Carson Eldercare Consulting & Management

What We Dont Know We Dont Know in Health Care: September 24, 2024 -Oral Care, Monitored Meals, and Aspiration PneumoniaProper oral care is crucial for maintaining optimal health. Keeping the mouth clean not only helps maintain the protective properties of saliva but also reduces bacteria in the mouth which can be a source of infection in aspiration pneumonia. In addition, monitoring meals and assisting with feeding for those at high risk for aspiration is also a necessity. The process of swallowing involves dozens of muscles that start in the mouth and include the pharynx, larynx, and esophagus. These muscles can become weakened with age and from various, often age-related diseases.  The aging population is especially at risk for aspiration pneumonia due to comorbidities, frailty, and conditions that can impair swallowing.  As a result, aspiration pneumonia is one of the leading causes of death from infection in individuals over the age of 65. One study shows that 1 in 10 deaths from pneumonia in elderly nursing home residents may be prevented by improving oral hygiene (Sjogren et al., 2008). Unfortunately, proper oral care and monitoring of meals is often overlooked in the health care setting.  Perhaps the greatest reason for this is the challenge that almost every health facility faces today: adequate staffing. When I started working in acute care as an RN over 20 years ago, nursing assistants (these are the staff generally responsible for proving oral care in an acute care setting) were typically responsible for 5-7 patients. Nurses had 3-5 patients (this was on a step down cardiac unit). Between the nurse and the assistant, we were able to provide oral care at every meal and offer one-on-one assistance to any patient that was at risk for aspiration. This is no longer the case.  RNs oftentimes look after upwards of 8 patients, and there is generally either no nursing assistant on the floor or only 1 for a patient load that can exceed 20.  Consequently, proper oral care is neglected.  I have often seen patients that are aspirating during meals, but do not have adequate staffing on hand to provide them with the supervision and monitoring that they need. This presents a hazardous catch-22: the aging individual needs to eat to maintain nutritional needs yet he/she needs assistance with eating to prevent aspirating pneumonia.   How can this be remedied? If the family is present, they can provide oral care and meal monitoring. If meal monitoring is required for an at-risk individual, its recommended to touch base with the health care team to inquire as to what the specific aspiration precautions are (every individual may have a different need and/or recommendation). A care companion can also be hired to provide the needed care. I hired a companion for my father when he was in a skilled nursing facility. He was not getting his teeth brushed or flossed regularly, and I was seeing a decline in his dentition. Having this extra support provided him with much needed assistance and the care companion had the added benefit of encouraging him to eat more at every meal, something that was a bonus as he was not meeting his nutrient needs. Touching base with staff to request that oral care and meal monitoring be done can also be helpful. Having an advocate to ensure necessary care is getting done can also be very effective in the health care setting.  What is proper oral care and effective meal monitoring?  Proper oral care includes brushing the teeth for at least 1 minute after every meal. It also includes using a soft bristle brush, fluoride toothpaste, flossing daily. A final component of oral care that is often not discussed is denture care. Dentures should be cleaned at least once per day and removed at bedtime. Removing them prior to sleeping can greatly reduce the risk of pneumonia (Iinuma et al. 2014). Effective meal monitoring includes adequate supervision during mealtime for those at risk of aspiration. Such supervision includes ensuring the individual is properly positioned for a meal (head of bed as high as can be tolerated and supine position), takes small bites, eats slowly, swallows a couple times in between each bite, and intermittently takes a sip of liquid to clear the mouth of food particles. The use of straws is generally not recommended for an individual at risk for aspiration as it propels the food to the back of the throat and hence can increase risk. I recall when I was working as a Registered Nurse (RN) in acute care that I was constantly removing straws from the bedside of at risk individuals and often reminding them to eat slowly and swallow at least twice between each bite to ensure food clearance. Individuals at risk for aspiration often require a modified texture diet as it can further prevent the aspiration of food and liquids.   This is a brief summary of the attention to detail needed in addressing oral hygiene and meal monitoring amongst the aging population. Both measures can play a significant role in reducing aspiration pneumonia.  If you would like more information on understanding proper oral care or any other questions that you may have regarding aging life care, please feel free to reach out to me.    Sources:1.      Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. 2008. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc. 56:21242130. 2.      Iinuma T, Arai Y, Abe Y, Takayama M, Fukumoto M, Fukui Y, et al. 2014. Denture wearing during sleep doubles the risk of pneumonia in the very elderly. J Dent Res. doi: 10.1177/0022034514552493 3.      F Muller, 2015. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541086/#   

The Role of a Geriatric Care ManagerThe share of the United States population over the age of 65 has risen to 16%, and it is expected to climb further to 23% by 2060. People are living longer, and that means that people also have more specialized health care needs.Aging life care calls for a different kind of attention, as various conditions and syndromes begin to present themselves. Depending on which conditions those are, the situation can get complicated pretty quickly. In some cases, it might be worthwhile to consider hiring a geriatric care manager.As we and our loved ones age, we usually end up needing support from the people around us to make sure our needs are met. Family members in particular tend to shoulder this responsibility. But there are many reasons that might make it difficult to have a good support network in place. The most common reason is that family caregivers simply live too far away to provide reliable senior care management.In this context, geriatric care managers can be thought of as "professional relatives." If a family member is not able to provide long term care, geriatric care managers can help provide any and all services related to elder care. They are usually licenced nurses or social workers who are trained in aging life care, and they organize care plans and advocate for their patients needs.If you hire a geriatric care manager, you will be able to count on them to navigate the complexities of the health care system. It can also be helpful to have someone who can make decisions from a neutral point of view, as family caregivers sometimes have to make difficult decisions that are deeply personal.The primary responsibilities of a geriatric care manager are:Coordinating elder care between multiple service providersDeveloping both short and long term care plansHelping manage emotional concerns, stress, and anxietiesHelping manage transitional careHiring additional caregivers as necessaryMake home visits and evaluate living conditionsOngoing assessment of aging life care needsAll of this helps take the pressure off family members and ensures that geriatric care management is always under control.When to Seek Support With an Aging Life Care ExpertThere are many cases in which families are perfectly capable of managing aging life care for someone they love. But it can be challenging to know when you might be taking on more than you can reasonably expect to handle. As discussed above, one of the most obvious challenges is that family members do not live near the person who needs their care. But other complications are not as straightforward.You should consider hiring a geriatric care manager when:You need help with a complex issue. Lots of medical conditions can lead to the kinds of behaviors that should really be handled by aging life care professionals. Issues related to dementia, verbal abuse, or physical violence are among these.Your loved one will not talk to you about their health. Whether it is out of concern for privacy, a soured relationship, or an inability to describe what they are experiencing, older adults sometimes do not let relatives help them. A geriatric care manager gives them someone they feel comfortable talking to about their health. You are having trouble communicating with service providers. Geriatric care managers have a better understanding of where other aging life care professionals are coming from, so if you have run into a wall in negotiations or are not able to get the information you are looking for, your care manager is in a position to communicate more effectively.You do not know what to do. Caring for a loved one can be complicated for reasons beyond their health. We always want the best for them, but sometimes there are multiple pathways and it is not clear which one will be best. Geriatric care managers can provide their objective point of view to help your loved one receive the senior care that is right for themFinding Geriatric Care ManagersA geriatric care manager does not have to hold a state level license. But because many of them come from fields in health care, they elect to maintain their credentials. Care managers who come from social work often have to have active licensure in order to practice in their state.So on the one hand, a lack of certification or licensure is not necessarily a deal breaker. On the other hand, it is important that they can demonstrate their experience as aging life care professionals. If you are hiring a geriatric care manager, be sure to ask about the following:Do they have direct experience with managing issues specific to your loved one? This is especially important to cover in cases of severe injury or cognitive decline.Do they have experience with crisis care management? If your loved one is prone to seizures or is at high risk for falls or heart attacks, aging life care professionals need to know how to handle this type of emergency situation. Also ask them if they are available to respond around the clock, or if they have set hours.How will they communicate information to you? It might seem like a tedious question, but being on the same page about communication methods and styles can save everyone a lot of frustration and confusion.Can they provide references? It can be hard to really understand who you are working with based on their resume alone. Talking to people who know them well is a good way to corroborate your first impressions.How are their costs and fees structured? Senior care can be expensive it is typically not covered under Medicare or most other insurance plans so it is important to understand how much things will cost up front. Geriatric care managers charge by the hour, typically within a range of $75200 per hour.When families turn to aging life care professionals for care management services, they need to know as much as possible about the roles and responsibilities of the people they are bringing into the fold. Geriatric care managers help families navigate the complexities of elder care and relieve them of the stress and anxiety that so often comes along with it. They are experienced in working with a variety of national and local resources, care providers, and care services to ensure the highest quality of life possible.Give me a call for a FREE 20 minute consultation at 714-403-7040. source: Keystone Health, 2024. https://keystone.health/geriatric-care-manager-role-responsibilities#table-of-contents

Introduction: I felt strongly compelled to write this blog on heart failure as it is such a pertinent issue in the aging population today. Before I go into details on this, Id like to address the definition of this disease process. Heart failure occurs when the heart doesnt pump well and fails to deliver adequate oxygen to the body. As a result, fluid builds up in the body and vital organs dont get the blood that they need. This can make it harder for individuals to perform everyday tasks and can lead to eventual overall decline. Problem:Heart failure is the number one reason for hospital admissions in older adults, and often leads to multiple readmissions (Agarwal et. al., 2021). As a cardiac nurse for many years, I can attest to the fact that heart failure is the biggest reason for multiple hospitalizations in seniors. Patients come in and out for problematic symptoms, sometimes coming into the hospital as often as every month. The three biggest symptoms I see that result in hospital admissions are shortness of breath (particularly when lying flat), weight gain, and swelling in the legs.One reason for such frequent admissions is the complexity of heart failure itself. It is a complicated clinical syndrome and is notoriously difficult to manage. A lot is put on patients to manage their heart failure at home, and this can be a challenge. In addition, individuals may have some level of cognitive impairment or multiple other comorbidities, making it even more challenging to perform the extensive monitoring needed to prevent heart failure from worsening. The importance of education:Education is also important in the treatment of heart failure. Unfortunately, this often does not get done. When I first started working in acute care back in 2004, every patient received extensive education in managing their heart failure prior to discharge. Nurses would provide lengthy verbal education on the importance of medication adherence, daily weights, low salt diet, and other factors, in addition to providing the patient with a heart failure educational pamphlet prior to discharge. Over the years, however, hospitals have increasingly faced staffing shortages and high nurse turnover. As a result, a lot of important patient education is not getting addressed. A lack of awareness and understanding in patients on how to manage their heart failure is definitely a key reason for worsening heart failure and repeated hospitalizations. Management:From a clinician standpoint, the goal in addressing heart failure is twofold: we want to reduce symptoms and prevent mortality. The best way to do this is through patient/family education and implementation of a treatment plan. A proper treatment plan will include such lifestyle modifications as a low salt diet, quitting smoking, and getting regular physical activity. A low salt diet can be incredibly helpful in preventing further fluid build up in the body. The American Heart Association recommends that all individuals consume no more than 2,300 mg of sodium per day (AHA, 2024). In todays era of processed and packaged food, a majority of the American population consumes much more than that, and it comes in the food itself rather than the saltshaker. Maintaining a low sodium diet has one other priceless benefit that I often do not see emphasized enough in heart failure: it can help reduce blood pressure. Almost half of all heart failure patients have uncontrolled hypertension (Heart Failure, 2022). It is a major risk factor in the development of heart failure and managing it can greatly reduce heart failure symptoms and decrease stress on the heart. Current guidelines recommend maintaining a systolic blood pressure of less than 130. Medication management is another important factor in the management of heart failure. This often includes the use of diuretics, beta blockers, and other medication classes that I will not go into detail on. I wanted to discuss diuretics and beta blockers because these are the two medications in heart failure that I see non-compliance with the most. I witness individuals often not taking one or the other for two main reasons:  they either dont understand the importance of them or they dont like the side effects. Seniors can often have difficulty getting up to go to the restroom. Diuretics cause frequent trips to the restroom because their purpose is to get excess fluid off the body. Many individuals do not comply with their prescribed diuretic because of the hassle of frequent bathroom trips. Unfortunately, ineffective diuresis causes heart failure to worsen and puts further stress on the heart. I often see non-adherence to beta blockers due to their side effects. The two biggest symptoms that get reported to me are fatigue and dizziness. As in the diuretic, a beta blocker can also help reduce the stress on the heart, and heart failure symptoms can worsen if the prescribed dose is not adhered to. Its important to maintain prescribed medication regime and if any negative symptoms are experienced to discuss them with the doctor. One final thing:I wanted to touch on one final monitoring recommendation for heart failure because it so often gets missed: daily weights. Weighing oneself daily is of tantamount importance in heart failure and can identify early on if heart failure is worsening. This can lead to early intervention, thus decreasing potential hospitalization. Adherence to this all too often does not occur. I see patients come into the hospital for large amounts of weight gain often 20 or more lbs. Many patients report that they never stepped on the scale to assess for weight gain and often do not get admitted to the hospital until symptoms are severe such as severe weakness and shortness of breath. In heart failure its recommended to contact the doctor if weight goes up by more than 2 pounds in a day or greater than 4 pounds in a week. The doctor can make modifications in the treatment regime and hence reduce potential hospitalizations and mortality. Conclusion:Heart failure is complex but manageable. Early action can prevent hospital admissions, reduce mortality, and optimize quality of life. Having ongoing guidance from an experienced clinician can be of great benefit if you or your loved one is having difficulty managing heart failure and other disease processes. Please do not hesitate to reach out to me if you have any further questions. I want to help and make the process of aging as stress free as possible while promoting positive health outcomes.  My name is Laura Carson and I have been a Registered Nurse (RN) for over 20 years and have witnessed firsthand the challenges and complications that aging presents. It affects not only the aging themselves but also their families and loved ones. Health care is complex, and in this increasingly fragmented and overburdened system, it can be extremely helpful to have a professional oversee all aspects of care. As your eldercare manager, I will comprehensively assess the needs of your loved one and we will work together in establishing a care plan. I will assist you and your family with difficult decisions and help promote healthy communication on issues that are often difficult to address and navigate. Contact me for a 20 minute free consultation at 714-403-7040.  References:Blood Pressure and Glycemic Control Among Ambulatory US Adults With Heart Failure: National Health and Nutrition Examination Survey 2001 to 2018 (April 28, 2022). Heart Failure. Almost half of heart failure patients have uncontrolled hypertension and diabetesAgarwal, M., Fonarow, G., & Ziaeian, B. (February 10, 2021). National Trends in Heart Failure Hospitalizations and Readmissions From 2010 to 2017. https://pmc.ncbi.nlm.nih.gov/articles/PMC7876620/Weber, C. (May, 2023). Heart Failure Pharmacology.  How much sodium should I eat per day? (2024). American Heart Association. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sodium/how-much-sodium-should-i-eat-per-day