people in old age get depressed because they do not adapt and develop into who they can be as they actually are...

instead they, and everyone around them, are in mouring for what they used to be and no longer are... they are defined by their losses, their illness, their diablities... almost unlimited resources are thrown at restoring, repairing, healing, rehabilitating, and even more at trying to stop the processes in play... all fear, all to avoid age and death...

it tanks everytime a senior looks at reality in the mirror or in the eyes of someone looking at them through yesterday's lens... small wonder they are depressed

where is the adaptation into age? where is the development into age? Its a normal process, but one not utilized...

I noticed that Baycrest does not identify the most significant source of depression ... people are not actualizing into old age in normative patterns of human development

identifies need to be proactively reformed... self-concepts proactively adapted to reality... self-esteem proactively built on real present potential and self-actualizing within that potential... this should be intentionally undertaken by seniors themselves and their caregivers...

it will usher in a new of old age, in which the aged are authentically celebrated for who they presently are, without reference to the dead past...

Interesting re the cognitive symptoms

Aldo, that is an interesting point you make about transitioning into an older age.  I have been in my congregation for 6 years, more focused on the younger demographics, so I get to know the older folks gradually and more socially.  When I attend a funeral, I am amazed every time at all the person was that I never knew.  We can't walk around with signs on us that says "Hey I also love being in a canoe, and going to rock concerts and roller coasters too, but feed me a cinnamon bun & I"m yours forever."

I once met a lonely elderly man who hung around in a coffee shop daily, with little else to do.  One day we found out he had met Robert Baden Powell (of Scouting) and also had 2 Olympic medals.  Who knew?? 

What can anyone do about that?

Carolla, I'll have a look and try to share them with the right folks.

Thanks for sharing that carolla . . . I just took a quick glance, will go back and read further later.

I believe it's essential to know who someone is, but I also think it's just as important to focus on creating a NOW and concentrate on the future. Nostalgia has it's place,but so many faced with changing directions aren't given direction and so they do languish in the past.

I can't tell you how many places I've been in that have young activity directors that rely on bingo or games that one would only tolerate at a bridal or baby shower. The elderly need to be tapped into in a more creative and adult way IMO. They're bored.

My point goes much deeper... I may take great rpide and be acclaimed for all the things I have done... but to be fulfilled as a person, I need to find self-esteem in what I am today or what I will be in the coming days...

there are no para-olympics or ability frameworks for aged seniors...

I recently saw an 84 year dead lift over 400 pounds... the pride was in that he was still good as compared to the younger lifters... in effect the pride was in denying his present actual self and appealing to how well he is hanging on to his old self...

Christ does not require  major miracles from people, just that they be in Christian in everyday things with the everyday people we encounter at home, in the community or at work...

In the same way, a person wants whatever beauty they have to be authentically valued for what it is today in everyday ways, same thing for all their abilities, skills and person...

But, I do not see it in how aged seniors related to themselves, or how family relates to them, or how we as a community and culture related to the 'natural call' of aging...

How quick we are to sacrifice the old for the sake of the young --- they young have no greater inherent worth than an ancient demented senior. In God's eyes they both of ultimate existential importance... and God treats them that way

... not sure as aged seniors we treat our selves that way or that others treat us that way...

I suggest there is a cultural and social revolution to come

You are right.

The old in residential care are warehoused and dynamically restrained with 'time fillers'.

Though some people/workers naturally value them for who they are and what they can do in the present... I have seen people whose dementia has left them with little interaction with the world except sensory exchange... I have seen the delight in some people's joy at having supported the senior to experience a sensory sensation that they responded to... no depression there. No devaluation there... no self-actualization based how the senior used to be 80 years old as compared to present...

Seniors self-actualize when they undertake activities that they prefer and that feed their present and actual identity, self-concept and self-esteem... the result is in the posture of their facial muscles and sometime in the lilt of their step...

And the truly mentally ill (not the bored, the situationally depressed) fare VERY badly in the residential care system. The complete inability of the system to deal with their unique challenges mean that they are drugged into submission, which further drains what life they have left to them.

... I am suggesting that the truly mentally ill, are ill for the reasons laid out above....

Aldo, I'm thinking more of the genetic diseases with a psychotic component, like bipolar, schizophrenic, borderline personality. My poor gentle mother was known to bite if a mania was allowed to spiral out of control.

.

Aldo, that lifter for me is celebrating self.

If he can do it, then it is him currently not some past self. He hasn't lost himself.

I do not agree with your premise.
I am a continuation of who I was in my 20s, i am discovering new interest and dropping others and rediscovering even more.

I am still me.

yes those folks are in dire straights... but they account for only a small percentage of depression and socially disruptive behaviours in aged seniors...

lets try this... when you are older and become incontinent {and smelly as a result) what is the discovery vision or interest at that point? Will there be fullfillment in not toileting yourself? and being dependant?

by the way for me, the answer is a definite absolutely!

Again, I am not following.

Forget getting older, I am a woman who has had children. Sneezing has been a challenge.

I am still me.

I learn to adapt. I talk with other women. I exercise.

Ditto with women in their peri menopause years. We laugh and understand why black pants and spare outfit in the car is essential.

So sure we alter our norms it practices but we don't alter the base of who we are.

ps all too many who are mentally ill by if genes or bodily deterioration are beibg funnelled into that queue

the base is altered when capacities and abilities intimately associated with one's self alter significantly... problems emerge if a personal dies develop and adapt anew... the developmental change in infants and children are of comprable scope... we do not prepare for these life altering changes, and usually mal-adapt when they came

Again, I don't agree with your premise.

The base may alter with dementia, however, a love of music may remain for example.

I start with what I see in nursing home populations... we allow children to grow and change... they look frward to the adaptations and developments, including personalities changes.... the anti-thesis plays out during significant developmental change the aged... it plays out negatively for individuals and for the community at large... most dramatically evidenced in the prevalence of depression...

there are a few exceptions....

Carolla, thank you for the link.

I am glad you allowed for exceptions.

I don't know your experiences Aldo, but I have worked with seniors for the past 6 years and my primary function is to make sure they enjoy the things they enjoy.  On my very first day I learned not to try and make someone over the age of 80 do anything they didn't want to do.

The other thing I have learned is that no two seniors are alike ... funny that, quite like every other human I have ever encountered who didn't like to be lumped into a homgenious box.

If people really want to make a senior happy then show them respect for what the senior wishes to be at this point in their life.  If they want to act as if they are 16 again, and swoon over the octagenarian that sits at their table, let them.  If they are sad, because they have lost more loved ones than they have left, then comfort them.  If the past is what gives them joy then listen to their stories over and over.  If they want to lift 400 lbs or ski down a mountain, encourage their dreams ... what is the worst that could happen, they break a hip - they can do that going to the bathroom so what is wrong with doing so on a grand scale.

The reality is we are all going to be there one day so why can't we treat seniors, regardless of their individual circumstances, as we wish to be treated; with respect, dignity and love.

LB

-----

“As long as I am breathing, in my eyes, I am just beginning.”   ― Criss Jami

All that you put forward is as it ought to be... but mostsystems rail against that...

(10 years of responsiblity and involvement in all aspects of long term care including residents, families and staff...)

I certainly agree on this point re activities promoted ... it's often a huge challenge to find something broadly acceptable & within general abilities of the groups present in such locations.  

Personally, I've never been able to abide those stupid games at showers ... I'm going to make one cranky old lady if they push me in that direction!! 

Aldo - if I understand - you're promoting better recognition of abilities, talents, interests, etc. in seniors - not just by others, but by people themselves.  Is that correct?   And preparation for adaptation to life changes?   I'm curious about how you would see such adaptation promoted? 

It seems to me our First Nations people have some pretty awesome respect & roles for elders - some lessons for us? 

Well its much more....

I am talking about a 'seismic' shift in theories of human development. At present aged seniors going through significant change become angry and frustrated at the changes they go through (which they did not ask for) ... they lose inhibitions and act out as result, with behaviours that are socially disruptive e.g. resisting care, aggressiveness, yelling, hitting, wandering, hoarding, etc... because they failed to adapt to the changes. But, also others around them failed them. Some turn their responses inwards and become depressed and lonely. Everyday is a day of warring and subsequent depression. ... Then we start to treat them not only for the dis-ablements, but also for their depression and aggression.

Implementing a developmetnal approach is a longer presentation, but here are few general thoughts on the overall issue...

a new age of old age… 
 
As people age they change, just as they changed through child and youth development. As children and youth undergo development and emerge differently as a result of their development, so seniors undergo development and emerge differently as a result of their development. 
 

Human adaptation and development result from feeding our strengths, not from feeding our weaknesses. All the same, the prevailing approach to care for the aged is to feed weaknesses, that is: dysfunction, disability, disintegration, disease and illness. The ‘Emergent Seniors’ Age-ability Framework’ is a developmental framework for supporting seniors to adapt and develop themselves in light of significant and irreversible changes due to aging. The ESAF attends to the person’s strengths, as they are and feeds those strengths to enable seniors to achieve their present actual potential based on their actual capacities and functionalities. The ESAF focuses especially on those changes that impact on self-concept, identity and self-esteem as a result of changes in behaviours or activities of daily living. Age-ability does not refer to chronological age by to the aging process, which is natural and normal and should have adaptive and development responses, if seniors are to live well to the end of their days.

Age-able is what an aging senior can do; age-disabled is what a senior cannot do. Age-ability covers a wide field of human functioning, including physical, mental and emotional activities. Assessment of age-ability should include perception, sensation, cognition, and responses to these in regards to behaviours or activities of daily living. And, as mentioned, in particular behaviours and activities that are intimately associated with self-concept, identity and self-esteem for it precisely these that adapt and develop as a human personality undergoes adaptation and development due to seniors’ aging.

The emergent person is the person to be valued. Emergent people should value themselves as they are in the present, and others should value them as they are in the present, and not as they were. This is essential for positive self-esteem, positive self-identity and positive personal functioning in daily living. Devaluation of the emergent person is catastrophic for the individual and the community supporting the individual. 
 

This developmental approach in regards to changes in old age is Age-ability and provides Age-able parameters, in effect ushering in 'a new age of old age'. It calls for a change in how seniors see themselves and their emergence in positive vital living. It calls for change in how others (in particular caregivers) see seniors and their emergence into new and vital living. 

The simple chart below illustrates the shifting of care from dealing primarily with disability, dysfunction, disease and illness (on the left) to giving primacy to supporting age-able goals that support senior self-actualization (on the right). What a person or the person’s care giver grasps or puts first, defines the person to the care givers as well as to the person him or her self, and accordingly generates responses .

At the time when seniors most rapidly lose their capacity to develop and adapt, they must take up significant and critical life changing developmental challenges. Building on concepts from the work of Wolf Wolfensberger (Normalization Principle and Social Role Valorization) and Urie Bronfenbrenner (Ecology of Human Development), Emergent Seniors heralds a new age of old age. Seniors and their care givers are introduced to a framework for affirmation of old age through development of new behaviours of daily living. Moving forward into this time of significant change, seniors take ownership of their personal destiny in order to positively and authentically affirm themselves by proactively and fully living to their present potential. 

Much appreciated comments, Aldo.

Aldo - I agree with some of your comments - in terms of valuing changing abilities - this is a foundational prinicple of occupational therapy.  So it doesn't really seem 'seismic' to me.    However, I also read lots of "shoulds" in your text - how do you actually propose to help society shift?  

I would also respectfully suggest that your comment below is an oversimplification and does not acknowledge the myriad of illnesses & conditions that can be contributory to the behaviours you describe. 

             " At present aged seniors going through significant change become angry and frustrated at the changes they go through (which they did not ask for) ... they lose inhibitions and act out as result, with behaviours that are socially disruptive e.g. resisting care, aggressiveness, yelling, hitting, wandering, hoarding, etc... because they failed to adapt to the changes. "

I rather suspect that as the baby boomers age, things will be different. 

And Aldo - when you quote/copy & paste  from what I suspect is your own book on Emergent Seniors - please be courteous about posting the reference.

how much real OT is done in Long Term Care in Ontario... do you think?

And Aldo - when you quote/copy & paste  from what I suspect is your own book on Emergent Seniors - please be courteous about posting the reference.

[/quote]

well I have a document trying to become a booklet.... not exactly 'peer reviewed' stuff...

- how do you actually propose to help society shift?  

[/quote]

will be trying it out in a nursing home.....

....any suggestions you can recomend?

Also, you ask - How much OT in Ontario Long Term Care - precious little these days, that's for certain.   Changes about a year or so ago (maybe longer!) to physio coverage in LTCFs (long term care facilities) somehow also had a very negative effect on funding for OT services - so it's virtually non-existant now.  Which is a shame, because OT has much to offer to improve quality of life of residents, and quality of work-life for staff. 

I think one of the issues in LTCFs is prevalence of staff with very limited training, who are providing primarily task-based care, rather than person-based care - also a problem I see in the hospital setting with regard to some bedside care.  On-site supports are often minimal for LTCF staff, with lots of pressure to 'get stuff done' - so hurrying and staff approach can and do trigger behavioural responses in residents.   'Gentle Persuasive Approach' has a fair bit of wisdom to offer, IMO.  

Aldo - The Allen Cognitive Disability Model - used extensively in the US, some parts of Austaralia & Israel, and in less so in Canada, but widely in my own facility - is a complex OT model that focuses on making a skilled assessment of current functional cognitive abilities & then matching activities & expectations based on this, to enable maximal functional independence.  It is a well researched model & one that, when well utilized, can facilitate care & independence in many spheres.  You might find that interesting. 

With regard to implementing change in a LTCF - or any large organization for that matter! - remember that it is a LOOOONG process ... be prepared to hang in there persistently, and with strong staff support for a very long time to effect cultural shift; often, the timeline is underestimated, and good ideas go out the window or are seen to 'fail' - often because of premature evaluation. 

Will look at the tool.... interesting that its labelled 'cognitive disability' as compared'cognitive ability'....

Aldo, why is that interesting.  We label roads as "speed limits" not having speed no limit.

We generally presume limitation, and use the limiting term when addressing a situation.

The exception might be computer performance, as generally it is a lack of performance that we are addressing when we look at a machine, not that it has infinite capacity.

almost everything we use to define the aged (e.g. in nursing homes) involves a deficit approach... Occupational therapy tends to be an exception... but here is a tool used by OTs and it focussed first on the disabilities... right away we are focussed on what the problem with this senior is... I would have thought we would and we should first be measuring the seniors abilities... instead we first define the disability and then work with what is left over...

the deficit approach ties to make do with what is left in order to preserve what is changing...

I would think that 'modern' OTs would not be trying to salvage what is left and making the best of that... modern OT identifies a person's strengths and feeds those strengths to create the person anew as a whole, valued and meaningful (dare I say --- perfect)  person that has no deficits...

I have since learned the tool was first developed decades ago and has evaloved since... perhaps they should change the name of the model....

I understand what Aldo is writing.

Here's a lady in her 80's dancing like crazy, its really very amazing. A friend sent it to me today. I've been having puter trouble showing  active links on chrome, hope it works.

stardust wrote:

I understand what Aldo is writing.

Here's a lady in her 80's dancing like crazy, its really very amazing. A friend sent it to me today. I've been having puter trouble showing  active links on chrome, hope it works.

 

 

 

This video brings to light an important point. We need to celebrate what the aged can do and unconditionally value that. When they do outstanding things, that should be celebrated. But, if their achievement is set as a standard, that can be very destructive. We should also unconditionally accept what the aged can do, when it is not anything stellar. And, it must be celebrated and valued just as much.

The fear of death feeds the fear of aging. We tend then to do what we can to avoid age. In that effort, we become extremely destructive to our selves as we age, and to others as they age.

People need to be accepted and valued because of their abilities, not because they are seen as old and disabled and lovingly accept for those reasons.

As every parent knows, each child is unconditionally accepted and valued as they are. None, no matter they accomplish is a more value than any other. I will as perfect at 97, in whatever condition I will be in, as I was at 17, 37, 57, or 77.

At this point in time, that is not what we as a society and community do in regards to the aged.....

An article I just came across about the high rate of antipsychotics and/ or sedatives being prescribed to seniors in long term care facilities in Ontario.

http://m.thestar.com/#!/news/antipsychotic-drugs-prescribed-to-seniors-at-alarming-rates-province-finds/516248dea8e1dbf6df997f618f699ad6

Sorry. You might need to copy the link into your browser or search key words. Link doesn't seem to want to paste properly.

I do not think its any lower in the community...

Is the issue that they are called ani-psychotic or that they are not helpful in relieving depression and anxiety, especailly before bedtimes?

I think the physicians who prescribe them find they are helpful and actually work....

Yes Kimmio - the Star is running a series on the issue of medications & seniors - we were talking about it at work today.  It's not very balanced reporting, and upsets many families. 

I haven't been following it. I happened to see it when I was reading news about something else.

I have also been reading the Star reports. I'm inclined to believe them. I think its old news. Its been going on for years. The truth is that some of these people are next to impossible to deal with re behavioural problems   ( sorry to say), they will try to run away etc. Also the articles don't mention the other unmentionable which is the violence of seniors on seniors in nursing homes or old age homes, beatings and  aggression perpetuated against each other, but its another topic. 

Quote:

Report shows thousands in nursing homes on ‘dangerous’ mix of antipsychotics, sedatives

http://www.pressdisplay.com/pressdisplay/viewer.aspx

Drugs also are ways to address issues.  So, something that may result in some damage may be less damage than an unmedicated person.  It is like anything it is important to be on top of it.

I do not doubt that there are patients with inappropriate medications for their age.  My dad had some that were wrong. I also know how much better he is getting the appropriate medication.  

I would be interested in hearing others thoughts on these articles, including what professionals in the field are saying about them.

A CBC interview with a doctor from a couple of years ago (click on blue highlighted paragraph to listen) saying seniors are over medicated and one concern is toxic delerium from too many meds.

http://www.cbc.ca/shift/columnists/house-doctor/2012/04/24/over-medicate...

Medical & psychiatric care of seniors who have complex issues is ... well .... complex.  It's also slow and tedious work when done well.  And there are very few physicians who are experts in the field.   So provision of care then necessarily falls to those who clearly try their best, but may not be fully up-to-date or appreciative of some of the differing presentations of issues in seniors.  And many folk today don't even have a family doctor who knows them - instead using walk-in clinics.  So it is in one respect, little wonder that we see these situations.  This is only one (albeit very important) factor, IMO. 

We have precious few geriatricians - as this article makes clear -  http://www.magazine.utoronto.ca/leading-edge/dr-barry-goldlist-geriatrician-shortage/  - quoting from the article - 

How many geriatricians are there in Canada? How many do we need? With 32 million people, Canada has about 200 geriatricians (not all of whom are practising), whereas Sweden, with a population of about nine million, has 500. We would need 1,800 geriatricians in Canada to be as well served, on a per capita basis, as Sweden.

When do people start seeing a geriatrician? Before the age of 75, most people – unless they have early-onset dementia, a disability or a stroke – don’t require a geriatrician. It becomes really important for those over 80.

And while this is serious enough - the number of specialists in geriatric psychiatry is substantially lower.  This area of practice was only recognized as a specialty by the Royal College of Physicians & Surgeons in Canada in 2009.  

Here is a  link to Canadian Coalition for Seniors Mental Health - some excellent free downloadable brochures explaining various conditions such as delirium to families & patients.  http://www.ccsmh.ca/en/booklet/index.cfm   

Health teaching is invaluable, and often in currently rushed systems of care it is not done as well as it could and should be.  It can also take families time to absorb such information, to adapt to understanding of changes in health & behviours of their loved ones. 

In long term care facilities, yes, medication is prescribed to help manage difficult behaviours.  Some (many?) long term care facilities are poorly designed to accomodate those with behavioural issues related to cognitive impairments/dementias.  These behaviours generally are addressed first with non pharmaceutical measures, then meds when they put the patient, other patients & visitors, or staff at risk of harm.  Think about biting, hitting, kicking, spitting, assaults, falls, seizures, constant yelling.

Yes, for sure - there are some who are over or incorrectly medicated. 

It is important to seek information from credible well-informed sources - the internet, as we know,  is rife with stories of drama and disaster - which often do not contribute to good decision making in times of need.  Sometimes it's hard not get alarmed by what is read. 

How does this then affect care?  Well, we encounter more families who insist that their elders be taken off medications because of something they read in the paper or on the internet; sometimes families blame behaviour changes on the meds that are actually prescribed to help manage these behaviours - because both things have appeared to occur simultaneously to them & they assume causality;  some physicians will underprescribe in terms of dosage, so target symptoms or issues remain unresolved; we encounter patients who stop taking their meds upon discharge, fearful about what they read.  Sometimes families develop accusatory & adversarial relationships with the care providers - creating further difficulties.  Lots of time consuming conflict resolution is then needed to actually acheive best outcomes for the patient.   

So I guess I'm saying - it's complicated.  I wish we had better staffing, better environments, better staff training, better societal understanding, better funding.  

And yes, I'm getting older too - that fact does not escape me. 

I'm reading about personal support workers, PSW's whose jobs are often up front with the patients and  quite difficult receiving   low pay. They probably know the patients better than the nurses or doctors but they have little time to spend with them. One PSW said she spends 15 min. per patient getting washed, dressed, ready for breakfast.

Read the comments here from PSW workers:

http://healthydebate.ca/2012/05/topic/community-long-term-care/personal-support-workers

Also..look at the qualifications required for this particular  PSW job. It must be high paying.

http://ca.indeed.com/viewjob?jk=c83a9fa08083e36a&l=Toronto,+ON&from=recjobs