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    Nursing homes differ by size, religious and ethnic orientation, and philosophy of care. Choosing a home depends on personal preference, your sense of where your relative would do best. For instance, larger homes tend to offer much more in the way of services and a richer variety of staff. They are less homelike, however, getting lower marks on staff/patient rapport. Your choice will also be dictated by the type of residents the home serves. Although the law prohibits discrimination in admission, many nursing homes cater to the needs and comfort of a particular ethnic or religious group – serving familiar foods, celebrating traditional holidays.
    Philosophical differences can be important. Does the home believe in separating residents by degree of disability? This may be good if your father is not very impaired and would be depressed by being in close contact with residents who are physically and mentally worse off. It may be bad if he would benefit from being with residents who are more alert. Does the home have a special unit for residents with Alzheimer’s disease? If so, this may be the best place for your mother with dementia.
    Consider the location. In general, the closer the better, either to you or to your relative’s hometown. If the home is near the patient’s town, remaining involved in the life of the community may be possible. Your relative’s personal doctor may agree to continue treatment. (Residents always have the right to be treated by a physician of their own choice, though they may have to pay extra for this service.) If the home is close to you, you can visit often. You will be better able to offer your love and attention and also to check up on what is going on.
    With these considerations in mind, talk to family and friends who know residents in the homes you are considering. Then visit each place. The first time you go, arrive unannounced. Expect what you see to be disheartening. Only people in the worst physical straits need nursing homes.
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    GENERAL HEALTH
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    Nursing homes are categorized in two definite ways: by the intensity of services they provide and by their mode of ownership. The first distinction is crucial. Medicaid (or Medicare) will pay for services only in nursing homes classified as offering either skilled or intermediate care.
    Skilled nursing facilities provide the most care, including round-the-clock nursing, physical, occupational, and dietary therapy, social services, and recreation. Health-related facilities for intermediate care facilities) are for people who do not need skilled care but do need some assistance in functioning. They offer less intensive nursing and medical care. Multilevel facilities are most common, providing skilled and intermediate care under one roof. The advantage of choosing a multilevel nursing home is that your relative will receive services in the same place (though probably on a different floor or in another building) if there is a change in condition and a different level of care is required.
    You cannot choose the level of nursing care when your relative is admitted. The person is placed at the appropriate level by a doctor or nurse certifying eligibility for that particular type. Although the evaluation process tends to differ from state to state, usually a standard preadmission form is required. The person is examined, and points are assigned for degrees of disability. Depending on this “impairment” score, the applicant may be categorized as not needing institutional care, needing a health-related facility, or needing skilled nursing care.
    Medicare will pay only for care in a skilled nursing facility, and then only in limited circumstances. Up to one hundred days may be covered if a doctor certifies that the patient requires ongoing nursing care for a condition that was first treated in the hospital and if the nursing home’s utilization review committee does not disapprove the stay. These rules are rigorously applied. Depending on the state, Medicaid is likely to pay for all or most skilled or intermediate care.
    (Check with your local office of the aging or the admissions department of the home you are interested in for more information.)
    The second nursing home difference, mode of ownership, is less relevant. Proprietary homes are owned and run for a profit. Voluntary homes are owned and run by nonprofit organizations such as church groups. Public homes are owned by the city or state. Recently there has been a tremendous increase in the number of proprietary chains. There is some perception that these institutions, because they are in the money-making business, tend to deliver worse care. But research shows there is no way to predict the quality of care a home offers by its mode of ownership.
    *150/159/5*
    GENERAL HEALTH
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    Parents will often have different concerns about a child’s sleeping patterns at different ages. In infancy these will usually be about the unpredictable nature of sleep. Many babies take a very long time to settle into any sort of predictable rhythm of sleeping, feeding and playing. This makes life very difficult for the rest of the family, of course, as it is impossible to schedule other activities, such as paying attention to other children, shopping, cleaning and most importantly, the parents’ (usually the mother’s) own relaxation or sleep. There is always the possibility that the baby will wake up, demanding a feed or attention.

    Babies who continue to wake through the night cause similar problems. Parents get very tired and become exasperated at having their sleep interrupted regularly, sometimes several times a night. This is always a source of considerable tension in the whole family. Nothing seems worse than having to get up in the morning to face the day tired and grumpy.

    Many children seem never to get into a predictable routine. Those who have a difficult temperament seem to go right through infancy and the toddler periods without sleeping through the night. Parents will report that ‘Johnny didn’t sleep through the night until he was 4 years of age’. While this may be true and it may also be true that some children do have an intrinsic predisposition to be irregular sleepers, the problem is often contributed to by the parents’ inadvertent reinforcement of the very sleep patterns that they complain of. There is no doubt that all children, no matter what their temperament, can be taught to sleep through the night.

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    Your loved one may continue to lose weight in spite of your combined best efforts. If they do this, try not to take it personally. Their weight loss doesn’t mean that you are not caring for them properly, nor does it mean that they are not grateful for your efforts and eating as much as they comfortably can of what you prepare. It is no more possible to stop some people with cancer from losing weight than it is possible to stop some people with cancer from dying of it.

    So try to aim for what is possible. If you refuse to settle for anything less than stopping a person who has extensive cancer or is having very intensive chemotherapy from losing weight, you are likely to succeed only in making both of your lives miserable. Both of you have enough to deal with without getting into battles over food. Why not simply aim for pleasant meal times, free of nagging or feelings of guilt? Perhaps there are even times when both of you would benefit more from a chat and a cuddle than more food!

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    It is important for everyone to know how to do artificial respiration.

    The easiest and most effective is mouth-to-mouth resuscitation — or the “Kiss-of-Life.” This is simple to learn — and simple to forget. So you will need to refresh your knowledge from time to time.

    Cardiac massage is harder to learn. You may do harm if you try this when a person’s heart has not stopped. But if it has, then that person will die unless CPR, a combination of external massage and mouth-to-mouth resuscitation is begun at once.

    The brain cells are very sensitive to lack of oxygen. If breathing stops, then oxygen is not taken in and various organs of the body will suffer from the lack of oxygen. The heart itself may also stop.

    If the brain cells are deprived of oxygen for longer than 3-4 minutes, irreversible damage may occur. However, this should not be considered a reason for not trying artificial respiration or heart massage. It is possible that breathing may stop but the heart may continue beating for some time, pushing around an ever diminishing amount of oxygen in the blood, but still supplying the brain with enough oxygen so that permanent damage has not occurred.

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    Chronic glaucoma comes on slowly and insidiously. It is a common cause of blindness and has often progressed to a stage where the vision is markedly impaired before it is noticed by the sufferer.

    It becomes increasingly common after 40 and most eye specialists recommend that all those over 50 should have the pressure in their eyes checked each two years, even if the vision seems satisfactory. Three per cent of people over 50 can suffer from glaucoma.

    Tonometry, or the measurement of the pressure inside the eye, can be done by an eye doctor, by an optometrist, or sometimes by your general practitioner if he has learned the technique.

    Sometimes, service clubs organise a drive in their suburb where all those over 40 can present themselves for a check on the pressure of their eyes. The condition is so uncommon under this age that there is little point in the routine screening of younger people.

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    About 100 hairs are shed each day from the average scalp. The normal pattern of cyclical growth of hair may be disturbed by general health factors, either physical or mental. Most women notice their hair becomes thinner and loses its lustre after childbirth and may take a year or two to recover.

    Alopecia areata is a condition where the hair is lost in patches. It may spread to involve the whole scalp or even the eyebrows or all the body hair. The cause is uncertain and there are several theories. Some believe it is one of the auto-immune diseases where the body, as it were, develops an allergy to its own tissues and produces antibodies which tend to destroy those tissues.

    Cortisone, by mouth or locally applied as a cream, or injected into the skin of the scalp seems to help.

    Women whose male relatives suffer from male pattern baldness may also suffer a more diffuse hair loss. This is more usual after the menopause and is due to the action of androgens or male hormones on the predisposed hair follicles. This may respond to the use of oestrogens.

    Diffuse hair loss may also be due to metabolic illnesses such as myxoedema or thyroid insufficiency.

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    There is no symptom that automatically means you have to go into hospital. However, you may choose to go into hospital for

    tests or to have some form of treatment that cannot be done at home. The need for hospitalisation is one of the costs you should

    take into account when deciding what tests and treatment to have.

    The decision as to whether to stay at home or go into hospital in the final stages should largely be yours. However, a decision to stay at home is practical only if you can rely on a lot of support and cooperation from family and friends. I suggest that, if you do want to be at home, you make some preparations towards this while you are still relatively well. Talk with your family and friends about what you want and find out how much help and support they are prepared and able to give you. Get to know a doctor who will make home visits. Find out whether there is a special palliative care/terminal care/hospice team in your town and ask to be referred to them when the time seems right for that. Keep in mind that, at least throughout Australia, there is a government-subsidised home-nursing service. It is easy and inexpensive to arrange for nurses to visit your home for a particular purpose such as to do dressings, supervise pressure care, help you with bowel or bladder problems or just for a friendly check on how you are managing. Special aids that you might need such as wheelchairs, bedpans, commodes, special bedding, oxygen masks, etc, are often available on loan or hire from public hospitals or through the home-nursing services, so the fact that you can’t afford to buy such things shouldn’t mean that you have to go into hospital.

    You may also be able to get financial assistance from your local cancer society, for example, to cover the cost of a nurse or companion to stay with you at times when friends and family cannot manage this.

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    If you are trying to reduce your kilojoule intake there is still a minimum amount of certain foods that you should be eating each day. These are:

    • Breads/cereals/and grain foods—5 servings or more. 1 serving means – 1 bowl breakfast cereal (30 grams), 1/2 cup cooked pasta or rice, ? cup cooked grain such as barley or wheat, 1 slice bread, ? bread roll or muffin.

    • Vegetables—4 servings. 1 serving means – 1 medium potato (about 150 grams), cooked vegetables such as broccoli or carrot—eat freely. Raw leafy vegetables, such as lettuce—eat freely.

    • Fruit—3 servings. 1 serving means: 1 medium orange (200 grams), 1 medium apple (150 grams), ? punnet strawberries (100 grams).

    • Dairy foods—2 servings.1 serving means: 300 ml milk, 40 grams cheese, 200 grams of low-fat yoghurt or other low-fat dairy foods.

    • Meat and alternatives—1 serving. 1 serving means – 60 to 80 grams cooked lean beef, veal, lamb or pork 120 grams lean chicken (cooked weight, excluding bone), skin removed 120 grams fish (cooked weight, excluding bone), 2 eggs, 1 cup cooked lentils or dried peas or beans. In our experience, looking at the diets of hundreds of people who want to lose weight, the change required is often to eat more!

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    The socio-cultural macro environment represents the values, expectations and attitudes of the wider social environment. Community attitudes to convenience foods and leisure saving technologies are examples. A hedonistic and materialistic atmosphere where moderation is considered unfashionable is common in many sectors of Western societies. Where this is coupled with easy access to palatable, high-fat foods and reduced necessity for energy expenditure, obesity levels are likely to increase. In Australia, an advertising expenditure of $1 million per day on food stuffs, confectionery and soft drinks is combatted by an equivalent amount per year spent on public health education, some of which is presumably aimed at eating for reduced body fatness.

    With increased affluence there is also an increased opportunity for over-indulgence through the social processes of dining out, business lunches, social festivities and celebrations. There are also cultural and ethnic differences in food preferences and exercise availability: European-style food is usually higher in fat, for example, than Asian foods; some foods, such as pork, have traditionally held a higher social status than vegetables or fruit in different cultures; opportunities for exercise are reduced for some ethnic and religious groups such as Middle Eastern and Muslim women.

    Male attitudes to health are known to differ from those of females. Men have typically been less responsive to health messages, attend doctors less often, but suffer more from most forms of illness than women. This has been attributed to social and attitudinal differences between the sexes—men feel more isolated and vulnerable if they admit any concern about their health. Overcoming these attitudes is a major obstacle to providing acceptable fat loss programs for men. Cultural attitudes in some ethnic groups also mean that partner support for fat loss practices, particularly by males for females, is low or non-existent.

    Social attitudes to physical activity can influence participation. Increased interest in jogging in the 1970s for example, followed by aerobics and then weight training in the 1980s, formed the pattern of a social ‘trend’. It is doubtful, however, if these have compensated for the decreases in physical activity that have occurred at the workplace or the decreases in other ‘incidental’ activity in day-to-day life. Multi-event sports like triathlons have become popular, but this is usually only amongst the very fit. Fun runs and community activities, however, have the potential to attract large numbers of people who may otherwise remain inactive. Socially acceptable forms of activity differ according to ethnic group, nationality, age and gender. Being fat carries a negative status, but more so for women, and being inactive also carries a negative status, but more so for men.

    The influence of the socio-cultural macro environment has been particularly noticeable in countries like the UK and the Netherlands. The overall nutrient intake in the food in both countries is similar, but the obesity rate in Britain is increasing at a much greater rate than in Holland. According to Dr Wim Saris, from the University of Limburg, this might be put down simply to the fact that only 3 per cent of British transport involves the bicycle, whereas the equivalent figure is over 30 per cent in the Netherlands.

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