American Society of Aging (ASA): Aging in America

SAN FRANCISCO – Retirement community staff should prepare themselves for norovirus outbreaks, which can shut down dining halls, damage public relations, and strain residents’ physical and mental health, according to staff members of a Portland, Ore., facility who learned the hard way last year.

"Knowing what we know now, there are a lot of things we would have done differently," said Mjere Simantel, director of social services at Willamette View, a continuing care residential community in Portland, at the annual conference of the American Society on Aging.

Norovirus, which causes diarrhea, vomiting, and fever, is seldom deadly and most patients recover in 48 hours, but it can spread quickly in the tight quarters of a retirement community. And victims can continue shedding the virus for weeks after symptoms fade.

The virus had visited Willamette View before, but without doing much harm. "Previous outbursts were taken care of very quickly," said Rikki Schoenthal, community counselor for the 500-bed facility.

She first became aware of last year’s outbreak in March of 2010 when some residents complained of food poisoning. That was on a Friday, and the local health department was closed because of furloughs. Over the weekend, the number of residents with symptoms began mushrooming. The health department ordered the community to close the dining room and stop cross-traffic between the community’s buildings.

"Our dining service had to figure out how to feed our residents," recalled Ms. Schoenthal. "How were we going to deal with the hair salon, the computer lab, the laundry room, the health center, the pool, the bank, the cleaning room, the library?" Eventually, almost all social activities were canceled.

And the staff found themselves on a sharp learning curve. One hard lesson was that the virus can live on ordinary surfaces indefinitely. "We actually had staff wiping down books," said Ms. Schoenthal.

Another lesson: Hand sanitizers don’t kill the virus. It has to be physically removed from skin with soap, water, and scrubbing. Likewise, vacuuming carpets can send the virus airborne. The community invested in a large stock of chlorine wipes, only to find them ineffective. Some chemicals that were used to sterilize surfaces proved so potent they took the paint off walls, corroded doorknobs, and damaged elevator buttons.

With such confusion, communication proved very important. The management slipped newsletters under each resident’s door every day. Still, residents felt isolated; the only human contact for some was the staff who delivered their meals.

"Some of the residents felt like it was room service," said Ms. Schoenthal. "Others reacted with dismay. They felt like they were being ‘quarantined.’ That word started to be used and we did not want it to be used."

Staff was strained to the breaking point. Those whose work was involved with social activities had to be reassigned. Dining hall staff had to work extra hours. Even the CEO began delivering meals.

The meal deliveries became the community’s main means of checking on the daily health of each resident. The management created a database to track who had fallen sick and who had recovered. Eventually, 96 residents got sick and 2 were hospitalized with dehydration.

Some 50 staff members fell ill as well. "Some of the older adults had accidents, and the environmental staff had to go in there and clean up, and most of them got sick," said Ms. Schoenthal.

She saluted their sacrifice. "The way the staff protected the dignity of the residents in an undignified situation was just stellar," she said. Although the management recognized this effort with a $50 bill for each staff member, many staff members suffered financially because they were forced to take time off after falling ill with the virus. Those who didn’t have enough paid days in their account had to take the time off unpaid. "That was something we still want to explore," said Ms. Schoenthal.

As the outbreak stretched on, the strains increased. The health department insisted that the dining hall be kept closed for 4 weeks, and no visitors or social activities were allowed.

"We had residents who didn’t leave their rooms for 4 weeks," said Ms. Simantel. "Our residents were used to being extremely social. They went from all to nothing. It felt to them like a lockdown, and we still have residents report that they have not recovered."

The staff piped brain teasers into the residents’ rooms through closed-circuit television and began making phone calls to them, but many residents suffered from the isolation. One man had to be referred to hospice care when the restrictions were ended.

The Willamette presenters recommended the following issues for similar communities to consider before they’re hit by norovirus:

• When to activate an emergency plan.

• How to collect data.

• With whom to share the data.

• What role state agencies will play.

• Whether staff has to use paid time off if they get sick from their work.

• What your business insurance will cover.

• How to clean infected rooms.

• How to communicate with state agencies and the news media.

• Whether to use the "Q word" (quarantine).

The presenters also listed the following measures that they would do differently:

• Broadcast a closed-circuit television program of physical exercises.

• Ask health department experts to visit and make recommendations tailored to the community’s circumstances.

• Allow visitors to go to residents’ rooms while wearing gowns, masks, and gloves, which they would discard after each visit.

And audience members who have experienced norovirus outbreaks offered the following additional suggestions:

• Keep a box of supplies on hand for such an emergency.

• Put magnets on the doors of sick residents so that staff can tell which is which.

• Create a system of phone friends to help break the isolation.

Whatever else they do, staff members should be prepared for a longer haul than they expect, said Ms. Schoenthal. "We just kept thinking it would end tomorrow."

SAN FRANCISCO – Retirement community staff should prepare themselves for norovirus outbreaks, which can shut down dining halls, damage public relations, and strain residents’ physical and mental health, according to staff members of a Portland, Ore., facility who learned the hard way last year.

"Knowing what we know now, there are a lot of things we would have done differently," said Mjere Simantel, director of social services at Willamette View, a continuing care residential community in Portland, at the annual conference of the American Society on Aging.

Norovirus, which causes diarrhea, vomiting, and fever, is seldom deadly and most patients recover in 48 hours, but it can spread quickly in the tight quarters of a retirement community. And victims can continue shedding the virus for weeks after symptoms fade.

The virus had visited Willamette View before, but without doing much harm. "Previous outbursts were taken care of very quickly," said Rikki Schoenthal, community counselor for the 500-bed facility.

She first became aware of last year’s outbreak in March of 2010 when some residents complained of food poisoning. That was on a Friday, and the local health department was closed because of furloughs. Over the weekend, the number of residents with symptoms began mushrooming. The health department ordered the community to close the dining room and stop cross-traffic between the community’s buildings.

"Our dining service had to figure out how to feed our residents," recalled Ms. Schoenthal. "How were we going to deal with the hair salon, the computer lab, the laundry room, the health center, the pool, the bank, the cleaning room, the library?" Eventually, almost all social activities were canceled.

And the staff found themselves on a sharp learning curve. One hard lesson was that the virus can live on ordinary surfaces indefinitely. "We actually had staff wiping down books," said Ms. Schoenthal.

Another lesson: Hand sanitizers don’t kill the virus. It has to be physically removed from skin with soap, water, and scrubbing. Likewise, vacuuming carpets can send the virus airborne. The community invested in a large stock of chlorine wipes, only to find them ineffective. Some chemicals that were used to sterilize surfaces proved so potent they took the paint off walls, corroded doorknobs, and damaged elevator buttons.

With such confusion, communication proved very important. The management slipped newsletters under each resident’s door every day. Still, residents felt isolated; the only human contact for some was the staff who delivered their meals.

"Some of the residents felt like it was room service," said Ms. Schoenthal. "Others reacted with dismay. They felt like they were being ‘quarantined.’ That word started to be used and we did not want it to be used."

Staff was strained to the breaking point. Those whose work was involved with social activities had to be reassigned. Dining hall staff had to work extra hours. Even the CEO began delivering meals.

The meal deliveries became the community’s main means of checking on the daily health of each resident. The management created a database to track who had fallen sick and who had recovered. Eventually, 96 residents got sick and 2 were hospitalized with dehydration.

Some 50 staff members fell ill as well. "Some of the older adults had accidents, and the environmental staff had to go in there and clean up, and most of them got sick," said Ms. Schoenthal.

She saluted their sacrifice. "The way the staff protected the dignity of the residents in an undignified situation was just stellar," she said. Although the management recognized this effort with a $50 bill for each staff member, many staff members suffered financially because they were forced to take time off after falling ill with the virus. Those who didn’t have enough paid days in their account had to take the time off unpaid. "That was something we still want to explore," said Ms. Schoenthal.

As the outbreak stretched on, the strains increased. The health department insisted that the dining hall be kept closed for 4 weeks, and no visitors or social activities were allowed.

"We had residents who didn’t leave their rooms for 4 weeks," said Ms. Simantel. "Our residents were used to being extremely social. They went from all to nothing. It felt to them like a lockdown, and we still have residents report that they have not recovered."

The staff piped brain teasers into the residents’ rooms through closed-circuit television and began making phone calls to them, but many residents suffered from the isolation. One man had to be referred to hospice care when the restrictions were ended.

The Willamette presenters recommended the following issues for similar communities to consider before they’re hit by norovirus:

• When to activate an emergency plan.

• How to collect data.

• With whom to share the data.

• What role state agencies will play.

• Whether staff has to use paid time off if they get sick from their work.

• What your business insurance will cover.

• How to clean infected rooms.

• How to communicate with state agencies and the news media.

• Whether to use the "Q word" (quarantine).

The presenters also listed the following measures that they would do differently:

• Broadcast a closed-circuit television program of physical exercises.

• Ask health department experts to visit and make recommendations tailored to the community’s circumstances.

• Allow visitors to go to residents’ rooms while wearing gowns, masks, and gloves, which they would discard after each visit.

And audience members who have experienced norovirus outbreaks offered the following additional suggestions:

• Keep a box of supplies on hand for such an emergency.

• Put magnets on the doors of sick residents so that staff can tell which is which.

• Create a system of phone friends to help break the isolation.

Whatever else they do, staff members should be prepared for a longer haul than they expect, said Ms. Schoenthal. "We just kept thinking it would end tomorrow."

SAN FRANCISCO – Retirement community staff should prepare themselves for norovirus outbreaks, which can shut down dining halls, damage public relations, and strain residents’ physical and mental health, according to staff members of a Portland, Ore., facility who learned the hard way last year.

"Knowing what we know now, there are a lot of things we would have done differently," said Mjere Simantel, director of social services at Willamette View, a continuing care residential community in Portland, at the annual conference of the American Society on Aging.

Norovirus, which causes diarrhea, vomiting, and fever, is seldom deadly and most patients recover in 48 hours, but it can spread quickly in the tight quarters of a retirement community. And victims can continue shedding the virus for weeks after symptoms fade.

The virus had visited Willamette View before, but without doing much harm. "Previous outbursts were taken care of very quickly," said Rikki Schoenthal, community counselor for the 500-bed facility.

She first became aware of last year’s outbreak in March of 2010 when some residents complained of food poisoning. That was on a Friday, and the local health department was closed because of furloughs. Over the weekend, the number of residents with symptoms began mushrooming. The health department ordered the community to close the dining room and stop cross-traffic between the community’s buildings.

"Our dining service had to figure out how to feed our residents," recalled Ms. Schoenthal. "How were we going to deal with the hair salon, the computer lab, the laundry room, the health center, the pool, the bank, the cleaning room, the library?" Eventually, almost all social activities were canceled.

And the staff found themselves on a sharp learning curve. One hard lesson was that the virus can live on ordinary surfaces indefinitely. "We actually had staff wiping down books," said Ms. Schoenthal.

Another lesson: Hand sanitizers don’t kill the virus. It has to be physically removed from skin with soap, water, and scrubbing. Likewise, vacuuming carpets can send the virus airborne. The community invested in a large stock of chlorine wipes, only to find them ineffective. Some chemicals that were used to sterilize surfaces proved so potent they took the paint off walls, corroded doorknobs, and damaged elevator buttons.

With such confusion, communication proved very important. The management slipped newsletters under each resident’s door every day. Still, residents felt isolated; the only human contact for some was the staff who delivered their meals.

"Some of the residents felt like it was room service," said Ms. Schoenthal. "Others reacted with dismay. They felt like they were being ‘quarantined.’ That word started to be used and we did not want it to be used."

Staff was strained to the breaking point. Those whose work was involved with social activities had to be reassigned. Dining hall staff had to work extra hours. Even the CEO began delivering meals.

The meal deliveries became the community’s main means of checking on the daily health of each resident. The management created a database to track who had fallen sick and who had recovered. Eventually, 96 residents got sick and 2 were hospitalized with dehydration.

Some 50 staff members fell ill as well. "Some of the older adults had accidents, and the environmental staff had to go in there and clean up, and most of them got sick," said Ms. Schoenthal.

She saluted their sacrifice. "The way the staff protected the dignity of the residents in an undignified situation was just stellar," she said. Although the management recognized this effort with a $50 bill for each staff member, many staff members suffered financially because they were forced to take time off after falling ill with the virus. Those who didn’t have enough paid days in their account had to take the time off unpaid. "That was something we still want to explore," said Ms. Schoenthal.

As the outbreak stretched on, the strains increased. The health department insisted that the dining hall be kept closed for 4 weeks, and no visitors or social activities were allowed.

"We had residents who didn’t leave their rooms for 4 weeks," said Ms. Simantel. "Our residents were used to being extremely social. They went from all to nothing. It felt to them like a lockdown, and we still have residents report that they have not recovered."

The staff piped brain teasers into the residents’ rooms through closed-circuit television and began making phone calls to them, but many residents suffered from the isolation. One man had to be referred to hospice care when the restrictions were ended.

The Willamette presenters recommended the following issues for similar communities to consider before they’re hit by norovirus:

• When to activate an emergency plan.

• How to collect data.

• With whom to share the data.

• What role state agencies will play.

• Whether staff has to use paid time off if they get sick from their work.

• What your business insurance will cover.

• How to clean infected rooms.

• How to communicate with state agencies and the news media.

• Whether to use the "Q word" (quarantine).

The presenters also listed the following measures that they would do differently:

• Broadcast a closed-circuit television program of physical exercises.

• Ask health department experts to visit and make recommendations tailored to the community’s circumstances.

• Allow visitors to go to residents’ rooms while wearing gowns, masks, and gloves, which they would discard after each visit.

And audience members who have experienced norovirus outbreaks offered the following additional suggestions:

• Keep a box of supplies on hand for such an emergency.

• Put magnets on the doors of sick residents so that staff can tell which is which.

• Create a system of phone friends to help break the isolation.

Whatever else they do, staff members should be prepared for a longer haul than they expect, said Ms. Schoenthal. "We just kept thinking it would end tomorrow."

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Music therapy can improve symptoms of depression and agitation in residents with dementia, according to researchers who described an innovative program in the MJHS health system* in New York.

"There was a major drop in agitation after 2 weeks of music therapy," said Dr. Mary S. Mittelman, director of the psychosocial research and support programs at nearby Langone Medical Center, and statistical analyst for the pilot program. "Depression went way down."

While most nursing homes offer music as passive entertainment, the researchers tried to systematically engage residents as active participants who move in time to the music, sing, or play instruments.

Music may stimulate people with dementia in a way that language cannot, said Jan Maier, RN, of the Research Triangle Institute International in Durham, N.C., who offered background information on music therapy. "In dementia, the parts of the brain that have to do with music and emotional memory are preserved," she said.

She cited anecdotal reports of people with dementia learning three-part rounds or recalling the words to long hymns they sang in their youth. In some documented cases, former professional musicians with such severe dementia that they couldn’t dress themselves have been able to play instruments in ensembles, she said.

"People who don’t remember their son or daughter who come to visit will remember the person who leads their music group, and say, ‘Do we have music today?’ " Ms. Maier said.

Photo courtesy Metropolitan Jewish Health System

A handful of randomized controlled trials have shown reductions in agitation in patients with dementia who participate in music therapy, she said, citing among other studies one by researchers in Taipei, Taiwan, that recently documented the effect (Int. J. Geriatr. Psychiatry 2011 July;26:670-8 [doi: 10.1002/gps.2580]).

Music therapy has great potential in long-term care, Dr. Mittelman said, since about 70% of nursing home residents over age 75 years suffer from dementia.

The MJHS health system* developed protocols in which the residents sang along or moved in time to the music, and others that incorporated music into activities of daily living, such as wound care, bathing, and range-of-motion exercises.

In a video demonstrating a typical session, women waved scarves in time to big band music. "The movement intervention worked best," said Kendra Ray, a music therapist* who directed the project.

Dr. Mittelman said the researchers collected data on 84 people, of whom 8 had agitation, 42 had depression, and 34 were wanderers. The research showed an average one-third drop on the Cohen-Mansfield Agitation Inventory and a similar improvement in depression, measured by the Dementia Mood Picture Test. Depression returned when the music therapists left and certified nursing assistants took over the activities. Results from the Algase Wandering Scale were inconsistent. Dr. Mittelman acknowledged that the data were only preliminary and that larger studies should be conducted.

But, as another measure of success, Dr. Mittelman said that some of the participants’ families testified about the benefits of the program. Some said that they enjoyed their visits more because the residents’ moods had improved so much. "My Mom is more upbeat, more attentive, and talkative," one wrote. And, at times, residents picked up instruments to practice on their own, outside of music-therapy hours.

If you are trying to address specific behaviors, Dr. Mittelman advised, time the therapy for when these behaviors are likely to occur. For example, if someone wanders in the evening, play music at that time. But don’t play music all day. That can become irritating, she said.

When designing a music-therapy program for an individual, "Pick the music that person loved," Dr. Mittelman said. "If you don’t know, go to their early adult years. If they like it, they’ll let you know right away."

Dr. Mittelman and Ms. Ray said they had no conflict of interest on the topic.

* CORRECTION, 6/3/2011: The original version of this article referred to the MJHS health system as the Metropolitan Jewish Health System. This version has been updated. Also, Kendra Ray was incorrectly referred to as an art therapist. She is a music therapist. We regret the error.

SAN FRANCISCO – Contrary to decades of tradition – and Sigmund Freud – psychotherapists working with frail elders should offer counseling on spirituality, according to three experts who have straddled the therapy-spirituality line in their own practices.

"I’m convinced you can take process psychology and marry it to theology," Jim Ellor, Ph.D., a professor of social work at Baylor University in Waco, Tex., said at the conference.

One reason that psychotherapists have avoided discussing their patients’ spirituality is that they confuse spirituality with religion, said Donald Koepke, director emeritus of the California Lutheran Homes Center for Spirituality and Aging, in Anaheim, Calif. Since the days of Sigmund Freud, who saw religion as a kind of neurosis, psychotherapists have been taught to avoid religion.

"While everyone may not have a religion, or be what we call religious, everyone has spirituality," said Mr. Koepke. "It’s core beliefs. It’s what drives them and helps them to experience the world."

He gave the example of Audrey, a communist atheist he met in the nursing home where he worked as chaplain. When she was diagnosed with a terminal illness, Mr. Koepke visited her and asked how she felt about having little time left.

"I move over and make room for someone else," she answered. But she went on. "The purpose in life is to leave the world better than you found it," she said. "I have done that." She went on to describe her activism in the labor movement.

Mr. Koepke said he left Audrey’s room feeling that "she felt connected to that which was greater than herself."

He said that everyone has four spiritual needs: to find meaning; to give love; to receive love; and to feel forgiveness, hope, and creativity. Something about the experience of living in a nursing home gives people an opportunity to face these needs, he added. "The spiritually healthy people I know are almost all in skilled care. They are marvelous people to know."

Barry Kendall, Psy.D., a private-practice existential psychologist in Beverly Hills, Calif., said that what is called existential psychotherapy can help such patients answer spiritual questions. This approach, as described by Stanford (Calif.) University psychiatrist Dr. Irvin Yalom, deals with psychological conflicts as stemming from the inevitability of death, the responsibility of freedom, isolation, and the inherent meaninglessness of life.

"Inside psychotherapy, people for the first time begin to have a relationship with someone who understands them," he said. With some patients, the conversation may turn specifically to religion, for others it may stay more generally on the meaning of life, Dr. Kendall said. "For some patients who are theists, the explicit questions are helpful. For other patients, the implicit questions are helpful."

How can a therapist help patients with their spiritual problems? Listen to their experiences, advised Dr. Ellor. "Look for the threads that are consistent in their story. If they are talking about the spiritual, listen." When patients ask for a spiritual professional, for example to conduct rites specific to a religion, psychotherapists should step aside.

But when the question at hand is really about feelings, then psychotherapists should continue trying to meet their patients’ needs because the therapists know how to work with feelings. In that case, bringing in a religious professional can force the patient to start over again building a new relationship.

"Look at the whole person," Dr. Ellor advised.

SAN FRANCISCO – Contrary to decades of tradition – and Sigmund Freud – psychotherapists working with frail elders should offer counseling on spirituality, according to three experts who have straddled the therapy-spirituality line in their own practices.

"I’m convinced you can take process psychology and marry it to theology," Jim Ellor, Ph.D., a professor of social work at Baylor University in Waco, Tex., said at the conference.

One reason that psychotherapists have avoided discussing their patients’ spirituality is that they confuse spirituality with religion, said Donald Koepke, director emeritus of the California Lutheran Homes Center for Spirituality and Aging, in Anaheim, Calif. Since the days of Sigmund Freud, who saw religion as a kind of neurosis, psychotherapists have been taught to avoid religion.

"While everyone may not have a religion, or be what we call religious, everyone has spirituality," said Mr. Koepke. "It’s core beliefs. It’s what drives them and helps them to experience the world."

He gave the example of Audrey, a communist atheist he met in the nursing home where he worked as chaplain. When she was diagnosed with a terminal illness, Mr. Koepke visited her and asked how she felt about having little time left.

"I move over and make room for someone else," she answered. But she went on. "The purpose in life is to leave the world better than you found it," she said. "I have done that." She went on to describe her activism in the labor movement.

Mr. Koepke said he left Audrey’s room feeling that "she felt connected to that which was greater than herself."

He said that everyone has four spiritual needs: to find meaning; to give love; to receive love; and to feel forgiveness, hope, and creativity. Something about the experience of living in a nursing home gives people an opportunity to face these needs, he added. "The spiritually healthy people I know are almost all in skilled care. They are marvelous people to know."

Barry Kendall, Psy.D., a private-practice existential psychologist in Beverly Hills, Calif., said that what is called existential psychotherapy can help such patients answer spiritual questions. This approach, as described by Stanford (Calif.) University psychiatrist Dr. Irvin Yalom, deals with psychological conflicts as stemming from the inevitability of death, the responsibility of freedom, isolation, and the inherent meaninglessness of life.

"Inside psychotherapy, people for the first time begin to have a relationship with someone who understands them," he said. With some patients, the conversation may turn specifically to religion, for others it may stay more generally on the meaning of life, Dr. Kendall said. "For some patients who are theists, the explicit questions are helpful. For other patients, the implicit questions are helpful."

How can a therapist help patients with their spiritual problems? Listen to their experiences, advised Dr. Ellor. "Look for the threads that are consistent in their story. If they are talking about the spiritual, listen." When patients ask for a spiritual professional, for example to conduct rites specific to a religion, psychotherapists should step aside.

But when the question at hand is really about feelings, then psychotherapists should continue trying to meet their patients’ needs because the therapists know how to work with feelings. In that case, bringing in a religious professional can force the patient to start over again building a new relationship.

"Look at the whole person," Dr. Ellor advised.

SAN FRANCISCO – Contrary to decades of tradition – and Sigmund Freud – psychotherapists working with frail elders should offer counseling on spirituality, according to three experts who have straddled the therapy-spirituality line in their own practices.

"I’m convinced you can take process psychology and marry it to theology," Jim Ellor, Ph.D., a professor of social work at Baylor University in Waco, Tex., said at the conference.

One reason that psychotherapists have avoided discussing their patients’ spirituality is that they confuse spirituality with religion, said Donald Koepke, director emeritus of the California Lutheran Homes Center for Spirituality and Aging, in Anaheim, Calif. Since the days of Sigmund Freud, who saw religion as a kind of neurosis, psychotherapists have been taught to avoid religion.

"While everyone may not have a religion, or be what we call religious, everyone has spirituality," said Mr. Koepke. "It’s core beliefs. It’s what drives them and helps them to experience the world."

He gave the example of Audrey, a communist atheist he met in the nursing home where he worked as chaplain. When she was diagnosed with a terminal illness, Mr. Koepke visited her and asked how she felt about having little time left.

"I move over and make room for someone else," she answered. But she went on. "The purpose in life is to leave the world better than you found it," she said. "I have done that." She went on to describe her activism in the labor movement.

Mr. Koepke said he left Audrey’s room feeling that "she felt connected to that which was greater than herself."

He said that everyone has four spiritual needs: to find meaning; to give love; to receive love; and to feel forgiveness, hope, and creativity. Something about the experience of living in a nursing home gives people an opportunity to face these needs, he added. "The spiritually healthy people I know are almost all in skilled care. They are marvelous people to know."

Barry Kendall, Psy.D., a private-practice existential psychologist in Beverly Hills, Calif., said that what is called existential psychotherapy can help such patients answer spiritual questions. This approach, as described by Stanford (Calif.) University psychiatrist Dr. Irvin Yalom, deals with psychological conflicts as stemming from the inevitability of death, the responsibility of freedom, isolation, and the inherent meaninglessness of life.

"Inside psychotherapy, people for the first time begin to have a relationship with someone who understands them," he said. With some patients, the conversation may turn specifically to religion, for others it may stay more generally on the meaning of life, Dr. Kendall said. "For some patients who are theists, the explicit questions are helpful. For other patients, the implicit questions are helpful."

How can a therapist help patients with their spiritual problems? Listen to their experiences, advised Dr. Ellor. "Look for the threads that are consistent in their story. If they are talking about the spiritual, listen." When patients ask for a spiritual professional, for example to conduct rites specific to a religion, psychotherapists should step aside.

But when the question at hand is really about feelings, then psychotherapists should continue trying to meet their patients’ needs because the therapists know how to work with feelings. In that case, bringing in a religious professional can force the patient to start over again building a new relationship.

"Look at the whole person," Dr. Ellor advised.