Is it OK to lie to someone with dementia?
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There was disagreement on social media recently after a story was published about an aged care provider creating “fake-away” burgers that mimicked those from a fast-food chain, to a resident living with dementia. The man had such strict food preferences he was refusing to eat anything at meals except a burger from the franchise. This dementia symptom risks malnutrition and social isolation.
But critics of the fake burger approach labelled it trickery and deception of a vulnerable person with cognitive impairment.
Dementia is an illness that progressively robs us of memories. Although it has many forms, it is typical for short-term recall – the memory of something that happened in recent hours or days – to be lost first. As the illness progresses, people may come to increasingly “live in the past”, as distant recall gradually becomes the only memories accessible to the person. So a person in the middle or later stages of the disease may relate to the world as it once was, not how it is today.
This can make ethical care very challenging.
Is it wrong to lie?
Ethical approaches classically hold that specific actions are moral certainties, regardless of the consequences. In line with this moral absolutism, it is always wrong to lie.
But this ethical approach would require an elderly woman with dementia who continually approaches care staff looking for their long-deceased spouse to be informed their husband has passed – the objective truth.
Distress is the likely outcome, possibly accompanied by behavioural disturbance that could endanger the person or others. The person’s memory has regressed to a point earlier in their life, when their partner was still alive. To inform such a person of the death of their spouse, however gently, is to traumatise them.
And with the memory of what they have just been told likely to quickly fade, and the questioning may resume soon after. If the truth is offered again, the cycle of re-traumatisation continues.
A different approach
Most laws are examples of absolutist ethics. One must obey the law at all times. Driving above the speed limit is likely to result in punishment regardless of whether one is in a hurry to pick their child up from kindergarten or not.
Pragmatic ethics rejects the notion certain acts are always morally right or wrong. Instead, acts are evaluated in terms of their “usefulness” and social benefit, humanity, compassion or intent.
The Aged Care Act is a set of laws intended to guide the actions of aged care providers. It says, for example, psychotropic drugs (medications that affect mind and mood) should be the “last resort” in managing the behaviours and psychological symptoms of dementia.
Instead, “best practice” involves preventing behaviour before it occurs. If one can reasonably foresee a caregiver action is likely to result in behavioural disturbance, it flies in the face of best practice.
What to say when you can’t avoid a lie?
What then, becomes the best response when approached by the lady looking for her husband?
Gentle inquiries may help uncover an underlying emotional need, and point caregivers in the right direction to meet that need. Perhaps she is feeling lonely or anxious and has become focused on her husband’s whereabouts? A skilled caregiver might tailor their response, connect with her, perhaps reminisce, and providing a sense of comfort in the process.
This approach aligns with Dementia Australia guidance that carers or loved ones can use four prompts in such scenarios:
- acknowledge concern (“I can tell you’d like him to be here.”)
- suggest an alternative (“He can’t visit right now.”)
- provide reassurance (“I’m here and lots of people care about you.”)
- redirect focus (“Perhaps a walk outside or a cup of tea?”)
These things may or may not work. So, in the face of repeated questions and escalating distress, a mistruth, such as “Don’t worry, he’ll be back soon,” may be the most humane response in the circumstances.
Different realities
It is often said you can never win an argument with a person living with dementia. A lot of time, different realities are being discussed.
So, providing someone who has dementia with a “pretend” burger may well satisfy their preferences, bring joy, mitigate the risk of malnutrition, improve social engagement, and prevent a behavioural disturbance without the use of medication. This seems like the correct approach in ethical terms. On occasion, the end justifies the means.
Steve Macfarlane, Head of Clinical Services, Dementia Support Australia, & Associate Professor of Psychiatry, Monash University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Are You Taking PIMs?
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Getting Off The Overmedication Train
The older we get, the more likely we are to be on more medications. It’s easy to assume that this is because, much like the ailments they treat, we accumulate them over time. And superficially at least, that’s what happens.
And yet, almost half of people over 65 in Canada are taking “potentially inappropriate medications”, or PIMs—in other words, medications that are not needed and perhaps harmful. This categorization includes medications where the iatrogenic harms (side effects, risks) outweigh the benefits, and/or there’s a safer more effective medication available to do the job.
You may be wondering: what does this mean for the US?
Well, we don’t have the figures for the US because we’re working from Canadian research today, but given the differences between the two country’s healthcare systems (mostly socialized in Canada and mostly private in the US), it seems a fair hypothesis that if it’s almost half in Canada, it’s probably more than half in the US. Socialized healthcare systems are generally quite thrifty and seek to spend less on healthcare, while private healthcare systems are generally keen to upsell to new products/services.
The three top categories of PIMs according to the above study:
- Gabapentinoids (anticonvulsants also used to treat neuropathic pain)
- Proton pump inhibitors (PPIs)
- Antipsychotics (especially, to people without psychosis)
…but those are just the top of the list; there are many many more.
The list continues: opioids, anticholinergics, sulfonlyurea, NSAIDs, benzodiazepines and related rugs, and cholinesterase inhibitors. That’s where the Canadian study cuts off (although it also includes “others” just before NSAIDs), but still, you guessed it, there are more (we’re willing to bet statins weigh heavily in the “others” section, for a start).
There are two likely main causes of overmedication:
The side effect train
This is where a patient has a condition and is prescribed drug A, which has some undesired side effects, so the patient is prescribed drug B to treat those. However, that drug also has some unwanted side effects of its own, so the patient is prescribed drug C to treat those. And so on.
For a real-life rundown of how this can play out, check out the case study in:
The Hidden Complexities of Statins and Cardiovascular Disease (CVD)
The convenience factor
No, not convenient for you. Convenient for others. Convenient for the doctor if it gets you out of their office (socialized healthcare) or because it was easy to sell (private healthcare). Convenient for the staff in a hospital or other care facility.
This latter is what happens when, for example, a patient is being too much trouble, so the staff give them promazine “to help them settle down”, notwithstanding that promazine is, besides being a sedative, also an antipsychotic whose common side effects include amenorrhea, arrhythmias, constipation, drowsiness and dizziness, dry mouth, impotence, tiredness, galactorrhoea, gynecomastia, hyperglycemia, insomnia, hypotension, seizures, tremor, vomiting and weight gain.
This kind of thing (and worse) happens more often towards the end of a patient’s life; indeed, sometimes precipitating that end, whether you want it or not:
Mortality, Palliative Care, & Euthanasia
How to avoid it
Good practice is to be “open-mindedly skeptical” about any medication. By this we mean, don’t reject it out of hand, but do ask questions about it.
Ask your prescriber not only what it’s for and what it’ll do, but also what the side effects and risks are, and an important question that many people don’t think to ask, and for which doctors thus don’t often have a well-prepared smooth-selling reply, “what will happen if I don’t take this?”
And look up unbiased neutral information about it, from reliable sources (Drugs.com and The BNF are good reference guides for this—and if it’s important to you, check both, in case of any disagreement, as they function under completely different regulatory bodies, the former being American and the latter being British. So if they both agree, it’s surely accurate, according to best current science).
Also: when you are on a medication, keep a journal of your symptoms, as well as a log of your vitals (heart rate, blood pressure, weight, sleep etc) so you know what the medication seems to be helping or harming, and be sure to have a regular meds review with your doctor to check everything’s still right for you. And don’t be afraid to seek a second opinion if you still have doubts.
Want to know more?
For a more in-depth exploration than we have room for here, check out this book that we reviewed not long back:
To Medicate or Not? That is the Question! – by Dr. Asha Bohannon
Take care!
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Celery vs Rhubarb – Which is Healthier?
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Our Verdict
When comparing celery to rhubarb, we picked the rhubarb.
Why?
In terms of macros, rhubarb has more carbs and fiber, the ratio of which give it the lower glycemic index, though both are low glycemic index foods. This means this category is a very marginal win for rhubarb.
When it comes to vitamins, rhubarb has more vitamin C, while celery has more of vitamins A, B5, B6, and B9. A win for celery, this time.
In the category of minerals, rhubarb has more calcium, iron, magnesium, manganese, potassium, and selenium, while celery has more copper and phosphorus. This one’s a win for rhubarb.
Let’s give a quick nod also to polyphenols; rhubarb has more by overall quantity, and more in terms of “more useful to humans” too, being rich in an assortment of flavanols while celery must make do with some furanocoumarins.
In short, enjoy either or both, but nutritional density is a great reason to get some rhubarb in!
Want to learn more?
You might like to read:
What’s Your Plant Diversity Score?
Take care!
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Algorithms to Live By – by Brian Christian and Tom Griffiths
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As humans, we subconsciously use heuristics a lot to make many complex decisions based on “fuzzy logic”. For example:
Do we buy the cheap shoes that may last us a season, or the much more expensive ones that will last us for years? We’ll—without necessarily giving it much conscious thought—quickly weigh up:
- How much do we like each prospective pair of shoes?
- What else might we need to spend money on now/soon?
- How much money do we have right now?
- How much money do we expect to have in the future?
- Considering our lifestyle, how important is it to have good quality shoes?
How well we perform this rapid calculation may vary wildly, depending on many factors ranging from the quality of the advertising to how long ago we last ate.
And if we make the wrong decision, later we may have buyer’s (or non-buyer’s!) remorse. So, how can we do better?
Authors Brain Christian and Tom Griffiths have a manual for us!
This book covers many “kinds” of decision we often have to make in life, and how to optimize those decisions with the power of mathematics and computer science.
The problems (and solutions) run the gamut of…
- Optimal stopping (when to say “alright, that’s good enough”)
- Overcoming cognitive biases
- Scheduling quandaries
- Bayes’ Theorem
- Game Theory
- And when it’s more efficient to just leave things to chance!
…and many more (12 main areas of decision-making are covered).
For all it draws heavily from mathematics and computer science, the writing style is very easy-reading. It’s a “curl up in the armchair and read for pleasure” book, no matter how weighty and practical its content.
Bottom line: if you improve your ability to make the right decisions even marginally, this book will have been worth your while in the long run!
Order your copy of “Algorithms To Live By” from Amazon today!
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Drug Metabolism (When You’re Not Average!)
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When Your Medications Run Out… Of You
Everybody knows that alcohol can affect medications’ effects, but what of smoking, and what of obesity? And how does the alcohol thing work anyway?
It’s all about the enzymes
Medicines that are processed by the liver (which is: most medicines) are metabolized there by specialist enzymes, and the things we do can increase or decrease the quantity of those enzymes—and/or how active they are.
Dr. Kata Wolff Pederson and her team of researchers at Aarhus University in Denmark examined the livers of recently deceased donors in ways that can’t (ethically) be done with live patients, and were able to find the associations between various lifestyle factors and different levels of enzymes responsible for drug metabolism.
And it’s not always how you might think!
Some key things they found:
- Smokers have twice as high levels of enzyme CYP1A2 than non-smokers, which results in the faster metabolism of a lot of drugs.
- Drinkers have 30% higher levels of enzyme CYP2E1, which also results in a faster metabolism of a lot of drugs.
- Patients with obesity have 50% lower levels of enzyme CYP3A4, resulting in slower metabolism of many drugs
This gets particularly relevant when we take into account the next fact:
- Of the individuals in the study, 40% died from poisoning from a mixture of drugs (usually: prescription and otherwise)
Read in full: Sex- and Lifestyle-Related Factors are Associated with Altered Hepatic CYP Protein Levels
Read a pop-sci article about it: Your lifestyle can determine how well your medicine will work
How much does the metabolism speed matter?
It can matter a lot! If you’re taking drugs and carefully abiding by the dosage instructions, those instructions were assuming they know your speed of metabolism, and this is based on an average.
- If your metabolism is faster, you can get too much of a drug too quickly, and it can harm you
- If your metabolism is faster, it also means that while yes it’ll start working sooner, it’ll also stop working sooner
- If it’s a painkiller, that’s inconvenient. If it’s a drug that keeps you alive, then well, that’s especially unfortunate.
- If your metabolism is slower, it can mean your body is still processing the previous dose(s) when you take the next one, and you can overdose (and potentially die)
We touched on this previously when we talked about obesity in health care settings, and how people can end up getting worse care:
As for alcohol and drugs? Obviously we do not recommend, but here’s some of the science of it with many examples:
Why it’s a bad idea to mix alcohol with some medications
Take care!
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You can thaw and refreeze meat: five food safety myths busted
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This time of year, most fridges are stocked up with food and drinks to share with family and friends. Let’s not make ourselves and our guests sick by getting things wrong when preparing and serving food.
As the weather warms up, so does the environment for micro-organisms in foods, potentially allowing them to multiply faster to hazardous levels. So put the drinks on ice and keep the fridge for the food.
But what are some of those food safety myths we’ve long come to believe that aren’t actually true?
Myth 1: if you’ve defrosted frozen meat or chicken you can’t refreeze it
From a safety point of view, it is fine to refreeze defrosted meat or chicken or any frozen food as long as it was defrosted in a fridge running at 5°C or below. Some quality may be lost by defrosting then refreezing foods as the cells break down a little and the food can become slightly watery.
Another option is to cook the defrosted food and then divide into small portions and refreeze once it has stopped steaming. Steam in a closed container leads to condensation, which can result in pools of water forming. This, combined with the nutrients in the food, creates the perfect environment for microbial growth. So it’s always best to wait about 30 minutes before refrigerating or freezing hot food.
Plan ahead so food can be defrosted in the fridge, especially with large items such as a frozen turkey or roll of meat. If left on the bench, the external surface could be at room temperature and micro-organisms could be growing rapidly while the centre of the piece is still frozen!
Myth 2: Wash meat before you prepare and/or cook it
It is not a good idea to wash meats and poultry when preparing for cooking. Splashing water that might contain potentially hazardous bacteria around the kitchen can create more of a hazard if those bacteria are splashed onto ready-to-eat foods or food preparation surfaces.
It is, however, a good idea to wash fruits and vegetables before preparing and serving, especially if they’re grown near or in the ground as they may carry some dirt and therefore micro-organisms.
This applies particularly to foods that will be prepared and eaten without further cooking. Consuming foods raw that traditionally have been eaten cooked or otherwise processed to kill pathogenic micro-organisms (potentially deadly to humans) might increase the risk of food poisoning.
Fruit, salad, vegetables and other ready-to-eat foods should be prepared separately, away from raw meat, chicken, seafood and other foods that need cooking.
Myth 3: Hot food should be left out to cool completely before putting it in the fridge
It’s not OK to leave perishable food out for an extended time or overnight before putting it in the fridge.
Micro-organisms can grow rapidly in food at temperatures between 5° and 60°C. Temperature control is the simplest and most effective way of controlling the growth of bacteria. Perishable food should spend as little time as possible in the 5-60°C danger zone. If food is left in the danger zone, be aware it is potentially unsafe to eat.
Hot leftovers, and any other leftovers for that matter, should go into the fridge once they have stopped steaming to reduce condensation, within about 30 minutes.
Large portions of hot food will cool faster if broken down into smaller amounts in shallow containers. It is possible that hot food such as stews or soup left in a bulky container, say a two-litre mixing bowl (versus a shallow tray), in the fridge can take nearly 24 hours to cool to the safe zone of less than 5°C.
Myth 4: If it smells OK, then it’s OK to eat
This is definitely not always true. Spoilage bacteria, yeasts and moulds are the usual culprits for making food smell off or go slimy and these may not make you sick, although it is always advisable not to consume spoiled food.
Pathogenic bacteria can grow in food and not cause any obvious changes to the food, so the best option is to inhibit pathogen growth by refrigerating foods.
Myth 5: Oil preserves food so it can be left at room temperature
Adding oil to foods will not necessarily kill bugs lurking in your food. The opposite is true for many products in oil if anaerobic micro-organisms, such as Clostridium botulinum (botulism), are present in the food. A lack of oxygen provides perfect conditions for their growth.
Outbreaks of botulism arising from consumption of vegetables in oil – including garlic, olives, mushrooms, beans and hot peppers – have mostly been attributed to the products not being properly prepared.
Vegetables in oil can be made safely. In 1991, Australian regulations stipulated that this class of product (vegetables in oil) can be safely made if the pH (a measure of acid) is less than 4.6. Foods with a pH below 4.6 do not in general support the growth of food-poisoning bacteria including botulism.
So keep food out of the danger zone to reduce your guests’ risk of getting food poisoning this summer. Check out other food safety tips and resources from CSIRO and the Food Safety Information Council, including testing your food safety knowledge.
Cathy Moir, Team leader, Microbial and chemical sciences, Food microbiologist and food safety specialist, CSIRO
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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How To Leverage Attachment Theory In Your Relationship
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How To Leverage Attachment Theory In Your Relationship
Attachment theory has come to be seen in “kids nowadays”’ TikTok circles as almost a sort of astrology, but that’s not what it was intended for, and there’s really nothing esoteric about it.
What it can be, is a (fairly simple, but) powerful tool to understand about our relationships with each other.
To demystify it, let’s start with a little history…
Attachment theory was conceived by developmental psychologist Mary Ainsworth, and popularized as a theory bypsychiatrist John Bowlby. The two would later become research partners.
- Dr. Ainsworth’s initial work focused on children having different attachment styles when it came to their caregivers: secure, avoidant, or anxious.
- Later, she would add a fourth attachment style: disorganized, and then subdivisions, such as anxious-avoidant and dismissive-avoidant.
- Much later, the theory would be extended to attachments in (and between) adults.
What does it all mean?
To understand this, we must first talk about “The Strange Situation”.
“The Strange Situation” was an experiment conducted by Dr. Ainsworth, in which a child would be observed playing, while caregivers and strangers would periodically arrive and leave, recreating a natural environment of most children’s lives. Each child’s different reactions were recorded, especially noting:
- The child’s reaction (if any) to their caregiver’s departure
- The child’s reaction (if any) to the stranger’s presence
- The child’s reaction (if any) to their caregiver’s return
- The child’s behavior on play, specifically, how much or little the child explored and played with new toys
She observed different attachment styles, including:
- Secure: a securely attached child would play freely, using the caregiver as a secure base from which to explore. Will engage with the stranger when the caregiver is also present. May become upset when the caregiver leaves, and happy when they return.
- Avoidant: an avoidantly attached child will not explore much regardless of who is there; will not care much when the caregiver departs or returns.
- Anxious: an anxiously attached child may be clingy before separation, helplessly passive when the caregiver is absent, and difficult to comfort upon the caregiver’s return.
- Disorganized: a disorganizedly attached child may flit between the above types
These attachment styles were generally reflective of the parenting styles of the respective caregivers:
- If a caregiver was reliably present (physically and emotionally), the child would learn to expect that and feel secure about it.
- If a caregiver was absent a lot (physically and/or emotionally), the child would learn to give up on expecting a caregiver to give care.
- If a caregiver was unpredictable a lot in presence (physical and/or emotional), the child would become anxious and/or confused about whether the caregiver would give care.
What does this mean for us as adults?
As we learn when we are children, tends to go for us in life. We can change, but we usually don’t. And while we (usually) no longer rely on caregivers per se as adults, we do rely (or not!) on our partners, friends, and so forth. Let’s look at it in terms of partners:
- A securely attached adult will trust that their partner loves them and will be there for them if necessary. They may miss their partner when absent, but won’t be anxious about it and will look forward to their return.
- An avoidantly attached adult will not assume their partner’s love, and will feel their partner might let them down at any time. To protect themself, they may try to manage their own expectations, and strive always to keep their independence, to make sure that if the worst happens, they’ll still be ok by themself.
- An anxiously attached adult will tend towards clinginess, and try to keep their partner’s attention and commitment by any means necessary.
Which means…
- When both partners have secure attachment styles, most things go swimmingly, and indeed, securely attached partners most often end up with each other.
- A very common pairing, however, is one anxious partner dating one avoidant partner. This happens because the avoidant partner looks like a tower of strength, which the anxious partner needs. The anxious partner’s clinginess can also help the avoidant partner feel better about themself (bearing in mind, the avoidant partner almost certainly grew up feeling deeply unwanted).
- Anxious-anxious pairings happen less because anxiously attached people don’t tend to be attracted to people who are in the same boat.
- Avoidant-avoidant pairings happen least of all, because avoidantly attached people having nothing to bind them together. Iff they even get together in the first place, then later when trouble hits, one will propose breaking up, and the other will say “ok, bye”.
This is fascinating, but is there a practical use for this knowledge?
Yes! Understanding our own attachment styles, and those around us, helps us understand why we/they act a certain way, and realize what relational need is or isn’t being met, and react accordingly.
That sometimes, an anxiously attached person just needs some reassurance:
- “I love you”
- “I miss you”
- “I look forward to seeing you later”
That sometimes, an avoidantly attached person needs exactly the right amount of space:
- Give them too little space, and they will feel their independence slipping, and yearn to break free
- Give them too much space, and oops, they’re gone now
Maybe you’re reading that and thinking “won’t that make their anxious partner anxious?” and yes, yes it will. That’s why the avoidant partner needs to skip back up and remember to do the reassurance.
It helps also when either partner is going to be away (physically or emotionally! This counts the same for if a partner will just be preoccupied for a while), that they parameter that, for example:
- Not: “Don’t worry, I just need some space for now, that’s all” (à la “I am just going outside and may be some time“)
- But: “I need to be undisturbed for a bit, but let’s schedule some me-and-you-time for [specific scheduled time]”.
Want to learn more about addressing attachment issues?
Psychology Today: Ten Ways to Heal Your Attachment Issues
You also might enjoy such articles such as:
- Nurturing secure attachment: building healthy relationships
- Why anxious and avoidant often attracted each other
- How to help an insecurely attached partner feel loved
- How to cope with a dismissive-avoidant partner
Lastly, to end on a light note…
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