adjunct to treatment of chronic disease, there are benefits to eating fish that are important for elders. The relation- ship of fish eating to hear t disease prevention alone should be enough to encourage fish eating in the elderly population, a group that suffers the highest rates of heart attack. Fish is also relatively low in calories (when not fried), a benefit to older adults who must decrease calorie intake as they age to prevent weight gain.

Older adults should not supplement their diets with fish oils on their own, for the reasons mentioned, but may want to consult with a physician if they have a condition that has been helped by the use of fish oil. []

REFERENCES

I. Knapp HR, FitzGerald GA. The antihypertensive effects of fish oil. N Engl J Med 1989;320:1037-43.

2. Kromhout D, Bosschieter E, Coulander C. The inverse relation between fish consumption and 20-year mortality from coronary heart disease. N Engl J Med 1985;312:1205-11.

3. Stenson WF, Cort D, Rodgers J, et al. Dietary supplementation with fish oil in ulcerative colitis. Ann Intern Med 1992;I 16:609-14.

4. Kremer JM, Bigauoette J, Michalek AU, et al. Effects of manipulation of di- etary fatty acids on clinical manifestations of rheumatoid arthritis. Lancet 1985;1:184-7.

L E T T E R

T h e I m p o r t a n c e o f L i s t en ing Wi th All O u r Senses

Several months ago I read a newspaper article about an elderly patient diagnosed with Alzheimer's disease who died in a nursing home following an injury that was not reported or treated. Such tragedies are not confined to nursing homes. Although most caregivers are concerned and loving, some may miss illnesses or injuries because they have not learned to listen to a cognitively impaired patient.

When alert, oriented people fall or suffer an illness, they can tell the family or the nurse and be promptly ex- amined and treated. Alzheimer's patients, however, often lack the capacity to remember and to tell what has hap- pened.

They do feel thepain, and caregivers must learn to lis- ten and to interpret their signals. Do patients cry or cringe when an area of the body is gently touched? Are they reluctant to move, turn, or get out of bed? Does a particular person or uniform elicit a fearful reaction? These actions are clues to an injury that may not be vis- ible.

It is difficult and sometimes frightening to care for pa- tients who cannot tell you when something is wrong. There are precautions that caregivers at home and in nursing facilities, hospitals, and day-care centers may take to help compensate for these patients' lost ability to protect themselves.

Careful checks of a patient's body during bathing and other care may help prevent an obvious injury from going unnoticed. Any complaints, verbal or nonverbal, deserve immediate investigation. A frail, elderly person may suf- fer a fracture from a slight bump or even from turning. A small blister or cut on the foot of a person who is diabetic or has compromised circulation may lead to gangrene, amputation, and death. A sore in the mouth may be an early sign of cancer; even if it is not, the discomfort may make the patient reluctant to eat and drink, causing mal- nutrition and dehydration and making the patient more

vulnerable to secondary illness. These few examples point out that it does not always take a traumatic incident to cause serious injury or illness.

How can we, the caregivers, compensate for our pa- tients' lost abilities? By using our senses--including our sixth sense, intuit ion--we can do much to prevent trag- edies.

With our eyes, we observe a patient's body, facial ex- pressions, and movements. Our ears must be attuned to hear complaints and cries. Our sense of smell may help detect an injury or infection that is not visible. With our touch, we can feel swollen or deformed areas that may be causing pain to the patient.

When a change has been detected, we must follow through. A nurses aide's observations are often invalu- able to the charge nurse, who may not have the time to carefully check each patient daily. Families should con- tact the patient's physician or visiting nurse if they sus- pect any type of health problem. Some reports may be un- founded, but it is better to be cautious than to allow a pa- tient to go without needed treatment.

After a diagnosis has been made and treatment pre- scribed, the caregiver continues to be responsible for its implementation. An Alzheimer's patient cannot be relied on to follow the physician's orders and may be reinjured if precautions are not observed. More than with mentally alert patients, the nurse needs to continually assess the patient's condition to ensure that the treatment is effec- tive and to guard against reinjury, infection, or other sec- ondary problem.

Loving care, combined with close observation and careful follow-up, may help to prevent the pain of an un- treated injury or illness in a cognitively impaired patient.

N A N C Y J O A N N E C ONN Case Manager

Wisconsin Peer Review Organization Madison, Wisconsin

Yen/Le t t e r Ger ia t r i c Nurs ing Volume 14, Number I 53