With Sri. Rama Iyengar who is 102 and going strong.
This is very loooooonnnnnnnng. Yet please read it.
An interesting note on the subject mentioned therein--useful for kal aaj aur kal population ,for knowing the origin of the problem theyhave/may have, for preparing themselves about what they may have to face in future, and for educating themselves to develop a sympathetic attitude towards persons facing this problem in their circles respectively.
By Dr.Achala Balasuriya MD
Consultant Physician(Special Interest- Elderly Care medicine)
Falls among elders is a common cause of morbidity , hospitalization ,disability and death. Nearly a third of the elderly have falls that trigger a chain of events that usually have them succumb to the situation or leave them bed-ridden till the end comes. With age, the ability of the body to heal itself reduces considerably and the
immunity drops. The muscles and ligaments tend to get more lax with bones becoming more brittle and porous. Under these circumstances, even a trivial looking fall may prove fatal.
Common causes of falls
Reduced muscle strength, coordination and reflexes
Poor sensation in the lower extremities due to diabetes or degenerative conditions
Poor balance due to neurological diseases, hypothyroidism or ear problems
Postural drop in blood pressure
Strokes, transient ischaemic attacks
Abnormalities of cardiac rhythm
Multiple medication use
Environmental hazards eg poor lighting ,carpets, rugs, clutter etc
Osteoporosis is a major risk factor for falls. What is debatable is whether brittle bones break after a fall, or break when stressed and in turn cause a fall. In either event, a decrease in bone density contributes to falls and resultant injuries. Osteoporosis is a condition wherein bones become more porous, less resistant to stress, and more prone to fractures. Caused by hormonal changes, calcium and
vitamin D deficiency, and a decrease in physical activity, osteoporosis is a chief cause of fractures in older adults, especially among women.
"Eat or drink sufficient calcium. Postmenopausal women need 1,500 mg of calcium daily. Calcium-rich foods include milk, yoghurt,cheese, fish and shellfish, selected vegetables such as broccoli,soybeans, tofu and almonds."Get sufficient Vitamin D in order to enhance the absorption of calcium into the bloodstream. Vitamin D is
formed naturally in the body after exposure to sunlight, but some older adults may need a supplement. "Regularly do weight-bearing exercise.
Lack of Physical Activity
Failure to exercise regularly results in poor muscle tone, decreased strength, and loss of bone mass and flexibility. All contribute to falls and the severity of injury due to falls.
"Engage regularly (e.g., every other day for about 15 minutes daily) in exercise designed to increase muscle and bone strength, and to improve balance and flexibility. "Undertake daily activities in a safe manner, such as reaching and bending properly, taking time to recover balance when rising from a chair or bed, learning the proper way to fall, and learning how to recover after a fall. "Wear proper fitting, supportive shoes with low heels or rubber soles.
Age-related vision diseases can increase the risk of falling. Cataracts and glaucoma alter older people's depth perception, visual acuity, peripheral vision and susceptibility to glare. These limitations hinder their ability to safely negotiate their environment, whether it be in their own home or in a shopping mall. Young people use visual cues to perceive an imminent fall and take corrective action. Older adults with visual impairments do not have this advantage to the same
"Have regular checkups by an ophthalmologist to discern the extent of age-related eye diseases such as cataracts and glaucoma, mascular degeneration etc." Use colour and contrast to define balance-aiding objects in the home (e.g., grab bars and handrails). Add contrasting colour strips to first and last steps to identify
change of level. "Clean eye glasses often to improve visibility.
People taking multiple medications are at greater risk of falling Sedatives, anti-depressants, and anti-psychotic drugs can contribute to falls by reducing mental alertness, worsening balance and gait, and causing drops in systolic blood pressure while standing.
"Know the common side effects of all medications taken."Talk with your physician or pharmacist about ways to reduce your chances of falling by using the lowest effective dosage, regularly assessing the need for continued medication, and the need for walking aids while taking medications that affect balance."Remove all out-of-date medications and those no longer in use. Limit intake of alcohol as it
may interact with medication Environmental Hazards Indoors At least one-third of all falls in the elderly involve environmental hazards in the home. The most common hazard for falls is tripping over objects on the floor. Other factors include poor lighting, loose rugs, lack of grab bars or poorly located/mounted grab bars, and unsturdy furniture.
It is useful to conduct a walk-through of your home to identify possible problems that may lead to falling.
Repair cracks and abrupt edges of sidewalks and driveways.Install handrails on stairs and steps. Keep floor dry, devoid of wet areas and greasy surfaces. Keep walk areas clear of clutter, rocks and mud. Install adequate lighting by doorways and along walkways leading to doors,gates.
Ensure adequate lighting inside the house. Remove unnecessary furniture and over crowding. Keep floor dry and clean and devoid of wires, toys etc. Indicate steps, stairs by painting in contrasting colours. If person has had a fall, he should get himself properly checked out by a physician to assess the risks of falling again and to ensure safety at home. When you go to see the doctor after a fall please remember to tell the doctor about all your current medications and medical conditions.
It is an illusion that youth is happy;an illusion of those who have lost it.
No man is so old as to believe he cannot live one more year.
------Sean O Casey.
The man who views the world at fifty the same as he did at twenty has wasted thirty years of his life.-------Mohammed Ali.
Preventing Falls for Senior Citizens:
Balance Problems and The Elderly Senior Medical Alert:
A lot of older people have trouble with balance and getting around safely. There are many common and serious problems associated with balance, the biggest one being falls and another being a loss of independence and mobility. The fear of falling can cause the elderly to lose confidence and consider moving into an elder care facility.The good news is that many of the causes of loss of balance, falls
and instability can be treated successfully.
How common are fall related injuries amongst the elderly?
About one third of people over age 65 fall each year. Over age 75 that likelihood increases to 50%. A good portion on people over age 65 say they have trouble getting around.
What are the biggest causes of falls for senior citizens?
There are several culprits; environmental hazards (like tripping over clutter, poor lighting, slippery floors and rugs that are not properly secured) muscle weakness, poor balance, vision problems, dizziness and medicinal side effects like confusion or dizziness.
How can you reduce your risk of falling?
Talk to your physician and get evaluated. Get your strength and balanced measured and have your medications reevaluated for possible side effects. To reduce your chance of falling you can have your prescriptions modified, begin an exercise program, get physical therapy or purchase a cane or walker to make getting around easier.
What are the warning signs that you’re at a higher risk of fall related
Do you have trouble getting up from a seated position without using your hands? That could be a sign of muscular weakness. Is your balance unsteady? Does it take you a long time to move around? Are you taking medications that indicate possible side effects include dizziness or confusion? Are you over age 75? If you answered “yes” to any of these questions, you are in the high risk group.
How can medical emergency alarms help?
A quality senior medical alert system can you the help you need fast. Many falls can result in serious injury, long term hospitalization or even death if medical help doesn’t arrive quickly. We recommend Lifestation as an affordable and reliable emergency call button for seniors.
What causes dizziness upon standing?
A sudden drop in blood pressure is the common cause, also known as orthostatic hypotension). It can be brought about by diabetes, Parkinson’s disease, heart failure, drop in blood volume, dehydration, infection, and a number of medications (such as diuretics and blood pressure medicines). A less common cause is caused by abnormalities in the inner-ear. Dizziness is a very common problem, affecting over two million Americans. About eight million report problems with balance.
A balance disorder is a disturbance of the inner ear that can make people feel unsteady or as if they were moving, spinning, or floating. Balance disorders are one cause of falls and fall-related injuries, such as hip fracture.
What types of balance disorders are there?
Balance disorders can be caused by a variety of disorders. Benign paroxysmal positional vertigo or BPPV is very common among the elderly. BPPV causes a short lasting, strong sense of vertigo that happens when you move head. Rolling over in bed, looking up or any other change in head position can trigger a loss of balance. BPPV is triggered when tiny calcium stones in the inner ear get displaced
creating a feeling of dizziness or vertigo.
What can you do to make your home safer and reduce falls?
Have your home inspected by a senior health care specialist. Have any loose flooring secured, make sure the entire home is well lit and keep the floors clear of clutter. Have anti-slip strips placed in places like bathrooms and any highly polished floors.
What type of cane, walker or scooter is best for reducing falls?
Speak to your doctor or physical therapist to find the best safety product for you based upon your needs and existing conditions. For some a simple cane will do, others may require more support. A medical alert device for seniors makes great sense for people who are at a high risk of falling.
Activity Ideas for Elderly Senior Citizens
Improve Visits - Easy Games and Ideas to Keep Seniors Active & Alert
Elderly seniors need interesting activities, fun games & things to do to help keep memory sharp and bodies strong. These simple activity ideas help senior citizen health. Family members, friends, activity directors, and senior citizen companions are often looking for interesting ideas for things to do with home-bound seniors and the elderly in adult care facilities. Engaging and taking pleasure in visits with failing, forgetful, or weak senior citizens is possible with a little effort and creativity. Improved time spent together is uplifting to all involved and can create nice memories. Every individual older person will have their own tastes, capabilities and preferences, of course. The ideas presented here may be adapted to fit your own situation and your senior's likes. Senior care should always be as personalized as possible. Following are easy ideas for things to do to bring out the
personality, energy, and humor in your older family members or friends with simple activities.
Engage Elders with Fun or Interesting New Gadgets
Some home bound older people have not had much exposure to recent electronic technology. An iPad, a Blackberry, or some other "new-fangled" object could be of interest to a senior. A digital camera isn't much of a novelty for younger folk, but for a older senior citizen, one can be quite interesting. Take photos of the
senior's favorite people, items, or animals. Pictures can be made into a slide show or printed and placed in a binder. Let the senior take pictures too. Digital photographs may be combined with asking questions and taking notes to create a senior citizen's life history, a weekly journal or a fun scrapbook. Scrapbooking is an activity that can be adapted to suit individual tastes and abilities. Exercise is Important for Senior Citizen Physical and Mental Health For older Americans, reversal of the brain shrinkage that occurs as people age is just one benefit of greater physical activity, according to research published in The Journal of Gerontology: Medical Sciences (Vol. 61A, No. 11).
Here are some ways exercise can be incorporated into the lives of
Friends and family can encourage continuation of present physical
activities and hobbies. If walks are appropriate, a stroll on a nice day is a fun and easy way to pass time with a senior. Even pushing a senior in a wheelchair
outside can encourage him or her to point to flowers, pets, and such. If a senior has been inactive, one may still be able to encourage regular exercise. A doctor or physical therapist may provide appropriate exercise and equipment suggestions.
See what types of exercise a frail senior can tolerate. According to April 2002 issue of the Journal of Gerontology: Biological Sciences, resistance training exercise just one day a week can give older adults the strength to maintain their independence and to avoid injuries (Researchers Scott Trappe, David Williamson, and Michael Godard).
Ideas for Physically or Mentally Frail Seniors or Elderly
Soft clay-like products (Sculpy crafting material or Play-Doh, for instance) or special exercise items (such as balls) can be manipulated or squeezed to help strengthen the hands. Simple toys can be a good option for keeping seniors active while encouraging hand-eye coordination. Baby and infant toys are generally colorful, soft-cornered, easy to grasp, and mind stimulating. The amusing Tangle toy pictured below is an amusement for all ages. Games can help stimulate the mind. Some elderly folk enjoy Scrabble, cribbage, or card games, which use a variety of skills. Ask about individual preferences. Just about any show or movie is available today.Many programs are also available to view for free online. Shows like Animal Planet (a cable channel), videos of young children or baby animals, and classic musicals are good for all ages and can be funny and uplifting. Watch along with your senior. It's much more fun to laugh with a companion.Some great musicals include The Music Man (1962), The Sound of Music (1965), The Wizard of Oz (1939), Brigadoon (1954), and Singin' in the Rain (1952). Ask seniors about their favorite older films.Many seniors enjoy game shows, science programs, or vintage television. There are cable networks dedicated to each of these types of shows. The Discovery Channel covers scientific subjects, for
Questions to Ask about the Senior's Childhood Who was his or her best friend and why?
What games did he or she like to play?
What was the best birthday present he or she ever got?
Did he or she ever have a nickname?
Put on a tape recorder or camcorder and save priceless memories to keep forever. Add to it on each visit.Bring Children and Small, Safe Animals to Visit Senor Citizens Children and babies can be a rare sight for older folks in a retirement
home or other senior care. There are significant benefits to old and young that might come from greater age integration (Uhlenberg, P, The Gerontologist; v40 n3 , p276-279 ; Mar 2000). In lieu of the real thing, bring pictures or videos.Many older folks miss their companion pets. Borrow a puppy, kitten or baby chick for the day and bring it in an appropriate box. Be careful to avoid scratches or bites as elders often have fragile skin. The July 2002 issue of Journal of Gerontology: Medical Sciences,found that even one animal-assisted therapy session of 30 minutes per week was effective in reducing loneliness. See Dogplay online for more information on this type of therapy. Activities and Ideas for Musical Seniors
Try singing old-time songs like In the Good Ol' Summertime. Search online for words to hymns, early barbershop quartet songs and classic camping tunes. A highly rated campfire songbook on Amazon.com is Campfire Songs by Irene Maddox (Globe Pequot Pr; 2nd edition, April 1994) or you can look at the book The American Song Treasury: 100 Favorites by Theodore Raph (Dover
Publications,October 1986).Just about everyone knows childrens' tunes such as Twinkle Twinkle Little Star, How Much is That Doggie in the Window, and Take Me Out to the Ball Game. In a senior group setting, a choir or band could be formed. The Brain and Body Connection Treatments to keep the brain healthy can be just as effective as exercise is for the body, according to the latest special issue of The Journal of Gerontology: Psychological Sciences (according to the June 15, 2007 press release from The Gerontological Society (by guest editor Neil Charness, PhD of Florida State University) My grandfather loved reciting memorized poetry to me even at the age of 99. In his case, talking literature and prose, or chemistry and physics, was much more interesting than any game I could think up. He was a teacher and loved sharing knowledge. Tapping into his
personal interests helped keep his mind active and strong all this life. When visiting with seniors at home or in an elderly care home, it's important to bring up old memories, delight them with things that will engage their senses, and just have a little fun. Enjoying visits with a senior will enrich two lives at once. For more ideas, read about Fun Visits With Senior Citizens and Memory Help for Seniors.
Precautions can prevent senior-citizen falls As senior citizens age, their health risks increase. That's why Rex Senior Health Center's Dr. Leroy Darkes likes to see his elderly patients often.
"I think that our seniors should get every second of quality life that they possibly can, and that begins with good prevention," said Darkes. He likes to keep his patients up to date on a number of health screenings including:
Vision and glaucoma checks
Mammorgrams for women and prostate cancer screening for men
Colonoscopies to check for colorectal cancer
Regular blood-pressure and cholesterol checks. Updating vaccinations for pneumonia, tetanus and shingles.
An annual flu shot
Darkes says that sometimes the greatest threat to seniors' health is right at home.
"As we age," he said, "we become more fragile, more likely to injure our head, sustain a head injury which could be very devastating." Seniors also may fracture a bone, which immobilizes them, and that can easily lead to other health concerns.
For 79-year-old Hermena Hunter, rheumatoid arthritis makes her even more vulnerable to a fall. That's why she's made some changes at home.
"There was gravel in the driveway, so I was able to get the driveway poured with concrete," she said. She also added more railing at the front steps and carpeting to cover a slick wood floor inside. "And I tried to choose the correct kind of shoes to wear, too, to keep from slipping and falling," said Hunter. She also uses a cane to keep her steady and tries to keep her home free of trip hazards like loose rugs.
Those simple precautions may help her to stay independent in her own home "for as long as I possibly can. I love to be self-sufficient," said Hunter. Darkes says it's very important for adult children to help their parents eliminate fall risks in the home and to encourage them to use a walking device if needed. Some of the suggestions Rex Healthcare rehabilitation professionals make on falls prevention:
Proper footwear (rubber-soled shoes) Keep floors dry and free of clutter to minimize slip and trip hazards Remove or secure down any throw rugs that may slide. Keep areas well-lit if they are to be walked at night (night lights) Have railings installed on stairs. Use the bathroom just before bed to limit the numbers of trips at night. When changing positions (lying down to sitting, sitting to standing)
take a minute to keep from being too dizzy. If you have been prescribed and shown how to use a walking device, use it. Talk with your physician and/or pharmacist about side effects of medications and take them as prescribed The conditions that affect many seniors can also increase your risk of falling. Since physical changes and many conditions are a part of aging, it's not always possible to remove these blocks from your risk tower. Learning how these medical conditions lead to falls is the first step towards understanding the risks. If you have… …then falls can be a concern because Heart disease or failure (CHF) Heart conditions can cause dizziness, balance problems, muscle weakness and fatigue, even with only slight exertion. Heart disease is also frequently associated with respiratory difficulties, which can result in many of the same falls-related conditions.Had a stroke Strokes often result in muscle weakness, and/or sensory imbalances on one side of the body, which can compromise one’s ability to move about safely. Parkinson’s Disease Tremors, stiff aching muscles, and slow limited movement (especially when the person tries to move from a resting position) are all falls risks associated with Parkinson’s. A person with Parkinson's disease is likely to take small steps and shuffle with his or her feet close together, bend forward slightly at the waist (stooped posture), and have trouble turning around. Balance and posture problems may result in frequent falls, especially as the disease progresses. Low blood pressure Low blood pressure, particularly when rising from a lying or sitting position, is a common cause of falls due to dizziness and/or fainting. Chronic obstructive pulmonary disease (COPD) The shortness of breath that is caused by COPD (chronic bronchitis and/or emphysema) can make you feel weak, dizzy or faint, even when you do simple things like get dressed or fix a meal. Diabetes Diabetes can cause a loss of feeling in the feet (diabetic ‘neuropathy’), which compromises your balance and sense of where obstacles and uneven footing may be a hazard. Arthritis The loss of joint flexibility due to arthritis makes it difficult to maintain a safe gait, to avoid potentially dangerous obstacles, and maintain balance.
A decrease in vision, whether caused by glaucoma and cataracts, or just aging eyes, makes it far more difficult to judge distance and avoid obstacles that could trip you up.This is naturally a particular concern at night or when in the dark.
Mental confusion Mental confusion can increase the chance of a fall since it may be more difficult to determine whether an activity is putting one at greater risk, or it may take longer to respond to a situation where a fall might otherwise be averted.
Although medicines help you stay well, they can put you at risk for falling. This is especially true if you are taking several medications several times a day. There are three reasons why: Some drugs have side effects, and may make you feel dizzy,
confused or otherwise less able to prevent a fall. Two or more drugs may interact in a way that produces undesirable side effects. Not following the doctor’s orders. Seniors might do this because they forget, or find their medication schedule too complicated, or are dismayed by the side effects.
WHAT YOU CAN DO
Keep a complete, dated list of the medications you take and bring it to your doctor for a ‘medication checkup’. Remember that ‘medications’ mean the prescriptions that you get from your doctor, as well as those non-prescriptions drugs, pain relievers, herbal remedies and other treatments you get at the pharmacy or market.
To print a copy of a handy purse-sized form that you can use for this purpose, download this checklist now. Report any new symptoms to your doctor right away, who will help you decide if the symptoms are side effects caused by the medication. Always take medications as directed. It’s easier to keep track of your
medications - which ones to take and exactly when to take them - if you use a medicine organizer, a medicine dispenser, or ask your pharmacist to dispense your medications in a blister pack. Combine all your prescriptions with a single pharmacy. That way, your pharmacist can more easily review your medications and communicate any concerns he or she may have with your doctors. Together, they might decide to try changing one or more of your medications, dosages, etc.
LEARN HOW MEDICINES INCREASE YOUR RISK
If you... …than falls can be a concern because… take four or more medications that are either prescribed or received “over-the-counter”, including herbal remedies, pain relievers, vitamins, and dietary supplements. The more medications you take, the more likely it may be that you experience drug interactions
and/or side effects that can increase your risk of falling. These side effects may make you lose your balance, become drowsy, blur your vision and make you feel weak or dizzy.Over-the-counter products may also interact with prescription medicines and increase the risk of side effects which can also increase your chances of falling. Take medication for high blood pressure High blood pressure
medications can make you feel light-headed or dizzy when you first stand up from a chair, or when you get up out of bed in the morning. This is called ‘postural hypotension’. drink alcohol When mixed with medicines, even a little bit of
alcohol can make you feel drowsy and dizzy and increase your risk of falling.
YOUR STRENGTH & BALANCE
Some people think that the best thing to do if you’ve fallen, or if you’re afraid of falling, is to be less active. Why take the chance of falling again, right? Well, research shows that seniors who are less active are more likely to fall, because they lack the strength and balance and they need to resist falls. This is why healthcare professionals recommend starting a regular exercise routine of any
kind – even if you start by taking only a few steps every day. Exercise may improve your… Strength and stamina
Giving your heart, lungs and the rest of your cardiovascular system even a modest workout can make a tremendous difference in the way you feel, in your energy level, and in the way you go about enjoying life as best you can.
When you were very young, you had to learn to balance yourself, and unless you continue to use your balance under safe conditions, this vital skill diminishes. Balance also helps you to keep the mass of your body over your feet, which helps you maintain your stability when moving your weight from one position to another.
Regain some of the spring in your step, and practice walking (either alone, or with a cane or walker) with a stronger, safer and more fluid gait. Reflexes Exercise can make you more responsive and help you react more safely to obstacles in your path and other potential dangers. How to Get Started Exercising
YOUR HOME ENVIRONMENT
Most falls happen at home where we spend most of our time. Fact is that as we get older, items in our home that used to be virtually harmless start to pose a greater risk. Stairs, bathrooms, dimly lit hallways, a little extra clutter around the house – even pets underfoot can be dangerous. The good news is that most of these possible home safety hazards can be minimized. All it takes is some time and attention – and maybe the assistance of a friend or family member – before an
unfortunate accident happens.Learn how making a few simple changes to your home can reduce your risk of falling.
The best time to get a ‘medication checkup’ is before you start a new prescription.
HOW OFTEN FALLS OCCUR
About one third of the elder population over the age of 65 falls each year, and the risk of falls increases proportionately with age. At 80 years, over half of seniors fall annually. As alarming as they are, these documented statistics fall short of
the actual number since many incidents are unreported by seniors and unrecognized by family members or caregivers. Frequent falling. Those who fall are two to three times more likely to fall again. About half (53%) of the older adults who are discharged for fall related hip fractures will experience another fall with in six months
What Happens After a Fall
Falls are the leading cause of death due to injury among the elderly 87% of all fractures in the elderly are due to falls. Falls account for 25% of all hospital admissions, and 40% of all nursing home admissions 40% of those admitted do not return to independent living; 25% die within a year.Many falls do not result in injuries, yet a large percentage of noninjured fallers (47%) cannot get up without assistance. For the elderly who fall and are unable to get up on their own, the
period of time spent immobile often affects their health outcome. Muscle cell breakdown starts to occur within 30-60 minutes of compression due to falling. Dehydration, pressure sores, hypothermia, and pneumonia are other complications that may result. Getting help after an immobilizing fall improves the chance of
survival by 80% and increases the likelihood of a return to independent living.
Up to 40% of people who have a stroke have a serious fall within the next year.
Fear of Falling
Why Seniors Fall
Where Seniors Fall
Falls Are A National Health Priority
FEAR OF FALLING
20% to 30% of seniors fear falling.90% percent of falls that do not result in injury can still have a detrimental impact on health and well-being. 30-50% of elders report that fear of another fall results in loss of confidence and selfimposed restriction of activities, thereby increasing the risk of falls.
WHY SENIORS FALL
A summary of 12 studies cites the following most common reasons for falls. The effect of drugs on the elderly, and the difficulties surrounding medication compliance, are also believed to be the root
cause for many of falls incidents.
WHERE SENIORS FALL
55% of all falls take place inside the home. More than three-quarters take place either inside or in close proximity to the home, where a medical alert system can be of immediate assistance.More fall injuries are caused by falls on the same level (vs. stairs) and from a standing highlight, i.e. tripping while walking.
WHAT IF YOU DO FALL?
Even if you’re careful, a fall might still happen. Healthcare experts recommend that you then prepare yourself by knowing two things:
How to get up: A full illustration given in next page
How to call someone for help. Have your own convenient method like wireless sensor etc.
Sent by Mr. Bhaskaran Sivaraman
Very informative, though lengthy. Couldn't avoid thinking of elders at home and how we can help them better. Thank you for sharing Sir.
Really, when I posted this , I was wishing youngsters should read this and take care of elders.I am glad you did not skip it.
And one salient habit of elders of earlier years was their eating habits i.e. avoid eating outside and of course such trash foods were not available in those days. Even if foods were available cleanliness was maintained and it was a pleasure to eat in such motels. And of course mobility of people of earlier was less or none.Now due to unavoidable mobility people eat outside - in various places, cities and states - and succumb to all kinds of disease. I remember in early sixties one Bhagavathi mess near Midland was maintained by Palakad Brahmins and all South Indian dishes were served neat and clean. If you are a regular visitor you will be taken inside to a separate room and you will be served with great attention.