Kristen Mauk

What is assisted living (AL)?
A Scandinavian model for senior care, now known as assisted living, made its way into America’s care system in the 1980’s. According to a 2012 report by AARP, there is no standard definition for assisted living (AL). Although individual states and residential facilities can give their own definition of AL, the term most often means that help is provided with meals, social support, medications, dressing and/or bathing and the like with 24-hour per day supervision. The Assisted Living Federation of America (ALFA) (2013) defines assisted living as “a long-term care option that combines housing, support services and health care, as needed”. The focus of AL is on maintaining dignity, respect, and independence of older residents.

In 2010, there were more than 51,000 licensed residential care settings (including assisted living) that reported more than 1.2 million beds (AARP, 2012). A study published by the National Center for Assisted Living (NCAL) cited 31,100 assisted living facilities serving 733,400 persons in 2010.

What is the typical assisted living resident like?
The average age of those in assisted living facilities is 86.4 years (MetLife, 2012). According to the National Center for Assisted Living (2013), the typical resident needs help with at least one activity of daily living (ADL), and most are over the age of 85. More females (76%) live in assisted living settings than males (26%). Thirty-seven percent of persons in AL receive help with more than three ADLs (NCAL, 2012). More than half of persons in AL facilities have some type of cognitive impairment (Alzheimer’s Association, 2009). A growing percentage of persons in AL facilities have Alzheimer’s disease.

What types of services are provided?
Some of the usual services provided in a licensed AL include:
• Assistance with eating, dressing, bathing, toileting
• Access to health services
• Medication management
• Dining services
• 24 hour staffing and security
• Emergency call systems
• Exercise and wellness facilities
• Social and recreational activities
• Housekeeping and laundry
• Transportation
• Access to banking
• Chaplain or religious services
• Memory care

How do I know if I need assisted living?
There are a variety of reasons why persons might choose an assisted living setting. Some people move to AL because they want more socialization than living alone, they want to be nearer to their adult children but do not reside with them, or because they can no longer manage at home. The person in an assisted living facility generally needs some help with activities of daily living, but does not need skilled nursing care. So, AL might be right for you if you wouldn’t be able live at home any longer without help, but you still don’t need to be in a nursing home or need the help of a nurse around the clock. You may be able to do many things on your own but maybe you have difficulty with dressing, meal preparation, or managing your pills.

How do I decide which senior living community to choose?
There are a variety of senior living options, of which assisted living is but one. Often, family members will help you decide which option is best for you, but you should look at all your choices. You should pick a place that offers the services that you need. Cost and location are additional considerations. It is also good to ask about the staffing ratios, what nursing care is available, and what happens if you later need a higher level of care than the AL provides. ALFA provides a Guide to Choosing an Assisted Living Community. This includes a helpful checklist that can be downloaded from their website.

How much does it cost to live in an AL facility?
The cost of AL depends on where you live. Keep in mind that most assisted living is paid for privately, meaning out-of-pocket, and not by insurance. According to MetLife’s Market Survey of Long-term Care Costs (2012), the national average base rate for assisted living was $3,550 per month. This means that a person who lives in an assisted living facility can expect to pay an average of $42,600 per year. Of course this also varies depending on the number of extent of services with which the resident needs help. The base rate generally includes specific services, but each additional service beyond that may add an extra monthly fee. Compare this to an average nursing home rate for a shared room at nearly $84,000 per year for a person needing Alzheimer’s care (MetLife, 2012) or a national median cost of $270 per day in a nursing home that provides 24-hour per day nursing care (Genworth Cost of Care Survey, 2013).

Are there alternatives to assisted living facilities?
So, are there other options besides going to an assisted living facility if you are an older adult who needs a little help? The answer is yes. Adult day services are one community option. Also, many home care agencies offer companions, homemaker aides, or nursing assistants to help people age in place at home. Most of the time, getting these services means a minimum number of hours per day must be paid for. The national average hourly rate for home health aides was $21 in 2012. Homemaker or companions who provide “hands-off” care such as running errands, shopping, housekeeping made a median of $19-20 the same year (Genworth, 2013).

This is where unique options for assisted living services at home are needed and can save consumers money. Senior Care Central offers persons needing assisted living in the home the opportunity to have more control over their care situation at a much lower cost while getting professional, quality care. Imagine that you could set the hours that you want to have a caregiver in the home, and that caregiver could be a nursing student who has a higher level of education than most home health aides. This care option may cost you half the price charged by a home health care agency. SCC’s model promotes aging in place on your own terms and lets you link with caregivers online, browse profiles to choose caregivers you want to contact, and make your care arrangements directly with them.

I had always heard that kidney stones were the closest thing to labor pain and childbirth that a man could experience, but being a woman who had been through labor four times, I didn’t quite believe it or understand the comparison. That is, until the other day…

I was sitting at the computer writing and felt a pain like a muscle cramp in my right side. But, since I couldn’t recall having done anything strenuous the day before, I just figured I had been sitting too long in one spot. Moving around helped for a brief time until the pain returned, more intense and radiating from the right flank around my side and down to my groin. Hmmm….being a nurse I wondered what this could be so I tried the usual techniques as the pain intensified: Tylenol, the massage chair, walking, lying down, sitting up, and having the kids rub my back. Yikes, the pain that can only be described as an unrelenting, constant hurt of the greatest magnitude, a 12 on the pain scale of 1 – 10, which no positioning or over the counter pain medication can touch had me rolling on the floor and telling the kids to call Dad to come home from work now.

Yes, that was just the beginning of my kidney stone experience. In trying to explain the pain to my husband on the phone, he said I sounded so short of breath that he thought I was having a heart attack and called EMS. When they arrived, the pain had subsided and I was left to diagnose myself with a kidney stone, with which the paramedics agreed. But since the pain was completely gone, did I really need to go to the hospital and in an ambulance no less? On their recommendation, the answer was yes.

In the ER, the IV was started and a CAT scan done to confirm our suspicions. Having no history of kidney stones, I was surprised at this painful attack that came on with no warning at all.

The ER doctor came in to see us and said in a thick accent, “Well, you were right. In 5 – 7 days you will have a special delivery!” he laughed.

I glanced at my husband who had turned white and later told me he thought for a second, “you mean she’s having a baby?!” (which at 53 surely would have been some sort of miracle). My first thought was “5 – 7 days of this pain? Are you kidding me?” How will I survive?

Another painful bout came as I lay on the gurney, and four strong IV medications didn’t completely take away the pain. We were told the pain comes from the spasms of the ureter as the stone blocks the flow of urine and irritates the inflamed tissues. Who could imagine that a 2 mm stone the size of a grain of sand could cause so much discomfort? The word intractable pain had new meaning for me now and I wished I had been more sympathetic to people and patients with kidney stones.

They sent us home with a urine strainer and prescriptions for Flomax and a combination of anti-inflammatories and pain medications. Another attack in the car and all I could do was writhe in pain and pray for relief. My husband kept repeating, “I hope I never get one of those”. It is the type of pain that one would do almost anything to stop but that nothing relieves short of passing the stone.

As I took my pain pills, strained my urine, and drank copious amounts of water to help the delivery along, I had time to reflect on the age old debate of kidney stone pain being akin to labor and childbirth. Having some experience in the childbirth area, I still found no way to compare the two in terms of what hurts more, but here were my reflections:

Labor pains were more predictable and increased with intensity as you moved towards the goal of delivery. Kidney stone pain, on the other hand, was unpredictable and had the most intense pain with every bout.

Doctors can predict when the baby will be delivered by closeness of contractions, and examining cervical dilation and effacement. Kidney stone delivery is much less predictable.
If your baby is too big to be delivered vaginally or there are complications, a C-section can be performed. And if your kidney stone is too big to pass, you may have laser treatment to break up the stones or major surgery to retrieve them. Both can mean painful recoveries.

There are medications they can give you for labor and delivery. You can even get an epidural, which I never had, but am told they can make the experience much less painful. But the kidney stone pain didn’t seem to be completely obliterated by anything short of passing it.

In comparing types of pain, I guess I can see where men would say they come close to labor pain with a kidney stone, but 10 hours of back labor was equally as bad, and having your OB doctor turn your baby internally prior to a natural birth still rates as the #1 pain I have ever had (but at least it was over quickly).

And last, but most significantly, with labor and childbirth you expect and usually earn a wonderful, lasting, happy surprise at the end of the process, where you hold your newborn in your arms and experience the glory of motherhood, quickly forgetting the pain that was endured to have your bundle of joy. Whereas, at the end of your kidney stone passing, you collect a little grain of something that goes into a plastic container for the urologist to later analyze and you can’t believe how much that little devil hurt to get out. You may experience relief and joy at the passing, but there are lifestyle modifications to make to try to avoid it ever happening again, and still without the assurance that it can be prevented, so unlike the conception process. Who, having had one kidney stone, would ever make plans to have another?

Fortunately, my stone did not take 7 days to pass and was gleefully collected in a matter of hours.

So, my answer to the question of which is more painful, a kidney stone or labor and delivery, is a simple one: they cannot be compared. It’s like apples and oranges. Different types of pain, but both extremely intense, though the kidney stone is much more unpleasant because the outcome is not a lasting joy for the rest of your life. Since every person experiences pain differently, no one could really answer this question anyway because pain is a subjective experience.

For me, given the choice between labor and a kidney stone, I pick labor. Childbirth is definitely more fun and with rewards that last a lifetime.

Background

Once thought to be mainly a disorder of children, recurrent seizures or epilepsy is thought to be present in about 7% of older adults (Spitz, 2005) and is usually related to one of the common comorbidities found in older adults (Bergey, 2004; Rowan & Tuchman, 2003). Epilepsy affects up to 3 million Americans of all ages (Velez & Selwa, 2003). Davidson & Davidson (2012) summarized findings of most studies on epilepsy in older adults with these main points:
Seizures can be caused by a variety of conditions in older persons, but “the most common cause of new-onset epilepsy in an elderly person is arteriosclerosis and the associated cerebrovascular disease” (Spitz, 2005, p. 1), accounting for 40–50% of seizures in this age group (Rowan & Tuchman, 2003). Seizures are associated with stroke in 5–14% of survivors (Spitz, 2005; Velez & Selwa, 2003). Other common causes of epilepsy in the elderly include Alzheimer’s disease and brain tumor.
There are three major classifications of epilepsies, although there are many additional types. Generalized types are more common in young people and associated with grand mal or tonic-clonic seizures. A number of cases have an un¬determined origin and may be associated with certain situations such as high fever, exposure to toxins, or rare metabolic events. In older adults, localized (partial or focal) epilepsies are more common, particularly complex partial seizures (Luggen, 2009). In contrast to young adults, Rowan and Tuchman (2003) cite other differences in seizures in the elderly: low frequency of seizure activity, easier to control, high potential for injury, a prolonged postictal period, and better tolerance with newer antiepileptic drugs (AEDs). Additionally, older adults may have coexisting medical problems and take many medications to treat these problems.

Risk Factors/Warning Signs

Risk factors for seizures in older adults include cerebrovascular disease (especially stroke), age, and head trauma. The most obvious signs and symptoms of epilepsy are seizures, although changes in behavior, cognition, and level of consciousness may be other signs. Also, note that exposure to toxins can cause seizures that are not epilepsy. Complex partial seizures in older adults may include symptoms such as “confusion, memory loss, dizziness, and shortness of breath” (Davidson & Davidson, 2012, p. 16). Automatism (repetitive movements), facial twitching with following confusion, and coughing are also signs of the more-common complex partial seizure (Luggen, 2009).

Diagnosis

Diagnosis is made by careful description of the seizure event, a thorough history, and physical. Eyewitness accounts of the seizure incident can be quite helpful, although many community-dwelling older adults go undiagnosed because their seizures are never witnessed. In addition, complete blood work, neuroimaging, chest X-ray, electrocardiogram (ECG), and electroencephalogram (EEG) help determine the cause and type of seizure (National Institute for Health and Clinical Excellence {NICE}, 2012).

Treatment

Treatment for epilepsy is aimed at the causal factor. The standard treatment for recurrent seizures is antiepilepsy drugs (AEDs). The rule of thumb, “start low and go slow,” for medication dosing in older adults particularly applies to AEDs. The elderly tend to have more side effects, adverse drug interactions, and problems with toxicity levels than younger people.
Research has suggested that older adults may have better results with fewer side effects with the newer AEDs than the traditional ones, though about 10% of nursing home residents are still medicated with the first-generation AEDs (Mauk, 2004). The most common older medications used to treat seizures include barbiturates (such as phenobarbital), benzodiazepines (such as diazepam/Valium), hydantoins (such as phenytoin/Dilantin), and valproates (such as valproic acid/Depakene) (Deglin & Vallerand, 2005; Resnick, 2008).
Several newer drugs are also used, depending on the type of seizure. Second-generation AEDs, including gabapentin (Neurontin), lamotrigine (Lamictal), oxcarbazepine (Trileptal), levetiracetam (Keppra), pregabalin (Lyrica), tiagabine (Gabitril), and topiramate (Topamax), are generally recommended over the older AEDs; however, older AEDS such as phenytoin (Dilantin), valproate (Depakote), and carbamazepine (Tegretol) are the most commonly prescribed treatment options (Resnick, 2008). Each of these medications has specific precautions for use in patients with certain types of medical problems or for those taking certain other medications. Regarding side effects in older patients, watch for potential stomach, kidney, neurological (especially poor balance or incoordination), and liver problems. Additionally, some newer extended-release AEDs are thought to be better tolerated and have a lower incidence of systemic side effects (such as tremors) (Uthman, 2004).

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L. Mauk’s (Ed.) Gerontological Nursing: Competencies for Care.Burlington, MA: Jones and Bartlett Publishers. Used with permission.

With the birth of my daughter’s second child, I began to reflect on the important role that grandparents can play in the lives of their grandchildren. Here are five essential tips for older adults who want to have a lasting influence in the lives of their children and grandchildren.

Visit often.  For those of us fortunate enough to live near our children and grandchildren, it is easy to see them often. Grandparents may even be the caregivers while parents are working. Visits don’t always have to be planned. Sometimes the best family time is a spontaneous invitation to dinner and a movie. However, sometimes distance can prevent regular visits. Some grandparents make it a goal to see their distant grandchildren once every 6 weeks or every few months. Be sure to take advantage of technology for your time together. Set a regular time to Skype or do Face-time. Don’t miss out on the subtle changes in those early years while babies are growing. Exchanging pictures may help, but they don’t replace the in-person experience. You may even think of relocating to be closer to family. For older grandchildren, be sure to have their cellphone number. Text them often and exchange pictures to stay involved in their lives and let them know you are available to them. Even small connections throughout the week (but without being annoying to teenagers of course) can make a difference in your relationship with your grandchildren.

Offer to help in practical ways. Working parents with young children will need a break at times. Ask how you can best help. Offer to keep the children for an overnight while mom and dad have a special dinner or weekend getaway. Many grandparents like to take their grandchildren on trips without the parents. Places like amusement parks, the zoo, or day trips to the water park or national forest all provide good diversion and quality time with Grandma and Grandpa while giving parents a rest. For even more quality time, take the older grandchildren on a cruise, camping in the mountains, or to a resort without their parents. For the mom with a newborn, take meals to the house (if you live close), do her grocery shopping or laundry, or send her a new bathrobe to show you are thinking of her. A favorite role model of mine sends the grandchildren a “baby shower in a box” with all sorts of goodies when she can’t be present due to distance or health concerns.

Plan special activities. Special activities need not be expensive. This could mean a trip to the park with Grandma or a special morning walk each week with Grandpa. My father used to take every grandson on a bow-hunting trip when they turned 12 years old. This was a rite of passage for every boy in the family. Grandpa would mount their first deer head for them and buy them a special hunting knife to commemorate the occasion. The girls in the family would take a trip to a Disney resort while the men were hunting. Grandchildren remember these events forever.

Attend special events. How fortunate are the kids whose grandparents are able to attend basketball and volleyball games, swimming tournaments, and Grandparent’s Day at school! Take advantage of being able to attend those dance recitals and school plays. If you live far, plan your visits to be able to attend some significant events like graduations, wedding showers, or school performances. This makes lasting memories with your family.

Be a constant in their lives. My parents divorced when I was 9 years old, and my paternal grandparents were the one constant in my life at that time. When a child’s world is jolted by change, grandparents can be that steadying influence that doesn’t change. They provide stability and security in an unsteady world for a child. The most important thing to remember is to be there. You don’t have to be the all-star parent or grandparent, but your children will remember that you were there for them when it counted the most.

This time of year, many people pause to give thanks for the good things in their life, but did you know that giving thanks is good for your health?

Having an optimistic outlook on life and using positive coping skills to manage stress has been linked in numerous studies to a longer and happier life. One of the common themes among people over age 85 who report very good to excellent health (in spite of dealing with chronic illnesses) is just that – thinking positive. Norman Vincent Peale, in his famous book, “The Power of Positive Thinking” said:

The way to happiness: Keep your heart free from hate, your mind from worry. Live simply, expect little, give much. Scatter sunshine, forget self, think of others. Try this for a week and you will be surprised.

But what if you are not naturally a positive thinker, but more of a “the glass is half empty” kind of person? The good news is that you can begin to change your thinking to improve your health. If you are not sure where to start, consider some of these suggestions as a place to begin:

Count your blessings. There is an old hymn that was sung when I was girl. When I felt down and discouraged, I would sing this song. It went like this:

When upon life’s billows you are tempest-tossed. When you are discouraged thinking all is lost. Count your many blessings every doubt will fly. Then you will be singing as the days go by. Count your blessings. Name them one by one. Count your many blessings. See what God has done.

Sometimes it helps to list what you are grateful for on paper. If you need a place to start, an excellent resource is the book “One Thousand Gifts: Reflections on Finding Everyday Graces” by Ann VosKamp. Through a series of 60 short devotionals, the author walks you through a journey to greater appreciation and thankfulness for all that you have.

Learn to be content with what you have.  At the holidays, especially, it is easy to get caught up in thinking about what we wish we had and those things we don’t have. Try looking at it the other way- even in relationship to your health. For example, several years ago I had a catastrophic skiing accident, breaking my leg and tearing all of my knee ligaments. A subsequent blood clot complication meant that I couldn’t have surgery to repair the knee right away. After being in a wheelchair, on crutches, and in awful pain for months, with the help of countless hours of painful therapy and surgery a year later, I was finally able to walk almost normally again. Every day since then, when I am tempted to complain that I will never ski again, cannot kneel or squat, or do not have complete range of motion in that knee, I remind myself of those months when I couldn’t walk at all without help and how it felt to be completely dependent on others for everything. Each step I take, each walk in the sunshine, each little jaunt to the car, and the ability to ride a bicycle is a blessing. Every movement without pain is a bonus I never thought I would have again. Take time to recall when your situation was worse, and express joy that things are better than they were then.

Help others.  One of the best ways to stop feeling sorry for yourself and cultivate an attitude of gratitude is to serve others, especially those who are less fortunate than you. Volunteer to help serve food at the community Thanksgiving dinner or participate in Operation Christmas Child by making a shoebox for a boy or girl in a developing country who would otherwise have no gifts. Take food to your local food pantry. Mow the lawn or shovel snow for your widowed neighbor. Invite the single and lonely person to share Thanksgiving dinner with your family. Buy gifts through the Angel Tree Ministry for children of those in prison. Adopt a needy family. Even if you are homebound, you can encourage others by simple but meaningful tasks such as sending birthday or holiday cards to the people in your church or community group. A simple encouraging phone call can change a person’s day. By giving to others, you focus on positive parts of life and meaningful activities that in turn promote your positive mental health.

So, this Thanksgiving, push the pause button for a little while and take a moment to reflect on what you are grateful for. You may just find that Thanksgiving is good for your health.