Can We Help Our Elders?
By Edward D. Miller,
M.D. and Sue Donaldson, Ph.D., R.N.
In September Ed Miller's
mother-in-law Mary Louise Engelhart lost her long battle with lymphoma.
She left behind her 90-year-old husband, Lawton, still vigorous and living
independently in the elegant South Carolina retirement community where
he had recently moved.
Then, in January,
Lawton Engelhart developed diverticulitis. When he failed to answer the
phone, Ed's wife, Lynne, learned that her stepfather had fallen in the
bathroom, injured his hip and been lying on the floor unable to move.
Engelhart was put in the nursing facility at the residence, lost 10 pounds,
became incontinent and spent his days slumped in a wheelchair. The staff
physician believed he'd need electroshock therapy to treat his depression.
At the urging of Sue Donaldson,
dean of the School of Nursing, the
Millers brought Engelhart to Roland
Park Place, an assisted-living facility
in Baltimore. Donaldson felt this
step was crucial because the Millers
had been rebuffed by the South Carolina
facility when they tried to become
involved in Engelhart's care. Hopkins
internist Bill Schlott examined
Engelhart and took him off all medication,
and almost immediately, he started
eating. In three days he gained
five pounds and began responding
to the world. Today, Engelhart reads
the newspaper, revels in watching
Tiger Woods on TV and is using a
Miller's experience with his father-in-law
inspired the dean/CEO to invite
Donaldson to talk about the problems
we face in caring for an aging population.
What struck me most about what we went through is that I know the system
and have the resources and I still was asking for help. What happens to
people who don't have resources and want to put a loved one in a good
Sue Donaldson: Nursing has been training geriatric nurse practitioners
to work with families on these problems. They help evaluate the resources,
look at the person and determine what will make them happiest. But nursing
is not going to meet all of those medical needs. There must be a partnership
between medicine and nursing.
EM: What I keep thinking about is that my father-in-law would have
been dead in two weeks if he'd stayed down there. He was living a maintenance
existence. And no one was interested in listening to anything that we,
the family, had to say.
SD: If a facility that bills itself as assisted living or a nursing
home makes you feel like you have to beg for information about your loved
one's status, then something is wrong. Good facilities welcome families.
You want and need them as a part of the team.
EM: The thing that surprised me most is that it's called "assisted
living." Lawton didn't need to be in a hospital; he needed a lifestyle
that would help him return to some of the independence that he had before.
SD: What you experienced with your father-in-law was a status change.
You saw an abrupt shift in his functioning, and clearly his caretakers
at the time did not help him come back up to his previous level. When
something happens like that, a broken hip say, it's often to an elderly
person who has been living successfully on their own, and it takes away
their independence. Most falls occur in the bathroom, by the way. We discharge
elders from the hospital very quickly now, but studies show that if they
receive transitional services at home for a week or two they begin to
improve. Without those services, they usually go into a nursing home and
EM: It seems to me that before that's necessary an advanced nurse
could simply coordinate a range of services to help this older person
regain independence. It's the simple things that count most, like getting
the person up out of a chair to walk. Making them feel safe.
SD: The name of the game is not to lose too much during these transitionsto
recover. You need someone to come to the house perhaps daily to do a short
evaluation, to help with bathing, to make sure the person is eating and
able to get around. Literally assisting them with personal hygiene. You
couldn't afford to continue such intense services for a long time, but
in the short term it allows an older person to reorient.
EM: The other thing that would be helpful is to instruct the family
in how to use their time most valuably when they have someone in assisted
living. One of the things we are facing now is knowing how often we should
visit Lawton. I told my wife that I would try to see him three or four
times a week for 45 minutes. But it would be nice to have someone tell
me if it might be more effective if I came in a few more hours on Saturday
and skipped during the week.
SD: Every elder needs an advocate. That's the best health management.
I think, Ed, that you've intuited what needs to happen exactly right.
Short, more frequent, visits work very well.
EM: It seems to me that we should be advocating to put systems
in place, perhaps require more graded levels of care for the elderly.
It makes sense economically as well as medically. If you save somebody
through prevention or early intervention, you cut back on the number of
admissions to the hospital.
SD: We need legislation and also education. There are some questions
that everyone should ask in choosing an assisted living facility with
transition into a nursing home: Who makes the decision whether or not
I can live independently? If I go into a bed at a nursing facility, do
I immediately lose my unit so I can never go back? So many things can
happen to an older person during these transition stages that can be so
disruptive in terms of who they are, who they relate to. It's a cruel
EM: What I've learned is that this is an area that needs more research,
measurement of outcomes, on how to do it better. This, I believe, is the
contribution the School of Medicine in collaboration with the School of
Nursing can make.