“Doc you know, dad was one of the top bank managers in the state and just look at him now! And mum was always at his side, cheerful and energetic. And look at the two of them - just a shade of what they have been. You know Doc, I tell you now, I don’t want to get old like this one day. I reckon this new thing of euthanasia is the answer...”
I’ve heard and have seen this over and over again.
Mum and dad in the nursing home – and later only mum. And she talks less and less; rarely smile anymore; seams to sleep most of the day; struggle to recognise the children and grandchildren; has no energy and slowly keep losing more and more weight.
The staff throw their hands in the air: “We try to feed her doc, but she does not want to eat. She just sits there with the food still in her mouth. What more can we do!?” And the children confer in low voices and look on in disbelief – “is this how it all ends?” they think.
Shakespeare nailed this ancient phenomenon around 1600 in "All the world's a stage". He ends his summary of the cycle of life like this: “Last scene of all, that ends this strange eventful history, is second childishness and mere oblivion, sans teeth, sans eyes, sans taste, sans everything”
Is this really the best we can do? No! The answer is simply No – we can do much better and we ought to do better.
Let me explain..
The “power-house” of the brain called the RAS is situated at the base of the brain. This centre is supposed to keep all the lights shining in the rest of the brain – keeping us awake, alert and responsive. One of the biggest sources of input into the RAS system to help ensure it is active and “generating electricity” is from proprioceptors. These little sensors with their associated nerve are placed near joints and monitor the movements of a joint.
When you feel sleepy simply stand up, move your arms and wrists, move up and down on your ankles or go for a walk. You will wake up and regain your energy within minutes!
When we get older and become less active, we not only loose muscle bulk, but because we move our limbs and joints less, we induce less stimulation of the RAS that makes us sleepier, less motivated and more lethargic. And the more lethargic we get, the less we move. And the less we move the more lethargic we get, starting an unhealthy situation of “the dog chasing his own tail”.
The second and even bigger contributor to our demise is dehydration & malnutrition.
And these are the “two elephants” in nursing homes around the world! As we get older, become less active and eat softer food our muscles lose their bulk and becomes weaker. And this include the muscles needed to chew and swallow.
I’m sure you can see where this is going!
Yes, you’re right.
Less food intake and less liquid intake causes malnutrition and dehydration.
There are two big problems with these conditions. The first is that they are very difficult to diagnose. We estimate that about 68% of nursing home residents have swallowing difficulties and the majority of them (probably around 75%) remains undiagnosed!
The second problem with these conditions is that they cause a downward spiral in health that quite rapidly can lead to the situation of “mum and dad in the nursing home” that we discussed above.
So how do we recognise malnutrition and dehydration?
The first symptom is often unexplained loss of weight. The staff would typically say there is nothing wrong with mum, she just doesn’t want to eat and the doc would confirm that physically he can’t find a cause of her weight loss. The rest is simply the way mum and dad presented in the story above: talking less and less, loss of energy, sleeping most of the day, less social interaction, depression, loss of appetite and a slow process in eating. There might even be complications like pressure sores, bladder and chest infections and slow recovery from disease.
And this is how the Grand Slam happens. Less exercise and less muscle bulk leads to increased sleepiness and less intake. Less intake leads to dehydration and malnutrition that leads to lethargy and even less movement and exercise. And this soon develops into a deadly downward spiral that often leads to pneumonia, septicaemia and an early death.
Back to the story above: “The staff throw their hands in the air: We try to feed her but she does not want to eat. What more can we do!? And the children confer in low voices and look on in disbelief – Is this how it all ends?”
The family and staff might even express the opinion: “I think she stopped eating because she wants to tell us that she wants to die.”
This to me is the saddest point of the saga, because if mum could break out of this downward spiral she would, but she can’t. She does not understand what is happening, she struggles to express herself and those around her is at a loss to understand and address the predicament.
I am convinced that if we were able to identify this problem early and address it effectively, we will be able to dramatically improve the quality of life, the enjoyment of life as well as communications and social interactions towards the end of life.
So, what do we need to do to address the problem?
There are 4 simple steps in the process:
1. Pick the problem early enough to still kerb the tide. Look for the symptoms and the story above and intervene early – or better even, try to prevent it from happening.
2. Increase exercise actively by walking and swimming as well as participating in exercise classes. Passive exercises of all the body joints are valuable if mobility is a problem. See a physiotherapist to supervise and prescribe specific exercises.
3. Target a fluid intake of more than 1500ml per day. Check the urine – it should be passed at least 4x per day and should be a light straw colour. Ensure a good nutritious food intake. There are many thickened liquid meals on the market. Pick one that taste good, is high in protein and energy and contains a whole suite of minerals and vitamins.
4. If there is any hesitancy in taking food or thickened liquid meals use a device early that is applicable to the condition and acceptable to the loved one. We expect that this market will expand rapidly over the next 10-15 years with various feeding devices coming onto the market that could make a big difference in the care and quality of life of our older residents!
And finally - start early with a healthy lifestyle. Good food, plenty of hydration and exercise and stimulating brain activity are the keys to quality in later life. If any feeding devices are needed, start early and prevent the doldrums.
You might just add 2-3 fantastic years with your loved ones to your portfolio on planet earth!