By Dr. Bill Thomas / Posted on January 6th, 2015
As a geriatrician, I’ve spent much of my time in the company of elders exploring life beyond adulthood. The shortcomings of our medical system to meet the human needs of elders as they navigate this uncharted territory are too numerous to list. Particularly when it comes to the way in which it treats people living with dementia. Of the 1.5 million people who have been institutionalized for medical problems, about 80 percent have been segregated from the general population because they are living with Alzheimer’s disease or dementia.
Because our medical system treats the trials of sickness, aging and changing cognitive ability exclusively as medical concerns, these people are too often tucked away from sight and treated with powerful psychotropic drugs. The treatment is not aimed at providing relief or a cure, but at making the patient more manageable – at the cost of hundreds of millions of dollars for drugs that provide limited relief and cause significant side effects.
For more than a decade, a handful of passionate organizations and advocates like myself have argued, and proved, that it can be different. Programs like The Eden Alternative, Ecumen’s Awakenings (http://www.ecumenawakenings.org), Anne Basting’s Timeslips (http://www.timeslips.org) and Dr. Al Power’s book “Dementia Beyond Drugs” demonstrate that non-pharmacological interventions for dementia provide meaningful benefits without the cost or the dangers of psychotropic drugs.
One of the most exciting of these new techniques is also the most elegantly simple – providing personalized music to people living with dementia.
The benefits of providing music to a person who has lost access to it include better memory, improved mood, decreased pain, increased engagement and enhanced well-being. Clinical studies demonstrate that it is possible for personalized music to have a greater effect than any medication.
Anyone who has doubts about the efficacy of personalized music can watch the technique graphically demonstrated in Alive Inside, the groundbreaking documentary on music and memory that is now available on DVD and streaming on Netflix.
I was honored to participate in the filming of Alive Inside with director Michael Rossato-Bennett. Time and again, Michael’s camera captured small miracles as life re-ignites in the eyes of people who have long been unresponsive after they are exposed to familiar, beloved tunes.
This simple, elegant film opens the door to a conversation about how we think about aging in general and about what we think makes a life worth living. For too long we have put the fate of our elders – our fate – into the hands of a medical system designed to focus exclusively on the repair of health and ignore what makes life significant. We’re not going to see music in the lives of every old person until we confront our own fear of aging and our own fear of death and demand a long term care system that does more than provide for safety and protection of elders. If we do that, we can build a society where nursing home means “nurturing” home. Where people go there to grow and live and love and laugh and listen to good music.
Music can be at the heart of the conversation about what makes a life worth living.
By Dr. Bill Thomas / Posted on January 24th, 2012
Flat is Good
Flat tires are bad. Flat cakes are bad. Flat organizations, can be, good. So, what makes an organization “flat?”
All human organizations have leaders and followers. One thing that defines a free society is that people can be a leader in one organization and a follower in another. All of us are part-time leaders and part-time followers. Some organizations create an enormous distance between leaders and followers. For example, the United States Army has a very steep and very large hierarchy that separates the lowest recruit from the highest general. An army private has very little chance of every becoming a general and generals never get busted down to private. The Army is the opposite of a “flat” organization.
A steep hierarchy is good for things like fighting wars and flying to the moon but steep organizations are pretty cold and very impersonal.
Flat organizations have a much smaller distance between leaders and followers. These two groups are able to challenge each other’s ideas. Green House homes are meant to be Flat organizations because the Elders need for all of us to work together. Everyone in The Green House home has ideas and insights and everyone can contribute to the conversation.
How can we tell if a Green House home is losing its “flatness?”
The main symptom is a decrease in problem-solving conversations and an increase in “problem-solving” by the leaders. In The Green House, leaders are not supposed to solve problems. In The Green House, leaders are supposed to help others solve problems.
The loss of “flatness” can become a big problem if people are not aware that it is happening. So, here is my challenge for you: Have a conversation about the flatness of your Green House home because when it comes to warmth and compassion, “flat is good.”
By Dr. Bill Thomas / Posted on December 15th, 2011
Some people eat to live. Others live to eat. Those in the first group regard food as fuel; those in the second group know better than that. Good food has always offered people much more than just calories, fat, carbohydrates, and protein. At its best, food nourishes us – body and soul. A meal can embody powerful symbols of love and acceptance. The bond between comfort and food, which begins at the breast, is fortified throughout childhood and gains renewed strength in the late decades of life. Properly prepared, the meals we cook and serve to our elders should be drenched in memory, ritual, and culture.
Reacting to case reports of actual starvation among nursing home residents, the government has established significant penalties for facilities that allow residents to lose weight “unexpectedly.” As a result, nursing homes struggle constantly to increase the dietary intake of their residents. Just how challenging a task they have undertaken becomes obvious when you look at how these facilities prepare and serve food.
They shop from industrial food catalogues and unload the groceries from a tractor-trailer parked at the loading dock. Meals are prepared in vast industrial kitchens that are deliberately isolated from the people who will eat what they produce. Some long-term care facilities, like airlines, outsource food production entirely and take delivery of dinners by the truckload. In a down-to-the-minute ballet, food is rushed upstairs in huge rumbling carts. Staff members distribute it to waiting residents as quickly as they can. It is a never-ending challenge to serve hot food when it is still hot and cold food when it is still cold.
The people involved do their best. The realities of large-scale food service demand, however, that the material characteristics of the food – its color, viscosity, temperature, and nutritional content- become its most important descriptors. The emphasis on consistency and low cost is constant. Food is shorn of meaning, leaving only numerical measurements. The lifelong rhythm of good food shared within the circle of family life is absent. It is just not possible to imbue six hundred meals a day with the essence of love.
The Romans had a special term for the particular pleasure that accompanies sharing good food with the people we know well. They called this experience convivium. The word has enjoyed a revival recently. The “slow food” (an alternative to fast food) movement has seized on the word as a way of describing dining experiences that are rich in meaning. Fresh, local ingredients prepared according to authentic regional recipes are served to people eager to share. They use smell, taste, and texture as a springboard to good conversation and vital relationships. The shahbazim foster a convivium that enriched the lives of elder and shahbaz alike.
The relationship between people and the food that sustains them begins with the planning that by necessity must precede each meal. The idea that meals can and should be planned with loving care and then prepared with loving hands will strike the typical food service manager as little more than wishful thinking. For the rest of us, it is simple common sense confirmed by our own experiences in our own homes. The suffering created by the industrialization of food in long-term care institutions deserves more than passing attention. Nursing homes are canaries in the mine, warning us of the assembly-line approach to food that is spreading across our social landscape. We are all losing our grip on convivium. Institutions may be able to blame their mechanical approach to food on their own gigantic size, but we can see the erosion of convivium all around us, even in our own lives.
The ability to create and maintain convivium demands an appreciation of the long, languorous meal and is one of the core competencies of a shahbaz. Time must be taken because food tastes better when it is soaked in anticipation. Elsewhere, soup may be purchased in bulk, heated, and then served. The shahbaz insists that the soup be made fresh and allowed to simmer all morning long with ingredients added slowly as the hours pass. In an institution, mealtime is a mad rush. For the shahbaz it is an opportunity to create and then deepen meaning. The spirit of convivium calls upon us to linger, to savor, and to draw strength not just from the food we are blessed to eat but also from the people with whom we are blessed to share our meal.
By Dr. Bill Thomas / Posted on December 5th, 2011
A long life ought to entitle one to a dignified old age. We may not be able to cure diseases such as Alzheimer’s but we can offer our elders a life that is rich with kindness, patience, encouragement and appreciation. The creation of such a life is just what Green House homes were designed to do.
Dr. Risa Lavizzo-Mourey, who serves as the leader of the Robert Wood Johnson Foundation, recently examined this challenge in an op-ed that ran in the Sacramento Bee.
In Pomona, construction is starting on two modest homes that could revolutionize the way California cares for seniors who can no longer live independently. Residents will not experience the long sterile hallways, hospital-style rooms or the boredom and loneliness too often found in traditional nursing homes. Instead, these “Green House” homes – the first of their kind in California – will provide seniors with quality care and something just as important to their well-being: the feeling of being in a real home.
There is a world of difference between places that aspire to be “home-like” and those that attempt to make a real home for real flesh and blood, living and breathing human beings.
Much has been written about the “silver tsunami” of boomers now entering their retirement years and expected to live longer than previous generations. No state has as much at stake as California, which will see its number of seniors 85 and older triple in the next 30 years.
These trends are daunting, but the good news is that we know more than ever before about what it takes to provide the most vulnerable seniors with the care they need and the dignity they deserve.
Although conventional wisdom tells us that aging is a bad thing, the truth is that aging is a very good thing which, if approached correctly, will enrich the lives of people of all ages.
A decade ago, an idea like this would have been unimaginable on the basis of cost alone. But more than 100 Green House homes in 19 states have now proven otherwise. In fact, a major study published in the Seniors Housing and Care Journal concludes that Green House homes cost the same as traditional nursing homes to operate but deliver vastly better care and quality of life.
Thanks to leadership from state Sen. Elaine Alquist, D-Santa Clara, California recently took an important step by clarifying its regulatory requirements to ensure that rules designed for bigger institutions 30 years ago were not inadvertently preventing smaller Green House homes from being built. The project under way in Pomona is a direct result of the updated policy.
“Senator Elaine Alquist”— this is a name that will go down in California legislative history. While it is true that it took the energies and drive of many people to bring California’s first Green House homes into being, without Senator Alquist—- it never would have happened. With skill and tenacity she built support for this innovation and then translated that support into action. This work is the very essence of “good government.”
These first Green House homes will, indeed, change the world of long-term care in California. Elders living in California Green House homes may never know her name but they will all owe her a debt of gratitude. On behalf of those elders, I say, “Thank you Senator Alquist.”