Tai Chi Boosts Quality of Life in Heart Failure

By Nancy Walsh, Staff Writer, MedPage Today

Heart failure patients may experience improvements in their quality of life and mood by participating in a tai chi exercise program, a randomized study suggested.

The small study of patients with chronic systolic heart failure found that disease-specific quality of life -- measured on the Minnesota Living with Heart Failure Questionnaire -- showed benefits among those who took tai chi, with scores falling from a median of 28 at baseline to 9 at 12 weeks, according to Gloria Y. Yeh, MD, of Harvard in Boston, and colleagues.

Participatory Action Research for Culture Change

by JOHN DAVY

The culture change movement brought a much-needed emphasis on the dignity and humanity of those receiving long-term care. Research has identified many outcomes of culture change—reduction in over-medication, more home-like environments in LTC, improved social life for residents, and many other targeted benefits. However, as an article in the most recent Gerontologist notes, “little evidence suggests that elders them­selves have participated in the identification of areas in need of improvement within their LTC communities and in the development of culture change initiatives.” (Shura et al 2011). This article presents a study that involved older adult residents directly as experts and participants in implementing culture change in LTC.
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What Is Nursing Home Quality and How Is It Measured? - The Commonwealth Fund

Authors: Nicholas G. Castle Ph.D., M.H.A., A.G.S.F., and Jamie C. Ferguson, M.H.A.

Journal: The Gerontologist, August 2010 5(4):426–42

Contact: Nicholas G. Castle, Professor, Graduate School of Public Health, University of Pittsburgh, castlen@pitt.edu

Summary Writers: Jennifer Dunham

The Issue

Numerous indicators are used to assess the quality of nursing home care, and there are many initiatives focused on quality improvement in nursing facilities. Questions remain, however, about the accuracy and effectiveness of these indicators and initiatives. Meanwhile, quality problems remain common.

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What the Study Found

The authors reviewed a range of quality indicators and improvement initiatives, including those used in the Facility Quality Indicators Profile Report, the federal Nursing Home Compare Web site, the Advancing Excellence in America’s Nursing Homes campaign, and deficiency citations issued as part of the Medicare and Medicaid certification process. Their analysis shows that all employ a mixture of structural, process, and outcome measures, "each of which has noted advantages and disadvantages."

Looking ahead, the health care reform law will require nursing homes to disclose ownership and financial information, as well as quality data on a Web site. Additional steps recommended by the authors include integrating nursing homes with the larger system of long-term care, enhancing current quality improvement initiatives, and upgrading the nursing home certification process.

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Conclusions

Improvements in nursing home quality have "likely occurred," the authors conclude, but more improvements are still needed.

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Lay Down

My sense of directions abandons me when I look for Samuel’s home number. After a few turns in his street, I surrender.   I park my Honda and find my way on a sunny and windy early afternoon. As soon as Samuel unlocks the door to his one-bedroom apartment, he asks me where I parked. He then invites me to park exactly in front of his building as he already told me over the phone. Without a word, I turn on my heels, walk back to my car, and park it right beneath his living room. As soon as I turn off the ignition key, he gives me the thumbs up from the rectangular windowpane.

Back in the living room, I make myself comfortable on the couch, the back of my head against the window facing the street, my green car, and a young tree. Samuel sits on a wheelchair right in front of my eyes. He switches off the TV on the side. He is an 88-yearold veteran with a deep and infectious laugh and an unrelentless faith in God. Formerly married, he has been living alone for 40 years. In his hands, almost anything becomes either a sign of God’s will at work or a source of banter. For example the supreme cleanliness and tidiness of his apartment is a sure sign that he does not need to marry anymore since his outstanding home care worker takes care of him much better than any wife.


I ask him why he needs a wheelchair. The story of his falls and a major surgery reveals that when he fell, his next-door neighbor rung one of his daughters because she noticed that at night the light in the living room was on but nobody picked up the phone. His neighbor has always an eye on him. In his words:

“How you doing?” She calls me. And then, in the night, “Close your windows; close your shades.” She’d tell me that all the time.

Curious, I ask why he needs to close the shades. He replies:

Guys drive-by and shoot. I see guys, some of these guys, up here drinking, and using that dope. And they don’t care; they’re shooting at one another. They don’t have to be shooting at you. […] They don’t care who they’re shooting, they just be shooting. And some of them don’t know how to shoot.

Formerly married, he has been living alone for 40 years. In his hands, almost anything becomes either a sign of God’s will at work or a source of banter. For example the supreme cleanliness and tidiness of his apartment is a sure sign that he does not need to marry anymore since his outstanding home care worker takes care of him much better than any wife. I ask him why he needs a wheelchair. The story of his falls and a major surgery reveals that when he fell, his next-door neighbor rung one of his daughters because she noticed that at night the light in the living room was on but nobody picked up the phone. His neighbor has always an eye on him. In his words:

“How you doing?” She calls me. And then, in the night, “Close your windows; close your shades.” She’d tell me that all the time.

Curious, I ask why he needs to close the shades. He replies:

Guys drive-by and shoot. I see guys, some of these guys, up here drinking, and using that dope. And they don’t care; they’re shooting at one another. They don’t have to be shooting at you. […] They don’t care who they’re shooting, they just be shooting. And some of them don’t know how to shoot.

My ears suddenly become more alert to the sounds of the street. Samuel continues:

So I always hit the floor when they start shooting. That’s the best thing you can do, when they start shooting. Lay down. You can get hit anyway, but this is safer. Fall on the floor. You have all the bullets have to go through a lot of stuff before they get to you. If you open the window, the bullets will go through that easy.

Samuel tells me how much he usually enjoys looking at the tree outside, but his neighbor would then tell him “Stay out the window.” Maybe he learned from his guardian-neighbor to insist on the right spot where I should leave my car when he remarks:

“Just like I told you when you came in here, I said I be the one to guide you.”

[One of  six stories on living alone in San Francisco published in Elena Portacolone’s monthly column in the newsletter of Planning for Elders -September 2010 – February 2011 The project is part of the UCSF Community Partnership Initiative]

Running Strong

Get your running shoes on and get ready to be inspired. Ida Keeling, a 95-year-old great-grandmother from the Bronx, set a sprinting world record with a time of 29.86 seconds in the 60-meter year dash last week in Manhattan. And this isn’t her first record-breaking time. Three years ago, Keeling set a record for the 90-and-over age group by running 50 meters in 31.80 seconds.

Over 90 & Loving It

Clearing the Fog in Nursing Homes - NYTimes.com

Image via CrunchBase
By PAULA SPAN

“What’s people’s biggest fear? Being a ‘zombie’ in a nursing home,” said Laurel Baxter, the Awakenings project manager.

Any visitor can see what she means. Even in quality nursing homes, some residents sit impassively in wheelchairs or nod off in front of televisions, apparently unable to interact with others or to summon much interest in their lives. Nursing home reformers and regulators have long believed that this disengagement results in part from the overuse of psychotropic medication to quell the troublesome behaviors that can accompany dementia — yelling, wandering, aggression, resisting care. For nearly 25 years, federal law has required that psychotropic drugs (which critics call “chemical restraints”) be used only when necessary to ensure the safety of a resident or those around her.

The drugs can cause serious side effects. Since 2008, the Food and Drug Administration has required a so-called black box warnings on their packaging, cautioning that they pose an increased mortality risk for elderly patients. Nevertheless, a national survey reported that in 2004 about a quarter of nursing home residents were receiving antipsychotic drugs. (Among the antipsychotic drugs most commonly used in nursing homes are Risperdal, Seroquel and Zyprexa.)

Though they may be prescribed less frequently following the F.D.A.’s warnings, these drugs are still overused in long-term care, said Dr. Mark Lachs, chief of geriatrics at Weill Cornell Medical College. And once the pills are prescribed, residents keep taking them. “They get perpetualized, like insulin,” he told me, even though the behaviors they’re meant to soothe may wane anyway as dementia progresses.

“If a place is understaffed, if it takes particularly unruly patients, you can see how it happens,” Dr. Lachs added. “Behavioral interventions are far more time-consuming than giving a pill.”

Nevertheless, Ecumen’s Awakenings project emphasizes nondrug responses. “Medications have a place, but that shouldn’t be the first thing you try,” said Eva Lanigan, director of nursing at the Two Harbors facility.

So the home trained its entire staff (housekeepers, cooks, dining room servers, everyone) in a variety of tools to calm and reassure its 55 residents: exercise, activities, music, massage, aromatherapy. It taught people the kind of conversation known as “redirecting” — listening to elders and responding to them without insisting on facts that those with dementia can’t absorb or won’t recall.

“The hands-on, caring part is the most important,” Ms. Lanigan said. “Sometimes, people just want a hug. You sit and hold their hand.”

At the same time, consulting with a geriatric psychiatrist and a pharmacist, the home began gradually reducing the doses of antipsychotics and antidepressants for patients whose families agreed. Among them: the woman with the mysterious cries.

As Dr. Lachs pointed out, behavioral interventions are labor-intensive. Two Harbors hired an additional nurse to oversee those efforts, and Ms. Lanigan was available to answer staff questions around the clock. Ecumen estimates that introducing the program to a 60-bed nursing home cost an additional $75,000 a year for two full-time employees.

The results startled even the believers, however. Every resident on antipsychotics (about 10) was able to stop taking them, and 30 to 50 percent of those taking antidepressants also did well without them. When drugs still seemed necessary, “we tried to reduce them to the lowest dose possible,” Ms. Lanigan said.
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Occupancy and Revenue Gains from Culture Change in Nursing Homes

by Saher Selod

Long-term care communities are undergoing innovative changes in order to improve the quality of life of their residents. “Culture change” is an example of a new practice being implemented in many of the communities around the United States. One of the ways long-term care communities are changing is by moving from a “provider-directed” model (focusing on the institution) to a “person-centered” model where the residents are able to participate in the majority of their daily decisions.
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Book Review Of Never Say Die: The Myth And Marketing Of The New Old Age By Susan Jacoby | The New Republic

by Sherwin B. Nuland

One evening a few months before my eightieth birthday, I found myself addressing an audience of approximately a hundred men and women on a topic to which I have devoted considerable study during the past decade or so. My subject was the process of aging, and the ways in which current gerontological research is teaching us to deal with it. It is hardly remarkable that such a theme would engage a group whose average number of years on this earth appeared to be approximately sixty-five, especially when the speaker is a rising octogenarian known to have written abundantly about such matters.

During the course of my talk, I focused—as does much of the recent scientific, clinical, and general literature—on the optimistic. I stressed the role of determination and conscious effort in combating certain of the ravages that nature inflicts on those of us in the latter decades of life. I spoke of the importance of physical exercise, the creativity that comes with continued intellectual exploration, the critical importance of a personal sense of closeness to family and the surrounding community. Such essential patterns of living are easily explained, and they were more or less familiar to the upper-middle-class audience of friends and benefactors of the university medical center to which I had been invited.

But I also described newer and more abstruse matters, such as our present understanding of the brain’s plasticity, which allows it to change and even to improve not only its ability to function but also its actual microscopic structure, and to do so regardless of chronological age. Even more remarkable, I pointed out, was the laboratory identification of protein substances produced during the exercise of mind and muscle, such as brain-derived neurotrophic factor (or BDNF), which acts to protect neural connections and to enlarge their number and strength while increasing blood supply to the cortex and encouraging the conversion of adult stem cells into cortical nerve cells. The message I delivered was this: the key to continuing productivity is continuing productivity. It is, as the late Ann Landers famously said about a particularly intimate problem of aging, “Use it or lose it.”

Not unexpectedly, following the delivery of such a buoyant message to such an audience, the applause was enthusiastic. But then a hand shot up, whose owner was a red-faced, chokingly angry man in the first row who appeared to be about sixty years old and to have deliberately disregarded the instructions on the event’s invitation that gentlemen wear business attire. Windbreaker askew, he was already halfway out of his seat and still impatiently rising before I was able to acknowledge him. I cannot recall the exact outpouring of words that he more spewed than spoke, but they were very much like the following, if a bit less organized: “What you’re saying is all very well, but don’t you realize that it applies only to men and women of means and education? The vast majority of the elderly don’t know about these things, and couldn’t afford them in any event. They often live alone and friendless or in some publicly subsidized care facility. Your ideas are suitable only for the more favored of older people. Society neglects everyone else and doesn’t care about them. Maybe you don’t, either.”
.....
All of this is by way of introducing Susan Jacoby’s disturbing and important book. Her focus is not at all on the advances that gerontological research has made in improving the health, happiness, and sometimes the longevity of much of our older population. She prefers to look into “the uncharted perils that lurk in the region of old age” and the self-delusion of “the expectation that things are going to turn out well if we only conduct ourselves well.” The notion that many of the elderly can postpone or even prevent much of the physical and mental deterioration associated with an increasing life span is, by Jacoby’s lights, the result of “myth and marketing.”

Never Say Die will stir up controversy, but it will also draw attention to social issues often ignored in our enthusiastic promotion of the health-sustaining values and behaviors in which we have placed so much faith in recent years. The book is in this way an important corrective to those of us who are so taken with the realization that conscious will and a determined approach are valuable resources that we forget the unpalatable fact that we live in a multi-tiered society in which the best will in the world, and the most determination, are limited by the reality of the actual circumstances of life.

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How Do You Feel About Aging? Secrets From Ladies In Their 60s

Proof from the wise and silver-haired set that personal style advances with age.

Ari Seth Cohen is the creator of Advanced Style. He roams the streets of New York looking for the most stylish and creative older folks. Ari says "Respect your elders and let these ladies and gents teach you a thing or two about living life to the fullest."

Advanced Style Videos show a more in depth look into the lives of the wonderful people featured on the site. Made by Ari Seth Cohen and Lina Plioplyte these videos allow our wonderful friends to share their own voice and opinions about personal style.


ADVANCED STYLE

End-of-life Consultations

Making End-Of-Life Decisions Is Hard On Family Members - Kaiser Health News

By Michelle Andrews

Most people would agree that when the time comes, they want a "good death." But what that means is all too often left up in the air until a crisis strikes or the stricken person is no longer able to communicate his wishes or his advance planning documents are not clear. When that happens, spouses, adult children, siblings and others find themselves in the unenviable role of surrogate decision-makers, trying to divine, sometimes with very few facts and under very emotional circumstances, what people they love would have decided to do if they were able to choose.

The critical role of the surrogate decision-maker deserves more attention and support, say experts. It's incredibly stressful -- on a par psychologically with having your house burn down, says Daniel Sulmasy, a professor of medicine and ethics at the University of Chicago Divinity School and co-author of a commentary on surrogate decision-making in the Nov. 3 issue of the Journal of the American Medical Association. Too often, hospital staff and clinicians want to move into the decision-making phase without taking into account the family members' need to come to terms with the situation, he says.

It's a role that many of us may have to step into. Only about one in four people have signed advance directives that spell out their wishes if they're unable to make medical decisions on their own, according to a 2006 report published by the Pew Research Center for the People & the Press.
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Daily Number: 80% - Boomer Gloom - Pew Research Center

As the first members of the Baby Boom generation reach the age of retirement, pessimism and gloom are pervasive on a number of fronts. While some of the negativity is related to aging -- the demands and stress related to middle age are not pecular to any generation -- Boomers have long trailed other age cohorts in life satisfaction. Currently, Baby Boomers are the most downbeat on the state of the nation. Fully 80% of adults ages 46 to 64 are dissatisfied with the way things are going in the country today -- just 15% are satisfied with the direction of the nation. While still substantial, such concern is significantly lower among other age groups: 60% of those ages 18 to 29 (Millennials) and 69% of those ages 30 to 45 (Generation Xers) are dissatisfied with the country's trajectory. Boomers also have little optimism about their personal state or their children's future. Some 21% of Baby Boomers say their own standard of living is lower than their parents' was at the age they are now, while more than a third (34%) believe their own children will not enjoy as good a standard of living as they themselves have now. Far fewer non-Boomer adults -- both younger and older -- expressed such gloom and doom. Read more

Fear Exhilaration and Fallling from Great Heights — This Old Brain

Image via Wikipedia
by Mike

I saw Sting, the perennial musician and rock star, interviewed on a morning program not too long ago. Sting’s career has included songwriting, singing, acting, producing and he’s been doing this for 30-40 years. He is now going to be producing some of his music with the Berlin Philharmonic as his band.

“My fans are always curious about what I’m going to do next. I want to keep them curious.” ~ Sting

The interviewer asked him why he kept challenging himself. He had certainly done all he needed to do to prove himself. Isn’t it best to bow out when you’re still popular? the interviewer asked. His answer, honestly, left me breathless. He said he knew life would be all over someday, that at some point we all fall. He just didn’t want to fall off the bottom rung of the ladder.

Falling From Great Heights

I would rather burn flying too close to the sun than to sit uncomfortably on my laurels. When it comes time, as it will for all of us, I want to be going over the top of Victoria Falls, not seeing my sad reflection in a slow moving stream.

How about you?

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Style Without End - NYTimes.com

Image via CrunchBase
By PAULA SPAN

Ari Seth Cohen can probably blame his fascination with glam older women on his grandmothers.

His mother’s mother, whom he describes as “my best friend, growing up,” successfully lobbied for him to leave Seattle, where he’d been working in galleries and in a men’s store, and to move east. “She always told me New York was where everything is happening, and if I wanted to do something creative, I should be there,” he told me.

His father’s mother was a fashion plate who took him shopping at Escada. “She wore beautiful suits and jewelry, a very elegant woman,” Mr. Cohen recalled.

When he did move to New York, initially taking a job in a museum bookstore, he noticed a number of idiosyncratically chic older women on the streets. He took to carrying his Canon Rebel digital camera with him everywhere, snapping their photos. The result is the blog Advanced Style, launched in 2008, which declares itself “proof from the wise and silver-haired set that personal style advances with age.”

“Older people are comfortable in their own skin, and they wear their style with confidence,” Mr. Cohen explained, sounding a bit envious. He’s a mere 29.

That appearance matters, at least to a number of old people, is something lots of nursing home, assisted living and adult day staffers can testify to. There’s a reason so many of these facilities have beauty salons on site, a reason many women cling to their red lipstick and hair color when even walking becomes difficult.


I often hear complaints about the limited range of clothing designed for older women who disdain pastel velour tracksuits. You won’t see a lot of those on Advanced Style.

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Can Good Care Produce Bad Health?

Excerpts from the Amy Berman post on the John A. Hartford Foundation blog

For those of you who haven’t yet heard, I have recently been diagnosed with Stage IV inflammatory breast cancer. This rare form of breast cancer is known for its rapid spread. True to form, it has metastasized to my spine. This means my time is limited. As a nurse, I knew it from the moment I saw a reddened spot on my breast and recognized it for what it was.

My recent journey through the health care system has been eye-opening. In only a few months, I have witnessed the remarkable capabilities and the stunning shortcomings of our health care system firsthand. I am writing here because in the time I have left, I hope my story and my journey can help illustrate why some of the reforms that my colleagues and I at the John A. Hartford Foundation, as well as many others, have championed are so important.

. . .

Based on a perverse set of metrics, the Philadelphia oncologist was offering technically the “best” care America had to offer. Yet this good care was not best for me. It wouldn’t give me health. Instead, it might take away what health I had. It doesn’t matter if care is cutting-edge and technologically advanced; if it doesn’t take the patient’s goals into account, it may not be worth doing.

. . .

I was determined not only to choose treatment that would maximize the healthy time I had remaining, but also to use that time to call on our health care institutions and professionals to make a real commitment to listening to their patients. In the health policy field, we call this patient-centered care. As a nurse and a senior program officer at a health care foundation, I understood my disease and my health care options well enough to make an informed decision about my treatment.

What about the millions of older Americans facing a terminal illness or chronic disease? How can they possibly stand up to the juggernaut of our health system and say, “No. I want care that focuses on my goals, care that is centered on me.” We need to make it easier for everyone to obtain care that fits their health care goals. How can we change the system and the measurement of quality to place the patient at the center? I call on everyone involved in health care practice and reform efforts to give serious thought about how we can reorient our health care system toward patient-centered care.

Read the full post at The John A. Hartford Foundation blog

Reform Plans Encouraging for Long-Term Care Facilities | NewsOK.com

Image by programwitch via Flickr
BY JIM KILLACKEY Oklahoman

If, when and how much Obamacare is overturned or modified, Oklahoma seniors need to be concerned about aspects of the health care reform package that directly affects their interests and those of elderly family members and friends. At issue is improving quality and safety at all of the state’s long-term care facilities: nursing homes, assisted-living centers, adult day-care centers, residential care homes and others.

Some $777 million is being used nationally during the next four years to institute reforms ranging from new criminal background checks of employees by using fingerprinting; the immediate reporting of crimes in long-term care facilities to law-enforcement agencies; tougher financial penalties for not reporting crimes of abuse; and penalties against long-term care administrators who retaliate against whistleblowers.
Facilities with repeated “noncompliance issues” will be inspected every six months instead of longer periods between inspections of long-term care locations.

“I like so much of this,” said Esther Houser, state ombudsman who’s considered the top advocate for nursing home residents and their families. Most of the reforms start in 2011 and 2012. Oklahoma currently has about 20,000 residents in 325 nursing homes. The state also has another 11,500 licensed beds for people occupying assisted-living centers, residential care facilities and intermediate care facilities for the mentally handicapped.

As Houser noted, Obamacare provides improved disclosure requirements related to nursing home ownership. “Many owners now hide behind various corporate disguises, and it has been harder for the average person, let alone enforcement agencies, to identify the true owner,” she said.

The law stipulates improvements in new compliance and ethics standards for nursing facilities intended to identify criminal or other violations. Improvements to the current www.Medicare.gov “Nursing-Home-Compare” website are being sought to provide better information for consumers.

There are benefits, too, aimed at helping long-term care centers that have high staff turnovers. There’s planned a study by the Center for Medicare and Medicaid Services, or CMS, on establishing a National Nurse Aide Registry.

There’ll be incentives to attract and support new direct-care workers for long-term care settings.

Many pros and cons exist about Obamacare requirements affecting long-term care facilities.
Full Article

Letters to the Editor Responses to Really Old Age - There’s No Denying It - NYTimes.com

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“Real Life Among the Old Old,” by Susan Jacoby (Op-Ed, Dec. 31) The New York Times received  a number of letters to the editor in response to the Op-ED.
The Letters

Comparing Resident and Family Opinions about Nursing Home Satisfaction | Aging In Action

by Saher Selod on January 4, 2011

Nursing homes routinely survey their residents and family members about their performance. Previously, little was known about how well the opinions of family and residents coincide with other measures of performance, specifically, findings from the state surveys regarding regulatory compliance.

A new study published in the Seniors Housing and Care Journal compares how residents and family members rate nursing homes to findings on the state survey of their nursing home

Researchers from My Innerview analyzed data from two surveys of over 8,000 long-term care organizations annually. Data from a total of 89 nursing homes (located in 30 states), 18 from 2006 and 61 from 2001, were analyzed. Family and resident responses were compared and contrasted to see if their opinions about the nursing home would converge and to determine what mattered more to each, quality of life (QoL) or quality of care (QoC). Then data from the state inspection survey, Online Survey, Certification and Reporting (OSCAR), was compared to the results of family and resident surveys. Three outcomes were derived from OSCAR data: deficiencies in a nursing home’s compliance with health-related standards cited by surveyors, characteristics of its residents as recorded by surveyors, and its organizational characteristics.

Overall, families and residents had high ratings for their nursing homes and interestingly, whether they would recommend the nursing home to others was highly correlated with the compliance measures from the state surveys. Both families and residents believed that staff show respect and ensured resident safety, as well as the nursing staff providing a high quality of care. Both residents and their families were least satisfied with the adequate numbers of nursing staff.

The biggest differences lied in how families and residents rated the specific areas of nursing home life. Residents gave most areas of nursing home life a more positive rating compared to families. Residents were more concerned with QoL issues, whereas families were more concerned with issues of QoC. The families’ recommendation of their nursing home had a higher correlation with the measures of compliance compared to the residents’ recommendation.

Comparing Resident and Family Opinions about Nursing Home Satisfaction | Aging In Action

Eden Moves HQ to New York « ChangingAging.org

by Dr. Bill Thomas

The Eden Alternative is moving its headquarters from Texas to Rochester, NY. Kudos to new Eden CEO Christopher Perna. And double kudos to the Rochester Biz Journal for posting an in depth report on Eden’s move and central role in the culture change movement: Read More