Tuesday, June 17, 2014

Staying Properly Hydrated

With the warm weather finally here, it is more important than ever to stay hydrated. And while staying hydrated is important for everyone, it is absolutely vital for senior citizens, who may already be medically compromised in other ways.

One good rule of thumb for people responsible for providing care and support to seniors at home or in a long-term care setting is to recognize that thirst is never a good indication of hydration status.  In fact, by the time you are thirsty, you are probably already suffering from dehydration.

The greatest barrier for seniors when it comes to hydration is mobility. A senior with mobility issues, specifically someone that relies on a caregiver for assistance, may not be forthcoming with their needs.  Or they may wish to reduce trips to the bathroom.

Caregivers should look for the following signs of possible dehydration:

  • Drinks less than six cups of liquid a day
  • Has one or more of the following: dry mouth, cracked lips, sunken eyes or dark urine
  • Needs help drinking from a cup
  • Has trouble swallowing liquids
  • Experiences frequent vomiting, diarrhea or fever
  • Is easily tired or seems confused

Everyone should consume at least six cups of water, juice or decaffeinated liquids a day.

An easy way for caregivers to address this health care need is to have a clearly marked pitcher in the refrigerator with six cups of water in it.   Offering liquid throughout the day and measuring how much has been consumed takes is an easy way to track water consumption.

Proper hydration is essential to all body functions including regulating body temperature, transporting essential nutrients and electrolytes, and helping to dilute and transport medication.

So, go ahead and enjoy the balmy temperatures – just bring along your water bottle!

Cultural Competence in Caring for the Hispanic/Latino Communities

By Lea Hernandez-Vespe, MSW, LSW, I Choose Home New Jersey

Our society is increasingly diverse and enriched with various cultural influences.  All cultures and subcultures have their own sets of values, beliefs, traditions, and customs that they prescribe to as a way life.  The Hispanic and Latino population in the United States is currently the largest minority and is expected to reach just under a third of the U.S. population by 2050 (Pew Research, 2008).  At the OOIE, we are committed to serving the elderly population 60 years and older living in institutions – including persons of all races, genders, religions, sexual orientations, etc.  We recognize that understanding cultural differences strengthens our ability to advocate for and protect long-term care residents of all walks of life.

As I travel the State of NJ as an Outreach and Advocacy Coordinator, I enjoy working with and on behalf of individuals of various cultural backgrounds.  A common question that many people have about the Hispanic/Latino culture is whether there is a difference between “Hispanic” and “Latino. ” Although the terms are often used interchangeably, they have different meanings.  A person is Hispanic if they come from or have ancestry from countries that are Spanish-speaking (Puerto Rico, Mexico, Cuba, etc.). Latino refers to individuals who are from or have ancestry from a geographical location in Latin America that is not necessarily Spanish-speaking.  A Brazilian American, for example, is Latino but not Hispanic because they are from South American (Latin America) but their language is Portuguese (not Spanish).  A Puerto Rican American is considered to be both Latino and Hispanic because they are from Latin America and their primary language is Spanish. 

Every culture has its distinctions that make it unique to others.  I will summarize six key Hispanic/Latino values that provide the foundation for their way of life (Carteret, 2011.)

In Hispanic/Latino culture, the family is highly valued.  The family in this culture is inclusive of grandparents, aunts/uncles, and cousins and even close friends.  Important decisions are made as a collective unit.  Individualistic decision-making is viewed as disrespectful and selfish.  (Carteret, 2011).  Important decision-making may be delayed until all key family members are available for discussion.  The intent is not to be uncooperative but rather to respect the family process of decision-making within their culture.  

Another important value is respect and reverence to authority. Within the family structure, authority is granted based on gender and age.  The oldest male in the family has the greatest decision making authority.  In the community, reverence to authority is provided based on age, gender, social position and economic status.  For example, doctors and clergy are viewed as authority figures and given such reverence that communication with them is reduced to one of listening rather than engaging, as a sign of respect.  It is helpful for someone in a position of authority working with individuals from the Hispanic/Latino culture to make an effort to engage the person by asking questions of them.

In this culture, respect is expected to be reciprocal.  A Hispanic/Latino individual prefers to be addressed formally by their last name until given permission to use their first name.  A greeting such as “good morning/good afternoon/good evening” accompanied by a smile demonstrates a professional friendliness that helps to build rapport and cooperation.

Many Hispanics/Latinos have a strong belief in spirituality and/or karma.  Many accept uncertainty as a part of life and believe destiny cannot be changed.  Many Hispanics/Latinos have a strong belief that God’s will controls their lives.  They may believe that bad things happen to them as punishment for their actions.   They may choose not to be treated for an aliment and allow that God’s will be done.  This may set the stage for ethical dilemmas, specifically in healthcare settings such as hospitals and long-term care facilities.  Being mindful that every person with decision-making capability has the right to self-determination and to make decisions according to their religious/spiritual values even if it differs from that of the conventional norm, would help mediate many ethical dilemmas.  Encouraging Hispanic and/or Latino patients to complete advance directives is a great way to have their wishes known and respected.

The values of kindness and professional friendliness may seem to be fundamental at first glance to all people.  In the United States, however, the value of maintaining a professional, business-like demeanor while maintaining strict professional boundaries can be perceived as indifferent and callous for individuals who place a greater value on relationships than professional or business protocol. To gain trust, cooperation and compliance, it is important for medical professionals to establish rapport by imparting compassion, benevolence, and friendliness when working with the Hispanic/Latino community.  The act of shaking hands, greeting with a smile, using a friendly tone, asking questions and engaging in friendly conversation makes members of this community feel valued. 

Many in the Hispanic/Latino community (old and young) have traditionally used alternative medical practices to cure the sick of physical and emotional ailments.  They have used herbal remedies to cure sickness and/or disease.  They have sought the help of folk healers, spiritual healers or witchdoctors to help them spiritually ward off or cure affliction.  Current practices can be viewed as another extension of the holistic medical movement in United States today inclusive of hypnotism, acupuncture, herbal remedies, etc. As a service provider to Hispanic/Latino communities, it would be sensible to inquire about such practices to not only demonstrate culture competence but to avoid any clinical adverse reactions during prescribed treatment.  

In summary, when dealing with Hispanic/Latino residents, please remember:

  • Health care decision-making might be more collective than individualized.
  • Residents may give great deference to health care professionals and may feel uncomfortable asking questions/challenging them.
  • Respect is highly valued, given and expected to be received in return.
  • Religious and spiritual views might grant more power over a health care situation/decision to God or a higher being.
  • Strict professionalism (without friendliness or compassion) may create barriers.
  • Natural/holistic/non-Western health remedies are more common and should be investigated.
I have provided a framework for professionals to use when working with individuals and families from the Hispanic/Latino community.  As professionals, we must be cautious to not over-generalize about any group or subgroup.  We must recognize that individuals belonging to any culture or subculture have varying beliefs and values shaped by many factors including education, socio-economic status, degree of assimilation, language proficiency and personal experiences (Carteret, 2011). We can strengthen our communities by systemically incorporating values, attitudes, goals, objectives and practices that are inclusive of individuals/groups that prescribe to different sets of beliefs, customs, traditions and values.

Therapeutic Recreation: More than just activities

By Jennifer Sills, I Choose Home New Jersey

Last year I was honored to present a program at a quarterly Volunteer Advocate meeting in Freehold on the importance of recreation in long-term care settings.

Because I spent most of my career as a recreation therapist – before joining the ICHNJ program—I have significant expertise in this area.  Throughout my career, I have worked with seniors with varying stages of dementia and it is always a challenge to find activities that will afford them autonomy and allow them to experience success.

I chose to discuss the topic of "Emotional Memory.” I showed the volunteers an extremely moving slide show I often used with my clients – it was called “Mother.”

When the slide show was complete, I could see that many of the volunteers were emotionally affected by the presentation.  One specific volunteer, Mr. Brian M. Gorman, of Princeton, approached me after the program to ask if I would please send him a copy of the manuscript I had read during the show. 

As I began to develop the idea behind this article I contacted Mr. Gorman to inquire why this manuscript was important to him, and how the role of recreation affects him when he visits the nursing home to which he is assigned. 

Mr. Gorman explained to me that the slide show and the manuscript reminded him of special times he spent with his Mother. He said when he sees seniors engaging in activities it "warms me up.”

I can’t think of a better way to describe how it feels to see someone become positively engaged in a therapeutic activity – especially someone with significant cognitive impairments or who has been otherwise difficult to reach.

Mr. Gorman went on to explain that even Bingo can be engaging. What many people don't realize is that Bingo is a very therapeutic activity!  It is more than gambling.  It utilizes fine motor skills, concentration and self-control.  Bingo has been used to assist people who have social anxiety issues. It provides a way for these individuals to be in a small group and have success without being overwhelmed by attention, or the feeling that they need to perform.  Bingo provides mental stimulation and is effective in helping to keep seniors alert and oriented to their surroundings.  It is also a way to help people with physical limitations engage in a group activity that is less physically demanding.

Recreation therapy and activities help to create a non-judgmental environment for seniors. Many people who are coming to long-term care facilities are experiencing loss.  Homes have been sold, autonomy of schedule has changed, and some are learning to adapt to physical and mental challenges that are frustrating and frightening.

Recreation therapy utilizes a wide range of interventions and techniques to help improve or maintain the physical, cognitive, emotional, and the social and leisure needs of clients.  The goal of recreation therapy is to restore or rehabilitate functional independence in a person. 

Therapeutic activities are included as a component of quality of life in nursing homes, and facilities must now provide for an "ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental and psychosocial wellbeing of each resident." (U.S. Department of Health and Human Services, 1989). It is imperative that recreation directors be creative in how they develop their programs so they meet the needs of all of their clients.  As we all know, everyone is different.  While one person may love musical programs and Bingo games, another prefers to read independently in their room.  With the assistance of volunteers, especially those from the Office of The Ombudsman, recreation directors are able to gain specific information about all of the residents and their recreation needs and desires.  With this valuable information, programs can be developed to facilitate and encourage autonomy and success.

There is a saying in the field of recreation therapy that, in my opinion, captures it importance: "Physical therapy heals from the waist down, occupational therapy heals from the waste up and recreation therapy heals from the inside out."

Jennifer Sills is an Outreach Coordinator with the OOIE I Choose Home NJ program. After spending most of her career as a Recreation Director in a long-term care community, Sills joined the ICHNJ program and now helps nursing home residents transition from a nursing home back to into the community.

Monday, June 16, 2014

Seniors Bullying Seniors: A Growing Problem

As the number of older adults grows, it appears that bullying among seniors has become a national problem. Consequently, senior-to-senior bullying sometimes take place in senior centers, nursing homes and assisted living facilities. These are places where seniors spend a lot of time together and need to share resources, whether it’s chairs, tables, TV stations or the staff’s attention.

Senior bullying is defined as an intentional and repetitive behavior involving an imbalance of power or strength (Hazeldon Foundation, 2008).  It is typically characterized as the assertion of one's will to intimidate, embarrass, or humiliate others.

Research indicates that between 10%-20% of residents in an institutional setting have experienced some form of bullying from their peers (Bonifas and Frankel 2012). It causes considerable emotional distress for not only the victims, but also for the other residents and staff. 

“A common response is feeling intense guilt for not intervening, which can contribute to a sense of poor self-worth.  Furthermore, living in an environment where bullying is allowed to occur creates a culture of fear, disrespect and insecurity that can actually lead to increased bullying as individuals retaliate against one another.  Such environments also reduce resident satisfaction because residents feel that staff does not care about their well-being” (Bonifas and Frankel, 2012c).

Victims of bullying
Bonifas and Frankel identify two types of victims: passive victims and provocative victims.  The passive victims tend to show a lot of emotion; are shy, insecure or anxious.  They typically do not read social cues well. Among older adults, such victims may have early dementia or a developmental disorder. Minority status based on race, ethnicity, or perceived sexual orientation can also contribute to individuals being targeted for bullying because individuals who bully have difficulty tolerating individual differences.

Provocative victims can be annoying or irritating to others, for instance, by intruding into others’ personal space. They are perceived as quick-tempered and may inadvertently “egg” bullies on. Among older adults, such individuals may have a dementia-related condition that is more advanced than that of passive victims.

What you can do!
Do your research.  Ask if the LTC community has a policy for peer-to-peer bullying, and if not, encourage them to consider implementing such a policy.  Many organizations involved with seniors have a “code of conduct” policy that bans yelling, obscene language, and other verbal abuse. Some programs require seniors to sign a code of conduct that states that all members will be treated with consideration, respect and recognition of their dignity.

What Facilities can do!

  • Convey a clear expectation about what kind of behavior is appropriate create and maintain a culture where bullying is unacceptable.
  • Encourage bystanders to act in positive ways when they observe bullying.
  • Empower seniors by letting them know they are not alone and that they can look to you for help if they are being bullied.
  • Teach bullying victims ways to prevent others from dominating them through assertiveness training that emphasizes the following:

  • Standing up for one’s rights
  • Managing feelings of anger
  • Using direct communication strategies
  • Using “I” statements
  • Setting boundaries
  • Creating win-win situations

  • Utilize additional resources like local community agencies and the Statewide Clinical Outreach Program for the Elderly (S-COPE), which may be able to provide assistance or training for the facility on meeting behavioral health needs of residents.

S-COPE is a program that provides specialized clinical consultation, assessment and intervention for older adults who have primary diagnoses of dementia with behavioral disturbances, and who are at risk of psychiatric hospitalization.  S-COPE can provide individual resident assessment before situations reach a crisis point and educate facility staff to better handle these situations in the future.  S-COPE representatives can be reached at 1-855-718-2699 to provide assistance to LTC providers 24 hours a day, seven days a week, including holidays. 

For advocacy in a long-term care facility and many licensed community settings, contact the Office of the Ombudsman for the Institutionalized Elderly at 1-877-582-6995.

For concerns of abuse of a vulnerable adult living in the community, please contact Adult Protective Services of New Jersey at 1-800-792-8820 or NJ EASE at 1-877-222-3737.

Bonifas, R and Frankel, M. (2012a). Senior bullying:Guest post, My Better Nursing Home, Posted by Dr. El Feb.8,2012.  http://www.mybetternursinghome.com/senior-bullying-guest-post-by-robin-bonifas-phd-msw-and-marsha-frankel-licsw/

Bonifas, R and Frankel, M. (2012b). Senior bullying, Part 2: Who bullies and who gets bullied? Posted by Dr. El Feb.21,2012. My Better Nursing Home. http://www.mybetternursinghome.com/senior-bullying-part-2-who-bullies-and-who-gets-bullied/

Bonifas, R and Frankel, M. (2012c). Senior bullying, Part 3: What is the impact of bullying?Posted by Dr. El March 6,2012. My Better Nursing Home. http://www.mybetternursinghome.com/senior-bullying-part-3-what-is-the-impact-of-bullying/

Bonifas, R and Frankel, M. (2012d). Senior bullying, Part 4: Potential interventions to reduce bullying.  Posted by Dr. El March 23,2012. My Better Nursing Home. http://www.mybetternursinghome.com/senior-bullying-part-4-potential-organizational-level-interventions-to-reduce-bullying/

Bonifas, R and Frankel, M. (2012e). Senior bullying, Part 5: Intervention strategies for bullies. Posted by Dr. El April 12,2012. My Better Nursing Home. http://www.mybetternursinghome.com/senior-bullying-part-5-intervention-strategies-for-bullies/

Bonifas, R and Frankel, M. (2012f). Senior bullying, Part 6: Strategies for targets of bullying.  Posted by Dr. El May 4,2012. My Better Nursing Home. http://www.mybetternursinghome.com/senior-bullying-part-6-strategies-for-targets-of-bullying/

Kreimer, S. (2012, March). Older adults can be bullies, too.  AARP Bulletin http://www.aarp.org/relationships/friends-family/info-03-2012/older-adults-can-be-bullies-too.html