Steven Littlehale

Six years ago, I shared the story of one resident and the indelible influence she had on my life. Returning to this cherished memory and life lesson has recently brought me unexpected insights. Here I retell the resident’s story, but this time with a different conclusion.

As you read this blog, keep this in mind: Approximately 45% of people living in a skilled nursing facility have cognitive impairment. In the top quartile of facilities, as many as 67% of residents have cognitive impairment, and even in the bottom quartile, as many as 21% of residents do 

Her name was Helen; she was 90 and I was 18. I was a nurse assistant, less than a decade before the U.S. passed a law requiring certified nursing assistant (CNA) training. Helen was one of seven people assigned to me on the extended care unit of a now-defunct community hospital. She had Alzheimer’s disease and spent most of her immobile days in a reclining chair close to the nurses’ station. She was a lovely lady, with snowy-white hair and careworn hands, a classic “Grandma” type. We all loved her very much. 

Helen was mostly nonverbal, with one exception: She called out “Nurse” repeatedly … over and over and over again. Whenever she wasn’t interacting one-on-one, she would start calling “Nurse!” “Nurse!” Nurse!” If you’ve ever worked in a nursing home, this is an all-too-familiar call.

On one particularly challenging day, I remember feeling completely drained. “Nurse!” “Nurse!” “Nurse!” I had just tended to Helen for what seemed the 20th time that hour, but still “Nurse!” “Nurse!” “Nurse!” echoed throughout the hallway. “Patient!” I replied — and then paused, hoping my frustration and exhaustion wasn’t audible.

It evidently was, because immediately Helen replied: “Is a virtue.” Then silence. More silence. Was it my imagination, or had everything suddenly just stopped?

Was Helen reminding me that “patience is a virtue”? Or, in her own way, was she letting me know that even with dementia she was a person of virtue? Helen and my other patients had entrusted their care to me, the highest honor they could bestow. Could it be that “patient is a virtue” even in the presence of cognitive impairment?

I got caught up in my memories of Helen when helping a group of skilled nursing home providers conduct a root cause analysis to improve their high rate of rehospitalization. They had invested a chunk of change on third-party software systems and had an excellent electronic health record. Yet despite their investments and willingness, nothing had elucidated how cognitive impairment and other common characteristics of nursing home residents affected hospital/ER utilization. 

Again returning to a prior writing, there is about a four percentage point difference in rehospitalization rates between the cognitively impaired and the unimpaired. However, when you rely on medical diagnoses to frame your root cause analysis, you run the risk of not identifying the actual cause. 

Consider this: In addition to the “usual suspects” of medical diagnoses that are handed down from referring hospitals, add cognitive impairment, mental illness, depression, frailty, advanced age, pain and incontinence. Seem overwhelming? Then I suggest that you remove the medical diagnoses from your analysis. Still too much? Then just look at those residents with cognitive impairment who went to the hospital; you will find pots of gold! Better anticipate and recognize change in condition in this population.

People with cognitive impairment are often lost, but Helen is everywhere. Whether you can hear her or not, she is reminding us that patience — and patients — are truly virtues. Keep them safe, keep them out of the hospital, and see your hospital metrics improve!

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.