Geriatric Care and the Chasm

[Barrett Dorko]

I hate to be the one to break the bad news, but what comes naturally is so far removed from our modern life as to be irrelevant.

Richard Brodie in Virus of the Mind: The New Science of the Meme (1996)

I pulled this book off the shelf a couple of days ago and soon came across Brodie’s admonition. It reminded me of those days when I used to teach and would emphasize the culture’s influence on our way of seeing patients and practicing therapy. As I recall, many in the class responded favorably, agreeing in a variety of ways and coming up with their own examples.

For the present, those times when I get the chance to speak in front of a live audience (the Internet isn’t the same) seem to be over, but I’ve still some things to say about that and my current clinical situation has offered me a tremendous amount of material.

My sense is that the subject of powerful but insidious cultural control and the purpose and/or meaning of therapy is most acutely at odds when I observe our colleague’s treatment of the elderly.

So, this new thread begins. Please add whatever you feel is relevant.

[Diane]

In the book, Rapture of Maturity, Chapter 2, The Human Predicament, Hayes comments:

Life is full of contradictions

... then goes on to outline several of them. One is:

it shouldn't come as a surprise for us to learn that people who have figured out how best to relate to others often feel absolved from the need to do so, since they think their contribution is made already by the observation. Moreover, people whose ability to relate is instinctive and on target to begin with are often hostile to theories about relating.

He goes on to explain that he thinks we are hardwired for contradiction because of "split-brain architecture", and being:

uniquely capable of adopting and holding on to irreconcilable ideas - ideas so incompatible that one should easily cancel the other, were it not for our capacity to isolate opposing beliefs within the corridors of our minds. In other words, we can hold contrary opinions in such a way that the inconsistency doesn't necessarily link up to reveal a discrepancy.

I'm sure the institutions that have been created are mere outward reflections of this apparent human proclivity, and equally apparent disinterest in integration. So, institutions that exist to "care" for the elders, or for their declining neural function, have ended up doing little or nothing of the kind. The elderly instead are pawns in the game of institutionalized "caring," an outward manifestation designed to reassure the troop that all is well, but which is essentially a factory/warehouse system, with glimpses of "care" showing up depending on the individual carer and their own personal caring capacities. In other words, individual carers are not (really) paid to (really) "care" - they are paid to oversee, control, feed, clothe, house, keep clean, keep safe, keep alive and (hopefully) try to amuse a usually large population of helpless individuals who have faltered. So much more efficient, on behalf of the greater human primate troop which values efficiency. "Orphanages" are the mirror institutions for those members of the troop at the other vulnerable end of life, who have no natural "carers."

Maybe maturity means an increasing personal ability to be aware of the paradoxes and contradictions of life and to be capable of holding/tolerating them anyway, increased capacity to bear the human situation. Then finally, to not care that contradictions exist. Just keep doing one's own best to understand and keep moving.

Computers simply grind to a halt when asked to not only encompass but actually process data that conflicts. They have to be rebooted. The human brain is capable of a great deal more, and it doesn't have much reboot available, only the evolution it has already undergone, and the apparently infinite processing capacity it already possesses. Reboot does not seem to be an option for institutions at all, not while they are busy circulating money, anyway.

Here's the thing: if reincarnation is an option, I do not want to come back except as a rock. Maybe a tree. Please don't make me be a human again, ever. It's too crazy-making.

OK, back to the chasm.

[Jon Newman]

There are likely cultural differences to consider here as well. I'd be interested in how other (international) PTs interact with their aging population and what sort of social structures exist for helping those unable to care for themselves independently.

I live near a small city that only has acute care beds in the hospital. There are no swing beds and no rehab floor. Once you are medically stable, it's time to leave. If you can't move around well enough to go home (or from where you came) and reasonable accommodations aren't available (usually insufficient social support) then a stint at the nursing home is the only option.

In the nursing home there those that are there for a temporary stay prior to (hopefully) returning home. There are also those that are unlikely to leave. When census is down, it is up to therapist to go search the building for someone to train ("screening"). At least that was my experience in 1996/97.

Pain was prevalent along with plenty of other co-mordities acquired during one's lifetime and some acquired quite recently.

I was able to enjoy one year in a nursing home prior to the advent of PPS or whatever it was that resulted in firing a bunch of staff and requiring that scare quotes now appear around the word care.

[Mary C]

70% of our hospital's beds are occupied by people waiting for nursing home accommodations.

When census is down, it is up to therapist to go search the building for someone to train ("screening").

Could you elaborate on this?

Mary

[Jon Newman]

This might not occur anymore but when the therapist's caseload was down there was a command from those in charge to search the existing population of nursing home residents to see if there was someone there that would benefit from our services. There were sufficient conflicting motivations that getting into the whether a benefit was realized is a difficult thing to determine. It depends on what one counts as a benefit and what types of things count as a subtraction of benefit.

[Walt Fritz]

Barrett,

The culture may dictate that you practice in a certain way, but does that same culture prohibit you from flexibiltiy within? Are you able to continue doing what you feel is best for the patient, or least in bits and pieces? I think that most of us feel the outside pressure to conform to the norms of the current PT culture, even when practicing autonomously. (Note that I am keeping an insulative barrier around naming any modalities, as they seem unimportant here)

Breaking cultural norms is a daily occurance for everyone, even those who feel that they are outwardly practicing and acting fully within the norms. (my opinion) We all pick and choose which we will follow, to some extent.

[nari]

...and I thought our aged care system was bad.

I suspect the cultural differences noted are due to the differences in health care philosophy in the USA and here. Of course money and stats are important but they don't dictate survival of patients and staff.

In our smallish city, there is one public hospital and three private. Those on nursing home placement occupy about 35-40% of beds in the public facility; including those on the Aged Care rehab ward. That is considered unacceptable, and great pressure to admit is placed on nursing homes/managed care homes by the hospital staff. There is considerable support for families who take their aged relative home while waiting for placement. It ain't easy, but there is support.
Within all nursing homes (about six) each has a dedicated PT, who does whatever (and I mean whatever) to keep the folks mobile. When I last had contact with a nursing home PT, it was more social contact than 'treatment' - nobody gave exercises, it was goal-oriented walk to the toilet, etc.

I tend to agree with Walt's sentiments. Pressure to conform is relative, and the only pressure which is apparent here is to follow EBP guidelines. Even then, there is plenty of leeway; PTs have their favourite rationales for certain methods, and they use them as seen fit.
If others don't agree, there might be some 'tut-tutting' with a laugh, but it is unforgiveable to criticise any PT out loud or even on the quiet, because we have the right to practise as we wish to. Looked from afar, we are seen as a rather homogenous lot, and the flexibility within isn't noticed much by others, but it's there.

When census is down, it is up to therapist to go search the building for someone to train ("screening"). At least that was my experience in 1996/97.

Yikes again. Again, figures/countdowns aren't important. What is relevant is communication, and that was quite good. The nurse/resident MO might suggest Mrs Smith needs a PT review re suitability for intervention. We would never 'look' for anyone, that was not our duty of care - it was up to others to do so, and it worked well.

Nari

[Barrett Dorko]

Walt,

As you say, "in bits and pieces" I provide what I defined as care here a few years ago:

In my travels I see that physical therapy is rarely about anything other than training, whereas, to me, the creative act begins with care.

Training takes place in a space full of effort, repetitions, charts noting progress and specific goals. An imagined future is as important here as the present, and the present is unacceptable.

But there is something about a unique connection between an individual therapist and one patient at a time. This connection is possible only when there aren’t insulating layers of machinery and generic protocols between them. It is then that the therapist has an opportunity to attend to the patient's story and not just to their diagnoses. When caring is the primary mode of treatment, the therapist is willing to allow the stew of symptoms, frustrations, fears, denial and bargaining emerge from the patient in no particular order. When caring is present, the patient is allowed to speak of the disruption of their life. When caring is present, measurement is replaced by acknowledgement and judgment by acceptance. But I've noticed that it seems no longer possible to expand any clinic or private office without turning it into a place where only training is available, and creativity is a foreign concept. No wonder their struggle to relieve pain.

Thanks for all the comments. More from me soon.

[Walt Fritz]

Barrett,

It is interesting that the part of your talk you quoted was part of a larger piece; one which talked of peer pressure as well. Peer pressure was what motivated me to post here from the beginning. I can see what you are referring to; that a "bits and piece" method of care, even quality care, is limited if both participants are not fully involved. In this case, neither can be fully invested in the outcome when the whole is not committed to this same outcome.

[Jon Newman]

A fellow PT informs me that due to tight budgets the "restorative aide" program has been cut at the nursing home he works at (in addition to his full time job in outpatient ortho.)

For those unfamiliar with restorative aides--it may be a local thing for all I know--it is a job description that entails routine ambulation/exercises with nursing home residents and is usually done by a CNA (certified nursing assistant). On the surface, it represents a profit loss and not a profit center for a nursing home.

[Barrett Dorko]

"At each opportunity I have stressed that we are the profession of choice for the restoration, maintenance, and enhancement of human function. I have stressed that there is no need to slow down at middle age and that in fact by maintaining a fit, healthy, and productive lifestyle there is much more that can be enjoyed."

Stanley Paris P.T. in News from the Foundation for Physical Therapy January ‘09

Perhaps the largest disagreement between those who emphasize care and those who focus on training revolves around this issue of function. I always find it interesting when questioned about the relation of instinctive motion to function. I sense that those asking the question have seriously misunderstood the purpose of instinct, which isn’t function – it is survival. They often then go on to explain to me what function entails, as if I were some kind of idiot. I know what function is, and I also know what it isn’t.

The profession has embraced the idea that function and painful sensation are intimately related, even to the point of being interchangeable. This reveals a profound ignorance of pain science to say nothing of what the therapist thinks is best for another’s “enjoyment.”

It’s not all bad. I’m well-aware of how being able to walk can lead to many good things, but there’s a line between that and our perfectly natural desire to rest. Contrary to my friend Stan’s opinion, I feel that there may very well be a “need to slow down at middle age” and that this is quite natural.

Each day I see patients strongly encouraged to achieve goals of function, strength, endurance and balance they had no real interest in setting and no reason to think they need, and the person setting these goals has never actually considered the conflict they’re creating.

Nothing good can come from that.

[Jon Newman]

I agree that slowing down is quite natural. I suppose there will be a day in the future when we can, as Stan suggests, choose not to.

Each day I see patients strongly encouraged to achieve goals of function, strength, endurance and balance they had no real interest in setting and no reason to think they need, and the person setting these goals has never actually considered the conflict they’re creating.

Nothing good can come from that.

There is quite a bit to digest in that first sentence Barrett. I still toil over this. I especially toil over which goals patients should have a real interest in as well as how to create such an interest when it seems relevant and important.

[nari]

Each day I see patients strongly encouraged to achieve goals of function, strength, endurance and balance they had no real interest in setting and no reason to think they need, and the person setting these goals has never actually considered the conflict they’re creating.

I think it depends on the level of cognitive functioning. If a patient can see no purpose or reason in setting the above goals with respect to their current status, then PTs/nurses are likely to fail. In that case, a more highly skilled approach including the CBT/validation thing might work,....or not.
However, I think no matter what we do, the goals have to be recognised and put in place by the patient, whether or not they are compus mentis. I don't think we have the right to enforce what we think is right for the patient, but merely to agree or disagree with any goals he or she has identified.
The pressure is placed on therapists to keep the patient mobile because of many reasons.

Nari

[Diane]

individual carers are not (really) paid to (really) "care" - they are paid to oversee, control, feed, clothe, house, keep clean, keep safe, keep alive and (hopefully) try to amuse a usually large population of helpless individuals who have faltered.

[Jason Silvernail]

Each day I see patients strongly encouraged to achieve goals of function, strength, endurance and balance they had no real interest in setting and no reason to think they need, and the person setting these goals has never actually considered the conflict they’re creating.

Nothing good can come from that. -Barrett

I wouldn't disagree with this, and especially as it pertains to complaints of pain, and the consideration of the patient's motivation as part of therapy.

However, I think the care/training dichotomy gets more interesting in the elderly when we consider Sarcopenia, and the established improvements in function, mobility, and mental outlook made through strength training, even in the frail elderly.
I think reviews like this point out that there are some key benefits to a "training" approach that ought to part of the discussion as well.

Bill Evans in particular has done some interesting work in this area. His paper here is a good summary.

I think there is definitely a good rationale to offer a structured training program for these patients, for those that choose to participate.

[nari]

I agree with strength training for the elderly because of the evidence behind the effort, but it depends on how it's done. It should be fun and with humour, and the 'fitness' programs I have seen under a dominating PT gave me the creeps. On one occasion I found several elderly patients in tears afterwards because of the Army-like regime. (Apologies to Jason if needed

I called the program brutal because of the same routine for all levels regardless of status.

Nari

[Barrett Dorko]

This is a difficult issue and I'm not surprised we've reached this point. I should say I admire the careful, thoughtful approach to training Jason refers to - not that I ever see it. For my colleagues, strengthening begins and ends with an ankle weight and some arbitrarily chosen set of repetitions while others are attended to. Pain relief is a hot pack and nothing more.

Nari's point about cognitive ability is especially important. The ability to learn is what I need from the patient and this is often hard to ascertain.

[Jason Silvernail]

Originally Posted by Barrett Dorko

I should say I admire the careful, thoughtful approach to training Jason refers to - not that I ever see it. For my colleagues, strengthening begins and ends with an ankle weight and some arbitrarily chosen set of repetitions while others are attended to. Pain relief is a hot pack and nothing more.

This is the twin ignorance of both pain science and exercise science. What did these people learn in school after all?

[Mary C]

It's not so much what we learned in school, it's what we learned since then. I have often said that I never learned how to learn until after uni was over and done with.

Did I have to wait for the physical maturation of the left-right brain connections? Or was it those three weeks of kindness, respect and courtesy of the Quakers that made the difference? All I remember is that I felt free to satisfy my curiosity without regard to what anyone else thought or said. I'm still doing it.

Mary

[nari]

Unless pressured and told to 'do this, do that', it seems many PTs forget to learn after uni. They do the compulsory CE courses, but it doesn't mean they will apply any of the contents to their practice.

The irony of all this is: they are first to complain about patients who do not improve, and put it down into the neat category of "difficult patients"...absolving themselves from any part in the failure to improve, whether it is they who fail to improve or the patient/s...or both.

Nari

[Jon Newman]

If it were the case that slowing down was simply a choice, why so few middle age professional sports stars in the most physically demanding sports?

If it is true that we slow down, and I think it is, do our work habits and demands reflect this inevitability? That is, does our culture change its expectations (the goals it expects) of its members in a manner that is consistent with our biological nature?

It's a fuzzy line and on one side I think people simply have unrealistic expectations and on the other people run the risk of being ageist. Stupid fuzz.

[John W]

I found this questionnaire while doing a project for the course I'm currently taking, and I wondered if those participating in this thread might have some thoughts on it.

[BB]

John,

I think the questionnaire asks some good questions (especially regarding social interaction and sleep as these have been shown to be 2 of the most relevant outcome factors by patients), but the use of the information seems a bit funny. It seems to be useful for identifying some areas to track, address. However, categorizing a person as having chronic pain based on these criteria seems a bit off to me.

Seems more an "impact of pain" questionnaire.

[nari]

I personally do not like questionnaires which focus on 'pain' 'your pain' etc.
The same questions can be asked in terms of lifestyle functioning without using the word 'pain'.

Nari

[John W]

Nari,
Would you expand on why you don't like the term "pain" used in a questionnaire of this sort? I tend to agree in some respects, but would like to get your take.

Cory,
Yeah, I agree. It seems strange to use this tool as a clinical decision-making tool to intervene, but that's what it's being used for in this particular facility.

[Jon Newman]

This might be of interest in this thread: Attitudes toward exercise.

[nari]

John, if a questionnaire has ten questions specifically asking about pain, it probably makes the respondent feel worse by the end of it.
However, if the questions can be answered in reference to someone's function it takes the focus off. For example:
What do you find is the most difficult activity each day?
Can you sleep for a reasonable length of time at night?
It allows the patient to tell a broader story of the impact of pain on their lives.
That's my take, and the tendency amongst PTs here is to avoid using the word pain. That includes verbal assessments.

Nari

[Jon Newman]

This might be slightly askew but I think it belongs here nonetheless.

Live Longer, Think Longer--an interview with Mary Catherine Bateson.