Confusion in the elderly — a life-threatening condition

Illness in the elderly is often manifested with a condition called delirium. This is an acute state of confusion presenting with drowsiness, loss of memory, fluctuating levels of consciousness and frequently hallucinations and delusions. Many individuals who are frail often do not present with the symptoms of a disease such as a urinary tract infection or pneumonia, but with delirium.

While uncommon in the community, delirium occurs in anywhere from 14-34 percent of hospital patients, but amongst those over the age of 80, over 70 percent have symptoms of delirium, particularly if they are about to undergo major surgery or are being treated in the ICU.

Delirium is often the initial symptom of an acute medical illness such as a urinary tract infection, pneumonia, sore throats, bronchitis and influenza. Many medications can lead to delirium, as can major illnesses such as a heart attack, stroke or hip fracture. On occasion it may be situational — brought on by a change in environment such as moving to a new facility or being admitted to a hospital for an elective procedure.

There are many risk factors for delirium, but far and away the most common is dementia, caused by strokes, Parkinson’s disease and most commonly Alzheimer’s. Delirium is more frequent in those with sensory deficits such as hearing loss or blindness, immobilization because of catheterization and frequently by the use of restraints. For reasons that are ill understood, delirium is more common in males and those with chronic renal or liver disease. The greater the number of chronic medical conditions, the greater the risk of delirium.

Dehydration is frequently present in patients with delirium and is the most common underlying cause of an acute state of confusion in the elderly. Compared to young people, older persons have a markedly reduced thirst drive. When they become ill, water loss is increased. Frequently the fluid loss is not replaced, and this in turn leads to increasing confusion and continuing worsening of symptoms.

When hospitalized, patients with delirium frequently become more agitated, pull out intravenous lines and may remove urinary catheters kept in place by an expanded balloon. This leads to injury and even worse, agitation. Often patients are restrained and prescribed psychotropic medications that may cause some but insufficient improvement. The combination of restraints to prevent injury and medications to reduce agitation frequently cause more harm than good. Hospital stays are increased, complications are high, and death is frequent.

There is much that can be done to prevent and manage delirium in ways that minimize complications. The importance of assuring adequate fluid intake is critical if an older individual develops an illness or shows signs of confusion. The earlier a diagnosis is made and the medical condition appropriately treated the better. Admission to hospital must be avoided as much as possible. Sadly, many families wait too long after symptoms develop to consult their doctor. Even over the phone, the physician can often help identify and treat the problem.

Hospitals are now more aware of the problems of delirium in sick older individuals. New guidelines have been developed to minimize the risk of confusion both before and after surgery. Appropriate anesthesia can do much as well. And today many hospitals have specialized delirium units. These often have four beds and are monitored continuously by one or more nurses. The goal is to avoid the use of restraints, assure hands on nursing care to reduce risks of removing tubes and minimizing drugs that can aggravate the problem. Wherever possible, family members are encouraged to spend as much time as possible at the bedside. A familiar face and voice can do much to help disorientation and reduce agitation.

Often patients remain confused throughout the hospital stay. For this reason, the patient is better off at home, provided the family has the resources to assure recovery. These days, the push to shorten hospital stays paradoxically leads to discharge too early that in turn increases complications and results in multiple readmission to hospital.

The solution to confusion in sick older patients is to assure a team of health care providers who participate in care prior and during an illness. Providing appropriate care after hospitalization can do much to improve chances of recovery and assure a better quality of life.

Elderly Housing Authority resident suffers stroke, receives eviction notice

Oh, the San Francisco Housing Authority. Its staff is always good for a “They did what?” article — but at least this one doesn’t end as badly as they usually do.

You may recall the sad story of Mary DiGuiseppi, a 94-year-old woman who has lived at Clementina Towers South of Market for 29 years. She lives on the 10th floor of the public housing high-rise for seniors and disabled people, and whenever the frequently malfunctioning elevators are both broken, she’s stranded in her room.

In September 2013, DiGuiseppi was dropped off at Clementina Towers in a shuttle van after visiting her adult day care program. The elevators were both out, and DiGuiseppi was stranded in the lobby for 10-1/2 hours with no food, no water and no access to a restroom.

“I was in the lobby all alone, and I was frightened and cold,” she told The Chronicle later, noting the only help she got was from a security guard who put two chairs together for her to lie on. “It was very uncomfortable and painful.”

DiGuiseppi became one of 24 tenants to sue the Housing Authority for not fixing the elevators despite years of complaints. In April, Mayor Ed Lee said he found $5.4 million in his housing budget to finally get the elevators at Clementina Towers and other public housing projects fixed – though the ones in DiGuiseppi’s building won’t be completed for another year.

DiGuiseppi suffered a severe stroke about six weeks ago and after a brief stay at St. Francis Hospital is being cared for in a rehabilitation center in the city. Her husband and two sons are dead, and DiGuiseppi has no power of attorney in place. She failed to pay her October rent of $259.

On Oct. 21, a notice from the Housing Authority was taped to DiGuiseppi’s door telling her she had 14 days to pay her back rent or she’d be evicted. Obviously, she wasn’t inside and wouldn’t have known she received it.

Her neighbor and friend, Terry Bagby, spotted the note, read it — and gave us a call. We contacted the Housing Authority about the matter, and Director Barbara Smith said it was a mistake. The 14-day notices are automatically generated by a computer when back rent is due — although we saw the notice, and it was hand-signed and hand-delivered so it wasn’t exactly automatic.

“When you got involved, housing wanted to change their tune,” Bagby said. “They don’t like the media attention they get.”

Smith said the agency staff is now working with DiGuiseppi’s social worker to help a conservator get put in place to manage her money and pay her bills. In the meantime, the eviction is off the table.

“Of course we’re going to keep her apartment for her while she’s convalescing — absolutely,” Smith assured us. “We have absolutely no intention of any kind of eviction against Miss DiGuiseppi.”

 Smith even visited DiGuiseppi at the rehabilitation center. She visited her after the 10 1/2 hour elevator malfunction too.

“We’re hoping she recovers and comes back,” Smith said.

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Residential homes, nursing or respite: Choose the right care home for you

We are living longer than ever before, with life expectancy rising year after year thanks to better lifestyles and advances in medical technology. In the past three decades the number of people in the UK aged 90 and above has almost tripled, according to figures published by the Office for National Statistics.

However living longer presents its own challenges. Although we all dream of enjoying a comfortable retirement where we live independently in our own homes what happens when we need the help of others to deal with the health problems of old age such as dementia or osteoporosis?
Although we are often reluctant to think about it many people will need care at some point.
The word "care" covers a wide range of services from having a care worker visiting for an hour or two every day to going to live in a home after being unable to carry on independently.
It can also be difficult to work out whether someone we know - friends, family or loved ones - needs assistance and equally tough to make the decision that they can no longer live on their own.
The type of assistance people need can change significantly over time
It's never too early to start thinking about the financial, logistical and emotional issues that could arise if you or a relative need care.
In some cases, following an operation or a serious health problem for example, it will be obvious that support is needed.
At other times a gradual deterioration in health and independence can make it difficult to know when to look for an At other times a gradual deterioration in health and independence can make it difficult to know when to look for an alternative.
Often the decision is made in the heat of the moment following a fall or a bout of ill-health and without time to consider all the options.
If possible start by talking to your GP or your relative's GP for guidance. Then ask your local authority for a care needs assessment to make clear what help is needed and provide an idea of what financial aid you or your loved one is entitled to.
To help steer you through the maze the Daily Express has published a free guide to Elderly Care in association with private healthcare provider Bupa.
It can help answer any questions you may have about the types of care available and how it can be funded.
The type of care people need can significantly change over time as their health deteriorates or improves.
These are the main types available:
CARE AT HOME
If you or your relative can manage alone for most of the time but need help with daily tasks such as washing and preparing meals you or your local authority may decide that having care workers visit a few times a day is sufficient.
RESIDENTIAL CARE
For those unable to live independently on their own care homes provide rooms, meals and personal care such as help with washing and dressing.
NURSING CARE
If health problems require constant medical attention nursing care should be made available in a care home or in your own home.
RESPITE OR SHORT-TERM CARE
In many cases residential care may be needed only temporarily. For example if a carer needs some time off the person they are caring for may go into a residential or nursing home for a few days or weeks.
Short-term or short-stay care may also be useful for those who are recovering from illnesses or operations.
It may also give someone who is thinking about going into a care home an insight into what life would be like there.
DEMENTIA CARE
As the number of people living with dementia increases more and more homes are specialising in looking after people with these conditions.
Depending on the severity of the condition these could be nursing homes or residential homes.
PALLIATIVE CARE
For terminal conditions palliative care in hospices or care homes can help relieve pain.
CHOOSING A CARE HOME
Whether you are paying for care yourself or relying to some extent on local authority funding you should have a choice about which care home you go into.
So what do you and your relatives need to bear in mind when making a decision? A key point is whether the home offers the kind of care needed. Some homes specialise in looking after people living with dementia for example.
The needs assessment carried out by your local authority should identify the specific care that should be provided for you or your relative, as well as whether the support of trained nurses will be needed.

I hate litter so much I even clean up the toilets at service stations, admits Joanna Lumley

With her clipped tones and posh persona, people might assume Joanna Lumley lets other people do the cleaning at home, let alone beyond her front door.
But the actress, 68, has admitted to taking it upon herself to tidy mess wherever she finds it, even cleaning bathrooms at motorway service stations.
And the veteran star of James Bond and Absolutely Fabulous has criticised modern attitudes that let people feel entitled to litter the streets with rubbish.
She said: ‘I can't bear people being sick in the streets and throwing paper out of the car window.
'Back [in] the olden days we had things like “Don't Drop Litter” campaigns. At school we drew posters.
‘[When I see someone dropping litter] I say, “I think you've dropped something”, or “Pick this up and put it in the bin.” They look at you as if you're speaking Swahili.
‘[They say] “What's your problem?” They think it's odd because they've had nobody to say, “Don't you dare do that or I'll make you clean the whole street.”’
And, speaking to The Times, she added: ‘In petrol stations on the motorways where people have left the place looking messy, I clear up each lavatory I happen to have occupied.
‘When people drop paper on the ground, and everything like that, I pick it up, put it in the lavatory, and make that room look nice.
'[I] cannot see why people are allowed to get away with letting everywhere look so foul.’
This desire to keep things tidy ties into her commitment to being environmentally friendly.
Miss Lumley, an experienced campaigner for nearly 80 charities, is a staunch advocate of recycling, which she does ‘obsessively’ at the Stockwell home she shares with her husband, composer Stephen Barlow, 60.
She said: ‘Even clingfilm — if it's gone over a salad bowl, take it off, use it again. I wash out carrier bags, I save brown paper from parcels. I save string, I save ribbons. I separate all my bits and pieces. All the tins — which might contain fox food — I rinse out and put in there. I have the plastic that can be recycled in there, all the ones that can't be, and all the stuff that can go on to the garden compost.

‘I switch off lights like a maniac. I drive at reasonable speeds so that I don't waste petrol.’
In the wide ranging interview she also revealed that despite her aristocratic image, she has ‘never felt British’ and dislikes being labelled as such, describing her upbringing as ‘pan-Asian’.
She said: ‘I'm three quarters Scottish but I sound English. I don't really see British as a race. I always think now it sounds like BNP and Nigel Farage — a rather ghastly thing’.
And, returning to a subject that has brought her controversy in the past, she reiterated her belief that young women should think carefully about how the dress and act on evenings out, to avoid attracting unwanted attention.
Claiming that critics have accused her of spoiling young people’s ‘fun’, she pointed to the rape by footballer Ched Evans as an example of where things can go wrong.
She said: ‘If someone takes advantage of you and it becomes a rape none of it is fun. Being left in the street with sick down your dress is not fun.
‘And we mustn't let our daughters or granddaughters think we don't care enough about them. So this is where you wave your finger, as a woman, and say, “Don't do that.” I'm not taking away people's fun, I'm saying, “Don't do that”.
‘I think of all younger girls as my daughters, I don't care whose children they are, they are my children as far as I'm concerned.’

Fall Day of Service: MCLA students, volunteers clean up North Adams

Decades of mildew and dirt were scrubbed from dozens of gravestones at Hillside Cemetery by about 60 MCLA students and other local volunteers as part of the Fall Day of Service on Saturday.
Other students and volunteers — more than 70 in total — painted curbs, spruced up the Good Will store property on Curran Highway, and cleaned up several small pocket parks around the city.
The work at Hillside Cemetery also included straightening some headstones and raking leaves. Roger Eurbin, a volunteer and member of the city Cemetery Commission, coordinated the effort, all part of a multiyear project to restore the historic cemetery.
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Eurbin said the work being done by dozens of college students was an important step forward in the restoration.
"It is critical — you can see what erosion does," he said waving at the hundreds of gravestones behind him, some of which are broken or tilted after years, even centuries, of wind, rain, snow and ice. "It's going to take a lot of work to get this cemetery in presentable order."
The students and other volunteers fanned out around the north side of the cemetery on West Main Street with buckets, brushes, rakes and shovels.
Most of them were busy scrubbing gravestones. The markers were noticeable brighter once cleaned.
This is the fifth Fall Day of Service. It was established as a follow up to the Spring Day of Service, which has been a successful community service event for years.
"A bunch of us come down and just try to give back," said Gary Lavariere, a junior at the Massachusetts College of Liberal Arts. "I've done this for three years, and this is a fun one. Scrubbing these graves down is good — they really need it. They end up looking a lot better."
MCLA sophomore Lily Breen said the volunteer effort is well worth it.
"It's not that hard to help the community out — you should at least do that," she said.
An MCLA student-volunteer scrubs a gravestone Saturday at Hillside Cemetery in North Adams as part of this year’s Fall Day of Service.
An MCLA student-volunteer scrubs a gravestone Saturday at Hillside Cemetery in North Adams as part of this year's Fall Day of Service. (Scott Stafford — The Berkshire Eagle)
Hillside Cemetery started out as a family cemetery when the daughter of Richard Knight was buried on the hilltop around 1789, Eurbin said.
More than 200 are the graves of Civil War veterans, he noted. About 350 are veterans of wars ranging from the French and Indian War and the Revolutionary War to World War II.
Every Wednesday and every other Saturday, Eurbin and two other volunteers, Ed Marino and Larry Burdick, work at the cemetery straightening or mending gravestones and cleaning up the property.
The restoration effort has been ongoing for about five years, Eurbin said. It will take another five years or more to complete, he added.
Today there are about 2,900 graves, 25 of which were uncovered about three weeks ago when volunteers — including Eurbin and his 17-year-old grandson, Justin Bryant — cleared some underbrush from the northeast corner of the cemetery for the first time in decades.
Eurbin said those graves would eventually end up being restored along with the rest.
"These are folks who deserve as much recognition and honor as early residents of the city — so we'll treat them like any other," Eurbin said. "We don't have any favorites out here."

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