcinoma, numerous pathological fractures requiring insertion of several rods, plates or screws, who had been increasingly adamant about avoiding and refusing any more hospital admissions. He was already on significant doses of regular analgesia. He remained remarkably coherent in speech and in understanding of his predicament.
When the nursing staff contacted me one afternoon to say he was in agony because of a newly displaced pathological fracture of mid-femoral shaft, what should we do? We discussed the options again, and gave some intravenous diazepam and morphine and waited to see if he would physically relax. He did relax but also commenced a rather prolonged phase of not breathing during which nurses and I achieved significant correction of his femoral displacement. We waited anxiously for him to breathe again. He managed about two more weeks of reasonable comfort with the help of excellent nursing care and his usual analgesics.
Always we can endeavour to accompany the patient on their journey and give them hope that we will not abandon them despite our inability to cure them.
“Always we can endeavour to accompany the patient on their journey and give them hope that we will not abandon them despite our inability to cure them.”
Feelings and Faith
It is rather common for nursing home residents to feel forgotten (by family, nurse, carer or doctor), burdensome or beyond their usefulness. A few see their nursing home admission as one of the best things that ever happened to them. Some are glad for the time to chat to others or to pray for others. Others may find everyone else a nuisance. Aged Care Chaplains do a great job, and we can be mutually supportive of all the other members of the team. Occasionally we might pray with and for the resident or the bereaved.
In summary, good care in nursing homes includes:
• Careful listening
• Accurate record keeping
• Clear conversations, and
• Lots of time!
Dr Richard Chittleborough Richard has worked for 17 years in suburban General Practice, 2 years in a rural district hospital in Tanzania, and spent his final 16 years in solo practice. These latter years were devoted to Aged Care and Palliative Care in hospital and domiciliary locations but mainly Residential Aged Care Facilities. He retired in 2014.