“When you are (mentally ill), you don’t know it. Reality is what you see. And when what you see departs from everyone else’s reality, it’s still reality to you.”
Bipolar writer Marya Hornbacher describes a place that only a troubled mind can occupy, a refuge where voices are calm and things make sense. It is a locked room of long shadows that most of us cannot enter.
The angry man balls up his fists and swings at every person who tries to help him. He is not a bad person. He is striking out at his confusion. But to those who come within range of his fists, a punch would hurt no less.
Judie Harrington, R.N., boldly walks up to the elderly man and stops as he tenses. Instead of shrinking back, she comes to attention and snaps off a salute that would make a general preen. The man in front of her, a Filipino-American retired military man, relaxes his fists and salutes in return. He then smiles and extends his hand to shake hers.
Harrington has just slightly parted the curtain that Alzheimer’s has draped over his mind. She recognizes that, to him, the unknown is the assaulting enemy. However, she has found a way through his defenses because she understands his disease. She has tapped into something at his core, something he is struggling to preserve.
The rest of the staff starts saluting also, and because the man has become more relaxed, they are able to give the care he needs.
Harrington has gotten to know many people like our military guy. She is a dignified woman of 74 who has spent many years working with nursing homes. She wants all patients to receive their own version of a snappy salute.
She taught at the University of Nebraska nursing school for over a decade before moving west. She and her husband now live on the eastern outskirts of El Cajon.
At least that retired military man was not over-medicated, which happens too often, she says, and which can worsen health issues.
“A man in his early 60s came into a Spring Valley skilled-nursing facility with a mental illness diagnosis. He was admitted with four different medications prescribed by his primary physician,” she says.
“He was agitated, distressed and uncooperative. He was obviously over-medicated. I conferred with the psychiatrist and we started to reduce his meds. As we did, his symptoms diminished, his sleep improved and he started participating in his therapies.”
Harrington says state law requires a semiannual review of a nursing home patient’s medications and on which a physician must sign off. She is a contract nurse hired to achieve compliance with that law. She goes in-depth into each patient’s chart to sort out which drugs should stay and which should go, and then makes recommendations to a psychiatrist.
Although she looks at medications for all residents, and for all conditions, she pays special attention to those of the mentally ill because they often are at the mercy of caregivers, and their protests are frequently seen as manifestations of their condition.
Harrington describes what happened to an elderly woman in yet another nursing home. “She was a severe diabetic who was restrained in bed and tied in a wheelchair when out of bed. She was on three antipsychotic meds and was dependent on staffers for everything — dressing, bathing and walking.
“I began a program to reduce these medications. The medical director said, ‘OK, I see what you’re doing. I’m with you.’
“It took a little time, but this woman came off all three meds. She could get out of her bed, get her clothes and dress herself, and take herself to the bathroom.
“Another patient was admitted because he was so distraught his wife couldn’t handle him. We reduced his medication, moved him closer to the nursing station for observation, and soon he was discharged.”
Frankly, she says, it is unacceptable for a doctor to prescribe a psychotropic drug, or any drug for that matter, without taking into consideration how it might interact with other drugs the patient is taking.
Harrington says drugs are obviously necessary, but they can’t substitute for human caring, which can easily be overlooked in the harried pressures of staffing a nursing home.
“There was this beautiful woman with big blue eyes. She had cerebral palsy, and then multiple sclerosis on top of that. I’d never heard her talk. I decided I would get to know her. I started spoon-feeding her while also carrying on a conversation.
“One day, I was feeding her, and suddenly she spoke. The words came out in slow motion. She said, ‘You … are … wearing … orange.’ I said, ‘Yes, I am.’ Then, she said, ‘You … are … wearing … a … crochet … top.’ ‘Yes, I am.’ She then said, ‘I’m … jealous … of … you.’”
What made her respond?
“Because I sat there and talked to her. The truth is, taking care of the mentally ill is hard work for everyone, including family and staff. It’s frustrating and often irritating,” Harrington says.
She says certified nursing assistants, those on the front line of care and treatment, are trained on how to take care of the physical needs of patients — feeding, emptying bed pans, hygiene, making beds, etc. However, they have little preparation for the enormous stress and frustration of dealing with people who can drive them to distraction — the patients themselves. After all, they are mentally ill, and that’s a tough thing to deal with day after day.
In fairness to those health workers and the patients they serve, Harrington believes there should be more seminars, group sessions and on-the-job training to deal with day-to-day pressures. Not everyone is born as a Mother Theresa.
“I’ve seen staff scream back at patients who are screaming at them. These are rarely unfeeling or angry people. They’re minimally trained aides struggling to control their own frustrations. Those feelings need an outlet to vent and to be understood.”
Harrington says when she reviews patients’ charts, she not only examines drug records, but also looks for pain not addressed, infections and dehydration. She also makes sure lab tests are up to date.
Prescriptions can make their way onto a patient’s chart from different physicians. For example, Harrington says ER doctors can prescribe drugs for psychiatric episodes only for the purpose of dealing quickly with an emergency. However, those drugs sometimes are not canceled when the crisis passes.
Harrington says home caretakers have to educate themselves and become active in monitoring — and questioning — the number of drugs and dosages prescribed for family members. That includes all cases of mental illness, including Alzheimer’s and dementia.
“You know your loved ones better than any doctor or nurse,” she says. “Educate yourself and get involved.”
Speaking to family members, she asks: “What is it that mentally ill people want to say to us that we’re often not hearing? They’re saying, ‘I’m suffering.’ They’ve forgotten what it was like to not suffer.”
The most effective painkiller is the caretaker with the soft touch of compassion.
The eyes can lie, but never the hands.
Fred Dickey’s home page is freddickey.net
His email is firstname.lastname@example.org