Meeting Notes 2000

Dementia-Related Behavioral Management

We had the privilege of a presentation by Dr. Albert Leung from Queen’s Health Care Centers, Kapolei Senior Care Clinic. Dr. Leung specializes in the care of the frail elderly, individuals 65 and older, and patients with dementia. Members welcomed the opportunity to ask him questions, make comments, and describe their personal experiences. We especially appreciated that Dr. Leung remained to support us during our member discussion period.

Dr. Leung graduated from the University of Hawaii John A. Burns School of Medicine. He is board certified in internal medicine and fellowship trained at the John A. Burns School of Medicine in geriatrics and senior care. When asked why he chose to specialize in geriatric medicine, Dr. Leung stated that working with elders has always been a high priority for him.

He explained that “dementia is not a disease, but rather a group of symptoms which accompany certain diseases or conditions.” Behaviors differ depending on the area of brain affected. Dementia is usually considered irreversible when caused by disease or injury, reversible when caused by drugs, alcohol, hormone or vitamin imbalances, or depression. Alzheimer’s disease is, currently, the most common cause of dementia; strokes, the second.

One caregiver inquired about the hereditary nature of Alzheimer’s. Dr. Leung explained that although the exact cause of the disease is still undetermined, it is thought that only a very small percentage of cases have a hereditary connection.

Behavioral disturbances do not occur in all patients, and when present they tend to be variable in type and severity. The symptoms often develop slowly over time. Sudden and acute presentations could signal acute illness and should be brought to the doctor’s attention.

Dr. Leung discussed the psychological, physical, and financial stresses experienced by caregivers and the importance of developing intervention plans, treatment strategies, and medication options for various behavioral “challenges.”

According to Dr. Leung, “behavioral symptoms are common and are important in management of dementia. It is important to rule out other causes. Conservative strategies should be considered before adding medications. Families and caregivers should always continue to learn about the disease.”

Anyone with questions should call the clinic at 674-9500.

Nursing Home Without Walls

For the past 13 years, our guest speaker, Ms. Fran Galdeira, RN, Unit Supervisor, has worked at Nursing Home Without Walls. The Medicaid program offers nursing home alternatives to qualified individuals by arranging for care in the home at higher levels than might be normally possible. Program participants must meet certain Medicaid income guidelines and be certified at nursing home level of care.

The program, administered by the State Department of Human Services, Social Services Division, has existed since 1983 and provides home and community-based support services, free of charge. The cost of this care cannot exceed the amount Medicaid would pay to a nursing facility. Individuals with incomes above Medicaid eligible limits could also receive program benefits, if they are willing to spend a part of their income for the assistance.

According to Fran, the program offers a wide range of services, including case management, private-duty nursing, non-medical transportation, handicap accessibility home modifications, respite services, and home-delivered meals. Services are not usually provided on a 24-hour basis; however, caregivers may make special arrangements for respite. “There are times caregivers must go on trips or be away from the home,” Fran explained.

Also, full-time caregivers are urged to inquire about eligibility for receiving limited hourly wages for care performed. Anyone interested in learning more about the program or the other services offered should call 832-0212.

Nutrition for a Healthier You

Caregivers must often give special attention to the nutritional needs of those being cared for, especially when frailties interfere with normal eating habits. According to our speaker, Ms. Cindy Reidt, Director of Dietary Services, Wahiawa General Hospital, the “food pyramid” still applies for healthy menus.

For those who don’t remember, the five basic food groups and daily servings are: (1) milk, yogurt, and cheese, 2 to 3 servings; (2) meat, poultry, fish, dry beans, eggs, and nuts, 2 to 3 servings; (3) vegetables, 3 to 5 servings; (4) fruits, 2 to 4 servings; and (5) bread, cereal, rice, and pasta, 6 to 11 servings. Indulge in fats and sweets sparingly. Use unsaturated fats like olive or canola oils. Each of these food groups provides some, but not all, of the nutrients we need. No food group is more important — we need them all in combination with exercise for good health.

Cindy mentioned that factors such as special diets, diseases, depression, difficulty swallowing or chewing, or the loss of taste and thirst sensations could affect weight maintenance. Consult your doctor or dietitian about snacks, nutritional supplements, higher calorie foods (peanut butter, honey, jam, eggnog, etc.) and vitamins and minerals. The latter, available in tablet or liquid form, can aid healing, bolster the immune system, and maintain bone mass, among other benefits. By age 50, as much as one-third of an individual’s bone mass could be lost. A number of members include a generic multiple in their daily regimen. “Whatever you take should include the minimum daily requirement of vitamins and minerals,” explained Cindy.

Several members care for patients requiring pureed foods. She suggested adding gravy, milk, or broth for a smoother consistency and more flavor. Extra servings can be frozen and reheated for another meal. To thicken liquids, mashed potato flakes, cereal flakes, or corn starch can be added as well as commercial thickening products.

To avoid constipation, especially for those with limited mobility, meals should contain a variety of fiber-rich foods, fluids (including prune juice), beans, and sprinkled bran.

Anyone with questions may leave a message for Cindy at Wahiawa General Hospital.

Aged To Perfection

Ms. Lorraine B. Medina, Director of Aged To Perfection, has been focusing on the care of others for many years, in positions with the Alzheimer’s Association, as a counselor to families, and staff and director of several adult day programs. She has been with Aged To Perfection since 1999.

The program, located at Wahiawa United Methodist Church, has existed for 20 years, providing families a day program for their disabled and frail elderly loved ones. The program is available to all races, religions, and backgrounds, Monday through Friday, 6:00 a.m. to 5:00 p.m. Full-time clients pay $650.00 per month, part-time clients pay $40.00 a day. Subsidies may be available for those eligible. Lunch and snacks are served, and “a new caterer provides hot, local-style meals such as adobo, stew, fresh vegetables, and fruits.”

The morning begins with a snack, and at 9:00 a.m. most participate in exercises. The day’s activities could include walking groups, guest speakers, painting, games, collage making, massages, hair cuts, van excursions, and a number of other special events, sometimes with the preschool children that occupy rooms in the same building.

“Staff members are experienced, loving individuals,” explained Ms. Medina. “One person has worked at the program for 19 years, others eight or nine. Our goal is to provide a welcoming, supportive, safe environment, where caregivers feel comfortable leaving family members for a time. Caregiving is one of the most difficult tasks, made more so,” explained Ms. Medina, “because the client determines the schedule, not the clock.” Through her years of experience, she recognizes that our fast-paced society rarely supports the caregiver’s need for relaxation or personal time.

Anyone interested in receiving more information about Central Oahu Senior Day Care, Inc. (dba: Aged To Perfection) should call 622-4771.

American Cancer Society

Michael and Lillian Nagaji have been volunteers with the American Cancer Society (ACS) Central/Leeward District for a number of years. Lillian’s involvement began about ten years ago when her job as an educator included disseminating information on cancer preventive measures to students. Mike, a retired engineer, has been donating his time for about four years, some of it as a driver for Angels on Wheels, a program staffed by volunteers able to occasionally take patients to treatment centers.

Recently, on behalf of ACS, the duo has been speaking to various community groups, describing the services and resources available to cancer patients and their families. “You might not have cancer,” expressed Lillian, “but you probably know someone who does. Now you can pass on the information.”

In addition to Angels on Wheels, the following are available:

• Programs. Toppers, a program for patients experiencing hair loss (ACS will provide a wig at no cost or some money toward the purchase of a new wig); Hotel Guest Rooms, a program that offers assistance to neighbor island, Guam, and American Samoa cancer patients who may need temporary housing; Camp Anuenue, a free one-week summer experience for children 7 to 13 years with cancer or in remission from cancer; Ho‘o Hula Meka Ikaikai, a free weekend program for young adults, aged 14 to 21, who are facing or who have survived cancer.
• Supplies. Equipment for loan (walkers, beds, wheelchairs, etc.) and liquid nutrients are available to cancer patients.
• Groups. The Society also sponsors several different support groups such as Us Too for men with prostate cancer; Reach to Recovery for women with breast cancer surgery; Hui Olelo (“Speech Club”), where laryngectomees can improve speech techniques; and Make Today Count, sessions focused on living each day as fully as possible with a life-threatening illness.

Please call 486-8420 to learn more about programs and volunteer opportunities or to ask questions.

Adult Protective Services

Our guest speaker, Ms. Lei Shimizu, former caregiver currently a social worker with Adult Protective Services (APS), has been with the organization since 1988. APS is a joint project of the Community Elder Abuse and Neglect Task Force and the Department of Human Services, supported by the Executive Office on Aging’s Long Term Care Ombudsman Program. The office employs intake and investigative social workers, two RNs, and an administrative staff. Prior to joining APS, Lei Shimizu worked with inmates at OCCC and juveniles at the Salvation Army.

APS implements Hawaii law, which mandates that suspected elder abuse be investigated. Most victims are frail elderly, dependent on others for daily assistance, suffering from physical or mental impairments.

Ms. Shimizu explained that abuse could be: (1) physical; (2) psychological; (3) sexual; or (4) financial exploitation. Cases of neglect occur through caregiver negligence or the inability of elders to provide for their own self care. Anonymous photos of bruised, bed sore covered bodies served to illustrate the extent of abuse and neglect suffered by our local elderly. In all situations, APS social workers thoroughly research and investigate cases to determine responsibility, provide remedies, or make suggestions. Occasionally, funds are available to those who qualify for assistance.

Caregivers who might be experiencing tremendous stress should seek immediate help. Ask physicians, nurses, or social workers where to find information or community support groups.

Members gained valuable perspective on the nature of abuse and neglect and greater understanding of the detailed process required to investigate suspected cases.

Anyone with questions, requiring assistance, or suspecting dependent adult abuse or neglect is encouraged to call the Department of Human Services at 832-5115. Lei Shimizu emphasized that all reports are kept strictly confidential.

Wahiawa Senior Behavioral Health Care Unit

“Our geriatric program is the first of its kind here,” described guest speaker Ms. Georgeanna Mann, MBA, Community Liaison of Wahiawa General Hospital’s new Senior Behavioral Health Care Unit. The 10-bed inpatient unit, located on the hospital’s second floor north, has been open since May 16, 2000, offering voluntary admissions to elderly with nonchronic emotional problems. The therapeutic team approach focused on the elderly differs from other island facilities where a mixture of clientele coexist.

Dr. Dan Tanahashi, Medical Director, and Dr. Michael Komeya, attending physician, have both been specifically trained in geriatric psychiatry. The team also includes a program director, psychologists, psychiatric nurses, a licensed/masters-trained social worker, and several therapists who provide occupational, physical, and activities sessions. Ms. Mann, in addition to her liaison duties, coordinates the outreach program and follow-up care.

“Approximately 95% of the people we have admitted suffer from behavioral difficulties and loss of control associated with major depression.” Ms. Mann explained that some display aggressive behavior such as spitting, kicking, and hitting. Others have abandoned self-care/personal hygiene or displayed suicidal tendencies. Ms. Mann described that many patients have been successfully treated and returned to their families. Treatment could include psychotherapy, group therapy, medication, or other remedies as appropriate. The average stay has been 12 days to a month.

Patients have been admitted from nursing homes, day care, and their own homes. Ms. Mann assesses the prospective patient, then reports to one of the doctors. If the individual appears to be an appropriate candidate, admittance is scheduled on a 24-hours-per-day basis. Patients may use Medicare and other types of medical insurance.

All patients are expected to meet individual goals prior to discharge. Once discharged, follow-up will continue for about one year. Anyone interested should call Georgeanna Mann at 388-3171 or 530-4646 (pager).

Public Health Nursing

Our speaker, Ms. Susan Fujii, R.N., Public Health Nurse, has been with the State Department of Health’s Public Health Nursing Branch for a number of years. She described that the agency, in their elder care mission, strives to “enhance the delivery of services for frail, vulnerable individuals, 60 years and older, to achieve their highest level of independence consistent with their capacity and preference of care.”

Ms. Fujii’s nursing career and her own caregiving experiences give her keen insight into the daily needs and demands of caring for loved ones at home.

The staff of Public Health Nursing assists caregiving families by identifying problems, serving as a link to resources, and coordinating services to aid the elderly patient and the patient’s family/caregivers. An initial assessment determines the extent of help appropriate. Will bathing services ease daily requirements? Does the family require advice on Advance Directives, insurance coverage, or other financial matters?

Family members participate with professionals in a team approach to develop a plan of services and assistance, designed to best support and care for all involved, without duplicating services.

Anyone with questions about the Public Health Nursing Branch should call the Wahiawa Nursing Office (622-6445), the Central Oahu Section in Pearl City (453-6190), or the Leeward Oahu Section in Waipahu (675-0073).

Grieving, Coping, and Support

Ms. Christa Freeze, L.S.W., one of the social workers with the St. Francis Hospice Bereavement Program, comforts, counsels, and supports the families of terminally ill patients and those coping with the loss of a loved one.

Her past employment includes work at a day center for Alzheimer’s patients and efforts with caregiver groups. In response to a question about the grieving process, she explained, “It is common for individuals to experience grief in different ways,” such as: (1) shock/numbness/denial, feeling like a robot; (2) anger; (3) guilt; (4) relief; (5) anxiety/panic; (6) depression; (7) sadness/loneliness; (8) confusion and difficulty concentrating. The feelings are normal and, in time, should decrease. “Be kind, gentle to yourself,” Christa explained. “Give yourself time to heal.” She suggested putting off life-changing decisions for a time until personal situations can be more clearly judged. She suggested that some should seek professional help if feelings persist or become debilitating.

The bereavement program includes follow-up telephone calls and visits by staff members to grieving families. Support group meetings are held monthly at the St. Francis Medical Center-West, Maurice J. Sullivan Family Hospice Center in Ewa (678-7580), or at the Sister Maureen Keleher Center in Nuuanu (595-7566).

More informal sessions occur monthly, with early morning mall walks at Pearlridge Center and Kahala Mall or dinners at various favorite restaurants. “These sessions are open to any person dealing with a loss,” explained Christa, who often leads the Pearlridge Center walk and talk sessions. For the two months remaining this year, the Pearlridge jaunts are scheduled for November 1 and December 6 from 8:00 a.m. to 9:00 a.m.

Anyone with questions about the mall walk schedule or the other programs offered by St. Francis Hospice should call 595-7566.

Nutrition and Aging

Our guest speaker, Ms. Natalie Petti, MPH, RD, has experience in a variety of nutritional settings while with a number of medical institutions, including Wilcox on Kauai, Maui Memorial Medical Center, Shriners, Queen’s Medical Center, and now the Wahiawa Dialysis Center. This wide exposure to nutrition offered members the opportunity for diverse inquiries, especially about elderly requirements: “My parent eats less now. How do I ensure she is getting all the nutrients she needs? Do liquid supplements help?”

Natalie explained that a separate version of the standard food pyramid (source: American Society for Nutritional Sciences, www.drkoop.com) has been developed to address the special dietary needs of adults 70 years and older. Individuals in this age group often have a diminished thirst sensation, eat smaller portions of food, or may have difficulty swallowing and chewing, thus consuming less fluids, fewer calories, and reduced nutrients.

Diminished thirst sensation and the potential of certain medications to affect the body’s ability to regulate fluid balance could result in dehydration, kidney dysfunction, constipation, or worse. As shown, the 70+ pyramid adds a bottom sixth section of eight glasses of water and a flag flying at the peak, which highlights the need for calcium, Vitamin D, and Vitamin B-12 supplements. The other five categories reflect the standard five pyramid sections.

To add calories, vitamins, and nutrients, a variety of liquid food suppplements are readily available; however, selection should be discussed with the physician, as high sugar content and other ingredients could interfere with some prescription drugs or aggravate certain conditions. Natalie recommended that patients should mention to their physicians any herbal remedies or vitamins being taken and inquire about any food that might adversely interact with their medications.

The presentation also included discussion about the beneficial effects of certain vitamins, minerals, and omega-3 fatty acids. “The emphasis of the 70+ and standard pyramids remains on grain products, vegetables, fruits, and fluids; but easy on the sugar, salt, and alcohol, especially for the elderly.”