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Ep. 145 - LiveWell Talk On...Skilled Nursing Pt. 2 (Dr. Clete Younger & Lindsay Glynn)

episode 145

Ep. 145 - LiveWell Talk On...Skilled Nursing Pt. 2

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Clete Youngermedical directorSt. Luke's Living Center, and Lindsay Glynn, executive director, AbbeHealth Aging Services

Dr. Arnold:
Hey everyone, it's Dr. Arnold. I'm excited to announce a new segment that will be coming to the podcast, and that is the mailbag. If you have questions about COVID-19, latest technologies and procedures, and other services provided at UnityPoint Health Cedar Rapids, or even other general medical topics, you can now submit those questions to me. They may be answered on the podcast. To submit your questions, go to UnityPoint.org/mailbag. Please note that the mailbag is certainly not in an alternative to a medical appointment. Any questions about personal symptoms or conditions need to be directed to your primary care provider or an urgent care, and as always in the case of an emergency, dial 911, or present to the nearest emergency room. Once again, you can submit your questions to me UnityPoint.org/mailbag. I look forward to hearing from you, our amazing listeners.

This is LiveWell Talk On...skilled nursing, part two. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. With recent rise in hospitalizations, geriatric patients are impacted by COVID-19 as well as other medical conditions that perhaps could have been delayed during the lockdowns of 2020. Returning the podcast today to discuss skilled nursing, as well as kind of the impact that hospitalizations have on our geriatric patients, is Dr. Clete Younger, who's the medical director of St Luke's Living Center. And for the first time on the podcast, is Lindsay Glynn, executive director of Abbe Health Aging Services. Today we'll discuss how hospitalization may impact geriatric patients, cognitive health, and how we can be supportive and improved upon with skilled care nursing. We'll discuss resources of aging services. Clete, Lindsay, welcome.

Dr. Younger:
Thank you.

Lindsay Glynn:
Thanks so much.

Dr. Arnold:
Okay. First question, Lindsay, do you know why it's called Abbe Health.

Lindsay Glynn:
Well, it used to be Abbe Inc, but you know, a lot of our focus historically has been on mental health. And as we started expanding our services, we focus on so much more than just mental health. Aging services is an affiliate of Abbe Health and we focus on older adulthood and making sure that people have the services they need to remain in their home for as long as possible, because we know that that's where people want to age. Mental health and aging are two very huge components to everyone's health.

Dr. Arnold:
I was actually was being a little bit more specific as to why it's called Abbe. Do you know the story behind that?

Lindsay Glynn:
You know, that's funny because I don't know specifically the "Abbe" component of that. No.

Dr. Arnold:
Well, the first director wanted it to be early in the yellow pages, you know, from an alphabetical standpoint. And he lived off Mt. Vernon road and Abbe Creek is there and that's how it became Abbe Health. That's a true story.

Lindsay Glynn:
In the front of the book?

Dr. Arnold:
Yeah, Jeff Wilharm told me that story, and he was there in the beginning so he should know.

Lindsay Glynn:
I wish I was that creative.

Dr. Arnold:
I can only repeat these stories. I'm not smart enough to come up with them. Well, I think that's nice to explain the aging health services because I, personally, I've never really understood exactly what their role is. And we'll kind of develop more upon that during this conversation today with Dr. Younger. Clete, or either one of you. Let's start with Dr. Younger, what impact does being hospitalized have on a geriatric patient, not just only whatever the medical condition was, pneumonia, heart failure, hip fracture, etc., but just on their overall wellbeing from a psychological standpoint, functional standpoint? What are the detriments to simply being hospitalized? And hence, it's a good reason not to be hospitalized.

Dr. Younger:
I think sometimes what we see is that hospitalizations expose frailty. So it'll expose something that's there before that you may not have been aware of. And, you know, we all want to be optimistic when we talk about our function and what we can do, but sometimes the hospitalization will expose what someone's frailties are and that will show to themselves or to their family or to the community. Oh, we have deficits in this area, or this is a limitation in function that a patient may be experiencing. Unfortunately, sometimes too, we see the hospitalization as a threshold. So where somebody may have a gradual decline in function, a hospitalization can be a drastic decline in function. Sometimes that function will come back and sometimes it won't. So sometimes patients will have a complete shift in their functional level associated with certain types of hospitalizations that then require higher levels of care going forward.

Dr. Arnold:
Lindsay, what's been your experience with the patients that you support and how hospitalization may influence their functional capacity and their ability to return home?

Lindsay Glynn:
Yeah, so we see that quite a lot. Really the amount of care after their hospitalization does rise, right? They need more support as they're transitioning out of the hospital. And there are a variety of reasons for that. Sometimes it's restricted mobility in the hospital, continence, medication issues. Lots of reasons for that. And like Dr. Younger said, sometimes it's something that we can really help with. Sometimes it's long-term effects of those hospitalizations, especially if they're frequent and people are returning to the hospital often. And so, a lot of attention and focus for us is on prevention and wellness as well.

Dr. Arnold:
I'll tell a quick story. I can remember this patient I had when I previously practiced in Grinnell, so in the late 90's. Nice old lady, nice little lady, cute. You know, every stereotype of the cute little lady that lived by herself, would come to the clinic and it would be the same routine every six months. She would come, introduce herself to the staff, they take your blood pressure, there'd be an exchange. I would see her, talk to her, she be perhaps slightly ingratiating in her answers, you know, give me nonspecific, but yet correct answers. Then she got admitted for pneumonia once and we were around her for 24/7. And, you know, she had rather significant dementia and we took her out of her routine and it became amplifying. Clete, can you talk to something along those lines? I mean, the hospitalization doesn't cause the dementia, but perhaps it reveals it. Is that a fair observation?

Dr. Younger:
Yeah. So what do you have to think about is when you're at home. So if you're at home in your chair, in your house, you know where your clock is, you have this object here, you're used to your food being this way. And because people develop these routines, they don't have to think about that as much. So if I'm at home, I know where the clock is. And I don't have to think about where is the clock, what time is it, when I'm going to eat, how I'm going to eat. So when you go to a hospital setting, that clock's in a different spot. The food's coming from a different person. Furniture's in a different location. So all of a sudden, you have to start using your cognitive ability to try to reconcile all this information. And in somebody who has a diminished cognitive capacity, if now they have to worry about what time it is, where their food is, and where their clothes are. They don't then have the capacity to have higher order thinking about answering complex questions or making complex medical decisions, because they're so absorbed in just the simple things of those little details that we take for granted when we're in our home setting. All of that goes away when you put somebody in an unfamiliar situation.

Dr. Arnold:
And I think your comment earlier, we'd infer that you may not get that back.

Dr. Younger:
That's possible. Especially if somebody then requires some other things. So if a hospitalization results in a transition to living somewhere different, like senior living or assisted living, it's going to take a while to build that back up, that confidence of where you're at. Or if it's a new medical problem, that all of a sudden requires a lot of extra thought. So if you have to take a new medication, there's a new management strategy, or is it a fracture that's led to a pain syndrome? So part of your cognitive ability is being absorbed by, you know, dealing with the pain you're experiencing. It's going to take away your ability to have other cognitive processes function as well.

Dr. Arnold:
You know, I don't recall discussing this with you on the last podcast, but I think now it'd be a nice point for you to illustrate what sundowning is. Because I think that term is sometimes misused, but most of the time accurate, but could you give us what sundowning is?

Dr. Younger:
Yeah. The term usually relates to the time of day for when a patient sometimes can have increased issues with cognition, or sometimes we see behaviors. When we wake up in the morning, we usually are a little bit more energetic. And what happens is people tend to fatigue throughout the day. So as you go throughout the day, your brain gets more fatigued, your body gets more fatigued. And there's a phenomenon where we will see in the hospital setting or in our skilled settings where patients somewhere between the time of like two o'clock and eight o'clock at night, will all of a sudden become more confused. Confusion sometimes can be met with a response of, people get more withdrawn. They don't want to do things. They seem less responsive, or sometimes it can cause agitation or aggressive behavior. So when we typically hear sundowning in a nursing home, they're usually referencing a patient who gets agitated or aggressive in the afternoon around dinner time. And part of that has to do with just the fatigue of the day, and trying to keep up with all the demands that they're having cognitively in an unfamiliar place. And sometimes it's pain, because they've been more active during the day doing therapy and things like that. And then they get more painful and that can cause some agitation throughout the day. And there's just kind of a general increase in energy as people go throughout the day in a facility, that sometimes leads to that behavior.

Dr. Arnold:
Yeah. My daughters say that I have bedtimer syndrome, where I just get grumpy about bedtime. And so it's a related condition perhaps. I don't know, I hope not. So it's not related to the circadian rhythm of the day necessarily, it's really the activities that proceeded the behavior.

Dr. Younger:
It depends. So circadian rhythm's interesting. So there are certain disease processes where we know you lose circadian rhythm, a very common one is Parkinson's disease. So Parkinson's patients tend to not sleep well because a part of their brain that's affected by the disease process, is part of their circadian rhythm. In certain dementias, we'll see the part of the brain affected that has to do with that sleep-wake cycle, and that sleep-wake cycle goes away. So then people either sleep poorly or they sleep at odd times that don't match with our traditional timing with therapy or with meals. And that can cause complications with that.

Dr. Arnold:
Lindsay, the role that aging services provides, are there things that can be done to determine this cognitive decline ahead of time? I mean, rather than it being a revealing event at the hospital, or with hospitalization and subsequent sundowning or agitation like Dr. Younger is describing?

Lindsay Glynn:
Yeah, absolutely. I think a lot of people can become anxious as they get older regarding: is this normal aging, or am I experiencing something here? And I think, you know, having, that self-awareness and thinking about how you and your loved ones are doing and knowing what's normal for you, is good. And having open conversations with your family docs about those concerns are really important. We do have the ability to assess cognition before hospitalization to really see. It's about looking at whether or not it's having an impact on your day-to-day life can be major factor in really being able to assess that. People are always forgetful, right. And figuring out a way to determine whether that's normal aging or normal forgetfulness is an interesting conversation. And having those conversations with professionals and doctors are important, because it can be nerve wracking.

Dr. Arnold:
Yeah. You know, that 23andMe and these genetic tests that say we can test find out whether or not someone might be more likely to have Alzheimer's. I'm like, yeah, that'd be great. And you know, the first time you forget your keys, you're like, oh, it's starting. You know, so I don't know how great that would be. But that being said, addressing these cognitive dysfunctions ahead of time is important, I don't want to make light of that. How do I try to say this? Nobody goes to rehab halfway to rock bottom, right? You don't wake up and say, man, I'm halfway to losing my job today. I think I'm going to, you know, go seek counseling and quit drinking and whatever ill that is affecting me. So sometimes to get patients and families to buy-in to recognizing this cognitive decline, it does take a significant hospitalization to reveal this. So how do you build that rapport with the family to explain to them why their loved one, or even explain to the patient themselves, can't go back to living alone?

Dr. Younger:
So, a couple of things to think about. So when we talk about this "recognizing it." There is a high sensitivity for cognitive disorders if a family member says my parent or grandparent is forgetful. If you hear that term, those patients can be diagnosed with dementia greater than 80% of the time if you do cognitive testing. So I think one thing is that people, sometimes family members will acknowledge it, but if you don't ask the right questions, sometimes you can't get that out of them. Like they may not tell you somebody forgetful, but if you ask a family member, Hey, is your parent forgetful? If their response is, yes, you need to be very on guard for a diagnosable dementia at that point. And it doesn't mean somebody can't be at home necessarily because there's different varying levels of dementia, but people do have some realization that their parents or their grandparents or a loved one may have some deficits.

Dr. Younger:
Now we are social beings. So we interact very socially and conversationally, particularly with family. And there are some patients with dementia, you can have a conversation with for two hours, they could have moderate advanced dementia, and you would never know. Because they're so conversational, and they read off of physical cues and verbal cues that they're able to converse with you. But if you ask them what time it is, or to add two numbers together, they may completely fail that question because the part of their brain that they can talk to you socially works great. But another part of their brain, which is do I remember to turn the stove off? Or can I drive safely in a car? There may be significant deficits there. So it does take some time to build rapport with families. But I think explaining some of those things that they start to acknowledge, oh yeah, they forget this stuff and ask them, have they done something functioning wrong? Oh yeah, they had this functional thing go wrong. And it helps people start to kind of realize the picture of, oh, there are deficits there. Because sometimes the social interactions can really trick you.

Dr. Arnold:
Yeah. I've had, you know, you have the daughter that lives out of state who talks to mom maybe once or twice a week. And then she comes home for the holidays, and says, oh my gosh, mom's demented. But then you have the daughter lives in town that says, no, mom's been forgetful for a long time. It's just that, like you said, that ingratiating personality. You know, like, I always say, you ask the patient, how was breakfast? It was good. What did you have? Oh, the usual. You know? And they might not even have had breakfast, you know, but if you just had that snippet, you would believe that was something. Either one of you can answer this question. How do you determine whether or not someone's going to return home after skilled nursing, with a cognitive decline, or need to be in a memory unit?

Dr. Younger:
Did you want to go Lindsay, or do you want me to go?

Lindsay Glynn:
Well, I think what's interesting is I think that we would have a couple of different perspectives on this. So I would like to hear your perspective first.

Dr. Arnold:
Yeah, let's hear both.

Dr. Younger:
So what I often ask patients is: can you sleep? Can you get dressed? Can you go to the bathroom? Can you get food? Are you then able to call for help if you need it? Right, so it gets at these very fundamental things about being a human being: eating, going to the bathroom, getting dressed, taking care of yourself, and being safe. Can you do those things, right? We have to start there. And if there's a deficit in one of those, we have to find something to replace that. Then the next level of complexity is, do you have a medical condition that you then have to manage on your own? So, do you have an unstable medical condition where if you're not able to take your medications effectively, are you going to get into trouble if you're not able to do that? So those are the two layers that I typically start with on, you know, can you do this simple stuff? Can you do this complex stuff? Okay. If we can do both of those, we can start talking about being at home. But if there's a deficit in one of those, and we don't have a solution for it that involves family or the patient doing it themselves, then we have to start looking at higher levels of care to supplement those deficits.

Dr. Arnold:
And is there, Lindsay maybe you can answer this, is there a gradation of levels of care that might be provided short of going to the nursing home or skilled care facility? I mean, is there stuff that we can do prior to that?

Lindsay Glynn:
Absolutely. There are absolutely differing levels of care that are options. And that's a great segue into the fact that we have medical professionals that assess whether or not somebody should be able to safely go home. And the thing that aging services often runs into is patients saying, we don't care, we're going home anyway. Like we just want to be home. And so we have people that are trying to live at home that are unsafe, but it's also their right and their choice to be at home. And so we're helping navigate, how do we keep them as safe as possible at home. Right. And so there are varying levels of care, and it's all about building that rapport with people so that they know that you're here with them, by their side throughout this process, because there are options for them at home to help keep them more safe. Working with physicians to really try and make sure that people are making the safest decision possible in that move.

Dr. Arnold:
Lindsay. How does one, let's say I have a parent, I'm concerned and I think they might need some assistance. Can I just call aging services and say help us?

Lindsay Glynn:
Yeah, absolutely. So we do a lot of work to help prevent any safety issues ahead of time. And we can help after somebody is discharged from the hospital back to home and work with a lot of social workers. They can just give us a call and talk about services that are available through aging services, but also other organizations as well. There are a lot of services and resources out there to help people remain in their home as long as possible after that discharged from the hospital to skilled, to their home. All of those levels of care that we're referring to, right.

Dr. Arnold:
I think if I could sum up this podcast, the two things I'd want listeners to hear are: one, is you're not alone in these decisions. There's highly trained professionals that are here to help you and they will help you. And number two, that you may never get back to where you were prior to the hospitalization and that's okay. So, you know, I don't want people to have unrealistic hope that grandma or your uncle is going to get back to where they were before, because they may not. And I think that's the important take-home that a significant hospitalization, that it is a significant hospitalization. It's a life event. And sometimes it has ongoing ramifications, or consequences, I should say. You know, one thing that we want to touch on in this podcast was driving. And Clete, you and I have had this conversation before. I've had this conversation many times, I was even thinking about this podcast on the way to work today as always driving. And I was thinking, sometimes it's easier to tell someone they have cancer than it is you can't drive anymore. So Clete, how do you approach that? That's a tough one.

Dr. Younger:
Yeah. So driving is, I mean, that's people's freedom. That's their ability to go out and do things, that's independence. And so unlike a lot of things, when you start taking away somebody's freedom and independence, as an American, that's very hard because we value that a lot. So if somebody chooses to not take a medication or if they don't use their CPAP, the impact of that decision is on themselves, right? And at some point we allow people to be autonomous, and if you don't want to take your medicine, there may be a consequence. I should explain to you what that is, so that you're prepared for that. But ultimately, if you choose not to do it, then that's your own decision. When you start to talk about driving, or this comes up sometimes with caregivers or patients with dementia, now your decisions can impact someone else.

And one of the things we really get concerned about are decisions with driving such as wrong way crashes. And these are the most significant what we worry about a lot with dementia, because if you get into a wrong way crash, the fatality rate of those kinds of accidents is significantly higher. It's not fender benders we're worried about. We're worried about somebody getting on the interstate going the wrong way. Because the impact of that can be so significant. So what I often try to talk to family members about is, you know, we need to acknowledge that this cognitive process may lead to somebody having a problem driving, or they're in my office because they had a car accident and the DOT made them come in. What I often tell families is: one, you don't want your family members legacy at the end of their life to be that they killed a kid in a car accident. Nobody wants that as a legacy, right? When you start to think of it in those terms, that changes people's perspective. And they say, I just want to drive. Well, what if you kill a kid? Oh, I don't want to do that.

Dr. Arnold:
It's a great tool.

Dr. Younger:
There you go. You know, we need to think about how to make that happen so we don't have that. Then you have to make people not feel abandoned or on an island. If you tell them, Hey, we're just going to take your car. Well then what are you going to do? So you always have to have that next step with that, is it a family member? Is it some other transportation services in the community to allow people to still have that ability to have mobility? Because if you just want to take their car and not give them another option, they're not going to be as receptive to that intervention.

Dr. Younger:
I personally have had families or the patient make the decision every time I've had the conversation. I've never had to call the DOT or call the police on a patient that I believe is unsafe before. Because we've been able to work through this discussion and either get the patient to give up their driving rights themselves, which is probably 90% of the time. And about 10% of the time we've had to do some alterations where the family takes the car away. Family takes the keys away. I had a family once that took the alternator out of the car because the patient was really mechanical and they wanted to fix everything, but they couldn't fix that problem. So we solved the problem because they couldn't fix the problem. And so there's just different levels of things you sometimes have to do to get to a decision where we're taking away driving rights, but we're trying to do it in the most amicable way that we can.

Dr. Arnold:
Makes sense. That's a great tool, that legacy. Clete, that is fantastic. I wrote it down.

Dr. Younger:
Nobody wants that to be what's you're remembered by.

Dr. Arnold:
You're right. I mean, you get away from putting them on the defense about what their skill level is and you transition it to their impact on other people. That's brilliant, quite honestly. So, Lindsay, did you have anything to add on driving and aging services?

Lindsay Glynn:
I guess I would just reiterate that you're not alone when you are a family member and you're thinking about your loved one being safe on the road. We run into that a lot, where people are concerned and they don't know how to have that conversation. And it typically isn't just one huge breakout conversation, having multiple conversations leading up to that, is very common and it's hard. And so don't be afraid to reach out to your family doc, to one of us here at aging services, when you're approaching those situations because you're not alone and it's hard.

Dr. Arnold:
Well, Dr. Younger always pleasure to have you. You're like a veteran. I need to check, I think you might have the most appearances on the podcast.

Dr. Younger:
I think we've done five, right?

Dr. Arnold:
Yeah. I think Abramson might be a close second, but we're going to look into that and see that you get a lifetime supply of Rice-A-Roni, the San Francisco treat. Lindsay, you're not old enough to remember the game shows that it used to be on. But Lindsay, thank you for joining me today. Once again, this was Dr. Clete Younger, medical director for St. Luke's Living Center. And you know Clete, that totally minimizes all the stuff that you do. Just to say medical director of Living Center, because you're hospice, you're an active primary care physician, you help supervise and lead the ARNP post-hospitalization team. So I think we need to get a bigger title, at least a footnote maybe, in the podcast.

Dr. Younger:
It's family medicine, we do everything right?

Dr. Arnold:
You do, and you do it well. You really do it well. And Lindsay, thank you for coming. This is Lindsay Glynn, executive director of Abbe Health Aging Services. And she'll now remember why it's Abbe Health and will perpetuate that legend. For more information on skilled nursing services provided at UnityPoint Health Cedar Rapids, call 319-366-8714. And for more information about Abbe Aging Health Services, visit UnityPoint.org/agingservices.

Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.