Humanizing the Care of Residents Long Term

Peter A. Lichtenberg, Ph.D., ABPPDirector, Institute of Gerontology

Professor of PsychologyWayne State University

p.lichtenberg@wayne.edu

Thirty Years of Enhancing Personhood

• Look back at behavioral approaches• Examine Eden and Greenhouse models• Examine Personhood models• Understand organizational influences on care• Three C’s of everyday care• Tie it all together and discuss

OLD AGE IS ALWAYS 15 YEARS OLDER THAN I AM

BERNARD BARUCH AGE 84UNITED NATIONS DIPLOMAT

1st cohort toGrow old and beVisible in U.S.

Changes from 100 years ago:Life ExpectancyNumber of eldersIdea of com-Pressed morbidityDementia after 90

My early Experiences in a 180 LTC bed unit

• Referral: “Man throwing himself on the floor due to manipulative tendencies”

• What I observed1. Often lost balance and fell to floor (22 times per

6 hour period)2. Tearful3. Stopped eating—losing considerable weight4. Poor verbal communication skills

What we did

• Got neurology referral—he had untreated PD• Got speech language referral—voc-aid and taught

him to use• Increased his social interactions with staff and

depression remitted

• WHY HAD HE BEEN VIEWED IN SUCH A DEPERSONALIZED WAY?

78 year old man with Schizophrenia

• In state hospital since his early 20’s• Seclusive• Spent entire day lying in bedBehavioral Modification techniques used• Used a shaping technique to increase physical

activity• In one year improved from walking a total of 10

feet to one mile each day

PREVAILING VIEW OF FRAIL ELDERS

Medical v Community/Social model of care: Deficit model

•Passive•Sedentary•Close minded•Lost too much cognitive abilityResults•De- individuation•Fostering of dependency

RODIN AND LANGER (1976)

• Gave more control to residents over day to day events and compared them to control group

• Outcomes—group with choice engaged in more activity, reported more happiness, were rated as more alert

MARQUETTE COUNTY MEDICAL CARE CENTER PROJECT

• Depression Treatment and Prevention in Persons With Alzheimer’s Disease

• Peter A. Lichtenberg, Ph.D., Principal Investigator

MARQUETTE STUDY DETAILS

• New home-like setting created for persons with Alzheimer’s Disease

• Unit de-emphasizes “institutional” behavior and emphasizes individual, client-centered approach to care

MARQUETTE STUDY DETAILS CONT.

• Baseline:• Neuropsychologist blinded to intervention

assessed 23 residents from the 2 new AD units• Geriatric Depression Scale• Cornell Scale for Depression in Dementia• Behave-AD• Clinical Interview & DSM IV Diagnoses

MARQUETTE STUDY DETAILS CONT.

• Marquette County Medical Care designated ½ time person for further baseline work intervention.

• Pleasant Events• Mood Monitoring• Relaxation• Tx. ongoing for 3 months• Reduced behavioral disruption in pleasant events

vs control group

ACTIVITIES ENGAGED IN

• Pampering –massage, aroma therapy, hair care 27%

• Reminiscence-old photos, verbal discussion 22%• Social activity—one to one visiting, small group

18%• Physical activity—walking, fixing, gardening 16%• Quiet activity—watch birds, reading 11%• Correspondence—holiday letters, cards 6%

CONCLUSION

• Personal choice, 1:1 relationships enhanced well being

• Model not practical for broad implementation

Nursing Homes and the Medical Model: Bill Thomas

• Staff Hierarchy much like hospital• 3 Plagues of Long Term Care:1. Loneliness2. Helplessness3. Boredom

Challenge—creating the Eden team concept in a LTC facility

Creation of the Eden Alternative

• 1991 By Dr. William H Thomas and wife Judy Chase Thomas

• Chase Memorial: reduced medications, infections, staff turnover and mortality rate after Eden was put into place

• What makes the Alternative come to Life?

EDEN ALTERNATIVE COMES TO LIFE:

From Parking Lot to Activity Room

• Gardens/landscaping• Children• Animals• Person Centered activities

GREENHOUSE MODEL OF LONG TERM CARE

• Goal is to rethink:• Philosophy of care• Architecture• Organizational Structure of care

WHAT IS IT?

• Independent housing unit for 6-12 people with dementia

• CNAs are called Universal Workers• UW’s organize day in collaboration with residents• Other staff are wrap-around support services• 2006 RWJ awarded $10M across country to

increase number of Greenhouses• HOWEVER policies and funding models do not

provide support for Greenhouse model to expand even more

Greenhouse in Action

CURRENT STATUS OF GREENHOUSE

• 1700 in existence across the U.S.• Staff do more but for fewer people• “Get to know resident as a real person”• Less rigid schedule; meals, bathing• To date: studies show that care is similar to that

found in larger nursing home

Expressions of Personhood

• Pia Kontos and Gary Naglie—U of Toronto• “Expressions” of personhood• “discourse” over-utilized by us all in defining

personhood• Artistic expression under-utilized and appreciated• Current model--- as cognition declines so does

self-hood• Negative views of those with more severe

dementia in long term care and less caregiver engagement

Expression of Personhood Cont.

• Kontos’ ethnographic study claims that selfhood continues even after cognition declines

• Key challenge in LTC: Maintenance of Personhood• Kontos: Selfhood taps into “pre-reflective” levels

of consciousness• Examples: 1. Importance of gesture in communicating2. Body and facial expression3. Items hold unique and personal meanings to

residents

Artistic Expression as Performance

SUMMARY AND QUESTION

• Choice, personhood is important• Wonderful models created across past 40 years• Why is personhood still the exception rather than

the norm in care?

REFRAMING ORGANIZATIONS: BOLMAN AND DEAL

• 4 frames needed to understand organizations and most people only look at 2

• 1. Structural• 2. Human Resource

1. STRUCTURAL FRAME

• Metaphor: Factory/MachineDimensionsDifferentiated or integrated jobsCentralized or diffuse in responsibilityRigid routine/flexibility

2. HUMAN RESOURCE FRAME

• Metaphor: Family• Employees: Replaceable v Valued• Fit between individual and organization

LTC workers—high levels of meaning in work, low participation in team decision making

Structural and HR frame are rational—ways of organizing work and treating workers

3. POLITICAL FRAME

• Metaphor: Jungle• Power—ability to make things happen• Coalitions form—compete for scarce resources• Conflicts—win/win v win/lose negotiators• Power can be coercive and destructive if not used

wisely• (e.g. space shuttle Discovery; Housing crisis;

Nanny cam of Abuse in the Nursing Home)

4. SYMBOLIC FRAME

• Metaphor: Carnival, Temple, Theatre• Meaning• Hope• Faith• Core Values• “Culture in Organizations”• Symbols/rituals

REFLECT ON LTC AND YOUR PLACE OF WORK

• How do 4 frames influence policy, power, structure and meaning?

• Frail persons– weak in terms of powerful coalition; chronic under-funding of LTC

• Stability of administrators in LTC—poorest functioning organizations have least stability in administrators let alone direct care staff

• Negative stereotyping of LTC

PERSONAL HABITS IN DAILY WORK

• Steven Covey: 7 Habits of Highly Effective PeopleBegin with the end in mindSeek to understand before being understoodPut first things firstThink win-win

3 C’S TO PERSON CENTERED CARE

• Curiosity– who is this person, what was their greatest passion, what brightens them up

• Compassion– what is this person’s greatest fear, what causes them to suffer, what grief do they have, how lonely are they

• Contemporaneous– Be mindful in the present, be aware, present in the moment, come to each day ready to engage with residents and colleagues