Christmas ball hanging on a Christmas tree

A very special holiday season

Being festive and mindful in the era of COVID-19

This holiday season is going to be different. Few of us would have thought that at some point in our lives we would be celebrating winter holidays during a global pandemic. Yet, in difficult times humans always find ways to adapt, support each other and continue those traditions that define them and form part of their cultural and personal identity. We worked together, learned to live with the pandemic and now we are entering this holiday season which will be very different from what we were used to but will retain its spirit and its importance for us and our loved ones.

It is a time when people come together and share love, joy and hope. But how can you be close to your loved ones when you can’t give them a hug or sit at the same table and share food with them? Luckily humans are resilient and adaptive and if there’s one thing this pandemic taught us, it is how to be close to the ones we love while staying physically separated in order to protect them. Once again, it has been shown that social cohesion can overcome physical distancing as love and care can reach out across vast distances.

We had time to prepare and we also live in an era where there are many tools that allow us to communicate easily and intuitively while staying safe. Video chat services have become an increasingly large part of our social life and even people with limited technological familiarity can easily use them with just a little help. We can join our loved ones remotely in decorating the house and make sure our favorite ornament gets the best spot, on top of the fireplace just like every year.  We can be content that our family won’t miss on that special holiday dish they’ve been waiting for by taking them through all the intricacies of our secret recipe. More importantly we can see the smiles of our loved ones when they open their presents!

Technology is not the only way to connect though. This holiday season is a good time to revisit favorite traditions like creating hand-made holiday cards and writing letter to loved ones. We can embark on festive projects like knitting Christmas sweaters or crafting hand-made tree ornaments for the whole family. We can make sure we cook enough cookies for everyone and have them delivered in a safe way. We can exchange our favorite books or even run a holiday-themed book club where we can combine a traditional activity with the use of technology to get together and discuss the books we’ve read.

As with all things, in this special holiday season it is important to ensure that we find our own ways to adapt and celebrate. After all, what matters is experiencing the spirit of the holidays and sharing joy and happiness with our loved ones. With so many options for adapting our holiday activities while staying safe, it is important to go with those that are meaningful to us and resonate with our personality, our lifestyle and the ways we connect with our loved ones.

What can I do? 

  • As an older adult: Accept that these holidays will be different and communicate with your loved ones. Don’t be afraid to ask for help and support from your family whether it is a video-call to hear your grandchildren singing Christmas carols or a no-contact delivery of your favorite food. More importantly don’t miss out on the joy of giving and caring for your family whether by making sure everyone gets your holiday cookies or by calling your grandchildren to tell them their favorite festive stories.
  • As a relative: Acknowledge the limitations imposed by COVID-19 but also be creative and think outside the box. While you may not be able to do all your favorite holiday activities, you can ensure that you and your loved ones experience the spirit of the holidays and the full range of emotions and human contact that comes with it. Communicate with your family to find new ways to share the holiday spirit in a manner that is meaningful and resonates with everyone involved. 
  • As an assisted living / nursing home owner: Ask your residents what helps them enjoy the holidays while staying safe. Expect different residents to have different preferences. Reach out to the wider community; maybe that choir that visited your facility every year to sing Christmas carols would like to perform online and still bring the joy of music to your residents. Facilitate contact and communication between residents and their loved ones by setting up virtual meetings and ensuring that residents can receive gifts safely. Promote activities inside your facility that allow for safe interaction between residents such as working together to create a book of festive stories or recipes.
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Senior man exercising next to a lake

Constipation in the elderly

Introduction

Constipation is a common problem in the elderly population. Epidemiological studies show that the incidence of constipation increases from the age of 65 by 25-50%. The frequency of constipation may be as high as 75% of patients who are in senior care facilities, hospitals or other institutions and in particular if they suffer from dementia, stroke, Parkinson’s disease or other degenerative neurological conditions. Constipation is also more common in patients taking medications that may affect bowel motility as discussed below.

Constipation is a problem that affects the quality of life, causes discomfort and many times significant concern that often results in several office visits, specialty referrals, hospital admissions, and surgical procedures. Constipation has therefore, a major impact on healthcare costs in the United States.

What is constipation?

The term constipation for everyone means different things. In general, it can mean a change in bowel habits, the production of hard stools, the production of small stools, difficulty in defecation, straining, reduced stool frequency, the feeling of incomplete evacuation, and so on. It is therefore very important to understand exactly what the patient is complaining about when he says that he suffers from constipation. Taking a detailed medical history is perhaps the most important factor in understanding and addressing the patient’s problem.

Medical history

As we explained earlier it is important to figure out what the term constipation means for the patient, to look for possible accompanying symptoms such as abdominal pain, bleeding, weight loss, discuss the patient’s diet, his medical treatment, his previous medical history, possible abdominal surgery in the past, etc.

The duration of the symptoms, any accompanying symptoms and other evidence from the medical history and physical examination will determine whether or not there is a need for laboratory, imaging examinations (e.g. CT scan) or endoscopic examinations (e.g. colonoscopy).

Causes of constipation

The causes of constipation are several and relate to problems of the bowel, but also other systems of the body, which can indirectly affect the intestine. In older people the causes of constipation are usually multifactorial. Trying to classify the causes of constipation, we can distinguish the following categories:

  • Obstructive causes: Colorectal cancer, narrowing of the bowel due to ischemia (poor blood circulation), inflammation of the bowel or external pressure from tumours and growths from neighbouring organs, etc.
  • Endocrine and Metabolic Causes: Diabetes, hypothyroidism (hypoactive thyroid), hypercalcaemia (high calcium in the blood), chronic kidney failure, etc.
  • Neuromuscular causes: Spinal cord injuries, Parkinson’s disease, multiple sclerosis, amyloidosis, scleroderma, myotonic dystrophy, etc.
  • Medicines: Opioids, antihypertensives, antidepressants, antiparkinsonian, antipsychotics, etc.
  • Other causes: diet low in fiber, dehydration, sedentary life, being bedridden, etc.

Management

The ways we deal with constipation depend on the severity of the symptoms, the causes, the accompanying diseases, and so on. Generally high fiber diet, hydration, daily regular toilet visit and exercise help the patient suffering from constipation. Many times, however, especially in the elderly, the above tactics do not help effectively or are not very practical. We therefore need to resort to some kind of pharmaceutical intervention for these patients. It is important to stress that the use of pharmaceuticals should be done with care and should be under medical supervision.

Categories of laxatives we use:

Stool bulking agents: The substances used contain natural or synthetic fiber in various forms. They are the first line of treatment for constipation and they work by increasing the volume of stools. Insoluble fiber has the tendency to cause gas and it is advisable to increase the dose gradually.

Osmotic laxatives: Osmotic laxatives consist of substances that are not absorbed by the digestive tract and thus remaining in the intestine retain a greater amount of water and as a result they soften the faeces.

Stimulant laxatives: These laxatives are based on senna or other synthetic substances and cause an increase in intestinal peristalsis (movement).

Fecal emollients / suppositories and enemas: This category is useful in cases where we suspect fecal impaction. They are usually combined with some oral laxatives for best results. Fecal impaction is more common in bedridden patients, neurological patients, people in nursing homes, and so on. These patients have a low sensitivity in the rectum, so they do not perceive the presence of stools. As stools accumulate in the rectum, they are dehydrated and cause paradoxical diarrea. This is confusing many times and delays the diagnosis which is established only with a rectal digital examination.

Summary

Patients aged over 65 often experience constipation, especially if they are suffering from neurological, metabolic or other systemic conditions, if they are taking certain medicines, are not being properly fed, or have reduced mobility. Good history and physical examination are often enough to assess the possible cause of constipation, but may sometimes require laboratory or other examinations to rule-out more serious conditions. Diet adaptation or simple pharmaceutical approaches are often enough to address the symptoms of constipation. However, there are cases where the severity or chronicity of constipation requires the help of a specialist.

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Senior couple with backpacks walking on the street

Growing old in the age of COVID-19

Physical distancing, social cohesion

2020 will probably be remembered as the year of the COVID-19 global pandemic. The whole world has paused in horror watching the virus spread. Fear, uncertainty and often misinformation followed in its wake. COVID-19 has affected our lives at every level. Our social and family lives, our careers and even our physical and mental well-being have been impacted. As the initial shock subsided, we had to content with redefining a new “normal” for our lives and adjusting to it.

Times of crisis tend to have a peculiar effect on people and societies. They often act as amplifiers, amplifying the good along with the bad. Fear, inequities and systemic issues are amplified along with kindness, courage and social cohesion. The dramatic changes brought by COVID-19 can disproportionally affect older adults and their caregivers. Older adults have to content with social isolation and fear for their health. Furthermore, pervasive ageist attitudes affecting healthcare provision can limit older adults’ access to care which is often reserved for younger people. At the same time, caregivers can feel powerless since physical distancing guidelines may prevent them from being close to their loved ones. They also have to content with their own fears and uncertainty while managing the fear of their loved ones.

The most common way to stop a virus from spreading is ensuring that people are not in close proximity with each other. This very important public health measure has been named “social distancing”. While the measure itself is necessary the term used to describe it is somewhat unfortunate. While staying physically apart from each other to combat the spread of the virus we should come closer to each other in a deeper way. We should communicate more, care more and empathize more with each other. In essence we should become more social while maintaining physical distance. As humans we crave contact and closeness so we must make up for the lack of physical closeness by focusing on our communication with each other.

The first step towards effective communication is recognizing our own feelings even if they are scary or perplexing. Honest discussions about our feelings, which will probably include fear and uncertainty, can help us and our loved ones. More importantly they can help us understand that we are all in this together and dealing with the same issues. Communication however should not be limited to discussing unpleasant feelings. We all enjoy having fun with our friends and family and nowadays technology can help us spend quality time together even when we are apart. Including virtual get-togethers with friends and family in our daily schedule can help us overcome loneliness and improve our mood and well-being. It’s a good time to get creative! Virtual book clubs, board games nights or tea breaks not only bring us closer to our loved ones but they also add some structure to our daily life. More importantly, they reaffirm our ability to control our lives even during times of crisis.

Retaining control of our lives means retaining all those things we enjoy. Maintaining our daily schedule (as much as possible) and continuing to invest time in what we enjoy is crucial. We must rethink our hobbies and favorite activities in light of the necessary public health measures but this doesn’t mean we can’t engage in them. We should think out of the box and change the way we engage with them. From focusing on those aspects of them that can be done safely to using technology to make up for the physical distancing, we can redefine them and explore aspects of them we hadn’t considered before. Perhaps we will come out of this crisis with new ideas, skills or interests.

Our world may still feel scary and uncertain but remember that we can stay informed without succumbing to panic, we can be close to each other even when we are miles apart, we can change our habits while retaining what defines ourselves and, most importantly, we can keep each other safe and loved through this crisis.

What can I do?

  • As an older adult: Reach out to friends and family. Your fears and concerns are valid and there are people who want to be close to you and help you through these difficult times. Try to maintain a daily schedule that includes mentally challenging activities and physical exercise. Stay informed and follow all safety guidelines. If safety guidelines feel overwhelming, try to integrate them in your daily routine and use visual cues and reminders. Monitor your health and contact your doctor if you have any concerns.
  • As a relative: Communicate honestly with your loved ones. Be open about your fears and acknowledge their concerns. At the same time provide reassurance and practical assistance whenever possible. Use technology to connect with friends and family and assist older adults in the use of technology for communication. Promote exercise and contact with nature in a safe manner. Dancing to a favorite song or watching the birds in the garden can be a welcome break and a boost to mental and physical health.
  • As an assisted living / nursing home owner: Ensure that residents can communicate with loved ones through the use of technology. Offer activities that promote physical exercise in a safe manner. Inform residents about upcoming changes in their daily lives and explain why these changes are necessary for their well-being. Implement regular health monitoring for residents and staff.

Resources

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Senior woman with dementia sitting on a chair and her caregiver by the sea

Caregiver Burden in Dementia

Dementia is a chronic deteriorating condition, in which patients experience symptoms such as: cognitive and functional decline, behavioral problems, lack of insight, and personality change. During the course of the illness, the number and severity of symptoms increase and daily functioning and participation in social activities become increasingly difficult for dementia patients, which leads to them becoming more dependent on the care of others.

Usually family members or friends provide care to patients, acting as informal caregivers. Care provision can be a serious burden for caregivers and can have an adverse effect on their mental and physical health, particularly if care is provided frequently or for a prolonged period of time. The progressive and often unpredictable illness process seems to be challenging for caregivers. The burden of caregiving is not only associated with the provision of care. It is also associated with the fact that caregivers, who are often faced with multiple concurrent stressful events and extended constant stress, have to learn to cope with the various symptoms of the illness, both cognitive and behavioral.

“Caregiver burden” is a term that includes all the consequences of caring for a chronically ill patient: economic, social, physical and psychological. In particular, when compared to non-caregivers, caregivers of patients with dementia often experience psychological, behavioral, and physiological effects that can contribute to impaired immune system function. When compared to caregivers of patients with other chronic diseases, such as cancer, caregivers of patients with dementia experience greater burden. The same has been reported for depression and anxiety. Depressive symptoms are also common in caregivers of dementia patients. Rates of depression in caregivers of patients with dementia range, among studies, from 10,5% up to 83%. Caregivers’ burden and depression are highly associated, although their association remains complex. Thus, the burden that caregivers experience is considered to be a key component in dementia treatment.

Despite that, the majority of caregivers lacks support, has poor knowledge of available formal services, and has no guidance on how to plan ahead for the relative’s care needs. It has also been suggested that caregivers should develop effective coping strategies and receive professional support during the course of illness, which may improve their ability to handle the continuously changing conditions and increasing needs of the person with dementia.

Providing support to caregivers is, therefore, essential to promote their well-being and prevent serious caregiver burden. In line with that, numerous interventions have been implemented, aiming either at reducing the objective amount of care provided or at improving the caregiver’s well-being and coping skills via psychoeducational or supportive interventions, support groups, or multicomponent interventions.

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Senior couple walking in the park

Depression in the elderly

Depression is considered among the most disabling conditions affecting the quality of life of millions and contributing to increased mortality rate, especially in the elderly population where depression accounts for over 80% of deaths by suicide. Self-harm in adults over the age of 60 is found to be 67 times greater than the general population. Depression can lead to profound loss of function, mood changes, physical symptoms, altered thoughts and perception. Depression is considered an heterogenous group of disorders with overlapping core features including low mood, lack of interest and pleasure (anhedonia), fatigue and physical symptoms such as lack of appetite, sleeping disorders, hallucinations, motor symptoms etc.

Depression especially in the elderly can complicate other chronic organic disorders such as coronary artery disease, diabetes, kidney failure affecting their treatment by virtue of apathy, lack of engagement and compliance with the medications. It is also considered a risk factor for the development of coronary artery disease, stroke, colorectal cancer, irritable bowel syndrome and others. Depression in the elderly does not always manifest the same way as younger adults. The symptoms many times tend to be more severe and more physical as compared to the younger patients. 

Depression in the elderly many times is under-detected by their primary physician. Depression in later life is also far less likely to be treated than in younger adults. And even in cases where it is recognized, it is less likely to be referred to the psychiatric service. It is estimated that around one in six older depressed people in the UK receive treatment of any sort and only 6% is referred to the psychiatrist compared to 50% of young adults.

Studies vary regarding the real prevalence of depression in the elderly with reports varying from 0.4 to 35% with an average of 13.5% in ages over 55. There is a broader agreement regarding factors contributing to increased prevalence of depression. The important factors are being widowed and divorced, living in communities with poor social networks and low socioeconomic conditions. Interestingly enough, protective factors are having a religious faith, excercise, good physical health, being married and living within a strong social network. 

In terms of treating depression in the elderly we have to consider that it is a condition that can be self-limiting in a percentage of patients that can reach 30-40%. The principles of treatment in the elderly are the same as for young people. Treatment with antidepressants can reach a 60% response rate. The choise of the antidepressant medication has to be tailored to each individual taking into consideration the side effect profile of the drugs and co-morbidities of the elderly patient. Best outcomes are achieved when combining drugs with psychological therapies.

As depression tends to be so heterogenous, old and new therapies show varied results. It seems that an early response to therapy predicts better outcome. Following recovery it is important to carry on the therapy in the elderly as this strategy seems to lower the relapse rate. Approaches that minimize disability, promote independence, supportive therapies, and social networks play an important part of a treatment plan.

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