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Let them eat chocolate, says advocate of change in senior care

Ventura County Star
By Tom Kisken
August 11, 2011

At Tena Alonzo's nursing home, residents sleep as late as they want. Care schedules revolve around their convenience, not the staff's. If they're used to a small cocktail at night, they have one.

And they eat what they want — chocolate or dessert before dinner — regardless of their health.

"If you're 85 and you're demented and it's the end of your life, isn't it time to eat lemon pie even if you're diabetic?" she said before talking to Ventura County nursing home operators Thursday about following a style of care presented as a national model. "Isn't it time to just enjoy whatever in life is important to you?"

Called a culture of comfort, it revolves around the principle that if residents are comfortable they'll be happy. There won't be the need for physical restraints or powerful antipsychotic drugs to control their behavior, Alonzo said.

The Beatitudes nursing home in Phoenix, especially the dementia floor, was once a place families avoided and doctors didn't want to admit their patients. People in the hallways cried out for help and suffered from dehydration.

About 14 years ago, staff turned everything upside down, said Alonzo, director of research at the Beatitudes community and part of the team that led the change.

Staff took extra time to know the residents and families to understand what makes people comfortable. That might mean adjusting the time of trips to the bathroom, a nurse flipping through a photo album with a resident or not trying to change the mind of someone who has Alzheimer's.

"Don't confront. Don't reason," she said, suggesting neither tactic works.

Understanding they couldn't change the way residents with dementia think, staff concentrated on changing the way residents felt. They used music, food, hobbies or anything else that made people feel at home.

The residents called the shots.

"It's really time to get out of people's way and let them live," Alonzo said.

Some Ventura County nursing home administrators said they already do much or at least some of what Alonzo advocates. But when she talked about letting people eat whatever they wanted, the debate started.

"Ludicrous," said Dr. Robert Buckingham, an Ojai internist involved in nursing home care, suggesting that allowing free access to sugar only worsens inflammation, joint flexibility, diabetes and even dementia. "There's a lot of things that cascade when you throw sugar at the patient."

When a nursing home administrator voiced his agreement with the doctor, others in the audience quietly booed. They cited patient rights and suggested adjustments in medication could lower the risks. At least one assisted living facility, the Ventura TowneHouse, has already removed dietary restrictions.

Others said they like the concept of food freedom but wondered about the feasibility.

"We need to know what is the balance," said Sister Lourdes Lara, mother superior of the community running Mary Health of the Sick nursing home in Newbury Park.

Alonzo said the choice is the resident's, expressing the mandate she hopes rules the last three or four years of her life.

"You will give me all the chocolate that I want," she said.

Buckingham suggested some of what Alonzo advocated is over-simplified. He cited her statement that Alzheimer's is terminal and can't be prevented or slowed.

He said families of his patients want comfort but they also want him to do whatever he can to improve their condition.

"At what point do you close the door and say it doesn't matter anymore?" he said, suggesting progress is being made on treating dementia.

Others saw comfort-based care as affirmation, or reason to incorporate more change.

Sylvia Taylor Stein of the Long Term Care of Ventura County ombudsman and watchdog program, which hosted Alonzo's presentation, said when nursing homes started, they were modeled as hospitals to care for seniors. But no one realized people would live in them for 25, even 40 years, she said.

Nursing home culture is built around pain management, Stein said. Alonzo's model is based on the premise that if a resident is made comfortable, much of the pain may go away.

Taylor Stein said it's not enough to incorporate isolated pieces of the new model.

"What we're trying to do is transform the whole thing," she said.