719.49....Joint Contractures, Those Challenging Beasts!

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Today, I want to write about a lurking beast among residents of skilled and long term care.

 

Joint Contractures...

 

Many therapists are a little intimidated by joint contractures.

 

As a result, it's like

 

 

sticking your head in the sand....

 

if you don't go looking for them in the building, you'll keep on working with your Med A rehab-to-home patients and never address the issues of the long term folks.

 

However...

 

If we're going to do a great job, we have to serve everyone.

 

(even those tough-to-treat long-term residents with contractures.)

 

Better yet...

 let's keep them from getting contractures

in the first place!

 

If you're a lay person reading this, contractures are the chronic loss of joint motion due to structural changes in non-bony tissue. These non-bony tissues include muscles, ligaments, and tendons.

 

Contractures may be caused by:

• Neurological insult (i.e. brain injury, stroke)
• Progressive neurological diseases (i.e. Parkinson's Disease, Multiple Sclerosis)
• Severe cognitive decline (dementia) leading to inactivity
• Birth defects caused by disease or anoxia (lack of oxygen) during birth
• Leprosy (yes, leprosy, not in this part of the world, but others!)

What do contractures look like?

Severe hip and knee contractures

Moderate elbow and wrist contractures

Claw Hand

How do you keep a person from getting contractures?

Simple! Keep the person moving. Every joint.

That means...EXERCISE, WALKING and P/AAROM (passive or active assistive range of motion)....

To Figure Out Who Has Contractures in the Building

 

1) Screen the residents of the facility. If you go through the dining room before a meal and ask each resident to straighten his or her knees, you'll immediately find about half the people or more are unable to straighten the knees fully. Voila. Instant caseload of people you can help.

2) Check the Minimum Data Set, MDS, which is usually in the resident's chart or at a large binder at the nurses' station. Check the ROM section to see if contractures have been documented. This will tell you where and how severe the loss is that nursing has documented. Honestly, this section is wrong half the time. It is up to us to communicate the correct info on ROM to the MDS coordinator so it can be corrected.

3) Talk to the nurses' aides and find out where the resident has difficulty (transfers, standing during clothing management/toileting, dressing upper or lower body, or rolling in bed to have brief changed)

If a person already has a contracture, here's how to treat it:

1. Make sure nursing staff have documented any functional changes, increase in assistance required by aides or loss of ROM. In addition, Activities, RNA or dietary can also document loss of function (i.e. decreased ROM during rhythm band, tighter mm during ROM from RNA, increased instability when walking due to bent knees, or difficulty with bringing hand to mouth during meals).
2. Request the order/evaluate.
3. Evaluate when the doctor's order arrives.

Evaluation

Evaluation must always related to function or medical condition. Is the person struggling to get dressed, hold a fork during meals, stand up fully or walk down the hall?

If the person is bedbound and unable to participate in functional activity, the reason for the evaluation then relates to decreasing caregiver burden, protecting skin integrity, managing pain or promoting joint integrity to provide care, such as dressing or peri hygiene.

Just because someone cannot move and participate in daily activities does not mean they are not a candidate for therapy.

(We must shift the way we think!)

1) Make sure you measure all joints, even the ones you have not been requested to evaluate. OTs, I also do knee splinting for positioning in the bed or wheelchair, especially in cases like the photo of the guy above, because he's going to have a pressure area on his butt if the knee contractures are not reversed.

2) Relate the ROM measurements to functional loss or consequence if the contracture is not reversed.

3) Write the goals in small increments so you can demonstrate improvement.

Email me at treccad@gmail.com if you need to brainstorm goal writing.

4) Use the correct ICD-9 codes!

718.4_ (joint contracture)

(The fifth digit must be one of the digits below)

0 site unspecified

1 shoulder region

2 upper arm

3 forearm

4 hand

5 pelvic region and thigh

6 lower leg

7 ankle and foot

8 other specified sites

9 multiple sites

 

Contractures also cause joint pain (719.4_). Follow the same instruction for the fifth digit of the code above.

 

Other related codes could include abnormal posture 781.92 caused by contracture formation, difficulty feeding 783.3, and difficulty walking 719.7 (among others!! Look at your eval when it's written before you print. It will give you all the answers.)



Treatment Tools:

Goniometer

Measure each joint!

Your Hands

Your hands can help heal a person's contracture formation. The only way to learn and become a master at normalizing muscle tone is to practice on people who have high muscle tone. The shifts are so subtle when working with high tone that you must work very slowly while watching for nonverbal (facial grimace, whole body withdrawal, pulling the limb away) or verbal signs of pain or discomfort.

What to do....gentle rocking, gentle shaking, cross friction massage over the muscle insertions, deep yet controlled pressure over tendons, slow stretching, myofascial release....get to know what works with your touch.

Estim

My favorite modalities company, ACP...

If the contracture is caused by hypertonic muscles, choose e-stim (PENS, or Patterned Electrical Neuromuscular Stimulation) to treat the tone prior to splinting. I recommend contacting ACP for information on their continuing education if you have not used modalities.

Diathermy

Ditto, ACP

If the contracture is caused by tightness at the muscle insertion, use the diathermy. I usually use this on the bicep and hamstring insertions.

Orthotics

Omnipro™ Finger Flex WHFO

 

 

Gotta get the joint straightened as much as possible, then keep it straight. I do this by splinting. I order splints through ACP, and they make the process easy.

Splints aren't something you can just slap on and wear for 6 hours a day. I start with 15 minutes and increase in 15 minute increments with observation following fitting, making modifications as necessary for comfort. If the person is in pain, they will not wear the splints, and that takes you back to

Square One.

This is the "big picture" of contracture management, and there are so many more moving parts that this could run too long.

If you have questions, send me a comment or an email!

From One of my Favorite Blogs

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Just a reminder about living life:

from one of my favorite blogs, Things We Forget.

So, so true!

What Can Come Out of Your Mouth

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WARNING:
IF ANY OF YOU HAVE SENSITIVE STOMACHS, DO NOT LOOK AT THE PHOTO IN THIS BLOG ENTRY...

We received a new, quite debilitated patient who was transported four hours from the nearest "big" city. Whitey had been in a top rated nursing facility, the kind that looks like a five-star hotel.

The rehab staff had given up on making progress with him, as evidenced by their therapy notes.

I completed Whitey's chart review and asked myself what I could do to start the process with this guy. What could I do to help him progress steadily so that he could go home with his family?

I went to Whitey's room and immediately heard the sound of a feeding tube at work. The bag of enteral nutrition hung on a pole at his bedside, and I could hear the hum of the machine delivering it to his stomach.

How you get fed when you lose your ability to swallow

I introduced myself. Whitey opened his eyes. He was "there," but I couldn't understand a word he was trying to tell me. His voice was muffled. His lips were dry.

I immediately realized I needed to check out his mouth. After all,

O.T.s = ADLs

(Occupational therapists = Activities of Daily Living = brushing teeth)

"Let's start with your mouth. I need to moisten your mouth and while we're at it, it would be good brush your teeth. I'll help."

I got the supplies together and put them on his tray.

"Whitey, please open your mouth."

Crooked, brown teeth. Many were missing on the sides, but there were teeth intact in the front and back. I handed him the brush mixed with water and mouthwash. He had been cleared during a swallow study to drink water in the presence of the nurse or the therapist.

He was able only to do a little. My focus shifted from attempting to have him do the whole task to having him hold up his head in neutral. He was so weak that he had difficulty holding his head in neutral and brushing his teeth at the same time. His head kept lilting to the left.

This was an opportunity to strengthen the neck and trunk.

I began flicking at those teeth with the brush. I really should have worn a pair of goggles.

What I had thought were brown teeth were really shiny white teeth covered with a slime of (don't gag) tube feeding and yellow/brown/green phlegm.

I methodically flicked the brush into the crevices of Whitey's teeth until the front teeth were pretty clean. Not bad!

Then...

I started on the sides. By this time, I was pulling out solid yellow green clumps. (I know, this is really gross.)

When I got to the inside of the roof of the mouth, I found brownish buildup all around the base of the teeth...

What the heck??

I kept flecking the buildup with the brush, alternating with brushing until a small section peeled away from the tooth. "Oh, my gosh, I thought! I am going to have to reach in and pull it."

That is what I did.

I nearly gagged.
I kept pulling.
He began to gag.
I just kept pulling.

And finally...off the roof of Whitey's mouth came a thick, hard, brownish yellow shell of old snot and feeding tube that had not only covered the whole roof of his mouth, but that had been growing down into his throat.

hate to say it, but this is what it looked like, except it was dry as a bone....

I almost came undone.

No wonder no one could understand him!

The moment that whatever-it-was (a plug??) was pulled out, Whitey's speech could be clearly understood.

In 16 years I have seen nothing like it. I can do blood, wounds and most bodily fluids, but I cannot do phlegm. I felt weak. I can only imagine how he felt!

What do I think about this?

 Even the "best" nursing facilities don't always give the best care. Every person on a G tube needs oral care throughout the day, not just twice a day.

If you have a family member on a tube, check your loved one's mouth.

If you are a caregiver, check your patient's mouth.

You never know what can come out of the mouth...

Photographical Whimsy From This Assignment

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I love to look for the unusual. Here's a bit of unusual from my time along the northern coast.

Most Unusual Mailbox

(it's a mermaid!)

 Most Unusual Car Front Adornment

Most Unusual Item in the Pharmacy

Most Wonderful Lesson To Share

Most Unusual House Number

I have really loved this crazy place!! There is no better experience than to meet new people and explore places you would never otherwise see...life is short. Get out there!

Tips for Caring For Ill or Bedbound Loved Ones

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Tonight, for those of you who are taking care of a loved one or who know someone who is a caregiver, this blog is for you.

Taking care of a loved one at home is one of the biggest sacrifices you can make. It can wear you out.

Methods of taking care of people have evolved over the years.

 

I want to share some recommendations for caregiving, simple things that can make a real difference for you if you are giving care to someone who is ill.

I did a google search to see what others had written.

Jennifer B. Buckley wrote an online article called Home Care Tips for Elderly Loved Ones in which she made four good recommendations.

1. Keep a small pitcher at the bedside for accessing fluids.
2. Avoid placing mirrors by the loved one. It can confuse them.
3. Buy your loved one's clothing in basic colors for increased ease in allowing them to choose what they want to wear.
4. Use large numbers and dials on remotes and phones.

Big Button Remotes

All good recommendations....

From therapist's eyes, I see some additional things that I believe are really helpful.

Positioning

The best thing you can do for your loved one is to keep them from getting pressure sores if they can no longer move their limbs in bed. You can do that by:

• Making sure the head of the bed is kept below 45 degrees if they are in a hospital bed at home. Above this angle, and they are at high risk to get a pressure sore at the sacrum (to put it bluntly, the top of the butt crack).
• Floating the heels by placing a thick pillow (or a thin one doubled up) just under the ankles so that the heels do not touch the surface of the mattress.
• Positioning your loved one on the flank of their buttock, which is the fleshy part, when you turn them into sidelying,
• Putting a pillow between the knees.

So good to keep the hips aligned!

Bathing

If your loved one is unable to be bathed in a tub or shower, you can still bathe and shampoo your loved one's hair.

The following technique is taken from Bathing Without a Battle, which describes a technique called The Towel Bath which has been used in skilled nursing facilities and by home health agencies. I had the pleasure of trying this technique with a great OT at one of my assignments. This technique is especially calming and effective with dementia patients who may become combative if you attempt to shower them.

Click on the colored link above to print out the full instructions!

For shampooing, this is a great product:

Comfort Bath Rinse-Free Shampoo and Conditioner Cap by Sage

It's a one-step, rinse-free cap that fits over the head after you warm it for 30 seconds in the microwave.  It feels great. It fully washes and conditions the hair. After massaging the cap, you pull it off, blow dry the hair and comb.
No more greasy, "I-can't-wash-my-hair" locks.

Medical Equipment

Your loved one may qualify through insurance or Medicare for a hospital bed, wheelchair, walker or 3 in 1 commode.

3 in 1 commode

This equipment allows optimal movement and positioning of your loved one in the home. The commode increases safety by allowing your loved one to use the commode at the bedside at night to reduce the risk of falls.

Meals on Wheels

Having one meal provided for each day may decrease the burden on you to cook meals. Don't be afraid to receive assistance from community or church groups.

Preventing Caregiver Burnout: Be Aware!

Common warning signs of caregiver burnout:

• You have much less energy than you used to
• It seems like you catch every cold or flu that’s going around
• You’re constantly exhausted, even after sleeping or taking a break
• You neglect your own needs, either because you’re too busy or you don’t care anymore
• Your life revolves around caregiving, but it gives you little satisfaction
• You have trouble relaxing, even when help is available
• You’re increasingly impatient and irritable with the person you’re caring for
• You feel overwhelmed, helpless, and hopeless

(Thank you, HelpGuide.Org...)

The best thing you can do for yourself as a caregiver is to connect with services and people who can help you. Check out The Family Caregiver Alliance Website for info on how to find these resources.

This is just the beginning of the list. If any of you have specific ideas to share, I would welcome your input!

10 Ways to Shift the Direction of Your Life, Part Two

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Stretch.

Fill your lungs with breath. Get in touch with how you feel. Be aware of where you hold stress in your muscles, and then learn to stretch those muscle groups so that you care for your body. It has to carry you through life!

 I have a tough one with this one. I literally have to schedule it in, and many times, I punt it for another activity. I find, though, if I stretch in the morning, I feel much better during my day!

Be open to the Divine in everyday life.

Being open to the Divine is far deeper than listening to a sermon in church every Sunday. There are miraculous moments every day taking place if we turn our gaze to them. An ocean wave, the sounds and flight patterns of a flock of birds,

reminds me of you, Elle

periennials sticking up through the ground after the last snow, unexpected generosity of a stranger, the miracle of love, an emotional or physical healing. The list goes on.

What if we open our eyes to all that is?

Listen for what you would normally not hear.

We only really hear part of what others say. What if we hear with sharper ears? What if we read body language with sharper eyes? What if we tune into our own intuition? It's about more than words.

How much do we take our senses for granted?

Let go of the need for material success.

Let me give you an example taken from a news article by CNN on 2010 Heroes. Narayanan Krishnan was a bright, young, award-winning chef with a five-star hotel group, short-listed for an elite job in Switzerland. But a quick family visit home before heading to Europe changed everything.

"I saw a very old man eating his own human waste for food," Krishnan said. "It really hurt me so much. I was literally shocked for a second. After that, I started feeding that man and decided this is what I should do the rest of my lifetime." (direct quote from CNN)...

 Narayanan Krishnan

Since then, he has served more than 1.2 million meals to homeless and destitute people in India. He let go of a need for financial wealth and followed a passion to help save his people. He is now recognized all over the world. Amazing man.

When I say he is a wealthy man, it's not at all about material success.


Choose joy.

I went through a period in life in which I thought I could certainly not get through it. I would certainly never want to re-live it. Everyone goes through at least one or two of these distressing times in their lives.The only thing that got me through was a conscious decision to choose joy.

Every morning, I looked in the mirror. At that defining moment, I decided on my day. I could choose joy or not....

I don't know about you, but I'd rather be around a positive person than a pisser!

My hope is that at least one of these ten "direction shifters" speak to you. Let me know...

10 Ways to Shift the Direction of Your Life, Part One

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If you know me personally or have read all my posts, you'll know that I am a "seeker."  A seeker of my own personal truth.

seek·er (skr)

n.

1. One that seeks: a seeker of the truth.

 

 

The past 18 months have been a grand search and experience of stretching beyond the life I knew, physically, emotionally, spiritually. It's exciting to get out of a comfort zone and push into the unknown.

 

 

Here is some of what I have learned and continue to learn...(part one)

Expand your mind and spirit.

Learn something new every day. Explore one new thing about the area in which you live every week. Open your mind to the simple and sometimes unintended teachings of others. See everyone as inter-connected.

Check out Mind Map Art by Paul Foreman

Simplify.

Identify what is "holding you down." Many times, it's "stuff." Get rid of all the extra stuff you're holding onto....closets full of old clothes and shoes you don't wear, a garage full of crap you haven't used, weight that slows down your body or negative thoughts that prevent you from living a better life.

See all that blocked creative energy!!

Focus on Positivity.

I run into people alot who have only negative things to say. They complain about their work, their spouses or children, where they live, their weight, anything you can image.

WOW.

That wears me out.

When I start to complain, it wears me out! Did you realize if you focus on positive things, you don't feel so TIRED. I really need to work on this one this week!

Try it?

See the best in everyone.

The princess didn't know there was a prince underneath....

You never know what's under all those warts...

when I am working with patients who stretch my patience (and lately there have been a few new challenges!), I have to remind myself to find one special thing about them that humanizes them, makes them likeable and creates a connection.

Often, it creates a shift in my own vision and enables me to connect and understand. Not always easy, I know!


Forgive.

I wrote a blog last fall on forgiveness. Click here to read it. We can agree that it's one of the most difficult challenges of our lives. What I have found, though, is that there is a great weight that is lifted when we forgive the other. We are able to move on, whether or not we keep that person in our lives, and have a clear slate. If we fail to forgive, we continue to be bound to another through a negative event.

I choose to forgive every day. Until I genuinely feel it in my heart.

Part Two to follow....

Steps + Gin = ?

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I was interviewing a new patient about her home....and this is what I found.

30 steps to enter cliffside home

(not her home, but like her home)

PLUS DAILY DOSES OF

EQUALS

Femur Fracture

Femur Fx

Lesson:

Be Careful

Where You Have

Your Cocktails

Laura

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I have received bad news several times already this year.

I heard more today. This was not a patient. This was a friend.

Laura was a nurturing healthcare provider, adventurer in life, lover of laughter and fellow storm chaser. Her laughter was contagious. She loved Tinkerbell,  country music, and most of all, her husband, John.

She graduated from this world yesterday. Valentine's Day.

How fitting. She was so full of love.

Although we work around those who are dying, when we lose someone we care about in our personal lives, the whole world shifts. It's never the same.


There's a future blog brewing on this subject, but for tonight, I can only give tribute to Laura and her ability to touch everyone around her with an amazing combination of sass and sweetness. To Laura and John, for their dedication to each other - they were absolutely crazy about each other. To John, for the great support he gave her.

I love you, girlie. I can't believe you're gone.

Heaven Got Another Angel

Happy Valentine's Day

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Happy Valentine's Day!

For other cool Valentine photos, check THIS out

You know, it's not about whether you have a sweetheart or not. It's about your feelings about you, the people in your life (family, lover, friends, even co-workers)....

LOVE is why we're all here.

To learn it...

To live it...

To be it...

Yep, it's not easy. It's not supposed to be a cake walk. It's an evolution. It requires surrender. Patience. Perseverance. Forgiveness. Seeing with new eyes. Being open to it in the first place.

What a gift it is! I'm learning this every day.

It starts with each of us. The best thing we can do is to be gentle with ourselves. After all, we're usually our own worst critics. Then, it's amazing what can happen.

...the most exciting, challenging and significant relationship of all is the one you have with yourself. And if you can find someone to love the you you love, well, that's just fabulous.”

(A great little quote from Sex and the City....)

YouTube

End Date

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I am happy to report that my building has hired a new OT!! She seems just great, with a skill set that will be greatly respected and appreciated.

So! The Subaru gets packed up on March 9-10....

and then I am heading EAST....

Blowin' with the Wind

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I ride my road bike on a trainer every morning before work while I watch netflix. This morning was an episode of Grey's Anatomy. I want to share with you something the pediatric surgeon, Robbins, said....

My dreams are coming true; dreams I didn't even know I had.

Right when she said it, I thought, I love that.

That's right...this is true for all of us!!

The Universe has a funny way of working. It puts us right where we belong. In the conditions we belong. With the people we belong. To learn the lessons we're supposed to learn.

It doesn't mean we don't have choice or free will. It means if we're open to the bigger picture of our lives, we can make choices that lead us to wondrous places we never thought possible.

Change can sometimes be a little intimidating. For those of you who know me well, you'll smile and shake your head when I say, I'll just "blow with the wind" to a great new place.

Streetlight by Joshua Radin

I'll wait for something under a streetlight
It won't be long
Because it's dark it's cold
It's one of those nights where
There's something out there
Keeps me alive

But I don't know where to go
So I think I'll sit and stay herę a while
Till I figure it out

So let the wind blow us
To wherever it says
We are supposed to go

When you want something but can't name it
It's under a streetlight
It's something you've never seen before
Open the door
It's something you've always been afraid of
It's under a streetlight
And now all you want is more

But I don't know where to go
So I think I'll sit and stay here a while
Till I figure it out
So let the wind blow us
To wherever it says
We are supposed to go
Let the wind blow us
To wherever it says
We are supposed to go

I don't mind the wait it's fine
As long as you know
It's the wait that could be the something

I don't know where to go
So I think I'll sit and stay here a while
Till I figure it out

So let the wind blow us
To wherever it says
We are supposed to go
So let the wind blow us
To wherever it says
We are supposed to go
We are supposed to go      

Blow, Tre, Blow

Look for Beautiful Things

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Heard this on pandora when I was getting ready for work. We all feel this way sometimes...I just loved the message so much I wanted to share it with you.

In Memory of Joan

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You guys who work in healthcare know when you're getting burned out. You feel itchy under the skin, the slightest irritants make you check the clock for when the hell you can get out of the building, and you realize you're not your usual patient self with the poor recipients of your treatment.


By last Friday afternoon, I was there. I canceled my evening plans, knowing I was a wrung out sponge with absolutely no energy to engage in fun. What a shame!


I was all the more understanding of my need to isolate when I got home and checked my text messages. I received a message that did me in.


My absolute favorite patient at my last assignment, Joan, with whom I spent a few minutes almost every evening at dinnertime, passed away Thu. I can use their real names because I have permission from her husband, Monty. And I want to show you who they are and were to me because they touched my life so beautifully.

My dear friends, Joan and Monty

Joan and Monty  have meant the world to me. Anyone who worked with us at the facility knew of the beautiful bond and the chemistry that occurred when the three of us were together. There would be songs, memories and laughter. Joan would often be cognitively clearer and able to converse appropriately.


Our connection was magic.


Monty would travel 45 minutes one-way every day to have dinner with Joan. He would show up about 3:30 or 4 with cookies from Whole Foods, and Joan would reach out with her arthritic hands to attempt to share every time I found them tasting their treats. She was so generous even in her cognitive decline.

Some days they would find me in the rehab department. Other days, I would traipse down the hall from one of the nurses' stations to find them exploring the far hallways in the building. The one thing that was consistent was that we would make sure to connect before I left for home.

There were many conversations of her travels to Europe as a singer with the Armed Forces Network during WWII, her experiences singing with traveling orchestras, her life as a young single mother and their touching "how-we-met" story.

One day before I left my assignment there, "Mont" began to sing to Joan. I had the great fortune to record just a snippet of it.

AUD0003 by travelingotr


It was a song created from the following poem:

Believe Me, If All Those Endearing Young Charms

by Thomas Moore

Believe me, if all those endearing young charms,
Which I gaze on so fondly today,
Were to change by tomorrow, and fleet in my arms,
Like fairy-gifts fading away,
Thou wouldst still be adored, as this moment thou art,
Let thy loveliness fade as it will,
And around the dear ruin each wish of my heart
Would entwine itself verdantly still.

It is not while beauty and youth are thine own,
And thy cheeks unprofaned by a tear
That the fervor and faith of a soul can be known,
To which time will but make thee more dear;
No, the heart that has truly loved never forgets,
But as truly loves on to the close,

As the sunflower turns on her god, when he sets,
The same look which she turned when he rose.

I never paid true attention to the words until now....how fitting that such a wonderful man would sing to his bride this song. 

Joan and Monty,

I love you both to the ends of the earth and back again...

Aging Ain't For Sissies

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Remember Bertie?

She stopped me last week as I whizzed by in the hall. She held out a small clear bag with something colorful in it.

"Someone gave me two of these. I want you to take the other one," she said.  "I want you to give it to someone who needs cheering up."

"Thank you for Tibetan prayer flags!" I told Bertie (though these didn't have the traditional five colors).  Tibetan Buddhists for centuries have planted these flags outside their homes and places of spiritual practice for the wind to carry the beneficent vibrations across the countryside. Prayer flags are said to bring happiness, long life and prosperity to the flag planter and those in the vicinity.

She had never heard of them. I explained to her what they were. She, being the inquisitive soul she is, wrote it down and was going to google it later.

So, this package sat on my desk last week and halfway through this one, patiently waiting for the perfect recipient.

The perfect recipient rolled in about 3 pm this afternoon. It was Ginny.
The look on her face was that of a child. I could tell immediately that something was very wrong. Thank God I was between treatments.

Up she rolled to my desk.

"Hi, Ginny, how are you? Come on in!"

"Oh, I need to leave school right now! Can someone help me get to my mother's house down the street? I am so tired. I don't know what to do!"

Poor dear! Then she flipped to the present within 30 seconds: "That library is too much for me right now! All those books, and people wanting to talk in my library!"

She had been shooing people out of the room, even though we explained to her daily that this room also served as a visitors' lounge. She simply didn't remember. On top of that, she's been spending more time in the distant past, indicative of either further cognitive decline or the need to do a UA (urinalysis) to check for a urinary tract infection.

It was all too much for Ginny.

She was so vulnerable, all I could do was put my arms around her and hold her while she cried. I mean, really cried. I could feel her warm breath on my neck as she exhaled. A few moments later, her body relaxed, and I reached over for a kleenex.

As I pulled the kleenex, I noticed the peace flags....

"Ginny....I have something special that might brighten this day. Would you like to hang this colorful flag in your room?" I pulled it out of the bag and stretched it out so she could see all the beautiful colors.

She took one look and brightened up. "Well, yes, it's beautiful!"

Off we went, me holding some tape, the flags, and her purse as we pushed her wheelchair down the hall.

We put the flags in their place. Ginny directed, "A little lower, yes...oh, let's move it to the side a little more."

When the flags were hung, I turned to her. "What do you think?"

Tears! (My heart swelled for her.)

"It's something beautiful on a really sad day!  I just miss my mother so much."

More hugs. Most of these people need to be held on tough days, darnit! You just have to know who and who not.

I left Ginny in the care of the nurse aide, who rubbed her back.

As I turned out of Ginny's room, I ran right into the Adminstrator, who I really respect and admire.

I gave her a quick briefing on Ginny's breakdown.

"Is it Mae West who said aging isn't for sissies?" I asked her.

"Something like that!" she replied.

And tonight, when I looked it up, I was close. It's Bette Davis, and she said,

"Old age is no place for sissies."