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Deprescribing: A promising approach to address problematic polypharmacy in seniors By Michaela Berniquez hat is “problematic polypharmacy”? We can all think of someone we know who takes a number of prescription drugs. Maybe it is a parent, a friend or it might even be you. Using many prescription drugs at the same time can lead to “problematic polypharmacy”. Problematic polypharmacy is the use of more drugs than clinically needed. Problematic polypharmacy can result in a number of side effects such as falls and negative impacts on attention and thinking.
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WHY ARE SENIORS AT HIGHER RISK FOR “PROBLEMATIC POLYPHARMACY”?
As our population ages, there are more people living with chronic diseases. Prescription drugs play a key role in disease and symptom management. According to the Canadian Institute for Health Information (CIHI), nearly two-thirds of people aged 65 and older are taking at least five prescription drugs, while nearly 40 per cent were taking 10 or more prescription drugs. Polypharmacy is of particular concern for older adults as they respond to medication differently. Older adults can also be frail and are not typically a part of the research used to develop the guidelines used when drugs are prescribed. Polypharmacy increases the risk for things like bad side effects or drug interactions, falls and broken bones, hospitalizations and higher healthcare costs. Polypharmacy can also contribute to a decline in how people function or think. Polypharmacy can also lead to confusion in how to take prescription drugs properly or can lead to people not taking them at all.
WHAT IS “DEPRESCRIBING”?
Deprescribing is the planned and supervised process of dose reduction or stopping medication that may be causing harm or no longer providing
benefit. The goal is to reduce the negative impacts of prescription drugs and harm in patients, while maintaining or improving quality of life. Deprescribing should always be done with planning and supervision by a healthcare provider to make sure it is the best plan for the patient and is safe.
HOW DOES DEPRESCRIBING HELP TO ADDRESS “PROBLEMATIC POLYPHARMACY”?
As life changes, medication needs may change as well. Prescription drugs that were once a good choice might not be the best choice over time. Over the course of a patient’s life, healthcare providers want to keep in mind balancing the benefits of a drug with the harms. Deprescribing is part of good prescribing – backing off when doses are too high, or stopping prescription drugs that are no longer needed. Deprescribing is a team effort. Conversations about deprescribing among healthcare providers and patients can be made easier when everyone is aware of the benefits and harms of certain drugs, how these can change over time, and what to do about it. In partnership with a healthcare provider, it is possible for patients to improve the number and kinds of drugs they take with the goal of maintaining a healthy quality of life.
THE BRUYÈRE DEPRESCRIBING GUIDELINES RESEARCH TEAM
The Bruyère Deprescribing Guidelines research team is based out of the Bruyère Research Institute in Ottawa. The team is lead by Dr. Barbara Farrell, Scientist at the Bruyère Research Institute and Pharmacist at the Bruyère Geriatric Day Hospital. As a pharmacist, she sees many older people often taking more than 20 prescription drugs a day. However, working closely with doctors and a team of other healthcare providers, patients and their families, she is able to help reduce or stop medications safely. Her clinical experience at the Day Hospital was the reason behind the development of the deprescribing guidelines. At the Day Hospital, Dr. Farrell saw that healthcare providers were aware of the risks of problematic polypharmacy but they needed more education, tools and support to deprescribe. With funding from the Ontario Government through the Ontario Pharmacy Evidence Network, the Bruyère Deprescribing Guidelines research team developed three drug-specific, evidence-based guidelines. They support healthcare providers in safely reducing or stopping prescription drugs and monitoring for effect. Further deprescribing guidelines and tools and resources have also been designed to build awareness, knowledge and capac-
ity amongst healthcare providers and the public, with support from the Canadian Institutes of Health Research, l’Institut universitaire de gériatrie de Montréal, the Government of Ontario through the Bruyère Centre for Learning, Research and Innovation in LongTerm Care, the Canadian Foundation for Pharmacy and the Centre for Aging and Brain Health Innovation.
AVAILABLE RESOURCES AND STAYING INFORMED
A number of deprescribing resources, including decision-support algorithms, whiteboard videos, information pamphlets, and infographics, have been developed by the team. These resources are available for free on their website, deprescribing.org. Some of the resources inform patients and family caregivers about deprescribing and support them in talking to their healthcare providers about their prescription drugs. Other tools were designed in partnership with healthcare providers to provide education and decision support around the deprescribing process. To stay up to date on the activities of the team follow them on Twitter (@Deprescribing) or sign up for their quarterly e-newsletter. For more information on the Bruyère Deprescribing Guidelines research team, their evidence-based guidelines and support tools, please email deprescribing@bruyere.org. LC
Michaela Berniquez is a Communications Assistant at Bruyère Research Institute and Bruyère Centre for Learning, Research and Innovation in Long-Term Care. 2 Home and LongTerm Care News MARCH 2018
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innovation here has been much talk about the silver tsunami as the senior population increases around the world and at home here in Canada. How will an already strapped healthcare system handle the increased demand these seniors will bring? Hospitals and long-term care homes are often scrambling to provide care to a growing patient population with limited resources at their disposal. That’s where innovation comes in – finding ways to keep seniors healthy and living as independently as possible in the comfort of their own home (where multiple studies indicate is the best place for them). These innovations also translate to more efficient and effective care in the long-term care facilities. This month’s cover story, Innovation in brain health and aging focuses on innovations that are disrupting the senior care market and have the potential to make a huge impact on how care is provided to the aging. As care increasingly moves into the community we need to continue developing innovations to keep brains healthy and technology that will keep seniors at home. The Centre for Aging + Brain Health Innovation (CABHI) has launched the third round of its Industry Innovation Partnership Program (I2P2). CABHI is inviting companies from around the world to apply!
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Gain access to the North American market, trial your innovative solutions with leading seniors’ care organizations from across North America, and leverage up to $500,000 CAD in matching-fund support from CABHI. In total, up to $3 million CAD in funding is available for solution testing and validation. Go to www.cabhi.com for more information and to learn more about how to apply. Application forms are due by 5:00 p.m. on March 12, 2018 (EST). If you have an innovation to share please email editor@longtermcarenews.ca LC
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Problem-solving therapy for seniors with depression By Marek Kubow
new non-pharmaceutical therapy program will help seniors suffering from depression manage life’s daily problems in the community. Funded by The Bell Let’s Talk Community Fund 2017, “Problem Solving Therapy: a community initiative project” is a partnership between Lawson Health Research Institute (Lawson), London Health Sciences Centre (LHSC) and the London Public Library.
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A NEW NONPHARMACEUTICAL THERAPY PROGRAM WILL HELP SENIORS SUFFERING FROM DEPRESSION MANAGE LIFE’S DAILY PROBLEMS IN THE COMMUNITY “Depression affects two to eight per cent of older adults and causes isolation, increased rate of hospital and long-term care admissions, and elevated mortality,” says Dr. Akshya Vasudev, principal investigator and associate scientist, Lawson, and geri-
From back left, Nancy Bol, nurse case manager, LHSC, Carolyn Doyle, adult services coordinator, London Public Library, Amey Allen, social worker, LHSC, Katy D’Angelo, social worker, LHSC and Dr. Dr. Akshya Vasudev, principal investigator and associate scientist, Lawson, and geriatric psychiatrist, LHSC, plan to provide problem solving therapy to seniors suffering from depression at the London Public Library. atric psychiatrist, LHSC. “Problem Solving Therapy is a time-limited skills-building treatment which addresses an individual’s problems, validates them, and teaches the individual to manage those problems in order to reduce or eliminate the symptoms of depression.” Over the next year, 30 seniors, who have been diagnosed with depression by a trained rater, will receive group
based Problem Solving Therapy at their local London Public Library branch. “Our libraries are accessible in all neighborhoods and are a welcoming access point for community services,” says Carolyn Doyle, coordinator, Adult Services, London Public Library. “The older adults we hope to serve will receive support in a comfortable community environment that is free of stigma.”
In 2016, a pilot project successfully showed that a community model to deliver Problem Solving Therapy is feasible and meets this need in the community. “We expect those who receive this therapy will see an improvement in mood and accompanying disabling symptoms such as anxiety, insomnia and reduced quality of life,” adds Dr. Vasudev. LC
Marek Kubow is Lead, Communications & External Relations at Lawson Health Research Institute.
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MP Phil McColeman with “The left side of 60.”
Advocating for the needs of young residents By Drew Tapley hey call themselves ‘The Left Side of 60’,” says Sandy Croley referring to the 20 per cent of younger residents under the age of 60 at Fox Ridge Care Community in Brantford, Ontario. Sandy is the executive director of Fox Ridge, and actively supports the needs of this demographic in her resident population as young as 37 years old. But major differences in acute care, social interests and privacy requirements are proving hard to meet within the same resources. An article in the Toronto Star on July 9, 2017, reports how thousands
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of residents under 65 are living in long-term care throughout Canada, as young as 21 in once instance, with the average age of an Ontario resident being above 83. Long-term care communities like Fox Ridge, which does not operate a wait list and is owned by Sienna Senior Living, have been designed specifically for seniors. This presents a challenge for people like Sandy and her team when it comes to the physical, emotional and social needs of much younger residents. Despite their health issues, The Left Side of 60 do not consider themselves to be in the final stages of life, dealing
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with end-of-life conditions that seniors cope with. They have a combination of complex mental and physical illnesses, including Huntington’s disease, chronic fatigue syndrome, and multiple sclerosis – which require 24-hour care. “If their needs were not as complex, they could probably get the services they need in their own homes,” said Sandy. Food preference is one of the many differences they have to manage at the care community. “We make high calorie food because seniors generally eat less,” explains Sandy. “I think a lot of our younger folks gained weight because of this.
Plus, they want to eat at different times of the day.” To get around this, they started a food committee comprised of residents under 65 to review menus and make suggestions and choices. The dietary staff then incorporate these decisions into a menu tailored to their requirements. Heat regulation is another issue with menopausal women under 65 living with a majority of older residents who prefer much higher temperatures. For now, they are managing this using air conditioners. Other matters, however, require a bit more creative thinking. www.longtermcarenews.ca
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Fox Ridge maintains a busy social calendar for seniors, which is not always suitable for younger residents. “We do special programming because they don’t want sing-alongs. They want to have a cook-out and drink beer,” says Sandy. “So, that’s what we did – organized a cook-out for them with one of our PSWs and his friend playing live music.” Many from this group would like to go back into the community and hold down jobs, but their health won’t permit it. Leonard is the exception. The residence helped him secure a paid position at Baskin Robbins, which he’s held for several years. Josh would like to start his own 3D printing business, but a few obstacles stand in his way. At 37, he is the youngest resident at Fox Ridge and a graduate in graphic design. He has Duchenne Muscular Dystrophy, and was living independently until a series of infections and a dramatic weight loss required that he move into Fox Ridge in January 2016. “Living in long-term care has allowed me to regain my health,” says Josh. “My appetite is back to normal and I’m on a steady weight gain. I am the healthiest I have been in a long time, and have been receiving excellent quality of care.”
‘THE LEFT SIDE OF 60’ REFERS TO YOUNGER RESIDENTS LIVING IN LONG-TERM CARE. With Sandy’s help, he has been campaigning for funding to finance his own room to set up the computer equipment he needs to start his business. Due to the progression of his disability, he says that working on a computer is the only type of work he is able to do. Josh’s campaign was the catalyst for the younger residents to form a committee, becoming The Left Side of 60. “That started the ball rolling,” says Sandy, “with Josh and me writing to organizations to get funding for his own room. Privacy is also important to these young people in their thirties and forties because some of them are still seeking romantic relationships.” She speaks for this unique group at lots of committees in the wider community, and says she’s received great support from Sienna’s head office in advocating for the younger residents. Room allocation is another issue. “Everyone says to put all the young people together. But this doesn’t work,” says Sandy. One reason she gives is that younger residents have a lot of electrical and manual equipment, including comput-
er devices, which compete for space. To help meet one of their needs, she has installed WiFi so they can use their laptops and smartphones to maintain contact with the outside world, which is essential for them. “Instead, we try and pair a younger person with an older person, and often find that the younger resident becomes a caregiver. We have a 25 per cent turnover rate in the resident population each year at a minimum, which can result in compassion fatigue for younger residents.” In an effort to combat this, they have introduced a quarterly program to celebrate the lives of residents who have passed away. Many of the younger residents participate by doing readings and handing out flowers to family members. A social worker is also on staff to assist with personal bereavement and compassion fatigue. Using a system of intergenerational occupancy can make nighttime routines difficult when younger residents want to stay up late and are sharing a room with a person up to fifty years older than them, in some cases.
Despite all of these lifestyle differences, Sandy insists that there isn’t any animosity across the age gap. She cares for the needs of all residents at Fox Ridge, which includes helping the younger ones get their voice out there and heard by the right people. Their goal is to change public policy to help themselves and thousands of residents like them under 65 in Ontario and throughout Canada. One way Sandy has chosen to channel their efforts is by inviting the MP and MPP for Brant district to come for lunch and give the residents a direct platform to address their concerns. During these lunch meetings, each resident presented a different agenda, such as ODSP funding, increased privacy, and suitable lifestyle choices. And it looks like they have made an impact. Sandy recently received an invitation to connect with the Office of the Ontario Minister of Health & Long-Term Care, and continue the conversation. Above all things, The Left Side of 60 has one primary request, inclusive of all others. It is for a living environment that is neither a hospital nor a long-term care home – but somewhere in between, specialized to the needs of much younger residents, with staff trained in complex and acute medical diagnoses. LC
Drew Tapley is a writer at Sienna Senior Living.
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7 things you need to know
Supporting persons with responsive behaviours By Patti Boucher he health and community care sectors experience the highest rate of lost time injuries associated with workplace violence. Those working with persons with dementia are at particular risk of harm. Although we prefer to avoid the term “violence” in dementia care, responsive behaviours can and do lead to catastrophic outcomes that can physically harm the person and their care providers. Gentle Persuasive Approaches (GPA®) is a practical, evidencebased education program that equips care providers with the knowledge, understanding and skill to deliver person-centred dementia care safely. The program has been implemented in over 2,000 Canadian organizations. In caring for persons living with dementia there are seven important things to know
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1. WITHOUT PROPER TRAINING, THOSE WHO CARE FOR OLDER ADULTS WITH DEMENTIA ARE AT RISK Dementia can affect memory, judgement, attention, mood, the ability to communicate and perform simple activities of daily living. The person often has trouble communicating their needs. Ensuing feelings of confusion, frustration, anger or fear can contribute to the behavioural and psychological symptoms of dementia (BPSD). BPSD can include extreme agitation, psychosis (e.g., delusions, hallucinations) and physical aggression. Without proper training, those working with older adults are at risk of harm.
2. THE NEED FOR EDUCATION AND TRAINING IS URGENT The number of older adults presenting to hospitals with responsive behaviour is increasing, yet not all staff are trained to recognize and manage these behaviours. The hospital environment can trigger or intensify responsive behaviours, leading to inappropriate use of restraints, which can further escalate behaviours. A 2017 report by the Canadian Federation of Nurses Union highlighted factors that contribute to workplace violence. These are particularly relevant to the dementia context: admission of patients into facilities ill-equipped to
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deal with a patient’s acuity/complexity, inadequate communications protocols/practices with respect to violence risks and lack of violence-prevention training. While long term care has made great strides in dementia care, hospitals still have a long way to go. Our aging population and the dramatic increase in people diagnosed with dementia underscore the urgent need for formal dementia education.
3. YOU MUST KNOW THE PERSON IN YOUR CARE “I am not my disease” is the universal rallying call for dignity by persons living with dementia. It’s an important distinction. Is the behaviour nor-
mal for the person or is it related to the disease process? How well do you know the person exhibiting responsive behaviours? What is that person like when calm? Knowing a person’s background, personality, likes, dislikes and preferences for care empowers caregivers to use a person-centred care approach. Before we can care for a person, we must know the person.
4. ALL BEHAVIOUR HAS MEANING. IT’S UP TO CARE PROVIDERS TO INTERPRET THAT MEANING Our behaviours directly relate to our thoughts and feelings. More than www.longtermcarenews.ca
NEWS 85 per cent of the messages we send in a day are nonverbal, delivered through body language, facial expression, eye contact, approach or distance. Since persons with dementia often have trouble communicating their needs, responsive behaviours can present when needs (e.g., preferences for care, hunger, pain, constipation, infection, etc.) go unmet. Care providers must be able to interpret a person’s non-verbal messages and assess their need. A program like GPA teaches how to identify behavioural triggers, recognize the impact of care providers’ actions, understand the progression of behavioural escalation and choose strategies to prevent and defuse behaviours.
5. CARE PROVIDER CONFIDENCE IS THE #1 PREDICTOR OF SUCCESSFUL OUTCOMES Increasing a care provider’s confidence in their ability to support persons with responsive behaviours is GPA’s main goal. GPA was designed for in-
GENTLE PERSUASIVE APPROACHES (GPA®) IS A PRACTICAL, EVIDENCE-BASED EDUCATION PROGRAM THAT EQUIPS CARE PROVIDERS WITH THE KNOWLEDGE, UNDERSTANDING AND SKILL TO DELIVER PERSON-CENTRED DEMENTIA CARE SAFELY terdisciplinary staff and organizations recognize the need to train all staff who interact with older adults. A GPA Certified Coach working in long-term care relayed a wonderful story that illustrates the benefits: “A food service employee approached me one day to tell me she’d picked up a shift on the Special Care Unit but was afraid of the residents, especially when alone with them. We immediately scheduled her into a GPA session. A few weeks later, she came back to tell me how helpful the session was. One thing that really stuck with her was how important it is to understand a resident’s needs. She had always been nervous when residents approached her or came up behind her.
After GPA training, the ‘light’ went on. She understood that a resident might come in simply because they were hungry or thirsty. She just needed to offer them something to eat or drink. The woman has since taken a full-time line on the unit and is much more confident interacting with residents.”
6. HOW DOES IT FEEL TO HAVE DEMENTIA? Persons living with dementia express it best … “This diagnosis has to be one of the worst things a person could experience – constant fear of not knowing what will happen to me next.”
“I try to answer a question and I feel there’s a coconut up here in my head.” “I can’t find my way back home. How do I get out of here? Where is my room?” “Some of us experience hallucinations – which increase our fear and make us agitated.”
7. IT IS OUR BRAIN THAT GIVES US OUR EXPERIENCE OF THE WORLD Each of us experiences the world differently by virtue of how our brain is functioning at a given time. Our experience is our reality. The experience of a person with dementia is absolutely real for him or her. Responsive behaviours are reactions to that reality. We must learn to look at the world through their eyes, since they cannot always recognize the world through ours. This learning can only happen through education that is grounded in a person-centred approach – a best practice that ensures a higher quality of care. LC
Patti Boucher is the Executive Director of Advanced Gerontological Education (AGE) Inc., a national not-for-profit social enterprise and the developer of Gentle Persuasive Approaches (GPA®). www.ageinc.ca
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Homes that adapt to you By Lisa Fitterman or people living with Alzheimer’s and other dementias, home can become an unsafe environment. Now imagine a “smart home” that is loaded with sensors to help people stay safe and independent for as long as possible. AGE-WELL researchers are working to make this a reality in the next few years. “The goal is to create a home that is adapted to each person’s quirks and habits,” says Dr. Hélène Pigot, a computer science professor at the Université de Sherbrooke – a bespoke system that would include features such as infra-red sensors in the floor that light the path from the bed to the bathroom, a garbage can that indicates when it is full and what day to empty it, a meal tray that provides hints on the right sequences for eating and a stove that reminds users to turn it on and, most importantly, off. “We want to give back as much autonomy and control as possible to people,” adds Dr. Pigot, a co-founder of the DOMUS (DOMotics at the Université de Sherbrooke) laboratory, which works on innovations to help people with cognitive deficits, including head trauma, schizophrenia and Alzheimer’s. “With a rapidly aging population, it’s so important to create features that give people the option to remain in their homes, still mostly independent, enjoying a real quality of life.” Dr. Pigot and her collaborators are creating the high-tech features, but caregivers are providing crucial input and, ultimately, will be the ones who pick and install the right features in their loved one’s home. Project co-lead Dr. Jesse Hoey calls it a “do-it-yourself” approach to a smart home. “Caregivers know the older person’s habits and can personalize the smart-home features to that person’s needs,” says Dr. Hoey, an associate professor of computer science at the University of Waterloo.
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A device called COACH that uses artificial intelligence, sensors and audio/video cues to guide people with dementia through the steps of handwashing and tooth brushing. The project is funded by AGEWELL, Canada’s Technology and Aging Network. Adding to the menu of smart-home features is Dr. Alex Mihailidis, a professor in the Department of Occu-
pational Science and Occupational Therapy at the University of Toronto and one of AGE-WELL’s scientific directors. He has created a device called COACH that uses artificial intelligence, sensors and audio/video cues to
guide people with dementia through the steps of handwashing and tooth brushing. “Sensors can help with whatever activity people with dementia are trying to perform, be it brushing teeth, getting dressed, making a meal or preparing a cup of tea. It’s about safety and it’s about independence,” he says. His team has also developed an intelligent emergency response system to detect falls in the home. Using artificial intelligence and computer vision, the system “learns” a person’s habits and knows when something has gone wrong. It can interact with the person and call for help, if necessary. Dr. Pigot imagines that sensors could detect when someone is distressed and help with a combination of calming lights and music. “The person may confuse nighttime with daytime and not find their way back to bed. Our goal is to help reduce the anxiety of someone disoriented during the night, so that they go back to sleep.” Features of smart homes will ideally be integrated into the homes of healthy older adults too, allowing them to get used to the technologies, says Dr. Hoey. “The Do-It-Yourself Smart Home aims to provide assistance over long periods to support older adults as functional ability and health status declines.” Smart homes will also be able to predict problems. Dr. Mihailidis is building “predictive algorithms” to determine who will develop dementia by gathering information on patterns of daily living. “Right now, healthcare in this country is mostly reactive. We want to be pro-active to act before it’s too late,” says Dr. Mihailidis, who holds the Barbara G. Stymiest Chair in Rehabilitation Technology Research at Toronto Rehab. “Smart homes will also reduce the burden on caregivers and help to keep people out of hospitals and long-term care. It’s a win-win scenario.” LC
Lisa Fitterman is a freelance writer. AGE-WELL is a federally funded Network of Centres of Excellence that is harnessing the power of new technologies to benefit older adults and caregivers. The pan-Canadian network brings together researchers, industry, non-profits, government, care providers and endusers to develop solutions for healthy aging. For more information, visit http://agewell-nce.ca/ 10 Home and LongTerm Care News MARCH 2018
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Rubbing the right way:
Geriatric Massage By Susan C. Jenkins hat comes to mind when you hear the word “massage”? A relaxing day at the spa? What about geriatric massage? While that’s not the first thing that comes to most people’s minds, it is a practice that may help many of your clients.
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WHAT IS GERIATRIC MASSAGE? In some ways, geriatric massage resembles a lighter form of Swedish massage, but there are some important differences. Geriatric massage involves using the hands to gently rub the soft tissues to improve blood circulation, relieve pain, and increase range of motion, but it employs specialized techniques designed for aging skin and muscles. Characteristics of geriatric massage include the following: • Prior to the treatment, the massage therapist should consult with the client’s healthcare team to become aware of any problems that may be encountered during the massage. • The massage therapist needs flexibility in positioning aging clients. Some clients may not be able to get on or off a massage table easily, and options might need to be explored. • Body placement is important. For example, someone with respiratory problems should not be placed in a prone position, and the back should be worked with the person in a sitting position or lying on his/her side.
• Long, stripping strokes should be avoided, because skin thins with age. A technique called fluffing, which combines rhythmic stroking and gently lifting and squeezing the skin, may be more appropriate. • In most cases, stretching techniques should not be used. • While the focus is on gentle motions, on occasion stronger movements may be needed – for example, to improve flexibility of the shoulders. • Sessions should be short – usually no more than 30 minutes.
BENEFITS OF GERIATRIC MASSAGE Older people are prone to developing age-related diseases that limit their physical capabilities and cause poor circulation. Geriatric massage can help some people regain certain physical functions and mobility. Additionally, many seniors are lonely, anxious, or depressed, and geriatric massage can provide comfort to touch-deprived elderly clients and improve their quality of life. Other benefits of geriatric massage include:
GERIATRIC MASSAGE EMPLOYS SPECIALIZED TECHNIQUES DESIGNED FOR AGING SKIN AND MUSCLES
• Speeding recovery from injury or illness • Enhancing the length and quality of sleep • Easing anxiety and improving sensorimotor functions after a stroke • Reducing the physical signs of agitation (e.g., pacing, wandering, resisting) in Alzheimer’s sufferers • Improving lymphatic flow, which increases the excretion of toxic substances from the body There is also some evidence that geriatric massage can have an effect on memory. Repetitive touch can help the elderly – particularly those with Alz-
heimer’s disease – to retain some body memory, and that in turn can trigger the recall of other memories.
CAUTIONS In general, geriatric massage is considered safe for most seniors; however, there are some cautions to be aware of. • Calf pain with heat can be a sign of phlebitis and should not be massaged. • If a client has a blood clot or an aneurism, a doctor’s permission must be obtained before that client can receive a massage. • Do not perform deep tissue massage on elderly people, because their skin is thinner and can tear more easily. • Do not massage: • open sores, skin ulcers, or burn wounds • eczema or undiagnosed rashes • the site of an injury or surgery • sore, enlarged lymph nodes Every client is different, and it is important to evaluate each one individually to determine if geriatric massage is an appropriate addition to the care program. LC
Sarah Pearson is a music therapist working in end-of-life care, a songwriter and professional musician, and is program development coordinator for the Room 217 Foundation. www.longtermcarenews.ca
MARCH 2018 Home and LongTerm Care News 11
MUSIC CARE
Why music is not a universal language – and what that means for care By Sarah Pearson usic is a universal language” is a common expression I hear all the time. It’s often used to sing the praises (pun intended!) of this amazing human language we call music. Music certainly deserves to be sung praises for! When working with older adults and their care needs, music is a wonderful complement to care. Used effectively and intentionally, music can connect people to themselves and others. For many people with advanced
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dementia, music may be the only thing they seem to remember, and the only way left to communicate. For all these reasons, music is a powerful language. But it is not a universal language. Firstly, songs have different meaning to different people. Memories can become encoded in music that can be as evocative for a person as smell. In long-term care, this awareness is important when we’re using music with residents. One resident could hear “Amazing Grace” and be transported
12 Home and LongTerm Care News MARCH 2018
back to warm memories of singing at her Grandma’s piano. Another resident may hear it and recall their wife’s funeral just six months ago. Neither of these emotional responses are wrong, and they deserve validation. For example, I’ve played Leonard Cohen’s “Hallelujah” at the bedside for people at the end of life, by request, more times than I can count. For many it’s a song that helps support them in letting go. It’s not hard to imagine how much the meaning of that song will
have changed for the loved ones sitting by the dying person’s side, hearing that familiar melody and internalizing those words at this tremendous time of loss. Not long ago I was asked by a good friend to play a special song as she walked down the aisle on her wedding day. The song she requested, that she’d always dreamt of getting married to, was “Hallelujah.” For her, this song now carries memories of overwhelming joy and happiness. www.longtermcarenews.ca
MUSIC CARE
Imagine if somehow this friend, and any of these family members who’d sat by their loved one’s bed as Hallelujah was sung, ended up one day in the same LTC home, and heard this song played at a sing-along. Their experiences would be vastly different. Secondly, musical tropes vary from culture to culture. Whether we are conscious of it or not, we all have a musical “literacy” that gives us cues about the mood and intention of a piece. These differ depending on the culture though. For example, in Western music, the “minor” scale has always signified sadness, melancholy,
USED EFFECTIVELY AND INTENTIONALLY, MUSIC CAN CONNECT PEOPLE TO THEMSELVES AND OTHERS anger, inwardness, or fear. However, the same or similar scales are used in many African and Asian music to signify joy, happiness, and success. The emotional reactions and general assumptions we make about music will inevitably be influenced by our cultural background. When introducing music in care, especially in settings with more cultural
diversity, it is important to be sensitive to the different musical languages everyone may be experiencing. It is also an opportunity for understanding a person’s own musical preferences and stories behind their most cherished songs. What does this mean for care? It means we can use music as a way to get to know people better. When we
acknowledge that music isn’t universal, we can instead use it as a tool for delivering more person-centered care. We can take the time to get to know someone’s beloved music, the stories that those songs tell, and the memories, joyous and bitter, that they carry. When using music in a group setting, we can remember that though something may seem like a “happy” song to us, it may be a sad song to someone else. If we take the time to honour these individual differences, we can show that we care. By embracing each person’s unique individual music, we can help strengthen the universal language of care. LC
Sarah Pearson is a music therapist working in end-of-life care, a songwriter and professional musician, and is program development coordinator for the Room 217 Foundation.
www.longtermcarenews.ca
MARCH 2018 Home and LongTerm Care News 13
COVER KARIE is a medication management solution that is loaded with multi-dose pouch packaging, gets plugged into a wall and lights up to inform users that their dose is prepared and it’s time to take their medication.
Innovation in aging and brain health By David Stoller
14 Home and LongTerm Care News MARCH 2018
www.longtermcarenews.ca
COVER
t is an undeniable reality that as the global population ages, all countries must improve their involvement in helping manage and care for older adults. This is critically important because, as indicated by the World Health Organization’s (WHO) “World Report on Ageing and Health”, the predicted number of people over the age of 60 around the world will double to 2 billion by 2050. Tied to the aging population is the rise in the number of seniors with dementia. The WHO goes on to note there are approximately 47.5 million people worldwide who currently have dementia, and that 7.7 million new cases are diagnosed every year.
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CABHI HAS LAUNCHED AND APPROVED $30 MILLION TOWARDS INNOVATION ACTIVITIES, AND ENGAGED WITH OVER 250 PARTNERS
The increase in the number of older adults, and specifically those who suffer from dementia, calls for organizations and professionals within the healthcare community to work together to provide better long-term outcomes for these patients and their families. Enter the Centre for Aging + Brain Health Innovation (CABHI), a solution accelerator focused on driving innovation in the aging and brain health sector. To accelerate the pace of innovation, CABHI collaborates with researchers, clinicians, point-of-care workers, and industry partners to develop, test, and disseminate solutions that improve brain health and quality of life for older adults.
Since the fall of 2016, CABHI has launched and approved over 90 innovation projects, levered $30 million towards innovation activities, and engaged with over 250 partners; all in an effort to bring the latest and greatest aging and brain health innovations to market. As CABHI works with projects and partners, exposure to the latest trends and innovation in this sector is inevitable. Here are some of the innovation trends that are likely to see further development in 2018:
FOCUS ON THE CAREGIVER As the population rises, so too does the pressure on both formal and informal caregivers. Family caregivers are going to need more support, training, and resources to help them care for their loved ones. At the same time, as demand for caregiving goes up with the aging population, formal caregivers are going to be experiencing potential staff shortages, which could stretch the industry and lead to quality concerns and challenges in attracting and training new people to the profession. Given these issues, more innovations that focus on caregivers are likely on the horizon. (CABHI) supports a number of projects geared specifically towards caregivers. One of them, the Road to Connection, is not your typical caregiver support group. For starters, it caters to both caregivers and their spouses experiencing dementia. Running for 10 weeks, the CABHI-supported program features a specialized art class for seniors dealing with dementia and a support group for their spouses. The two groups run simultaneously for about an hour. After that, they converge so the couples have a chance to collaborate and see the art their spouses have created. Thanks to the group, one caregiver now feels like she has a support network in Toronto, and hopes more couples will be able to take part in Road to Connection. “When we came from Montreal, we were completely lacking resources,”
she admits. “Now, in addition to having a support network, we know where to go and who to approach. This program has been tremendous – truly an asset to the community.”
INNOVATING FOR COGNITIVE FITNESS Finding new ways to engage older adults cognitively will be another focus going forward. As the number of older adults continues to climb, the need to develop new technologies that can increase awareness, reduce stigma and improve prediction will help longterm care providers better support their residents. One such innovation has managed to combine cognitive fitness with physical exercise, and CABHI is currently supporting a trial of this technology in Ontario. Motiview, a technology that pairs slow TV (slow TV is a genre that broadcasts visual experiences in real time) with adapted exercise bikes, asks questions such as: What happens when you pair slow TV with exercise bikes in the care of older adults? Will it increase a person’s motivation to exercise? This project is currently being trialled at three sites in Canada. Early trials brought about a reduction in aggressive behaviour along with a decrease in medication for pain and for depression. There was also a reduction in anxiety and a great decease in falls incidences. This project still has a long way to go, but it is a good example of how cognitive fitness is finding its way into the innovation space.
COORDINATING AND NAVIGATING CARE The older you get, the more complex the healthcare sector can become. Older adults often have at least two chronic conditions, and finding ways to negotiate multiple medications, appointments, doctors, specialists, and locations will continue to challenge both older adults and their caregivers. That is why innovations that focus on making the coordination
and navigation of care easier will continue to grow in 2018. Families and their providers will need new innovations to support care transitions, collaborations, remote care, and many of the other challenges that arrive with advanced age. Today, CABHI has a number of projects in the pipeline that are addressing these concerns, and the expectation is that the next round of project funding will include several more projects that focus on care coordination and navigation. One such example is KARIE, a medication management solution that is loaded with multi-dose pouch packaging, gets plugged into a wall and lights up to inform users that their dose is prepared and it’s time to take their medication. The device reads the information on the packaging and automatically schedules when it should be dispensed. If for some reason the user forgets to do so, a family member or caregiver is automatically notified that a dose was missed. With one out of every five people admitted to nursing homes owning their admission to medication non-compliance, this solution hopes to reduce admissions and empower older adults to age in the setting of their choice.
THE TIME TO INNOVATE IS NOW The need for innovation is critical! Patients, families, and members of the healthcare community are facing ever-mounting challenges from an aging population. Of particular note is the struggle people face in caring for someone with an illness that affects their cognitive abilities. However, thanks to funding programs made available through organizations such as CABHI, the future of innovation in Canada is bright, and the prospects for our aging population continue to improve. For more information on how you can participate in CABHI innovation programs, or support their innovations as a trial partner visit www.cabhi.com or email info@cabhi.com. LC
David Stoller is the Senior Marketing Specialist at The Centre for Aging + Brain Health Innovation, Baycrest Health Sciences. www.longtermcarenews.ca
MARCH 2018 Home and LongTerm Care News 15
NUTRITION
Feeding assistance: Strategies for success By Dale Mayerson and Karen Thompson hen eating issues are identified and there is timely intervention, the effects on a resident’s quality of life can be profound. When a resident is assisted with eating and is able to maintain/improve nutrient intake, overall health and well-being will benefit.
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POSITIONING One of the most important steps in preparing to assist a resident at meal or snack time is assuring proper positioning, making it easier for the resident to eat as independently as possible. Resi-
dents require individual strategies for positioning, but this usually includes keeping the upper body securely in an upright position, with hips, knees and ankles bent as closely to a 90 degree angle as possible. The feet should be flat on the floor or on wheel chair supports, and the head should be held straight with the chin down slightly. There should be approximately 12 inches/30 cm from the mouth to the food. Poor positioning leads to a higher risk for choking or aspirating food or liquid into the lungs. There are many effective strategies that can improve a resident’s mealtime positioning. Some
16 Home and LongTerm Care News MARCH 2018
residents who tend to slide forward or to the side in a chair may be assisted with non-skid matting or wedge cushions, or simply by placing forearms on the table to maintain an upright posture. Pillows may be tucked at one side to help maintain a safe position. Special consideration needs to be given when positioning bedridden residents to eat. Positioning at mealtime is important for all residents and needs to be monitored by everyone on the care team. Regulations in the Ontario Long Term Care Homes Act support staff by mandating that no person assist
more than two residents who need total assistance with eating or drinking at one time. This allows each resident adequate time for swallowing and to prepare for the next mouthful of food. Caregiver positioning is also important. In most instances, the caregiver needs to be seated at the same height as the resident so eye contact can be made without excessive twisting or turning. Height adjustable swivel chairs designed for assistance with eating are helpful and should be readily available in the dining rooms. Consider using stools with back supports for the safety of the staff. www.longtermcarenews.ca
NUTRITION
FOOD AND FLUID TEXTURE
TECHNIQUES/ CONSIDERATIONS
Prescribing the optimal texture for residents that require assistance with eating is key to success. Residents may be at risk for swallowing difficulties and need to be assessed to determine the most appropriate food and fluid textures for provide adequate intake in a safe manner while still being pleasing to the resident. Chewing stimulates digestive enzymes and is a natural part of eating and digesting foods. When residents lose this ability, we need to adjust the diet accordingly. Caregivers need to ensure that residents receive the correct texture, and that any observations of coughing, choking, pocketing of food in the cheeks, or drooling are reported to the Registered Nursing staff or Dietitian.
Some rules for assisting residents with eating would include: 1. Do not rush 2. Wash hands before beginning to assist and perform hand hygiene between residents 3. Serve one course at a time 4. Use a metal or hard plastic teaspoon or parfait spoon for those on minced or pureed diets 5. Ensure foods are not dangerously hot by placing a small amount of food on forearm to determine if temperature is safe for resident 6. Offer small bites at a time, bring the spoon to where the resident can see it and give resident time to open his/her mouth 7. Allow time for chewing/swallowing and try to observe the swallow taking place
8. Check that resident’s chin remains slightly tucked for safest swallowing 9. Check that there is minimal amount of food residue in the mouth after swallow. 10. Alternate liquids with solids unless the plan of care indicates otherwise 11. Do not mix foods together unless the resident requests this or the care plan allows this 12. Cue resident to open mouth if necessary 13. Encourage resident to wipe his/her mouth with a damp cloth or napkin throughout the meal. Assist as required 14. Reheat food if it becomes cold 15. If resident begins to cough or choke – stop providing food and allow time before starting again
16. Report coughing, choking, pocketing, drooling, spitting to Registered staff overseeing the dining room service 17. Record intake as soon as possible after assisting resident When serving a large number of residents that require assistance with eating, Homes are often grateful for any help they can get to ensure everyone has assistance with their meal as needed. Excellence in practice needs to be promoted and supported by providing opportunities for training, role playing, monitoring and interdisciplinary care planning on an ongoing basis. Well trained and well informed staff, families and volunteers have the power to improve their own satisfaction while enriching the lives of those they serve. LC
Dale Mayerson B Sc RD CDE, and Karen Thompson, B A Sc RD are Registered Dietitians with extensive experience in Long-term care. They are coauthors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians of Canada.
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www.bayshore.ca MARCH 2018 Home and LongTerm Care News 17
NEWS
Caring for elderly parents from afar By Susan Hyatt e want to be there for our elderly parents or friends when they need us, but sometimes we can’t. We might live in another province, be a day’s drive away, or unavoidably busy with work or family responsibilities. It just isn’t always possible for us to be there all the time. I learned this first-hand when my parents, both now over 90 years old, went into health crises at the same time. My Dad’s first health crisis was 16 years ago and for the past decade he has been in a long-term care community. He lives about a two-hour drive from me. My Mom has not been able to live at home for the past six years, and now lives in a nearby assisted-living community.
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IT’S CRITICAL TO BUILD A TEAM OF PEOPLE AROUND THEM WHOM YOU CAN TRUST
For me a typical week involves two or three phone calls for each of them from their various caregivers, medical practitioners, volunteers, and facility staff. That number can increase exponentially if one of them becomes ill or needs to go to the hospital. All told, it’s not unusual for me to spend an average of 13 hours per week managing their various caregivers. I know how tough it is to coordinate care from afar, managing care for parents in two different cities, and do all that while running a business! Through my own experience, as well
as my work serving hundreds of families at Silver Sherpa, I have discovered a few essential tips for managing the care of elderly parents over long distances. Here are four key ones.
1. KEEP A NOTEBOOK OR E-FILE WITH ALL RELEVANT INFORMATION AT HAND Keep records of everything you need in dealing with your parents’ care, and keep them within reach since you can receive a phone call at work, at home, or when you’re on the go. I have two colour-coded notebooks (one for each parent) on my desk with all the information at my fingertips. Unfortunately, many medical and healthcare professionals will not send files or even communicate by email, so you need these paper files. Also, update your notebook with important details that you may need at a moment’s notice. This is the kind of information you should have at your fingertips: • Up-to-date summaries of their medical records, including their physicians with contact numbers, as well as the family doctor, relevant specialists, and current medication record. • Name of the head nurse or Director of Care from their facility, along with that person’s direct line. • Administration number and after-hours number. • Room number and complete mailing address with contact for the concierge or front-office number. • List of their main caregivers and how to reach them.
2. BUILD A TRUSTED TEAM AROUND YOUR ELDERLY PARENT If you live even one hour away from an elderly parent, you cannot always
help out when they need something. That’s why it’s critical to build a team of people around them whom you can trust. You need these people to rely on for even the simplest things. It might be when Dad’s clock stops working and needs batteries, or Mom is in a wheelchair and she needs someone to run errands for her. Spend time face-to-face with the people around your parent and get to know them. Communicate with the team frequently to make sure everyone is on the same page. Make sure they have your contact numbers/emails, and an alternate back-up number just in case. Remember that this trusted team should include a doctor on call, charge nurses, caregivers who are there day-to-day, the managing director of the facility, the handyman, the housekeeper, and the list goes on.
3. KEEP IN TOUCH WITH YOUR ELDERLY PARENT You should be talking with your parent often, whether something is wrong or not. Since you can’t be there all the time, a regular phone call keeps you in the loop, especially if there are problems or concerns. But it must be two-way communication so they can tell you what is happening. Your parent should be comfortable calling you if something is wrong or if they have specific needs, and if they require help, staff should be able to help them call you. You can also use an iPAD and ask the staff to contact you through FaceTime at a set time. In addition, make sure your elderly parents have emergency numbers where they can reach you, or the numbers of people who can get a message to you. It’s a good idea to tape
your phone number to their phone if they have trouble remembering.
4. SET PERSONAL BOUNDARIES AND GET EMOTIONAL SUPPORT FROM FAMILY AND FRIENDS Do not “go it alone.” Rely on close family members and friends to support you emotionally and to lend a helping hand, but be realistic about what you can and can’t do. For elderly parents who live far away, your travel comes at a financial, physical and emotional cost. How often can you realistically afford to visit them? Many people find it helpful to talk about their challenges and struggles with family, friends or a support group for caregivers. Managing elderly care via long distance is hard work, but with a strong support network you can avoid burn-out. And if you have siblings you can count on, divvy up responsibilities of caring for Mom or Dad to lessen the load on your shoulders. There is no doubt that caring for an elderly parent over a long distance requires good management skills. You become the care coordinator, health advocate, decision-maker, project manager and team manager. Your job is to manage the crowd around your parent so they are properly cared for and have a good quality of life, and all this while you may be the “Coordinator-in-Chief” of your own busy home. For sure, it can be stressful, overwhelming and isolating. But you’re not alone; hundreds of thousands of other Baby Boomer families in Canada are going through the same thing. With these tips and a solid plan in place for your elderly parents, you can do it. LC
Susan Hyatt is the CEO of Silver Sherpa Inc. She can be contacted at shyatt@silversherpa.net. herpa.net. The website is https://www.silversherpa.net https://www.silversherpa.net. t. 18 Home and LongTerm Care News MARCH 2018
www.longgtermcarrene ewss.cca www.longtermcarenews.ca
NEWS
Managing elderly care via long distance is hard work, but with a strong support network you can avoid burn-out
www.longtermcarenews.ca
MARCH 2018 Home and LongTerm Care News 19
CAREGIVER SOS
If older parent becomes forgetful, here’s what you should know A person with Mild Cognitive Impairment, unlike a person with dementia, has no trouble with their usual activities of daily living. My 77-year-old mom has been forgetful and not as sharp as she used to be. Her doctor said she has a problem called Mild Cognitive Impairment. Is this a real illness or just her being older? Signed, Worried about mom s we age, our bodies change and so do our brains. Your question is a good one, as normal aging includes changes in how our brain functions. The real issue is how does Mild Cognitive Impairment (MCI) fit in as part of normal aging? A diagnosis of MCI is determined by looking at the history
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provided to the physician and through some cognitive testing. Individuals with MCI often complain of forgetting things, having trouble with decisions and finding their way around. They may mix up social engagements and not be able to follow books or movies as easily as they did in the past. It should also be noted that a person
with MCI may have mood changes and be irritable, anxious or depressed. Often, people notice the changes themselves and may come forward with complaints. They may feel that they are not “at the top of their game.” This may be a cause of stress for them or their family. A key difference between dementia and MCI is that the individual does not have trouble with their usual activities of daily living, such as shopping, managing their schedule of commitments and getting around town on their own. With an MCI diagnosis, Mom is likely still able to do the things that she needs to do, but maybe not as well. With MCI, there is a decline over time that is noted by people who are diagnosed with the condition. Their history usually reveals that they are having more trouble with decision-making and planning, and possibly following more complex instructions. You can’t be diagnosed with MCI and dementia simultaneously. The doctor likely did some cognitive testing and a complete checkup to rule out any other serious neurological problems. People with MCI are at greater risk of developing dementia. Some studies note that 10-15 per cent of people with MCI develop dementia every year. However, not everybody progresses to dementia and a certain proportion of individuals actually get better. The risk factors for MCI are age and other medical and lifestyle factors such as exercise, smoking, high blood pressure, diabetes and social isolation or lack of mental stimulation.
Presently, there is no drug or treatment specifically designed to treat MCI, but research is underway to look at what can be done to delay or prevent the symptoms from progressing to dementia. Your doctor surely ensured that mom is treated for any other concerns (like high blood pressure or depression). Making sure that all medical problems that can affect the brain are dealt with is imperative. “Research shows that people with MCI can learn and apply memory strategies. This is good news, as memory habits that promote everyday memory in turn promote sustained functional independence,” says Dr. Kelly Murphy, a psychologist at Baycrest Health Sciences. Dr. Murphy co-authored the book “Living with Mild Cognitive Impairment: A guide to maximizing brain health and reducing risk of dementia” published by Oxford University Press [2012]. Keep an eye on mom and on her day-to-day functioning, and report any concerns. She may need some additional support, but don’t let the MCI diagnosis panic you or her. The best thing to help mom is to ensure she keeps active and stimulated, and make sure she is both mentally and socially busy. Ensure that she is eating properly and exercising. There are programs to help learn strategies to cope with some of the memory issues and support for caregivers like you. LC
Nira Rittenberg is an occupational therapist who specializes in geriatrics and dementia care at Baycrest Health Sciences Centre and in private practice. She is co-author of Dementia A Caregiver’s Guide available at baycrest.org/dacg. Email questions to caregivingwithnira@baycrest.org. This article originally appeared in the Toronto Star. 20 Home and LongTerm Care News MARCH 2018
www.longtermcarenews.ca
NEWS
Balancing caregiving and your relationship By Pamela Stoikopoulos ven the strongest relationships are put to the test when one or both partners are caregivers for someone they love. Financial pressures, exhaustion, resentment, distance and lack of privacy are just some of the ways caregiving stress can overwhelm a relationship. As a caregiver, you may become so focused on the needs of your loved one that the connection with your partner can start to slip. Recognizing your needs as a couple and making your romantic relationship a priority is critical to your health and happiness. To protect and strengthen your relationship while caregiving, aim to:
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TAKE TIME TO TALK It’s so common for caregivers to keep their emotions and stress inside, but this will only inevitably push you further away from your partner. Opening up will help you better understand each others’ feelings and behavior, prevent resentment or misunderstanding and bring you closer. Your partner will also be more willing to help manage responsibilities and offer emotional support when they understand where you’re coming from.
FORGIVE AND FORGET When caring for a loved one and juggling life’s demands, your patience may not be at its best. If you are unkind to your partner during a tense moment, resolve to apologize right away. Give your partner this same leeway and be willing to forgive. This doesn’t mean that you should accept cruel behavior, but cut each other some slack and allow for slip-ups and bad days.
SPEND TIME TOGETHER Don’t let the difficulties of caregiving take the joy out of your relationship – make time to reconnect and have fun. If date nights and weekends away aren’t possible, find connection in the small, everyday moments. Even going to your loved one’s doctor’s appointments or running errands as a team can offer time together in an otherwise packed schedule. Make little romantic gestures like a walk around the block while the sun is setting, a candlelit (takeout) dinner, or hidden love notes. Little actions can go a long way!
When the people you love are pulling you in many different directions, it can feel impossible to make it all work. By prioritizing your relationship through teamwork, understanding and patience, you can not only cope with the challenges of caregiving but create a bond that is better than ever. LC
ALLOW FOR SPACE While it may sound like a contradiction, you also need to be willing to give each other space. When you’ve spent all day meeting the needs of your sick loved one, children, coworkers, partner and friends, you may want and need some time alone. Offer your partner the same space. Don’t take it personally and encourage each other to get out of the house, do things you love or take up new hobbies.
GET SUPPORT Don’t be afraid to ask for backup. Look to family, friends, community resources and respite care to help you
Pamela Stoikopoulos is the senior Communications and Public Relations Manager at VHA Home HealthCare. www.longtermcarenews.ca
take time for your relationship. Join a caregiving support group so you can get new perspectives and talk to other people experiencing similar challenges. It can also be enormously helpful to have other people to lean on for support instead of always expecting your partner to fill that role.
Helping people live with independence, dignity and in comfort since 1925. • Nursing • Physio and other therapies • Personal care and support • Homemaking
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MARCH 2018 Home and LongTerm Care News 21
NEWS
Human Microbiome and Probiotics lab.
‘Ridiculously healthy’ elderly have the same gut microbiome as healthy 30 year-olds By Crystal Mackay n one of the largest microbiota studies conducted in humans, researchers at Western University, Lawson Health Research Institute and Tianyi Health Science Institute in Zhenjiang, Jiangsu, China have shown a potential link between healthy aging and a healthy gut. With the establishment of the China-Canada Institute, the researchers studied the gut bacteria in a cohort of more than 1,000 Chinese individuals in a variety of age-ranges from three to over 100 years-old who were self-selected to be extremely healthy with no known health issues and no family history of disease. The results showed a direct correlation between health and the microbes in the intestine. “The aim is to bring novel microbiome diagnostic systems to popula-
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RESEARCHERS HAVE SHOWN A POTENTIAL LINK BETWEEN HEALTHY AGING AND A HEALTHY GUT tions, then use food and probiotics to try and improve biomarkers of health,” says Dr. Gregor Reid, professor at Western’s Schulich School of Medicine & Dentistry and scientist at Lawson Health Research Institute. “It begs the question – if you can stay active and eat well, will you age better, or is healthy aging predicated by the bacteria in your gut?” The study, published last month in the journal mSphere, showed that the overall microbiota composition of the healthy elderly group was similar to that of people decades younger, and that the gut microbi-
ota differed little between individuals from the ages of 30 to over 100. “The main conclusion is that if you are ridiculously healthy and 90 years old, your gut microbiota is not that different from a healthy 30 year old in the same population,” says Dr. Greg Gloor, the principal investigator on the study and also a professor at Western’s Schulich School of Medicine & Dentistry and scientist at Lawson Health Research Institute. Whether this is cause or effect is unknown, but the study authors point out that it is the diversity of the gut microbio-
ta that remained the same through their study group. “This demonstrates that maintaining diversity of your gut as you age is a biomarker of healthy aging, just like low-cholesterol is a biomarker of a healthy circulatory system,” Gloor says. The researchers suggest that resetting an elderly microbiota to that of a 30-year-old might help promote health. “By studying healthy people, we hope to know what we are striving for when people get sick,” says Reid. The study also found a distinct anomaly in the group aged 19 to 24 that has not been observed in largescale analyses of other populations and they suspect may be unique to this healthy cohort in China. The distinct gut microbiota of this group was a surprising finding and requires further study. LC
Crystal Mackay is the Sr. Media Relations Officer at the Schulich School of Medicine and Dentistry. 22 Home and LongTerm Care News MARCH 2018
www.longtermcarenews.ca
NEWS
Home is where the health is Dramatic results show shifting chronic disease care closer to home reduces hospital use
ccording to the Canadian Foundation for Healthcare Improvement (CFHI), new results from an initiative moving chronic care from the hospital to the home could have a transformational impact on the sustainability of healthcare. New results from health systems participating in the INSPIRED collaboration show that providing the right services to support Canadians with chronic obstructive pulmonary disease (COPD) in their homes has improved quality of life for patients, while also dramatically reducing hospital readmissions by 64 per cent and emergency department visits by 52 per cent. “Too often, people with chronic diseases like COPD end up in hospi-
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tal because the care they need is not available in the community,” says Maureen O’Neil, President, CFHI. “INSPIRED provides the services patients and their families tell us they need to manage their disease outside of hospital and now we are expanding this innovative collaboration to benefit more patients.”
DRAMATIC IMPROVEMENTS These latest results show how INSPIRED’s hospital-to-home model resulted in a sustainable reduction in the number of emergency department visits and hospital readmissions among more than 2000 patients with COPD, since the program was implemented in 2014-15. (see Table 1)
“These results are important because they show we can keep people with chronic disease out of the hospital by partnering with them to reinvent the way we deliver care so it meets their needs,” says Maria Judd, Vice President of Programs at CFHI. “All Canadians who use and pay for the healthcare system, not just those with a chronic disease, will benefit from the emergency department and hospital bed capacity this approach will free up as it spreads across the country.”
NEW TEAMS ANNOUNCED Based on their success in the first phase of the INSPIRED collaboration and their potential to reach more people with COPD, CFHI has selected six
Table 1 Hospital or Health System/Region
Reductions is Hospital Use for INSPIRED patients Emergency Department Visits
Hospital Readmissions
Alberta Health Services (Edmonton Zone)
- 47%
- 54%
Health PEI
- 40%
- 52%
Joseph Brant Hospital (ON)
- 46%
- 70%
Nova Scotia Health Authority
- 58%
- 62%
Winnipeg Regional Health Authority*
N/A
N/A
Horizon Health Network (New Brunswick)**
N/A
- 69%
- 52%
- 64%
Average
NSHA first developed the INSPIRED COPD Outreach Model™ In 2010 that CFHI spread (with NSHA’s support) In 2014-15. *Results pending, as analysis cannot be provided until number of subjects tracked over time exceeds 50. **No data available for Emergency Department visits
1
24 Home and LongTerm Care News MARCH 2018
teams from across the country for the next phase of this multi-year effort: • Alberta Health Services (Edmonton Zone) • Manitoba (including Winnipeg Regional Health Authority, Interlake-Eastern Regional Health Authority and Prairie Mountain Health) • Joseph Brant Hospital and Caroline Family Health Team (Burlington, Oakville and Hamilton, Ontario) • Horizon Health Network (New Brunswick) • Nova Scotia Health Authority (NSHA) • Health PEI CFHI is providing a total of $1.4 million in funding and significant support to scale up existing INSPIRED programs to more providers, sites and patients. The teams are coalitions of hospitals and health regions/systems, primary care organizations and community partners that have come together to better meet the needs of people with COPD.
THE GOAL: BENEFIT MORE CANADIANS Participating in this collaboration, these teams estimate they will reach an additional 2300 people living with advanced COPD across up to 39 hospitals and 13 primary care organizations by March 2019. The ultimate goal is to continue expanding until all patients who could benefit from INSPIRED have access to the program. Third-party analysis has shown that expanding this program to reach 5,800 patients annually by 2021 could prevent nearly 70,000 emergency department visits and 400,000 hospital bed days, avoiding $688 million in acute care costs. For every dollar invested in INSPIRED, $21 in hospital-based costs could be prevented.
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NEWS
A DEADLY, PREVALENT, AND COSTLY CHRONIC DISEASE Of the chronic diseases, COPD is the number one reason for hospitalizations in Canada, accounting for the largest number of hospital admissions from emergency departments and hospital readmissions. COPD is a chronic and progressive lung disease that includes chronic bronchitis and emphysema, and is characterized by uncomfortable breathing that worsens over time. A conservative estimate finds that about 800,000 Canadians live with COPD and people with advanced COPD are among the highest users of Canada’s hospital resources. One in four Canadians (25 per cent)
is expected to develop the disease in their lifetime, meaning the impact of COPD will worsen in the coming years unless we begin to meet more of the needs of people with COPD and other chronic diseases outside of hospital.
HOW INSPIRED WORKS INSPIRED enhances patient confidence to manage their illness more effectively in their homes and communities. The program was first developed by Dr. Graeme Rocker and two colleagues, a respiratory therapist and a spiritual care practitioner, at Capital Health in Halifax (now part of the Nova Scotia Health Authority) based on extensive input from patients and their caregivers.
Healthcare teams identify patients who visit emergency departments or are hospitalized with advanced COPD, and invite them into a supportive program that equips them to better manage their illness by providing them with: written action plans for managing their disease; phone calls after they are discharged home and at later intervals; at-home self-management education and psychosocial support; and advance care planning when needed. Patients in the program are also given a day-time telephone number to call for support. “The more you know, the more control and the less stress you have,” says Charlotte Starratt, the wife and caregiver of INSPIRED patient Wil-
bur Starratt of Sackville, Nova Scotia. “The questions we’re able to ask and are encouraged to ask is a big thing. It’s about getting control of a whole new way of life.”
CALL-TO-ACTION Right now, Canadians, their governments and healthcare organizations are looking for ways to advance the shared priority of enhancing home and community care. Many are focusing on scaling evidence-based models that reduce the number of patients in hospital who could be better cared for at home or in the community. CFHI is offering its support and we encourage others to join us in making change happen. LC
This article was provided by The Canadian Foundation for Healthcare Improvement
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NEWS
Driving Access to Care: Canada Health Infoway’s Goals for 2018-2019 By Michael Green anadians are proud of our universal healthcare system, but despite the money we spend on it, research shows that our country ranks at or near the bottom in international comparisons of timely, equitable access to appropriate care. A study of 11 countries published by The Commonwealth Fund in July 2017 found that only 57 per cent of Canadians, on average, can get same or next-day appointments with doctors. Out of frustration, they go to hospital emergency rooms, where 29 per cent of them reported waiting four or more hours to receive attention.
C
CANADA RANKS AT OR NEAR THE BOTTOM IN INTERNATIONAL COMPARISONS OF TIMELY, EQUITABLE ACCESS TO APPROPRIATE CARE Sweden ranked lower at 20 per cent, while France ranked first, with only one per cent having to wait that long. In terms of online access to health information, such as viewing lab results, Canada ranked third from the bottom, with only six per cent of people able to do so, while France ranked first at 27 per cent. As for the ability to email a doctor with a question, Canada ranked last at four per cent and France was again first, at 24 per cent. Canada needs to do better. We need to “flip the script” and improve access
to care and access to health information for all Canadians, especially those who are most vulnerable and have the greatest need. Improving access will result in better health outcomes and healthier, more productive citizens. Digital health solutions can help us turn things around, so Canada Health Infoway (Infoway) has developed a strategy called Driving Access to Care. Over the next four years (20182022) we will focus on large, multi-jurisdictional or pan-Canadian projects to empower Canadians and strengthen their care teams. We will: • Put patients and their families at the centre of everything we do; • Ensure providers have the right tools to deliver optimal care; • Focus on initiatives that deliver meaningful positive impact to Canadians, including improved patient experiences; and • Establish strategic partnerships and alliances with public and private sector organizations to leverage their collective power to drive innovation. This is an ambitious strategy, so every year we will outline specific goals and performance expectations in our Summary Corporate Plan, which is essentially our business plan for the fiscal year. Our 2018-2019 Summary Corporate Plan defines two strategic goals, which are to: • Provide safer access to medications, starting with PrescribeITTM, a multi-jurisdiction e-prescribing solution; and • Provide Canadians and their providers with access to personal health information and digital health services.
We will support these goals by providing ongoing national digital health leadership in areas such as privacy, security, solution architecture and standards, interoperability, clinical engagement, change management, and benefits evaluation. Our goals for 2018-2019, as well as our broader Driving Access to Care strategy, are aligned with the federal government’s healthcare priorities, including tackling the opioid crisis, and addressing needs like homecare, mental health services and services for Canada’s Indigenous Peoples.
They are also aligned with the healthcare priorities of the provinces and territories. We see Infoway’s role as being a catalyst for change – a constructive disruptor of the status quo. It won’t be easy to “flip the script” so Canada ranks at or near the top in international comparisons of timely, equitable access to appropriate care. But we are committed to leading the way by working with our government and other partners to maximize the potential for digital solutions to transform our health systems. LC
Michael Green is President and CEO, Canada Health Infoway. Follow him on Twitter @MGreenonHealth 26 Home and LongTerm Care News MARCH 2018
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Dear Mom, You were my rock. My best friend. From the beginning it was always us. Then suddenly, I was alone. Gliding out on the ice, my legs were shaking. My heart was broken. But you steadied me. As you always did. Thousands watched... except the one I wanted most. But we did it mom. I wish you were there. Almost as much as I wish you were here.
Joannie
Joannie Rochette Olympic medallist Lost her mom to heart attack ™ Life. We don’t want you to miss it. and the heart and / Icon on its own or followed by another icon or words are trademarks of the Heart and Stroke Foundation of Canada.
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NEWS
Helmets and seatbelts for the flu lanes By Kevin Reel he recent headlines about surging flu numbers have been alarming. Media in the UK are talking of the worst flu season in seven years, with 35 people dying in just one week of January – three times as many as in January 2017. Other news reports in the US rank it as the worst flu season in 15 years. Loma Linda University Medical Center set up tents outside their emergency room to help cope with the numbers. Multiple strains are circulating, with children appearing particularly vulnerable – at least 37 have died this year in the US, with that official number likely lagging well behind the actual number. The expectations are that up to five times as many children may die this year. In Florida and Texas, some school districts closed to reduce the spread of the flu virus. Boomers are also being hit harder than usual – more than children. Amidst the suffering and death of flu victims, the perennial discussion about vaccination raises, yet again, the issue of vaccinate or mask policies for staff in healthcare roles. I am not a fan of these. Firstly I don’t feel the evidence is of a standard that warrants the coercive requirement of being made to wear a mask. Without that strong evidence, my second hesitation
T
FOR ME, THE BIGGEST PRESSURE TO GET VACCINATED IS SELF-IMPOSED – THE PROSPECT THAT I MAY BE THE REASON SOMEONE ELSE IS INFECTED AND MUST ENDURE SOME DEGREE OF AGONY, OR EVEN DIE persists: I feel these policies end up pitting individuals and colleagues against each other in unhelpful ways. Those stickers on name badges are seen as a form of virtue signalling by many, while the masks are often perceived as ‘having the aim to shame’. For me, the biggest pressure to get vaccinated is self-imposed – the prospect that I may be the reason someone else is infected and must endure some degree of agony, or even die. Vaccination is one form of added insurance against that disturbing responsibility. I accept the fact that vaccines are not entirely effective and some years they seem absurdly ineffective, and that they can produce a degree of discomfort, which I have experienced myself. There is also a minimal risk of more severe reactions. But I also know it is impossible to predict how bad the season will be each year. It is difficult to grasp the impact of the 1918 Spanish flu. That out-
break infected upwards of 500 million people – more than the population of the entire US. And it killed between 50 and 100 million – many times the population of Canada. There were arguably particular reasons for the severity of that pandemic, but we cannot predict the year we’ll encounter the next severe one. It makes little sense to me to wait to find out how severe the season will be – the risk will by then have escalated significantly, and getting a vaccination at that point still leaves one vulnerable for weeks before it takes effect. I consider that fact that children and others die from the flu every year. We may not have direct experience of these deaths, but we are certainly well able to be aware of them. When such deaths occur nearer to us, we may never know if we have been the causal agent. It’s somewhat more likely if we haven’t had the vaccine, and especially likely if we don’t practice proper hand
hygiene. However, I feel the mere possibility of being the cause is likely to haunt good people for the rest of their lives and the ‘costs’ of getting the vaccine are probably far less than the burden of that haunting. In the end, I accept the fact that these decisions are not always rational ones, and thus no amount of good reasons will shift whatever it is that prevents some people from deciding against a vaccination. So I don’t expect to change everyone’s mind. But I hope to introduce some nagging cognitive dissonance… some subtle moral uncertainty about that decision. In this way, someone might begin pondering a rethink, without risking the sort of relationship harms that I feel accompany those policies that dictate vaccinate or mask. At the very least, I use any discussion of vaccination to share agreement on the need for fastidious hand hygiene by everyone – vaccinated or not. Given those low efficacy rates some years and the unknown severity of any flu season, the duty to be mindful about that non-invasive prevention tactic never diminishes. Hand washing and vaccines are much like mandatory seatbelts and non-mandatory bicycle helmets: I hope I never need them but would not want to be without either in case I do. LC
Kevin Reel is a Practicing Healthcare Ethicist, University of Toronto. 28 Home and LongTerm Care News MARCH 2018
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NURSING HERO AWARDS Nominate A Nursing Hero!
Along with having their story published, the winner also will take home: CASH PRIZES
1st PRIZE: $1,000 2nd Prize: $500 3rd Prize: $300
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,ŽƐƉŝƚĂů EĞǁƐ͕ ϲϭϬ ƉƉůĞǁŽŽĚ ƌĞƐĐĞŶƚ͕ ^ƵŝƚĞ ϰϬϭ͕ sĂƵŐŚĂŶ͕ KE͕ >ϰ< Ϭ ϯ
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NEWS
Fewer than 1 in 5 Ontarians
receive doctor house calls or palliative home care in their last year of life M ost Ontarians want to die at home, but despite this nearly 70 per cent die in hospitals or long-term care facilities. A new study from the Institute for Clinical Evaluative Sciences (ICES) shows end-of-life care like doctor house calls or in-home palliative care could reduce the chance of dying in hospital by about 50 per cent. “Our research has shown that endof-life care in a patients’ home can
RECEIVING DOCTOR HOUSE CALLS FOR ENDOF-LIFE CARE REDUCES THE CHANCE OF DYING IN HOSPITAL BY ABOUT 50 PER CENT AND RECEIVING PALLIATIVE HOME CARE ALSO REDUCES THE CHANCE OF DYING IN HOSPITAL BY ABOUT 50 PER CENT
dramatically reduce the risk of dying in hospital,” says Dr. Peter Tanuseputro, the lead author of the study, adjunct scientist at ICES, researcher at the Bruyère Research Institute, a staff physician at division of palliative care at The Ottawa Hospital and assistant professor at the University of Ottawa. The study published in PLOS ONE is the largest of its kind to show the effect of doctor home visits on where people die. Using secure patient health records housed at ICES, the researchers looked at 264,755 Ontario decedents from April 1, 2010 to March 31, 2013 and found receiving doctor house calls for end-of-life care reduces the chance of dying in hospi-
30 Home and LongTerm Care News MARCH 2018
tal by about 50 per cent and receiving palliative home care also reduces the chance of dying in hospital by about 50 per cent. “Most people would be able to die at home if they had the supports in place to make that happen. Unfortunately in most areas across Canada, it’s quite arbitrary who gets palliative care in the home, depending on factors like if your family doctor does home visits, what neighborhood you live in, and what you’re dying of. Canada remains in the back of the pack in developed nations in terms of the percentage who die in hospital,” says Tanuseputro. The researchers found less than one in five Ontarians receive doctor
house calls or palliative home care in their last year of life. “Our research points to the need for a structured palliative care strategy across the province to ensure people have a choice of dying in their homes, and not in hospitals, if they wish. As it stands now, who can access home palliative care really varies across Ontario,” adds Tanuseputro. About 38 per cent of physicians in Ontario deliver palliative care, and only a small minority of those doctors provides home visits. Only one in five palliative care encounters happen in patients’ homes. Tanuseputro points to other studies that his group has done that show patients with certain diagnoses, like cancer, and those who live in wealthier neighborhoods have a much higher chance of getting a home visit. “Associations between physician home visits for dying and place of death: a population-based retrospective cohort study” was published last month in the journal PLOS ONE. LC
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