Grand Junction is an arid desert community in Western Colorado, close to the Utah border. Up until that time when I thought of Colorado, I thought of mountains, green in the summer and snow in the winter. Grand Junction didn’t fit that preconceived picture. It does get snow, so I’ve been told. However, I was there in the summer. It’s hot and it was very hot that year with temperatures well into the 100’s during the day. Yes, you can fry an egg on a sidewalk with temperatures like that. What can I say, it was a slow day time at work. Take a look at your immediate scenery in Grand Junction and you’ll see red rock, a mini Grand Canyon. You can almost imagine tumbleweeds going down Main Street when the town was even less populated than its 20,000 or so when I was there. Yet it’s an area of contradiction. So dry, hot and barren but go a few miles East on I70 and there’s an exit that I recall that took me up in elevation to an area of vast greenness, lakes and still cool enough that in July you could still find little pockets of snow. From this vantage point you could look down on Grand Junction and all it’s dry red rock glory. I had never experienced anything like it being an East Coast girl. I’d always been near the oceanside of Rhode Island or the gulf coast of Florida. It blew my mind.
I spent the summer of 1997 working as a speech pathologist in a nursing home in Grand Junction. I was still early on in my career, three years to be exact. I thought I knew a lot, not all, but a lot about how the human brain works, remembers and thinks. I thought it was true that after a “certain age” the human brain begins to deteriorate and there’s nothing we can do to improve it; just be there to modify the environment, assist and wait until the end. See a diagnosis of Dementia on a chart and say inside your head that providing therapy would be a waste of my time but I was being told to do it anyway. I was about to be shown how wrong and closed minded I was thinking this was the path for all older adults. My lesson came in the form of a weathered and patient cowboy.
Part of the job of a speech pathologist in a nursing home setting is you are required to do quarterly screenings of the long-stay or permanent residents. The Medicare/Medicaid purpose is to monitor the residents’ overall status and write an evaluation/treat order if you observe a decline in your area(s) of expertise. This serves to keep the resident at their maximum functional level for as long as possible. Many rehabilitation companies (for which speech pathologists, physical and occupational therapists are often employed by) also use this as a way to build our caseloads and their income. Some companies put significant pressure on their therapists to build caseload, keep a high productivity level or else – the dreaded Action Plan warning. Remember I mentioned it was slow at work so we fried an egg on a sidewalk? Well, there was pressure to build therapy caseload that summer. As a result, I was under pressure to screen the living heck out of the residents regardless of whether a quarterly was due or not.
One morning I was handed a screen referral to go see one of the oldest residents in the place. “He’s having trouble being oriented. Go do the screen and write an order to evaluate/treat him for cognition.” I remember looking down at the information sheet and seeing he was 105 years old. Well, heck! Of course he can’t stay oriented. “What the *?!* am I supposed to do with him?! This is fraud.” I thought to myself, but went off to do my job thinking I would find a very debilitated man sentenced to living his life in his bed. Ah, preconceived notions. I was about to find out how incorrect I was on several aspects.
I’ll refer to this man from this point on as The Cowboy. That’s how he was known in the place, one of the last early cowboys of Grand Junction. Some staff on the floor pointed me to his room, noting he was there presently. “Oh, so he gets out of bed? He’s active?” I believe were some of my questions. All I remember now are the knowing smiles of the staff members’ faces. “Oh he’s active, more active than we’d like sometimes.” I knocked on his door and asked permission to come in. A craggy but strong voice told me I could.
I still vaguely remember what he was wearing that day. He had on dark wash dungarees with a crisp blue checked shirt. The shirt had a bolero tie, the jeans a belt with a bronze-like buckle. Cowboy boots were there too. When I see this memory now, I also swear he had on spurs. I can hear them in my head. He didn’t though but you knew he should. His face was etched from the years of being outside but it was amazingly young looking given he was on record of being 105. His legs were bowed from many years of riding Western style. I noticed this because he was a gentleman and had stood to fetch me a chair to sit on while we talked. Now I knew why they called him Cowboy. He was not weak or feeble.
We greeted each other and I explained to him that I’d been asked to come talk to him, that I was a speech pathologist on staff and I was told to see if I could help him with some therapy. He laughed and noted several of us had been there that morning to see if they could help and offer therapy. He didn’t think he needed any but didn’t want to get us kids in trouble. I was told to go ahead and ask my questions anyways. He enjoyed the company and conversation. Then he gave me a wink. Obviously, highly verbal, articulate, socially pragmatic…but hmm, social skills can be maintained long after memory and higher thought processes have declined. Yeah, about to get my lesson.
I asked questions from sheet on my clipboard. Everything done within acceptable limits. I still needed to target his memory and thinking (cognition). I thought that was where I’d see some trouble and would be able to get the validation to order an evaluation and get management off my back. He asked if I was almost done because he had some visits he wanted to make before lunch came. I should have given that response more weight in my mind but pressed on anyway. I started to screen his orientation to person, place and time. Medical people like to see adults having all three of these. We write it as, Ox3. If you weren’t Ox3, someone like me was supposed to see if I could “fix you”. Now we also keep the parameter of situation in mind. It was awareness of situation and The Cowboy’s personal use of problem solving that saved him from having me waste his time that summer.
The Cowboy knew where he was, right down to the address. Orientation to place intact. I already could see he knew who he was, person. Orientation to time, that’s where he faltered. He didn’t know day, month or year. He possibly didn’t know his age either. Some of it I suspect was he didn’t need to care anymore and maybe he thought it rude to blatantly ask. Back in the early to mid 1990s we still thought an older adult should maintain orientation to time, that re-orientation therapy was appropriate and highly indicated. We know better now. I won’t go into all the arguments about this present day vs what we were taught back then. Suffice it to say, because Cowboy had failed on aspects of time, I was supposed to order speech therapy. So what did he say that made me decide to buck the system and take the wrath from management?
It actually started when I told Cowboy the Careplan nurses were concerned that he didn’t remember time anymore and that he showed me this when he couldn’t correctly answer those question with me. I also noted I was concerned he couldn’t recall his age. This was his response. “Dear girl, none of this matters anymore. I know I’m old. I’m one of the oldest ones here. I stopped counting at 75 because I didn’t care to see the number. Once I passed 100 I figured I was like one of them petrified cactus out in the desert and someone forgot to bury me. As for time, the specifics don’t matter in here (a nursing home). Every morning I wake up to hear then smell the food trays coming down the hall I give thanks that The Lord has seen fit for me to see another day. When I get my dinner at the end of the day and see the sun set I again give thanks that The Lord wanted me to experience all of this day. If I’m told it’s time to go to church, then I know it’s Sunday. If I wake up the next day then I know a new week has started. This is how I mark time now. What matters to me is that I get up, move around. I drive my nurses crazy because I help them get trays, make beds. I visit with the others, especially the ones who can’t get up anymore. I’ve know most of them all of my life. We’ve helped each other through the lean years out here before it was truly settled. That’s how we did things. I respect the concern you all have but I don’t need you like that. I’m sorry to disappoint you. But your always welcome to come spend time with me.” Well, he told me didn’t he. I left his room with a little smile on my face.
I don’t recall word for word anymore this conversation, my memory has 18 years of wear on it now. So this is an approximation of the words spoken. I don’t work as a speech pathologist anymore but I still come in contact with many nursing home residents and older adults. The impression of this conversation has stayed embedded in my mind and how I view older adults whether they have an official diagnosis of dementia, Alzheimer’s Disease or not. In fact I now specifically look to see how adults with these diagnoses adapt, many in very creative high level ways for many years after diagnosis. I never automatically count them out. In fact I go in expecting to find ways to be amazed. You taught me that Cowboy. May you be resting in peace out on the range. Thank you for my lesson, too.