Elderly Care
https://eldercare.acl.gov/Public/Index.aspx
https://www.seniorcare.com/assisted-living/resources/assisted-living-costs/
"Cranky Old Man"
What do you see nurses? . . .. . .What do you see?
What are you thinking .. . when you're looking at me?
A cranky old man, . . . . . .not very wise,
Uncertain of habit .. . . . . . . .. with faraway eyes?
Who dribbles his food .. . ... . . and makes no reply.
When you say in a loud voice.. . .'I do wish you'd try!'
Who seems not to notice . . .the things that you do.
And forever is losing . . . . . .. . . A sock or shoe?
Who, resisting or not . . . ... lets you do as you will,
With bathing and feeding . . . .The long day to fill?
Is that what you're thinking?... .Is that what you see?
Then open your eyes, nurse, you're not looking at me.
I'll tell you who I am . . . . .. As I sit here so still,
As I do at your bidding, .. . . . as I eat at your will.
I'm a small child of Ten . .with a father and mother,
Brothers and sisters .. . . .. . who love one another
A young boy of Sixteen . . . .. with wings on his feet
Dreaming that soon now . . .. . . a lover he'll meet.
A groom soon at Twenty . . . ..my heart gives a leap.
Remembering, the vows .. .. .that I promised to keep.
At Twenty-Five, now . . . . .I have young of my own.
Who need me to guide . . . And a secure happy home.
A man of Thirty . .. . . . . My young now grown fast,
Bound to each other . . .. With ties that should last.
At Forty, my young sons .. .have grown and are gone,
But my woman is beside me . . to see I don't mourn.
At Fifty, once more, .. ...Babies play 'round my knee,
Again, we know children . . . . My loved one and me.
Dark days are upon me . . . . My wife is now dead.
I look at the future ... . . . . I shudder with dread.
For my young are all rearing .. . . young of their own.
And I think of the years . . . And the love that I've known.
I'm now an old man . . . . . . .. and nature is cruel.
It's jest to make old age . . . . . . . look like a fool.
The body, it crumbles .. .. . grace and vigour, depart.
There is now a stone . . . where I once had a heart.
But inside this old carcass . A young man still dwells,
And now and again . . . . . my battered heart swells
I remember the joys . . . . .. . I remember the pain.
And I'm loving and living . . . . . . . life over again.
I think of the years, all too few . . .. gone too fast.
And accept the stark fact . . . that nothing can last.
So open your eyes, people .. . . . .. . . open and see.
Not a cranky old man .
Look closer . . . . see .. .. . .. .... . ME!!
Remember this poem when you next meet an older person who you might brush aside without looking at the young soul within. We will all, one day, be there, too!
PLEASE SHARE THIS POEM (originally by Phyllis McCormack; adapted by Dave Griffith)
What do you see nurses? . . .. . .What do you see?
What are you thinking .. . when you're looking at me?
A cranky old man, . . . . . .not very wise,
Uncertain of habit .. . . . . . . .. with faraway eyes?
Who dribbles his food .. . ... . . and makes no reply.
When you say in a loud voice.. . .'I do wish you'd try!'
Who seems not to notice . . .the things that you do.
And forever is losing . . . . . .. . . A sock or shoe?
Who, resisting or not . . . ... lets you do as you will,
With bathing and feeding . . . .The long day to fill?
Is that what you're thinking?... .Is that what you see?
Then open your eyes, nurse, you're not looking at me.
I'll tell you who I am . . . . .. As I sit here so still,
As I do at your bidding, .. . . . as I eat at your will.
I'm a small child of Ten . .with a father and mother,
Brothers and sisters .. . . .. . who love one another
A young boy of Sixteen . . . .. with wings on his feet
Dreaming that soon now . . .. . . a lover he'll meet.
A groom soon at Twenty . . . ..my heart gives a leap.
Remembering, the vows .. .. .that I promised to keep.
At Twenty-Five, now . . . . .I have young of my own.
Who need me to guide . . . And a secure happy home.
A man of Thirty . .. . . . . My young now grown fast,
Bound to each other . . .. With ties that should last.
At Forty, my young sons .. .have grown and are gone,
But my woman is beside me . . to see I don't mourn.
At Fifty, once more, .. ...Babies play 'round my knee,
Again, we know children . . . . My loved one and me.
Dark days are upon me . . . . My wife is now dead.
I look at the future ... . . . . I shudder with dread.
For my young are all rearing .. . . young of their own.
And I think of the years . . . And the love that I've known.
I'm now an old man . . . . . . .. and nature is cruel.
It's jest to make old age . . . . . . . look like a fool.
The body, it crumbles .. .. . grace and vigour, depart.
There is now a stone . . . where I once had a heart.
But inside this old carcass . A young man still dwells,
And now and again . . . . . my battered heart swells
I remember the joys . . . . .. . I remember the pain.
And I'm loving and living . . . . . . . life over again.
I think of the years, all too few . . .. gone too fast.
And accept the stark fact . . . that nothing can last.
So open your eyes, people .. . . . .. . . open and see.
Not a cranky old man .
Look closer . . . . see .. .. . .. .... . ME!!
Remember this poem when you next meet an older person who you might brush aside without looking at the young soul within. We will all, one day, be there, too!
PLEASE SHARE THIS POEM (originally by Phyllis McCormack; adapted by Dave Griffith)
American Geriatrics Society
Ten Things Physicians and Patients Should Question
(1) Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.
Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers.
(2) Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary.
(3) Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better.
There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 1 0 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy.
(4) Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
Large scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies.
(5) Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.
(6) Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
In randomized controlled trials, some patients with mild-to-moderate and moderate-to-severe Alzheimer’s disease (AD) achieve modest benefits in delaying cognitive and functional decline and decreasing neuropsychiatric symptoms. The impact of cholinesterase inhibitors on institutionalization, quality of life and caregiver burden are less well established. Clinicians, caregivers and patients should discuss cognitive, functional and behavioral goals of treatment prior to beginning a trial of cholinesterase inhibitors. Advance care planning, patient and caregiver education about dementia, diet and exercise and non-pharmacologic approaches to behavioral issues are integral to the care of patients with dementia, and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then consider discontinuing the medication. Benefits beyond a year have not been investigated and the risks and benefits of long-term therapy have not been well-established.
(7) Don’t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.
Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis and treatment of tumors that would not have led to symptoms. For prostate cancer, 1,055 men would need to be screened and 37 would need to be treated to avoid one death in 11 years. For breast and colorectal cancer, 1,000 patients would need to be screened to prevent one death in 10 years. For patients with a life expectancy under 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit.
(8) Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient goals and expectations.
Unintentional weight loss is a common problem for medically ill or frail elderly. Although high-calorie supplements increase weight in older people, there is no evidence that they affect other important clinical outcomes, such as quality of life, mood, functional status or survival. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events, fluid retention and death. In patients who take megestrol acetate, one in 12 will have an increase in weight and one in 23 will die. The 2012 AGS Beers criteria lists megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide and anabolic steroids, have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression, but there is little evidence to support its use to promote appetite and weight gain in the absence of depression.
(9) Don’t prescribe a medication without conducting a drug regimen review.
Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Polypharmacy may lead to diminished adherence, adverse drug reactions and increased risk of cognitive impairment, falls and functional decline. Medication review identifies high-risk medications, drug interactions and those continued beyond their indication. Additionally, medication review elucidates unnecessary medications and underuse of medications, and may reduce medication burden. Annual review of medications is an indicator for quality prescribing in vulnerable elderly.
(10) Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.
Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Effective alternatives include strategies to prevent and treat delirium, identification and management of conditions causing patient discomfort, environmental modifications to promote orientation and effective sleep-wake cycles, frequent family contact and supportive interaction with staff. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraint-free approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. Physical restraints should only be used as a very last resort and should be discontinued at the earliest possible time.
Ten Things Physicians and Patients Should Question
(1) Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.
Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers.
(2) Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary.
(3) Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better.
There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 1 0 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy.
(4) Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.
Large scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies.
(5) Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.
(6) Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
In randomized controlled trials, some patients with mild-to-moderate and moderate-to-severe Alzheimer’s disease (AD) achieve modest benefits in delaying cognitive and functional decline and decreasing neuropsychiatric symptoms. The impact of cholinesterase inhibitors on institutionalization, quality of life and caregiver burden are less well established. Clinicians, caregivers and patients should discuss cognitive, functional and behavioral goals of treatment prior to beginning a trial of cholinesterase inhibitors. Advance care planning, patient and caregiver education about dementia, diet and exercise and non-pharmacologic approaches to behavioral issues are integral to the care of patients with dementia, and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then consider discontinuing the medication. Benefits beyond a year have not been investigated and the risks and benefits of long-term therapy have not been well-established.
(7) Don’t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.
Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis and treatment of tumors that would not have led to symptoms. For prostate cancer, 1,055 men would need to be screened and 37 would need to be treated to avoid one death in 11 years. For breast and colorectal cancer, 1,000 patients would need to be screened to prevent one death in 10 years. For patients with a life expectancy under 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit.
(8) Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient goals and expectations.
Unintentional weight loss is a common problem for medically ill or frail elderly. Although high-calorie supplements increase weight in older people, there is no evidence that they affect other important clinical outcomes, such as quality of life, mood, functional status or survival. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events, fluid retention and death. In patients who take megestrol acetate, one in 12 will have an increase in weight and one in 23 will die. The 2012 AGS Beers criteria lists megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide and anabolic steroids, have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression, but there is little evidence to support its use to promote appetite and weight gain in the absence of depression.
(9) Don’t prescribe a medication without conducting a drug regimen review.
Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Polypharmacy may lead to diminished adherence, adverse drug reactions and increased risk of cognitive impairment, falls and functional decline. Medication review identifies high-risk medications, drug interactions and those continued beyond their indication. Additionally, medication review elucidates unnecessary medications and underuse of medications, and may reduce medication burden. Annual review of medications is an indicator for quality prescribing in vulnerable elderly.
(10) Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.
Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Effective alternatives include strategies to prevent and treat delirium, identification and management of conditions causing patient discomfort, environmental modifications to promote orientation and effective sleep-wake cycles, frequent family contact and supportive interaction with staff. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraint-free approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. Physical restraints should only be used as a very last resort and should be discontinued at the earliest possible time.
‘Cookbook Medicine’ Won’t Do for Elderly
By Jane E. Brody : NY Times Article : December 30, 2008
The Martha Stewart Center for Living at Mount Sinai Medical Center in New York is like no medical clinic I’ve ever seen. It is brightly lighted and quiet — there is no television blasting. It has wide corridors and plenty of comfortable chairs with sturdy arms, and yet few people wait more than 10 minutes to see a doctor or nurse practitioner.
The center, which opened in 2007, was designed especially for primary care of older adults, many of whom have complex chronic medical problems like diabetes, heart disease and hypertension as well as debilitating conditions like arthritis and osteoporosis.
Just as a child is not a small adult and requires specialized care, adults over the age of, say, 65, are not just old adults and should not be treated like patients half their age.
The population of aging Americans is expected to mushroom in the years ahead. Geriatricians, the experts in elder care, are already in short supply, and their numbers will continue to shrink. But knowing the kind of care that these specialists provide may help older people and those who look after them learn to seek it out wherever they go.
“Cookbook medicine may be appropriate for younger people but is not always appropriate for older people,” Dr. Mark Lachs, a geriatrician at Weill-Cornell Medical Center in New York, said in an interview. He sees two dangers in how older adults are treated: overtreatment and undertreatment.
“If a high-functioning 80- or 90-year-old develops angina, aggressive treatment would be appropriate,” Dr. Lachs said. “Care should not be withheld solely on the basis of age.”
On the other hand, overtesting and overtreating older patients can result in debilitating side effects. Before deciding on tests and treatment, he said, “the doctor must take into account the whole picture of the patient, the patient’s family and life situation.”
Screening for Lifestyle
Dr. R. Sean Morrison is one of the geriatricians at Mount Sinai. “The overall goal is to help older adults achieve the best quality of life possible, given the limits of medical technology and knowledge,” he said.
When I asked how he would approach a new patient of 85, Dr. Morrison said he would start with a series of questions: “Tell me about yourself. What do you like to do? What are the things you would like to do that you cannot do anymore? What is your medical history? What medications do you currently take? What brings you here today?”
The geriatric exam itself would depend on the patient’s answers. “If the patient is a healthy 75-year-old who plays golf and tennis and has no functional limitations,” Dr. Morrison said, “the focus would be on preventive screening and advance care planning.
“But if the patient has functional limitations, the focus would be to restore and improve what can be restored and improved, such as reducing the risk of falls, addressing any acute medical conditions, and streamlining medications for chronic health problems so that the right drugs are taken for the right conditions.”
“You want a doctor who asks more than just about your medical conditions,” he added. The doctor should ask about the effect of medical conditions on quality of life, and then should explore what improvements are possible. “The focus of care should be on quality of life,” he said. “Too often, doctors lose sight of this goal when the focus is on treating specific diseases.”
The doctor should address a patient’s most serious health threats, of course, but also the patient’s most serious concerns. Is the patient troubled by problems like fatigue, pain or shortness of breath, or having problems with medications?
For example, he said, if a patient has serious arthritis and hypertension and cannot go to places without a readily accessible bathroom on the first floor because she takes a diuretic for high blood pressure, perhaps the blood pressure medication should be changed. The patient may prefer a different drug that carries a slightly greater risk of stroke if it means a better quality of life.
The Exam
“When going to a new doctor, an older patient should receive a comprehensive assessment, not just a physical exam,” Dr. Chad Boult, a geriatrician at the Johns Hopkins School of Public Health, said in an interview. “The patient should be asked, What is important to you about your health now? What is your life like — your exercise habits, diet, use of alcohol and tobacco? Is your environment safe and convenient?”
There are three areas that should be explored during a geriatric exam that are often missed if the doctor focuses on a specific illness, Dr. Morrison said:
¶Dementia. He asks the patient: “Are you having trouble with your memory? Is it O.K. if I check with a family member about this?” He said there were often treatable causes for memory problems, like thyroid disease, medication side effects or depression.
¶Risk of falls. Checking balance, gait and strength is easy, he said. “I would meet you in the waiting room, watch how you stand up from a chair and walk to the exam room. I’d throw a pen on the floor and ask you to pick it up. I’d ask you to sit in a chair and stand up three times as quickly as you can. Can you get up and down without using the arms of the chair? If the patient uses a cane, how is it used and is it the right height?”
¶Incontinence. “There’s a tremendous social stigma associated with incontinence even when there are medical reasons for it,” Dr. Morrison said. It is as common as hypertension and diabetes among the elderly, but patients rarely discuss it with their doctors unless asked about it, he said.
Dr. Boult said that patients’ feet were often overlooked, leading to problems that can become life-limiting. Many older people cannot reach their feet to clean them and cut their toenails, and they develop painful sores.
Other Considerations
Dr. Morrison said that before recommending screening tests like mammograms for breast cancer and PSA tests for prostate cancer, the question to ask is, “What are we going to do with the test results? If we’re not going to act on them, screening should be stopped.” If a patient has chronic conditions that limit life expectancy, he said, there is no point in screening for most cancers.
On the other hand, he said, two medical procedures can greatly improve the quality of life for older adults: joint replacement and cataract surgery. Too often, patients think such surgeries aren’t worth the bother because they won’t be around much longer. He described a woman who at 82 was having trouble walking but chose not to have a knee replacement. Now 102, the patient told him, “I should have listened to you years ago.”
Like this woman at 82, many older people are quite healthy, Dr. Boult said.
But about one-quarter of the older population has multiple chronic conditions and spends 80 percent of Medicare dollars, he added. “These patients need coordinated care, a system of regular monitoring, and regular access to a primary care doctor who can detect problems early before they require expensive, dramatic treatments.”
When the time has come to move older relatives from their homes and into a more supportive environment
Paula Spencer Scott, senior editor at Caring.com, recently compiled a guide to help families determine when the time has come to move older relatives from their homes and into a more supportive environment or, alternatively, to bring in a home health aide who can provide assistance. These signs to look for and questions to ask are adapted from Ms. Scott's recommendations.
¶ Recent accidents or close calls, like a fall, medical scare or minor car accident.
¶ A slow recovery. How well was a recent illness weathered? Did it develop into something serious? Was medical help sought when needed?
¶ Worsening of a chronic health condition. As problems like chronic obstructive pulmonary disease, dementia or congestive heart failure progress, more help will be needed.
¶ Greater difficulty managing the so-called activities of daily living, like dressing, bathing and cooking.
¶ Bodily changes, like obvious weight loss or gain, increased frailty or unpleasant body odor.
¶ A loss of active friendships, including outings with friends, visits with neighbors or participation in religious or other group activities.
¶ Days spent without leaving the house, perhaps because of difficulty driving or a fear of using public transportation.
¶ Is someone checking in regularly? If not, is there a home-safety alarm system, a personal alarm system or a daily calling service in place?
¶ Is someone nearby to assist if there's a fire, earthquake, flood or other disaster, and does the older resident understand plans for a catastrophe?
¶ Mail in a chaotic state, scattered about and unopened. Are there unpaid overdue bills, surprising thank-you notes from charities, piles of unread magazines?
¶ If an older relative is still driving, go along for a ride and look for failure to fasten the seat belt or heed dashboard warning lights; signs of tension, preoccupation or distraction while driving; damage to the vehicle that may indicate carelessness.
¶ In the kitchen, signs of excess or forgetfulness, like perishables well past their expiration dates.
¶ Favorite appliances are broken but not scheduled for repair.
¶ Signs of fires. Look for charred stove knobs or pot bottoms, potholders with burned edges, a discharged fire extinguisher. Do smoke and carbon monoxide detectors have live batteries?
¶ A once-neat home now cluttered, spills that were not cleaned up, grime coating bathroom and kitchen appliances or an overflowing laundry basket.
¶ Neglected plants or pets.
¶ Signs of neglect outside the home, like broken windows, debris-filled gutters and drains, uncollected rubbish and an overstuffed mailbox.
¶ Ask friends and neighbors whether your family member's behavior has changed lately.
¶ Ask the person's doctor whether you should be concerned about the person's health or safety and whether a home assessment by a social worker or geriatric care manager may be advisable. If you expect resistance from the person, ask the doctor to "prescribe" a professional evaluation.
¶ If you are the primary caregiver, how are you doing? Are you increasingly exhausted, depressed or becoming resentful of the sacrifices you have to make to care for the person?
¶ Consider your older relative's emotional state. If she is riddled with anxieties or increasingly lonely, then it may be time to make a move for reasons other than health and safety.
Why Hire a Geriatric Care Manager?
By Jane Gross : NY Times Article : October 6, 2008
During one especially dicey period with my mother, then in an assisted living facility, my brother and I hired a geriatric care manager, first for a consultation and then for additional help at an hourly rate. It felt like such an extravagance, given that we weren't rolling in money, but the care manager helped solve a series of complex problems that I doubt I'd have solved by myself, mostly involving brokering a compromise with the facility, whose management wouldn't let me hire a private aide for my mom but could not provide what she needed.
Relations had soured to the point that all I could do was scream at them, which was making a bad situation worse, so having an advocate was a blessing. Also, the care manager, who visited regularly with my mother, often was privy to concerns she was keeping from me, and she was always there for me by telephone, which was a lifesaver.
Many of you have asked questions about geriatric care management and how it is performed. I posed some of them to Patricia Mulvey, a care manager who has worked in hospitals, nursing homes, home-care agencies, hospice and bereavement programs, and as an independent contractor. Currently she is the director of the private geriatric care management service at the Jewish Home Lifecare System, which runs several long-term care facilities in New York City and its suburbs. With some modest editing, here are her thoughts.
Would you explain what geriatric care managers do, how they are trained and certified, how much they cost, and how consumers can make wise decisions if they decide to hire one?
A professional geriatric care manager has been educated in various fields of human services — social work, psychology, nursing, gerontology — and trained to assess, plan, coordinate, monitor and provide services for the elderly and their families. Advocacy for older adults is a primary function of the care manager. We belong to the National Association of Professional Geriatric Care Managers and are certified by one of the three certification organizations for care management — the National Association of Social Workers, the National Academy of Certified Care Managers, or the Commission for Case Managers.
Our rates vary by region and firm. Some firms charge an initial assessment fee; others bill by the hour only. In New York, an initial assessment is in the range of $250 to $750 for a one-and-a-half-hour assessment visit. Hourly charges run from $150 to $200. Some firms also require a retainer to cover the last month's bill.
To be a savvy consumer, check the credentials of the care manager you are considering hiring to be sure they are a member of the National Association of Professional Geriatric Care Managers, as well as a member in good standing of their basic professional organization — say, the National Association of Social Workers. They also should be certified by one of the certification boards. You should check references and interview candidates.
An important part of working with the client and their families is chemistry. Be sure you get along with and like the individual you are considering hiring. They should be available 24 hours a day, seven days a week, and you should have access to their cell phone number or answering service. You should also be aware of other members of their team — nurses they may work with or their support staff — in case you have a question and can't wait for the care manager to return your call.
What circumstances are most suitable and valuable for using a geriatric care manager? To put it another way, if you were in a caregiving situation and had limited means, when would this extra expense be money well spent?
An example is when things are going well — the elder is managing on his or her own, with little help and oversight, but the family is noticing slight changes, or the physician has indicated a change in status or diagnosis. This would be the time where it would be very beneficial for the family to know what resources are available to them, how much they would cost, how to access these resources and what options are available. Some of the key points to cover would be these.
- What is day care? What types of rehab might be available? What does "short-term rehab" mean?
- What is "respite" and where might it be available? Who pays for it?
- Information about home care services. What kind of care and how much care can be provided at home?
- Who pays for what services? This is key because a common misconception is that Medicare pays for long-term care.
- What is the difference between Medicare and Medicaid?
- What does insurance, either medical or long-term care, actually pay for?
- What happens at the end of a hospitalization when discharge is imminent? Time is of the essence, because it is often Medicare or the insurance company's determination as to how quickly things related to discharge must happen.
- Is the health care proxy in place, appropriately witnessed and current? Is there a power of attorney? Does your state recognize other documents, such as a living will?
- Has the conversation about the wishes stated in the health care proxy been discussed with the individual who has been nominated proxy? Does the physician have a copy of the document?
- With a long-term care insurance policy, what is required for the policy to begin coverage?
- What resources are available to pay for services? How much can the family afford? And who is going to pay for what?
I'd imagine that long-distance caregiving and trying to keep someone in their own home with reliable help would be the two hardest things to navigate without professional assistance. Can you tell us some of the special challenges of having an elderly parent in Florida, or Chicago, or any place where you can't go scope out the situation regularly and thus need eyes and ears on the ground?
As for home care, I know from friends how arduous it is to manage a staff of people working in a parent's home. They quit. Or you have to fire them. They compete with one another for who's top dog. The client, who is so dependent, becomes almost an emotional hostage, needing the aide so badly they may be afraid to complain or offend.
How does a care manager guide families through this?
It is imperative to have eyes and ears available locally. This is not a process that can be managed long-distance, even as in-touch as we are with cell phones, text messaging and video conferences. We always work with another care manager in the other location to have an independent individual assess the facility and situation. I've frequently moved parents from the tri-state area to California, Florida or Arizona to be closer to their children, and moved the parents to the New York area from those very same states. Moving is one of the most stressful life events we can experience, and this applies at any age. The client needs as much support as possible, someone to help them pack, stop the newspaper, disconnect the cable, and much more.
Anyone with help in the home most definitely would benefit from help coordinating the aides and other staff going in and out of the home. Adding home care to the services delivered to an elder can be very traumatic — it's saying that "you can't take care of yourself anymore." How would you feel if someone you didn't know turned up one day and moved into your spare room, cooked meals in your kitchen, sat with you when you were watching TV or reading? It's a huge transition for people to incorporate help into the home.
A care manager can closely monitor the situation, soothe over the hurt feelings and address the anger that comes from losing our independence. And yes, you are right, the elder may become an emotional hostage, afraid to say something for fear of retribution or recrimination. It's best to let a professional address issues the elder is concerned with.
10 Things to Know About Assisted Living
By Jane Gross : NY Times Article : October 20, 2008
Dr. Cheryl Woodson, you may recall from last week’s post, is a seasoned geriatrician in Chicago Heights, Ill., who has found that she can no longer afford to accept new Medicare patients.
She is also a blunt and funny woman who liberally dispenses wisdom to her elderly patients and their adult children, and herself a daughter who cared for her own mother with Alzheimer’s disease for a decade. Here’s some of Dr. Woodson’s advice on navigating the caregiving maze, which I culled both from her book, “How to Survive Caregiving,” and from observing her during a recent day-long visit to her office.
1. Assisted living, a popular solution for elderly people who cannot live independently, is a “myth,” Dr. Woodson said, “a place for people who don’t exist.” Families often believe these facilities will meet all of their loved ones’ needs, enabling caregivers to focus on jobs and family, only to find this isn’t the case. Before long, the elderly resident will require more than “meals you don’t have to cook, grass you don’t have to cut and socialization,” Dr. Woodson said. At that point the elderly resident is in trouble, since assisted living facilities are not permitted by law to provide medical care and consider it to be the family’s responsibility.
2. Squaring a family’s expectations with those legal limits would require a thorough, first-hand assessment of the elderly person’s physical and cognitive health before admission to an assisted living facility. That rarely happens. New residents are admitted based on a report from their current physicians, who may not be qualified to diagnose the early signs of dementia and impending immobility or may sugarcoat the situation in order to help a desperate family. “They just need a little help,” the usual rationale for accepting elderly prospects into assisted living, is ridiculous on its face, Dr. Woodson said. “If they just needed a little help, they’d still be in the community.”
3. Instead, without verifying the physician’s report or the family’s representations, these facilities may admit residents who already need help with simple tasks like dressing or eating, or will in the very near future, and then charge extra for these services. Some do this to fill empty beds; others give residency a shot as a kindness to desperate families, Dr. Woodson said. But when the resident declines, as all of them will unless they die suddenly, more and more a la carte services mean a bigger and bigger monthly bill, or more and more work for family members who expected the opposite.
4. Coordinating all the services that the assisted living facility doesn’t provide generally falls to one sibling, Dr. Woodson noted, who then becomes overwhelmed, sacrificing more than should be expected. The solution is hiring a geriatric care manager — “They should be called rent-a-daughters,” Dr. Woodson said — adding further to the expense, until the resident and family can no longer afford this kind of accommodation and are forced to consider a nursing home.
5. Most families balk at the prospect of transferring an aging parent to a nursing home because they like the aesthetics of assisted living — the carpeted floors, overstuffed chairs and crystal chandeliers. But without round-the-clock care, many residents are “as alone at night as if they were in their own homes,” Dr. Woodson said. Other families are unwilling to break a promise to Mom or Dad never to put them in a nursing home. The spirit of that promise — to give a parent the best possible care — is what matters, Dr. Woodson said, “and sometimes that means not doing it yourself.” An aging parent’s condition may eventually require three shifts of nurses and aides, not a family member trying to take care of everything 24/7.
6. The doctors who see residents at assisted living facilities are essentially freelancers, not employees, since their fees are paid by Medicare and they also may maintain private practices. So rather than hang around the facility expecting them to answer your questions on the fly, Dr. Woodson suggested calling and arranging to see them “by appointment, not by ambush.” This consultation will not be covered by Medicare unless it coincides with a medical procedure for the resident. Still, it is essential in order to stay on top of an elderly person’s medications, some of which may be unnecessary and even dangerous, and to make decisions about which medical care improves the quality of life and which is pointless and wasteful.
7. If a parent lives in an assisted living facility, families should closely monitor the monthly pharmacy bill, less for cost than for content. Is Xanax being prescribed for anxiety? There are numerous other remedies available without the potentially dangerous side effects. What about muscle relaxants for arthritic pain? They increase confusion in the elderly and add to the risk of falls; instead, ask for pain medication and/or a heating pad. If the assisted living facility offers to have prescriptions filled and delivered by a local pharmacy — a huge convenience for family members — be sure it’s a pharmacy that insists upon periodic blood work or other tests for drugs that are supposed to be closely monitored.
8. The goal of medical care for the elderly, in Dr. Woodson’s view and the view of every geriatrician I’ve ever interviewed, is to make day-to-day life more comfortable, not to cure illness or extend longevity. Examples? A joint replacement to relieve pain and improve mobility makes sense only if the patient has the cognitive ability to complete physical therapy. Otherwise, he or she will never walk again and would be better off avoiding surgery and simply being kept comfortable. Similarly, anyone who would refuse cancer treatment because of advanced age probably doesn’t need a mammogram, Pap smear or colonoscopy. “Why draw a map to someplace we know we’re not going?” Dr. Woodson asked.
9. Apply similar standards to immunizations and vaccinations. If someone is so ill or disabled that death would be welcome, refuse the vaccine for pneumonia, long known as “the old person’s friend.” But never say no to the shingles vaccine, which can prevent an excruciating rash. “Even if someone was only going to live five more minutes, that’s the one thing I’d suggest,” Dr. Woodson says. “It’s a quality-of-life issue.”
10. Do not assume that the presenting symptom of Alzheimer’s disease will be forgetting words, losing things or other obvious examples of short-term memory loss. Often the first thing a family member will notice is an empty checking account, Dr. Woodson said, because a normally cautious and frugal person has been tricked by a get-rich-quick scheme or other scam. And like missing money, look out for pills missing from those seven-day dispensers that help people with multiple medications keep track of what they’re taking and when. Family members may find the dispensers empty and worry about overdose, Dr. Woodson noted, but often the missing pills will turn up under couch cushions or scattered elsewhere around the house. Take this as a cue that it may be time for a cognitive assessment.
In 'Sweetie' and 'Dear,' a Hurt for the Elderly
By John Leland : NY Times Article : October 7, 2008
Professionals call it elderspeak, the sweetly belittling form of address that has always rankled older people: the doctor who talks to their child rather than to them about their health; the store clerk who assumes that an older person does not know how to work a computer, or needs to be addressed slowly or in a loud voice. Then there are those who address any elderly person as "dear."
"People think they're being nice," said Elvira Nagle, 83, of Dublin, Calif., "but when I hear it, it raises my hackles."
Now studies are finding that the insults can have health consequences, especially if people mutely accept the attitudes behind them, said Becca Levy, an associate professor of epidemiology and psychology at Yale University, who studies the health effects of such messages on elderly people.
"Those little insults can lead to more negative images of aging," Dr. Levy said. "And those who have more negative images of aging have worse functional health over time, including lower rates of survival."
In a long-term survey of 660 people over age 50 in a small Ohio town, published in 2002, Dr. Levy and her fellow researchers found that those who had positive perceptions of aging lived an average of 7.5 years longer, a bigger increase than that associated with exercising or not smoking. The findings held up even when the researchers controlled for differences in the participants' health conditions.
In her forthcoming study, Dr. Levy found that older people exposed to negative images of aging, including words like "forgetful," "feeble" and "shaky," performed significantly worse on memory and balance tests; in previous experiments, they also showed higher levels of stress.
Despite such research, the worst offenders are often health care workers, said Kristine Williams, a nurse gerontologist and associate professor at the University of Kansas School of Nursing.
To study the effects of elderspeak on people with mild to moderate dementia, Dr. Williams and a team of researchers videotaped interactions in a nursing home between 20 residents and staff members. They found that when nurses used phrases like "good girl" or "How are we feeling?" patients were more aggressive and less cooperative or receptive to care. If addressed as infants, some showed their irritation by grimacing, screaming or refusing to do what staff members asked of them.
The researchers, who will publish their findings in The American Journal of Alzheimer's Disease and Other Dementias, concluded that elderspeak sent a message that the patient was incompetent and "begins a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal and the assumption of dependent behaviors."
Dr. Williams said health care workers often thought that using words like "dear" or "sweetie" conveyed that they cared and made them easier to understand. "But they don't realize the implications," she said, "that it's also giving messages to older adults that they're incompetent."
"The main task for a person with Alzheimer's is to maintain a sense of self or personhood," Dr. Williams said. "If you know you're losing your cognitive abilities and trying to maintain your personhood, and someone talks to you like a baby, it's upsetting to you."
She added that patients who reacted aggressively against elderspeak might receive less care.
For people without cognitive problems, elderspeak can sometimes make them livid. When Sarah Plummer's pharmacy changed her monthly prescription for cancer drugs from a vial to a contraption she could not open, she said, the pharmacist explained that the packaging was intended to help her remember her daily dose.
"I exploded," Ms. Plummer wrote to a New York Times blog, The New Old Age, which asked readers about how they were treated in their daily life.
"Who says I don't take my medicine as prescribed?" wrote Ms. Plummer, 61, who lives in Champaign, Ill. "I am alive right now because I take these pills! What am I supposed to do? Hold it with vice grips and cut it with a hack saw?'"
She added, "I believed my dignity and integrity were being assaulted."
Health care workers are often not trained to avoid elderspeak, said Vicki Rosebrook, the executive director of the Macklin Intergenerational Institute in Findlay, Ohio, a combined facility for elderly people and children that is part of a retirement community.
Dr. Rosebrook said that even in her facility, "we have 300 elders who are 'sweetie'd' here. Our kids talk to elders with more respect than some of our professional care providers."
She said she considered elderspeak a form of bullying. "It's talking down to them," she said. "We do it to children so well. And it's natural for the sandwich generation, since they address children that way."
Not all older people object to being called sweetie or dear, and some, like Jan Rowell, 61, of West Linn, Ore., say they appreciate the underlying warmth. "We're all reaching across the chasm," Ms. Rowell said. "If someone calls us sweetie or honey, it's not diminishing us; it's just their way to connect, in a positive way."
She added, "What would reinforce negative stereotypes is the idea that old people are filled with pet peeves, taking offense at innocent attempts to be friendly."
But Ellen Kirschman, 68, a police psychologist in Northern California, said she objected to people calling her "young lady," which she called "mocking and disingenuous." She added: "As I get older, I don't want to be recognized for my age. I want to be recognized for my accomplishments, for my wisdom."
To avoid stereotyping, Ms. Kirschman said, she often sprinkles her conversation with profanities when she is among people who do not know her. "That makes them think, This is someone to be reckoned with," she said. "A little sharpness seems to help."
Bea Howard, 77, a retired teacher in Berkeley, Calif., said she objected less to the ways people addressed her than to their ignoring her altogether. At recent meals with a younger friend, Ms. Howard said, the restaurant's staff spoke only to the friend.
"They ask my friend, 'How are you; how are you feeling?' just turning on the charm to my partner," Ms. Howard said. "Then they ask for my order. I say: 'I feel you're ignoring me; I'm at this table, too.' And they immediately deny it. They say, no, not at all. And they may not even know they're doing it."
Dr. Levy of Yale said that even among professionals, there appeared to be little movement to reduce elderspeak. Words like "dear," she said, have a life of their own. "It's harder to change," Dr. Levy said, "because people spend so much of their lives observing it without having a stake in it, not realizing it's belittling to call someone that."
In the meantime, people who are offended might do well to follow the advice of Warren Cassell of Portland, Ore., who said it irritated him when "teenage store clerks and about 95 percent of the rest of society" called him by his first name. "It's the faux familiarity," said Mr. Cassell, 78.
But he mostly shrugs it off, he said. "I'm irked by it, but I can't think about it that much," he said. "There are too many more important things to think about."
Query for Aging Patients: How Much Do You Drink?
By Jane Brody : NY Times Article : December 16, 2008
Is alcohol a tonic or a toxin? The question is especially critical to older people, whose overall medical picture gives alcohol the potential to be a health benefit or a life-shortening hazard.
Yet experts say that doctors rarely ask older patients how much and how often they drink. Not knowing the answers to these questions can result in misdiagnosis, medical complications and life-threatening accidents. Doctors may also fail to recognize the symptoms of alcohol abuse, a problem that is expected to become increasingly common as baby boomers, who have been found to drink more than previous generations, reach age 65 and beyond.
At the same time, older people who are in good health should know that moderate drinking under the right conditions may improve their health in several important ways. In a comprehensive review in the October issue of The Journal of the American Dietetic Association, Maria Pontes Ferreira and M. K. Suzy Weems described the myriad health benefits and risks of alcohol consumption by aging adults.
In summarizing the findings in an interview, Dr. Ferreira, a registered dietitian, said that “although there are a lot of benefits from moderate alcohol consumption, you can’t make a blanket statement; you have to look at the big picture.”
“Moderate alcohol consumption can improve appetite and nutrition and reduce the risk of several important diseases, including cardiovascular diseases and diabetes,” said Dr. Ferreira, a postdoctoral fellow at Haskell Indian Nations University in Lawrence, Kan. “But a lot of folks over 50 are already dealing with diseases associated with aging and medication use that can result in possible complications and drug interactions. And older people who abuse alcohol are consuming an inordinate amount of calories that can displace important nutrients.”
Furthermore, Dr. Frederick C. Blow, professor of psychiatry at the University of Michigan Medical School and an expert on alcohol and aging, pointed out in an interview that “even at lower levels of consumption, alcohol can be problematic for older people.”
“Because of an increased sensitivity to alcohol and decreased tolerance as one ages, lower amounts of alcohol can have a bigger effect,” he said. “Older people get into trouble with doses of alcohol that wouldn’t be a problem with a younger person.”
Madeline A. Naegle, professor at the New York College of Nursing, fears that publicity about the benefits of alcohol has dangerously tipped the scales, prompting some people to think that “if one drink is good, two or three must be better.”
“Recommendations about drinking must be qualified by the level of a person’s health,” she emphasized in an interview.
In an article on screening for alcohol use and abuse among older adults in the November issue of The American Journal of Nursing, she noted: “Often clinicians fail to ask, ‘Do you drink alcohol?’ when obtaining medical histories and performing routine examinations. Because alcohol consumption is such a common practice, questions about drinking are necessarily part of a general health assessment.”
The Benefits
Evidence for the benefits of moderate alcohol consumption comes almost entirely from epidemiological, or population, studies that can reveal important associations but cannot prove cause and effect. There have been few randomized controlled clinical trials of alcohol use to definitively show that alcohol consumed in any amount by any group of people benefits health.
That said, here is what the studies indicate. It’s important to note that most findings refer to moderate consumption, defined as one alcoholic drink a day for women and up to two for men. Also, the benefits are confined to people who do not have ailments, like chronic liver disease, or take medications, like psychoactive drugs, that would render any amount of alcohol risky.
Heart disease and mortality.
While many studies have emphasized the benefits of red wine to cardiovascular health and longevity, more than 100 studies in 25 countries have linked these benefits to moderate consumption of any type of alcoholic beverage. On average, moderate drinkers 50 and older are less likely to suffer heart attacks and die prematurely than abstainers and heavy drinkers.
Diabetes.
Though it may seem counterintuitive, a controlled clinical trial of nondiabetic older women found that insulin sensitivity was improved among those who consumed two drinks a day.
In studies of men with diabetes, drinking up to two drinks a day was associated with lower levels of factors linked to an increased risk of heart disease, like markers of inflammation and arterial dysfunction.
Dementia.
Although excessive alcohol drinking can raise the risk of dementia in older people, “there are emerging data to suggest that moderate alcohol intake — one to three drinks a day — is associated with a reduced risk of developing Alzheimer’s disease and vascular dementia,” Dr. Ferreira and Dr. Weems wrote. In this case, they added, drinking wine confers the primary benefit; drinking beer, on the other hand, appears to raise the risk of dementia.
Osteoporosis.
Several studies have suggested that elderly women who drink moderately tend to have better bone density. But chronic heavy drinking “can dramatically compromise bone quality and may increase osteoporosis risk,” H. Wayne Sampson of Texas A & M University Health Science Center in College Station has reported for the National Institute on Alcohol Abuse and Alcoholism. Furthermore, skeletal damage from excessive drinking is not reversible.
Psychosocial effects.
Although there is relatively little research on the effects of moderate alcohol consumption on mental and social well-being among the elderly, studies in retirement communities have noted an improvement in social interactions, health-related quality of life and survival.
Nutritional benefits.
Again, there is not a lot of research, but studies so far indicate that an alcoholic drink taken with meals can improve appetite and the consumption of calories and nutrients needed by many elderly people, Dr. Ferreira said.
The Risks
Immoderate consumption of alcohol — more than three drinks a day — can be hazardous for people of all ages, but it is especially so for the elderly, who reach higher levels of blood alcohol faster and maintain them longer than younger people.
Yet, Dr. Blow said, “we don’t do well identifying older people who are getting into trouble with alcohol.”
Potential hazards include an increased risk of falls and vehicular accidents, a decline in short-term memory, a worsening of existing health problems and interactions with medications that may diminish the effectiveness of some drugs and increase the toxic effects of others.
Dr. Ferreira called alcohol abuse and alcoholism in aging adults “a silent epidemic.” Dr. Naegle wrote that “many older people pursue drinking patterns established earlier in life and may not realize that continuing to drink the same amount of alcohol as they did when they were younger may place them at risk for health problems.”
She recommended using diet and exercise to reduce cardiac risk; trying alternative relaxation methods like meditation, yoga and exercise; and, for those who drink, cutting down on the amount of alcohol consumed by mixing it with water, taking an hour to finish one drink and alternating alcohol with nonalcoholic drinks.
Dr. Blow and Dr. Naegle urged health professionals who treat the elderly to administer the “Short Michigan Alcoholism Screening Test — Geriatric Version” as part of routine checkups. This test, which also can be self-administered, has proved highly accurate in identifying older people with alcohol-related problems. A “yes” answer to two or more questions suggests an alcohol problem, Dr. Blow has reported.
- When talking with others, do you ever underestimate how much you drink?
- After a few drinks, have you sometimes not eaten or skipped a meal because you didn’t feel hungry?
- Does having a few drinks help decrease your shakiness or tremors?
- Does alcohol sometimes make it hard for you to remember parts of the day or night?
- Do you usually take a drink to relax or calm your nerves?
- Do you drink to take your mind off your problems?
- Have you ever increased your drinking after experiencing a loss in your life?
- Has a doctor or nurse ever expressed concern about your drinking?
- Have you ever made rules to manage your drinking?
- When you feel lonely, does having a drink help?
No Single Path for Cancer Care in Elderly
By Jane E. Brody : NY Times Article : March 17, 2009
Elliot was 83 when a routine checkup that included a digital rectal exam suggested prostate cancer. A biopsy then revealed that he had an aggressive form of the disease. His doctor recommended treatment despite Elliot’s age and several existing problems, including mild cases of high blood pressure, Type 2 diabetes, depression and angina, all of which were being treated with medication.
Elliot also has leg pain that limits his walking. But none of his health problems interferes with his weekly bridge game or nights out for the theater, concerts and dining. When cancer popped into the equation, Elliot, a man with a self-deprecating sense of humor always at the ready, said he was just not inclined to let it end his life.
So when the doctor suggested hormone and radiation therapy, five days a week for nine weeks, Elliot did not hesitate. Except for some radiation-induced fatigue that he noticed only after therapy was over, he sailed through the treatment. Three months after finishing his therapy, his P.S.A., a blood test for possible cancer, registered zero, suggesting that the malignancy was destroyed.
The outcome for Elliot is a direct assault on the oft-given advice that most cancers affecting people his age be left to take their course. The theory is that either the treatment will kill them or destroy their quality of life, or some other health problem will kill them before the cancer does.
But there is a great paucity of factual information to support either a wait-and-watch approach or an aggressive approach to treating cancer in the elderly.
Although about 60 percent of newly diagnosed cancers occur in people 65 and older, there is little research to help doctors and patients decide how, when and even whether to treat the many forms of cancer that afflict older people, especially those with other ailments that can complicate therapy.
Limited Research
For a variety of reasons, older cancer patients are rarely included in clinical trials that test new therapies, so relatively little is known about potential responses to treatment under various circumstances.
Research protocols commonly eliminate people with chronic health problems, in case the therapy makes those problems worse or the medications patients are taking interact poorly with the treatment being studied. Another deterrent is limited longevity in the elderly, making it difficult to determine the long-term effectiveness of a treatment.
Patients themselves can be a problem, if they fear “being experimented upon,” if they are not physically able to get to treatment facilities, or if the research protocols are too difficult for them to understand and follow.
Despite the limited research, one fact is clear: there is no “one size fits all” treatment for cancer in the elderly. Whether the patient is 60, 80 or 100, a host of factors — medical, practical and emotional — must be taken into account when devising a therapeutic plan. To the distress of some families, decisions are too often based more on a patient’s chronological than physiological age.
“The doctor may be dealing with two 65-year-old patients with the same disease,” Dr. Jerome W. Yates, national vice president for research at the American Cancer Society, said in an interview. “Yet one is like a 55-year-old, healthy, strong and resilient, and the other is more like an 85-year-old, frail and chronically ill. Each should be treated differently.”
Treatment decisions should be influenced by patients’ physical and mental health, of course, but also by their financial status, living situations, family support systems and ability to get to and from the treatment facility, Dr. Yates said.
Don’t Forget the Patient
Still another consideration, Dr. Yates said, and not a small one, is what the patient wants. He described a former patient, a 78-year-old woman with diabetes who had lost a leg to osteogenic sarcoma. The cancer had spread to her lungs, and she faced possible treatment with chemotherapy that would cause nausea and hair loss and carried the risk of a fatal lung infection. Her four college-educated children agreed with the doctor’s suggestion to skip chemotherapy and administer comfort care, since treating her cancer was likely to kill her.
“But she said she wanted to be treated — she was adamant,” recalled Dr. Yates, who will be leaving the cancer society for the National Institute on Aging. “To my surprise, she had a dramatic response to the treatment. Her lung tumors all but disappeared, and she lived another two years.”
Barbara and Charles Given, family care cancer specialists at Michigan State University, told a national conference on cancer and aging in 2007 that older patients, “when they are selected carefully, appear to tolerate and respond well to cancer treatments.”
They added that older patients who have had surgery for lung cancer or have been treated for cancers of the colon, rectum, breast or prostate, or non-Hodgkin’s lymphoma, “all have tolerated and shown positive responses to their treatments.” And those with a life expectancy of more than five years have also benefited from additional therapies, like postoperative radiation or chemotherapy, they reported.
Still, out of fear that the side effects of cancer treatment will hasten an older patient’s death or destroy the quality of the remaining years of life, doctors often undertreat the elderly, indirectly hastening their death with less-than-optimal therapy.
In other cases, elderly cancer patients are overtreated despite the likelihood of life-threatening complications, because doctors fear being accused of giving up or are pressured by family members to provide therapy that is medically inappropriate.
Full Disclosure
One of the greatest challenges clinicians face with elderly cancer patients is incomplete information about their health.
“There is often a lack of documentation about pre-existing problems,” Dr. Yates said. “A patient may suffer from chronic alcoholism or a psychiatric condition that would interfere with cancer treatment, yet such problems are often not disclosed. Or, if an older person has five or six medical conditions, it’s not unusual for them to mention only the most prominent condition, the one that bothers them most at the moment.”
Patients should be prepared to give their full medical history, and caregivers and family members should help fill in the blanks if necessary. In addition, Dr. Yates suggested that treatment decisions for the elderly be family decisions, since older patients must often depend on their children to make therapy happen.
But he also warned that family members should not insist on aggressive treatment that the doctor considers futile. If the family has good reason to doubt the doctor’s judgment, an independent second opinion should be sought, he said.
There are nonthreatening ways to expand the conversation about treatment options, Dr. Yates said, starting with a couple of perfectly reasonable questions for the doctor: “Is this the best option? If this were your mother or father, what would be your recommendation?”
Ask an Elder Law Attorney
By Paula Spahn and Craig Reaves
NY Times Article : February 5, 2010
Craig Reaves, immediate past president of the National Academy of Elder Law Attorneys, will field legal questions from readers on occasion. You may submit yours to [email protected]. Please limit your inquiries to general legal issues, as Mr. Reaves cannot offer personal legal advice.
We’ll start with a question that arises frequently.
Q. If a parent “spends down” to qualify for Medicaid, which will pay for nursing home care, can he or she still own a house?
A. The short answer is yes, Mom can keep her house and be on Medicaid. A house is an “exempt resource.”
But there are caveats. Most states set a $500,000 cap on the equity in her home. In a few (including California, Connecticut and New Mexico), it’s a $750,000 cap. She won’t qualify for Medicaid if her equity exceeds that, so she may need to borrow against the house to reduce her equity or to sell it.
A second caveat: The house may not be worth keeping anyway, unless a spouse, a child under 21 or a disabled child lives there. If parent is in a nursing home on Medicaid, all her income goes to the nursing home except for a very small monthly “personal needs allowance.” There won’t be enough money to cover real estate taxes, utilities and upkeep on the house.
And when the parent dies, the state will want to be repaid for its Medicaid outlays — this is called “estate recovery” — and will go after the house. Unless the parent doesn’t live very long, leaving only a small amount to repay to Medicaid, there’s no real incentive for the family to hold onto the house.
If there is a spouse or a child who is under 21 or disabled living in the house, however, then the occupant can use his own income to maintain the house. When the parent in the nursing home dies, the state can’t pursue the value of the house for “estate recovery.” In such a case, the $500,000 equity cap doesn’t apply.
Because state laws and individual situations vary, consult a local elder law attorney for more detailed advice.
By Paula Spahn and Craig Reaves
NY Times Article : February 5, 2010
Craig Reaves, immediate past president of the National Academy of Elder Law Attorneys, will field legal questions from readers on occasion. You may submit yours to [email protected]. Please limit your inquiries to general legal issues, as Mr. Reaves cannot offer personal legal advice.
We’ll start with a question that arises frequently.
Q. If a parent “spends down” to qualify for Medicaid, which will pay for nursing home care, can he or she still own a house?
A. The short answer is yes, Mom can keep her house and be on Medicaid. A house is an “exempt resource.”
But there are caveats. Most states set a $500,000 cap on the equity in her home. In a few (including California, Connecticut and New Mexico), it’s a $750,000 cap. She won’t qualify for Medicaid if her equity exceeds that, so she may need to borrow against the house to reduce her equity or to sell it.
A second caveat: The house may not be worth keeping anyway, unless a spouse, a child under 21 or a disabled child lives there. If parent is in a nursing home on Medicaid, all her income goes to the nursing home except for a very small monthly “personal needs allowance.” There won’t be enough money to cover real estate taxes, utilities and upkeep on the house.
And when the parent dies, the state will want to be repaid for its Medicaid outlays — this is called “estate recovery” — and will go after the house. Unless the parent doesn’t live very long, leaving only a small amount to repay to Medicaid, there’s no real incentive for the family to hold onto the house.
If there is a spouse or a child who is under 21 or disabled living in the house, however, then the occupant can use his own income to maintain the house. When the parent in the nursing home dies, the state can’t pursue the value of the house for “estate recovery.” In such a case, the $500,000 equity cap doesn’t apply.
Because state laws and individual situations vary, consult a local elder law attorney for more detailed advice.
The value of exercise
Even More Reasons to Get a Move On
By Jane E. Brody : NY Times Article : March 2, 2010
“I’m 86 and have walked every day of my life. The public needs to wake up and move.”
“I’m 83 going on 84 years! I find that daily aerobics and walking are fine. But these regimens neglect the rest of the body, and I find the older you get the more attention they need.”
These are two of many comments from readers of my Jan. 12 column on the secrets of successful aging. At the risk of sounding like a broken record, a new series of studies prompts me to again review the myriad benefits to body, mind and longevity of regular physical activity for people of all ages.
Regular exercise is the only well-established fountain of youth, and it’s free. What, I’d like to know, will persuade the majority of Americans who remain sedentary to get off their duffs and give their bodies the workout they deserve? My hope is that every new testimonial to the value of exercise will win a few more converts until everyone is doing it.
In a commentary on the new studies, published Jan. 25 in The Archives of Internal Medicine, two geriatricians, Dr. Marco Pahor of the University of Florida and Dr. Jeff Williamson of Winston-Salem, N.C., pointed to “the power of higher levels of physical activity to aid in the prevention of late-life disability owing to either cognitive impairment or physical impairment, separately or together.”
“Physical inactivity,” they wrote, “is one of the strongest predictors of unsuccessful aging for older adults and is perhaps the root cause of many unnecessary and premature admissions to long-term care.”
They noted that it had long been “well established that higher quantities of physical activity have beneficial effects on numerous age-related conditions such as osteoarthritis, falls and hip fracture, cardiovascular disease, respiratory diseases, cancer, diabetes mellitus, osteoporosis, low fitness and obesity, and decreased functional capacity.”
One of the new studies adds mental deterioration, with exercise producing “a significantly reduced risk of cognitive impairment after two years for participants with moderate or high physical activity” who were older than 55 when the study began.
Most early studies demonstrating the benefits of exercise were done with men. Now a raft of recent studies has shown that active women reap comparable rewards.
Research-Based Evidence
Sedentary skeptics are fond of saying that of course exercise is associated with good health as one ages; the people who exercise are healthy to begin with. But studies in which some participants are randomly assigned to a physical activity program and others to a placebo (like simply being advised to exercise) call their bluff. Even less exacting observational studies, like the Nurses’ Health Study, take into account the well-being of participants at enrollment.
Thus, in one of the new studies, Dr. Qi Sun of Harvard School of Public Health and co-authors reported that among the 13,535 nurses who were healthy when they joined the study in 1986, those who reported higher levels of activity in midlife were far more likely to still be healthy a decade or more later at age 70. The study found that physical activity increased the nurses’ chances of remaining healthy regardless of body weight, although those who were both lean and active had “the highest odds of successful survival.”
Taking the benefits of exercise one system at a time, here is what recent studies have shown, including several published in The Archives of Internal Medicine in December.
Cancer.
In a review last year of 52 studies of exercise and colon cancer, researchers at Washington University School of Medicine in St. Louis concluded that people who were most active were 21 percent less likely to develop the disease than those who were least active, possibly because activity helps to move waste more quickly through the bowel.
The risk of breast cancer, too, is about 16 percent lower among physically active women, perhaps because exercise reduces tissue exposure to insulin-like growth factor, a known cancer promoter.
Indirectly, exercise may protect postmenopausal women against cancers of the endometrium, pancreas, colon and esophagus, as well as breast cancer, by helping them keep their weight down.
Osteoporosis and fragility.
Weak bones and muscles increase the risk of falls and fractures and an inability to perform the tasks of daily life. Weight-bearing aerobic activities like brisk walking and weight training to increase muscle strength can reduce or even reverse bone loss. In one of the new studies, German researchers who randomly assigned women 65 and older to either an 18-month exercise regimen or a wellness program demonstrated that exercise significantly increased bone density and reduced the risk of falls. And at any age, even in people over 100, weight training improves the size and quality of muscles, thus increasing the ability to function independently.
Cardiovascular disease.
Aerobic exercise has long been established as an invaluable protector of the heart and blood vessels. It increases the heart’s ability to work hard, lowers blood pressure and raises blood levels of HDL-cholesterol, which acts as a cleansing agent in arteries. As a result, active individuals of all ages have lower rates of heart attacks and strokes.
Though early studies were conducted only among men, in a 2002 study published in The New England Journal of Medicine, Dr. JoAnn E. Manson and colleagues found that among 73,743 initially healthy women ages 50 to 79, walking briskly for 30 minutes a day five days a week, as well as more vigorous exercise, substantially reduced the risk of heart attacks and other cardiovascular events.
In another study, women who walked at least one hour a day were 40 percent less likely to suffer a stroke than women who walked less than an hour a week.
Diabetes.
Moderate activity has been shown to lower the risk of developing diabetes even in women of normal weight. A 16-year study of 68,907 initially healthy female nurses found that those who were sedentary had twice the risk of developing diabetes, and those who were both sedentary and obese had 16 times the risk when compared with normal-weight women who were active.
Another study that randomly assigned 3,234 prediabetic men and women to modest physical activity (at least 150 minutes a week) found exercise to be more effective than the drug metformin at preventing full-blown diabetes.
Dementia.
As the population continues to age, perhaps the greatest health benefit of regular physical activity will turn out to be its ability to prevent or delay the loss of cognitive functions. The new study of 3,485 healthy men and women older than 55 found that those who were physically active three or more times a week were least likely to become cognitively impaired.
One study conducted in Australia and published in September 2008 in The Journal of the American Medical Association randomly assigned 170 volunteers who reported memory problems to a six-month program of physical activity or health education. A year and a half later, the exercise group showed “a modest improvement in cognition.” Various other studies have confirmed the value of exercise in helping older people maintain useful short-term memory, enabling them to plan, schedule and multitask, as well as store information and use it effectively.
Even More Reasons to Get a Move On
By Jane E. Brody : NY Times Article : March 2, 2010
“I’m 86 and have walked every day of my life. The public needs to wake up and move.”
“I’m 83 going on 84 years! I find that daily aerobics and walking are fine. But these regimens neglect the rest of the body, and I find the older you get the more attention they need.”
These are two of many comments from readers of my Jan. 12 column on the secrets of successful aging. At the risk of sounding like a broken record, a new series of studies prompts me to again review the myriad benefits to body, mind and longevity of regular physical activity for people of all ages.
Regular exercise is the only well-established fountain of youth, and it’s free. What, I’d like to know, will persuade the majority of Americans who remain sedentary to get off their duffs and give their bodies the workout they deserve? My hope is that every new testimonial to the value of exercise will win a few more converts until everyone is doing it.
In a commentary on the new studies, published Jan. 25 in The Archives of Internal Medicine, two geriatricians, Dr. Marco Pahor of the University of Florida and Dr. Jeff Williamson of Winston-Salem, N.C., pointed to “the power of higher levels of physical activity to aid in the prevention of late-life disability owing to either cognitive impairment or physical impairment, separately or together.”
“Physical inactivity,” they wrote, “is one of the strongest predictors of unsuccessful aging for older adults and is perhaps the root cause of many unnecessary and premature admissions to long-term care.”
They noted that it had long been “well established that higher quantities of physical activity have beneficial effects on numerous age-related conditions such as osteoarthritis, falls and hip fracture, cardiovascular disease, respiratory diseases, cancer, diabetes mellitus, osteoporosis, low fitness and obesity, and decreased functional capacity.”
One of the new studies adds mental deterioration, with exercise producing “a significantly reduced risk of cognitive impairment after two years for participants with moderate or high physical activity” who were older than 55 when the study began.
Most early studies demonstrating the benefits of exercise were done with men. Now a raft of recent studies has shown that active women reap comparable rewards.
Research-Based Evidence
Sedentary skeptics are fond of saying that of course exercise is associated with good health as one ages; the people who exercise are healthy to begin with. But studies in which some participants are randomly assigned to a physical activity program and others to a placebo (like simply being advised to exercise) call their bluff. Even less exacting observational studies, like the Nurses’ Health Study, take into account the well-being of participants at enrollment.
Thus, in one of the new studies, Dr. Qi Sun of Harvard School of Public Health and co-authors reported that among the 13,535 nurses who were healthy when they joined the study in 1986, those who reported higher levels of activity in midlife were far more likely to still be healthy a decade or more later at age 70. The study found that physical activity increased the nurses’ chances of remaining healthy regardless of body weight, although those who were both lean and active had “the highest odds of successful survival.”
Taking the benefits of exercise one system at a time, here is what recent studies have shown, including several published in The Archives of Internal Medicine in December.
Cancer.
In a review last year of 52 studies of exercise and colon cancer, researchers at Washington University School of Medicine in St. Louis concluded that people who were most active were 21 percent less likely to develop the disease than those who were least active, possibly because activity helps to move waste more quickly through the bowel.
The risk of breast cancer, too, is about 16 percent lower among physically active women, perhaps because exercise reduces tissue exposure to insulin-like growth factor, a known cancer promoter.
Indirectly, exercise may protect postmenopausal women against cancers of the endometrium, pancreas, colon and esophagus, as well as breast cancer, by helping them keep their weight down.
Osteoporosis and fragility.
Weak bones and muscles increase the risk of falls and fractures and an inability to perform the tasks of daily life. Weight-bearing aerobic activities like brisk walking and weight training to increase muscle strength can reduce or even reverse bone loss. In one of the new studies, German researchers who randomly assigned women 65 and older to either an 18-month exercise regimen or a wellness program demonstrated that exercise significantly increased bone density and reduced the risk of falls. And at any age, even in people over 100, weight training improves the size and quality of muscles, thus increasing the ability to function independently.
Cardiovascular disease.
Aerobic exercise has long been established as an invaluable protector of the heart and blood vessels. It increases the heart’s ability to work hard, lowers blood pressure and raises blood levels of HDL-cholesterol, which acts as a cleansing agent in arteries. As a result, active individuals of all ages have lower rates of heart attacks and strokes.
Though early studies were conducted only among men, in a 2002 study published in The New England Journal of Medicine, Dr. JoAnn E. Manson and colleagues found that among 73,743 initially healthy women ages 50 to 79, walking briskly for 30 minutes a day five days a week, as well as more vigorous exercise, substantially reduced the risk of heart attacks and other cardiovascular events.
In another study, women who walked at least one hour a day were 40 percent less likely to suffer a stroke than women who walked less than an hour a week.
Diabetes.
Moderate activity has been shown to lower the risk of developing diabetes even in women of normal weight. A 16-year study of 68,907 initially healthy female nurses found that those who were sedentary had twice the risk of developing diabetes, and those who were both sedentary and obese had 16 times the risk when compared with normal-weight women who were active.
Another study that randomly assigned 3,234 prediabetic men and women to modest physical activity (at least 150 minutes a week) found exercise to be more effective than the drug metformin at preventing full-blown diabetes.
Dementia.
As the population continues to age, perhaps the greatest health benefit of regular physical activity will turn out to be its ability to prevent or delay the loss of cognitive functions. The new study of 3,485 healthy men and women older than 55 found that those who were physically active three or more times a week were least likely to become cognitively impaired.
One study conducted in Australia and published in September 2008 in The Journal of the American Medical Association randomly assigned 170 volunteers who reported memory problems to a six-month program of physical activity or health education. A year and a half later, the exercise group showed “a modest improvement in cognition.” Various other studies have confirmed the value of exercise in helping older people maintain useful short-term memory, enabling them to plan, schedule and multitask, as well as store information and use it effectively.
Finding the Right Care for the Elderly
By Lesley Alderman : NY Times Article : March 12, 2010
Two years ago my father, then 83, became very ill. Until then, he had been living alone in a pleasant one-bedroom apartment on the Hudson River, an hour’s drive from my home in Brooklyn.
After a couple of months in the hospital it became clear that my dad, Harvey Alderman, could not return to solo living. He was fragile and forgetful, and there was no way he could keep track of the 14 or so pills he had to take each day.
But where would he go — and how would we pay for it? Could he stay in his apartment if he had regular visits from an aide? Or should he go to an assisted-living facility where there would be more services available for him?
So began my family’s crash course in caring for an aging parent in declining health.
If you’re in this predicament, you know already there is no simple answer. Older people each have unique medical and emotional needs. And finances often dictate how far you can go in creating the ideal situation for them.
That is what Linda Chase, a lawyer in Reston, Va., realized after running the numbers on what it would cost for home care for her mother, who has dementia and needs round-the-clock attention.
“We couldn’t afford private home-health care, so the only option for us was assisted living in a facility with dementia care,” Ms. Chase said.
Once you do the calculations you, too, may be surprised by what you learn. I know that my sisters and I were, as we researched the options for our father. Below, I offer guidelines and considerations that can help you make an informed — if not always easy — decision about what type of housing will support your parent’s needs, without bankrupting the family in the process.
And note: While the following discussion refers to a single parent who lives alone, many of the considerations would also apply to an elderly couple who are each in declining health.
IS HOME STILL SAFE?
If your parent is living at home, he or she probably wants to stay there. If that’s the case, hire an expert, like a geriatric care manager, who can assess whether your parent will be able to manage at home and what kind of support will be needed.
A geriatric care manager, who charges $50 to $200 an hour, will look at how your parent functions in the space — able to cook? able to manage medications?— and may suggest modifications. These may include adding grab bars and removing throw rugs, to make the home safer. If your parent will be in a wheelchair, the care manager can figure out whether doorways need to be widened or a stair lift should be added.
In a column last fall, I offered fuller advice on how to find a geriatric care manager, but here are a few basics:
Ask friends for references or contact the National Association of Professional Geriatric Care Managers (www.caremanager.org). If money is tight, call the local federally funded office on aging or plug your ZIP code in at www.eldercare.gov to find the nearest one.
“The office should be able to send a case manager to your parent’s home to do a home assessment at no charge,” says Chris Stone, a registered nurse and clinical liaison for LifeQuest Nursing Center, in Quakertown, Pa.
Next, determine what kind of day-to-day care your parent requires. A care manager or your parent’s doctor should be able to help you figure this out. Some older people can manage surprisingly well with minimal help. But parents with dementia or a chronic medical condition may require a full-time aide, and the cost of that can add up quickly.
According to a survey by Genworth Financial, an insurance company that sells long-term care policies, the median hourly rate for a licensed caregiver ranges from $18 to $46 an hour, depending on the qualifications of the aide. The cost runs on the higher side if the aide works for a Medicare-certified agency.
To learn about rates in your area, call a local home health care agency, said Vanessa Bishop, president of Elder Care Consultants (www.eldercc.com), in Reston, Va. If you do opt for in-home care, be sure to use an agency that is licensed, bonded and insured, Ms. Bishop says, and one that conducts thorough background checks on its employees.
THE ASSISTED-LIVING OPTION
Even if parents insist on remaining in the home, doing so may not be in their best interests. A parent in failing health or somehow impaired is not the only one in jeopardy; other family members may be under a lot of stress, too. It can also be lonely and isolating for a parent to stay at home.
Assisted-living residences, which have proliferated in recent years, have small apartments that residents can furnish with their own belongings, along with a common dining room where meals are served, a nurse’s office where prescription drugs are dispensed and activity rooms for socializing. The great advantage of such places is that you can ramp up the level of care as your parent needs it, adding services like help with dressing and bathing. Many have special wings or floors for people with financial planner for advice on how to stretch the funds over time.
We were able to pay for my dad’s rather steep assisted-living bill through a combination of his annual income and the proceeds from the sale of his apartment.
It might also be wise to speak with an elder-law attorney, who can explain when your parent might qualify for government programs like Medicaid. Medicaid does not cover the costs of assisted living, but it does cover care provided in nursing homes.
“Everyone thinks Medicaid is only for the poor, and that you have to impoverish yourself to be eligible,” says Robert S. Bullock, a lawyer in Washington and a senior partner of the Elder Law & Disability Law Center, “But it’s not.”
COMPARE COSTS
Add up the costs that would be involved in keeping your parent at home, including home upgrades, caregivers, rent, mortgage payments and taxes. Factor in what long-term care insurance will cover, if there is any.
If your parent is a military veteran, find out if he or she is eligible for the Aid and Attendance Pension benefit, which provides a monthly stipend of up to $1,632 (or $1,949 for couples), to veterans who need help with basic daily tasks, like eating and dressing.
Once you have an idea of what it would cost to keep your parent at home, the decision might be made for you. The Genworth survey found that the median cost for an assisted-living facility was $34,000 a year, which translates into about 30 hours a week of home care at $20 an hour. But in major urban areas the cost for assisted living can be twice or even three times that amount.
Even so, assisted living sometimes works out to be a better deal, as Ms. Chase, the lawyer in Virginia, learned. When she did her research, Ms. Chase found it would cost around $150,000 a year to hire full-time home caregivers for her mother, Jeanette Chase.
“It was a horrendous amount of money,” Ms. Chase said.
A nearby assisted-living facility, on the other hand, charged $80,000 a year for a room on a secure floor intended for memory-impaired patients. And her mother’s long-term care insurance, which did not cover in-home care, covered 40 percent of the bill for assisted living.
Even assisted living “was expensive — but worth it,” Ms. Chase said. “I was able to continue working and she was safe and nearby.”
By Lesley Alderman : NY Times Article : March 12, 2010
Two years ago my father, then 83, became very ill. Until then, he had been living alone in a pleasant one-bedroom apartment on the Hudson River, an hour’s drive from my home in Brooklyn.
After a couple of months in the hospital it became clear that my dad, Harvey Alderman, could not return to solo living. He was fragile and forgetful, and there was no way he could keep track of the 14 or so pills he had to take each day.
But where would he go — and how would we pay for it? Could he stay in his apartment if he had regular visits from an aide? Or should he go to an assisted-living facility where there would be more services available for him?
So began my family’s crash course in caring for an aging parent in declining health.
If you’re in this predicament, you know already there is no simple answer. Older people each have unique medical and emotional needs. And finances often dictate how far you can go in creating the ideal situation for them.
That is what Linda Chase, a lawyer in Reston, Va., realized after running the numbers on what it would cost for home care for her mother, who has dementia and needs round-the-clock attention.
“We couldn’t afford private home-health care, so the only option for us was assisted living in a facility with dementia care,” Ms. Chase said.
Once you do the calculations you, too, may be surprised by what you learn. I know that my sisters and I were, as we researched the options for our father. Below, I offer guidelines and considerations that can help you make an informed — if not always easy — decision about what type of housing will support your parent’s needs, without bankrupting the family in the process.
And note: While the following discussion refers to a single parent who lives alone, many of the considerations would also apply to an elderly couple who are each in declining health.
IS HOME STILL SAFE?
If your parent is living at home, he or she probably wants to stay there. If that’s the case, hire an expert, like a geriatric care manager, who can assess whether your parent will be able to manage at home and what kind of support will be needed.
A geriatric care manager, who charges $50 to $200 an hour, will look at how your parent functions in the space — able to cook? able to manage medications?— and may suggest modifications. These may include adding grab bars and removing throw rugs, to make the home safer. If your parent will be in a wheelchair, the care manager can figure out whether doorways need to be widened or a stair lift should be added.
In a column last fall, I offered fuller advice on how to find a geriatric care manager, but here are a few basics:
Ask friends for references or contact the National Association of Professional Geriatric Care Managers (www.caremanager.org). If money is tight, call the local federally funded office on aging or plug your ZIP code in at www.eldercare.gov to find the nearest one.
“The office should be able to send a case manager to your parent’s home to do a home assessment at no charge,” says Chris Stone, a registered nurse and clinical liaison for LifeQuest Nursing Center, in Quakertown, Pa.
Next, determine what kind of day-to-day care your parent requires. A care manager or your parent’s doctor should be able to help you figure this out. Some older people can manage surprisingly well with minimal help. But parents with dementia or a chronic medical condition may require a full-time aide, and the cost of that can add up quickly.
According to a survey by Genworth Financial, an insurance company that sells long-term care policies, the median hourly rate for a licensed caregiver ranges from $18 to $46 an hour, depending on the qualifications of the aide. The cost runs on the higher side if the aide works for a Medicare-certified agency.
To learn about rates in your area, call a local home health care agency, said Vanessa Bishop, president of Elder Care Consultants (www.eldercc.com), in Reston, Va. If you do opt for in-home care, be sure to use an agency that is licensed, bonded and insured, Ms. Bishop says, and one that conducts thorough background checks on its employees.
THE ASSISTED-LIVING OPTION
Even if parents insist on remaining in the home, doing so may not be in their best interests. A parent in failing health or somehow impaired is not the only one in jeopardy; other family members may be under a lot of stress, too. It can also be lonely and isolating for a parent to stay at home.
Assisted-living residences, which have proliferated in recent years, have small apartments that residents can furnish with their own belongings, along with a common dining room where meals are served, a nurse’s office where prescription drugs are dispensed and activity rooms for socializing. The great advantage of such places is that you can ramp up the level of care as your parent needs it, adding services like help with dressing and bathing. Many have special wings or floors for people with financial planner for advice on how to stretch the funds over time.
We were able to pay for my dad’s rather steep assisted-living bill through a combination of his annual income and the proceeds from the sale of his apartment.
It might also be wise to speak with an elder-law attorney, who can explain when your parent might qualify for government programs like Medicaid. Medicaid does not cover the costs of assisted living, but it does cover care provided in nursing homes.
“Everyone thinks Medicaid is only for the poor, and that you have to impoverish yourself to be eligible,” says Robert S. Bullock, a lawyer in Washington and a senior partner of the Elder Law & Disability Law Center, “But it’s not.”
COMPARE COSTS
Add up the costs that would be involved in keeping your parent at home, including home upgrades, caregivers, rent, mortgage payments and taxes. Factor in what long-term care insurance will cover, if there is any.
If your parent is a military veteran, find out if he or she is eligible for the Aid and Attendance Pension benefit, which provides a monthly stipend of up to $1,632 (or $1,949 for couples), to veterans who need help with basic daily tasks, like eating and dressing.
Once you have an idea of what it would cost to keep your parent at home, the decision might be made for you. The Genworth survey found that the median cost for an assisted-living facility was $34,000 a year, which translates into about 30 hours a week of home care at $20 an hour. But in major urban areas the cost for assisted living can be twice or even three times that amount.
Even so, assisted living sometimes works out to be a better deal, as Ms. Chase, the lawyer in Virginia, learned. When she did her research, Ms. Chase found it would cost around $150,000 a year to hire full-time home caregivers for her mother, Jeanette Chase.
“It was a horrendous amount of money,” Ms. Chase said.
A nearby assisted-living facility, on the other hand, charged $80,000 a year for a room on a secure floor intended for memory-impaired patients. And her mother’s long-term care insurance, which did not cover in-home care, covered 40 percent of the bill for assisted living.
Even assisted living “was expensive — but worth it,” Ms. Chase said. “I was able to continue working and she was safe and nearby.”
Nursing Home Unthinkable? Be Prepared in Case It’s Inevitable
Jane E. Brody : NY Times : July 28, 2014
Nobody looks forward to spending their final years in a nursing home, yet 1.4 million Americans are living in this often-feared institutional setting.
You may not want to place a loved one in a nursing home for more than a short-term recovery — but never promise an aging relative that it won’t happen.
“When faced with the responsibilities of providing 24-hour care for an aging person with ever-increasing physical needs beyond what one person can physically handle, a nursing home frequently becomes the best alternative,” Joanna R. Leefer writes in “Almost Like Home,” a user-friendly guide to choosing a nursing home.
Nursing homes generally have had a bad reputation as smelly, indifferent places where people go to die. But “there are some homes that are better than being at home,” Ms. Leefer said in an interview. “And there are many more good facilities than bad ones.”
Ms. Leefer developed her expertise through personal and professional experience, and her book is replete with checklists and scores of relevant websites. She learned a lot firsthand as primary caregiver for her aging parents, one of whom lived three years with nursing-home-type care. She worked five years for an advocacy organization for older adults, and she founded a consulting firm, ElderCareGiving, to help families make difficult care decisions.
Finding a place that suits the needs of an aging relative or friend, and those who plan to visit, requires considerable preparation.
“The biggest mistake people make is waiting until the last minute, when faced with a crisis, to find a suitable facility,” Ms. Leefer said. “You’re forced into an impulsive decision that you’re not likely to be happy with unless you’re really very lucky.”
She likened it to shopping for a new car: “Do the research, start looking around, find out what’s available, what each facility offers, what’s best for your loved one. Become an educated consumer.”
Crass as it may seem, you might start with the cost. When paid for privately, the average ranges from $10,000 to $15,000 a month.Medicare does not pay for long-term nursing home care, only temporary skilled care, usually in the rehabilitation section of the home.
If the patient qualifies for Medicaid, and the nursing home accepts it, most of the cost is generally covered. The beneficiary must be age 65 or older, disabled and a United States citizen. He or she can have no more than a certain amount of assets, as determined by the state. Some patients become eligible by transferring savings and assets to a third party at least five years ahead of time.
Next, choose a reasonably convenient location for likely frequent visitors. You can search for possibilities online by township or ZIP code. Ask neighbors and friends in the area for any recommendations or information they might have about homes in the area.
Make a list of homes in the chosen area and check out the government’s report card at NursingHomeCare.com. Every home that receives federal funding must be evaluated and rated on a scale of 1 to 5 (5 being best). The assessments are far from perfect; a recent study, for instance, found that star ratings often don’t correspond to how patients feel about their nursing homes.
Still, Ms. Leefer suggests considering only homes with a rating of 3 or higher. Then start examining their characteristics.
What specialized services might the patient need — a dementia program, mobility practice, hospice care? Are there medical specialists on call? Is the home affiliated with a good nearby hospital? If the patient has a personal physician, you might prefer a home where that doctor has privileges.
If the patient is not fluent in English, are there staff members (and other residents) who speak the person’s language? Are there activities that would interest the patient, including opportunities to go outdoors?
Don’t rely on brochures. Take a tour, preferably more than once at different times, including mealtimes. Visit more than one floor. Does the place look and smell clean? An odor of urine is a clue to neglect. Are the rooms light and airy? Are residents permitted to have a few personal decorative items or furnishings?
Observe how patients are treated by staff members. Are they courteous, patient, friendly and respectful of patients’ privacy? Are patients greeted by the staff and addressed by name? Are those that need it helped with eating and drinking?
Are there rigid wake-up, bed and meal times, or do patients have some choice? Do the menus offer selections? If possible, talk with a few of the residents and their family members.
Ms. Leefer suggests preparing a checklist for the nursing homes you are considering, listing issues relevant to quality of life, quality of care, safety, nutrition and hydration.
Admission to a nursing home is not automatic but based on such factors as bed availability, care requirements and the patient’s condition. It is best to submit applications to chosen homes well in advance of a needed admission. Waiting lists can be longer than a year.
Your job does not end once a family member is admitted; monitoring the care provided is critical. At first, expect resistance from the patient, often accompanied by a loud desire to “get me out of here now.” Visit often and stay as long as possible to ease the transition, Ms. Leefer says.
Be sure you or someone trustworthy is authorized to serve as the patient’s health care proxy, so critical medical decisions can be made when he cannot speak for himself. Make sure you have access to medical records and be present when the patient is examined and dressed. Check for any hints of physical abuse and signs of incipient or existing bed sores, which can become infected and hasten death.
Find out the names of staff in charge of various services and speak to them about the patient’s special needs or problems. Keep notes, dated, with any issues of concern.
Try to solve any problems with the nursing home staff. Be polite, soft-spoken and avoid confrontation. A hostile approach puts people on the defensive and is unlikely to get the patient’s needs addressed.
If necessary, speak to the heads of departments; filing a formal complaint with the health department should be a last resort.
This is the first of two columns on choosing a nursing home.
Stressful but Vital: Picking a Nursing Home
By Walecia Konrad : NY Times Article : March 18, 2010
The decision is one of the hardest you will ever make. Your spouse, parent or another loved one needs care that assisted living or home health care simply cannot provide. You need to choose a nursing home.
It’s a difficult and emotional task. The horror stories are well documented, and even in the best nursing homes the transition can be wrenching for the entire family.
Finding a good nursing home takes research and perseverance. You want a safe, engaging and pleasant environment with caring staff and solid medical practices.
“You can actually get all of that in a nursing home — if you know what to look for and how to search,” said Larry Minnix, chief executive of the American Association of Homes and Services for the Aging, a trade group for nonprofit nursing homes and other organizations for the elderly.
Unfortunately, the typical search for a nursing home is made under duress. More than 60 percent of admissions come from hospitals. The patient may have broken a hip or had a stroke and now needs rehabilitative care. The hospital is in a hurry to discharge and may move quickly to get the patient moved to an available nursing home bed, regardless of the operator’s quality or reputation.
“Hospitals ought to be more aware, but it often is just not on their radar screen whether they are sending a patient to a good nursing home or a bad one,” said Janet Wells, director of public policy at the National Consumer Voice for Quality Long-Term Care, an advocacy group.
In such situations, you have precious little time to do your research. What is more, these temporary stays often become permanent, depending on the individual case and sometimes on the quality of the temporary care received.
Paying for a nursing home is another huge source of stress. Medicare pays only for medically necessary care in a skilled nursing home, like physical therapy or intravenous medicine. It does not pay for what is called custodial care — help with walking, eating, bathing and other daily tasks. Instead, the majority of nursing home residents pay from personal money, long-term care insurance policies or, if they qualify, through Medicaid.
The average cost of nursing home care is $200 a day, and that does not include additional fees for specialized services like care for patients with dementia.
To find a nursing home you can really feel good about, consider these important steps.
START WITH THE DATA
Every year the Centers for Medicare and Medicaid Services collect data on more than 15,000 nursing homes throughout the country. Health inspection data, staffing and quality measures are combined to come up with an overall ranking of one to five stars. To look up nursing homes in your area, go to medicare.gov and click on the “nursing home compare” tool.
In addition to the rankings, the site offers a useful brochure entitled Medicare’s Guide to Choosing a Nursing Home, as well as other resources.
Keep in mind that government rankings have their limits, and they reflect the nursing home’s performance during only a short period.
“Health inspection data is only as good as the data itself,” Ms. Wells said. She points out that many studies show that state inspections tend to underreport nursing home deficiencies and the seriousness of those deficiencies. “The home could be even worse than it appears in the rankings,” she said. “Of course, it could also be better.”
There are other shortcomings. For example, under the grading curve Medicare uses, precisely 10 percent of nursing homes in any one state are permitted to get five stars.
That could mean a four-star-rated facility may be just as good as a top-rated home down the street but simply falls below the percentage cutoff, said David LaLumia, president of the Health Care Association of Michigan, which represents nursing homes and rehabilitation centers in the state. On the other hand, it could also mean that more homes would fall into lower rankings if the curve did not exist.
VISIT, THEN VISIT AGAIN
Nothing substitutes for what you see, hear and smell when you visit a nursing home, Mr. Minnix said. Be sure to visit more than once and at different times of the day and different days of the week. Take the checklist from the Nursing Home Compare Web site with you.
“Trust your five senses,” advised Mr. Minnix. “Does it smell like cleaning fluid and urine when you walk in or fried chicken and apple pie? You also want to see an ant farm of activity. Are the staff friendly and interacting with the residents?”
Be sure to ask to speak with crucial leaders, including the executive director, lead physician and head nurse. If those people are not available, ask when you can meet with them. If you get the runaround, Mr. Minnix said, that could be a red flag.
When you do meet with the staff, ask them if you may attend a resident council or family council meeting. These groups are usually run by family members to address concerns and improve the quality of care. You will get a good inside view of what is really going on at the nursing home from these meetings.
After your visits, always ask your loved one’s doctor, clergy, friends and family what they know about the homes on your short list.
WHAT TO ASK
There are two big buzzword trends in nursing home management that can significantly increase the quality of care.
Ask the nursing homes you visit if they engage in “person-centered care,” as well as “consistent assignment,” suggests Carol Benner. She is the National Director of the Advancing Excellence Campaign, a coalition of industry, government and consumer groups working to improve nursing home quality.
Nursing homes that provide person-centered care allow residents to wake up when they want to, eat when they want to and generally set their own schedules. Traditionally, many nursing homes have had residents wake, eat, bathe and go to bed at the same times.
Consistent assignment, meanwhile, simply means that the same staff members — doctors, nurses, aides — treat the same patients each shift. The continuity of care reduces errors or problems and helps residents and staff members to develop a lasting relationship that can significantly improve a resident’s emotional well-being.
“Imagine how much nicer it would be to know the same person will bring your tea each evening and already knows you like sugar in it,” Ms. Benner said. “We know from the evidence out there that a strong relationship between residents and staff consistently leads to better care.”
It can also lead to lower staff turnover, because employees are naturally more engaged in their jobs and less willing to leave if they have developed relationships with their patients.
Be sure to ask each nursing home you visit what percentage of their staff leaves each year. Less than 30 percent annually is considered good. More than 50 percent is a sign to look elsewhere.
A nursing home is not obliged to disclose this information to you, but if it does not, “that tells you something, too,” Mr. Minnix said.
CALL YOUR OMBUDSMAN
Each state has a federally funded long-term care ombudsman who is an advocate for nursing home patients.
This person can tell you if there are state rankings or surveys available in addition to the Medicare ratings. The ombudsman can also help you find the latest health inspection reports, which are public information, on specific nursing homes. Ombudsmen can also tell you how many complaints the office has collected about a specific nursing home and the nature of those complaints.
You can find the ombudsman in your state online at the National Long-Term Care Ombudsman Resource Center.
Maybe most important, a good ombudsman will know about recent significant changes at various nursing homes.
When Ms. Wells recently helped a family member find a nursing home, for example, she was considering a three-star center close to home. But when she called the ombudsman’s office she discovered that the well-regarded director of that center had moved to a nearby one-star home. Ultimately, Ms. Wells decided to go with the lower-ranked facility because of the change in management.
When the Family Needs an Umpire
By Joshua Tapper : NY Times Article : October 25, 2010
The home care aide didn’t expect her new charge to be particularly cantankerous. After all, she had worked for the elderly woman’s late sister for four years, and they’d gotten along well.
But the new relationship was rocky from the start. More than once the aide received confusing calls from the 88-year-old woman late at night. She traveled to the woman’s apartment on the Upper West Side, only to be met with a curt “What’s going on? Why are you here?” The older woman, bedridden and recovering from a broken hip, repeatedly told the caregiver to leave because she didn’t need help.
Frustrated and angry, the aide threatened to quit. That’s when the patient’s family called in Joy Rosenthal, an elder mediator.
Ms. Rosenthal and a co-mediator umpired the conflict at the older woman’s bedside. “She was just frustrated with her condition, angry about being so debilitated,” Ms. Rosenthal said. “She felt locked in and was taking it out on the caregiver.”
Over the course of a daylong session, Ms. Rosenthal encouraged the two women to listen to each other.
“We talked to them, each in front of the other, about what they felt the problem was, what they felt would make it better,” Ms. Rosenthal said. Then the mediators helped brainstorm solutions, like installing a big glow-in-the-dark clock in front of the client’s bed so she would know not to call too late.
While lawyers and mediators have practiced elder mediation for years, only recently has the practice garnered recognition as a specialty separate from, say, family mediation. The mediator acts as a neutral third party, helping families and caregivers — and sometimes even medical providers and estate lawyers — make unified decisions about elder care.
“There’s a phenomenal need,” Ms. Rosenthal said. “These are central problems in people’s lives.”
It is no surprise to caregivers that as parents age, long-standing tensions can erupt into family discord. A 2001 study published in Conflict Resolution Quarterly found that close to 40 percent of adult children caring for a parent described “serious conflict” with a sibling, frequently the result of one sibling shouldering the bulk of caregiving responsibility.
Despite mutual concern for a parent’s well-being, adult children often have lived apart for decades and have little experience working together. Visits, end-of-life decisions and estate planning all become sources of sibling strife when old rivalries begin to play out, said Penny Hommel, co-director of the Center for Social Gerontology in Ann Arbor, Mich.
It’s not just adult children, of course. Caregiving can strain relationships inside the family and out. The mediator steps in to temper the situation, hash out misunderstandings and, perhaps most importantly, help head off estrangements, said Janet Mitchell, a co-founder of Elder Care Mediators in Fort Wayne, Ind., which has trained 80 elder mediators nationwide.
“A good mediator can delve right to the bottom of things, parse out the important issues and help the family deal with them,” said Ms. Rosenthal. “It’s different from therapy because it’s really about decision-making, not feelings and emotions.”
While there are no national statistics, elder mediators now practice in every state, charging clients from $150 to $500 an hour. And with no national standards, the practice differs from one mediator to the next.
Ms. Rosenthal, for example, chats privately with each side before bringing everyone together. This helps her understand each viewpoint, she said, and ensures each party will be given equal consideration during the mediation. Ms. Mitchell, on the other hand, first brings family members together, coaching them on how to communicate without hurting one another’s feelings. She uses Web cams in the mediation if one party can’t be present.
Elder care mediation can be tricky, as mediators must balance the opinions of many parties, not only adult children but in-laws, home aides, and sometimes grandchildren. “You’re trying to maintain neutrality and a little distance,” Ms. Rosenthal said, “but in this kind of mediation, you tend to favor the voice of the elderly person.”
A mediator generally should be trained in such subjects as the physical and mental effects of aging and how to communicate effectively with the elderly. But in a field with no national credentialing and no standard approach, potential clients should be wary before asking an outsider to sit in on a dispute.
Start with National Eldercare Mediation Network, founded by Ms. Mitchell, which posts profiles of elder mediators in all 50 states. Another Web site, Mediate.com, also allows prospective clients to search elder mediators by state.
By Joshua Tapper : NY Times Article : October 25, 2010
The home care aide didn’t expect her new charge to be particularly cantankerous. After all, she had worked for the elderly woman’s late sister for four years, and they’d gotten along well.
But the new relationship was rocky from the start. More than once the aide received confusing calls from the 88-year-old woman late at night. She traveled to the woman’s apartment on the Upper West Side, only to be met with a curt “What’s going on? Why are you here?” The older woman, bedridden and recovering from a broken hip, repeatedly told the caregiver to leave because she didn’t need help.
Frustrated and angry, the aide threatened to quit. That’s when the patient’s family called in Joy Rosenthal, an elder mediator.
Ms. Rosenthal and a co-mediator umpired the conflict at the older woman’s bedside. “She was just frustrated with her condition, angry about being so debilitated,” Ms. Rosenthal said. “She felt locked in and was taking it out on the caregiver.”
Over the course of a daylong session, Ms. Rosenthal encouraged the two women to listen to each other.
“We talked to them, each in front of the other, about what they felt the problem was, what they felt would make it better,” Ms. Rosenthal said. Then the mediators helped brainstorm solutions, like installing a big glow-in-the-dark clock in front of the client’s bed so she would know not to call too late.
While lawyers and mediators have practiced elder mediation for years, only recently has the practice garnered recognition as a specialty separate from, say, family mediation. The mediator acts as a neutral third party, helping families and caregivers — and sometimes even medical providers and estate lawyers — make unified decisions about elder care.
“There’s a phenomenal need,” Ms. Rosenthal said. “These are central problems in people’s lives.”
It is no surprise to caregivers that as parents age, long-standing tensions can erupt into family discord. A 2001 study published in Conflict Resolution Quarterly found that close to 40 percent of adult children caring for a parent described “serious conflict” with a sibling, frequently the result of one sibling shouldering the bulk of caregiving responsibility.
Despite mutual concern for a parent’s well-being, adult children often have lived apart for decades and have little experience working together. Visits, end-of-life decisions and estate planning all become sources of sibling strife when old rivalries begin to play out, said Penny Hommel, co-director of the Center for Social Gerontology in Ann Arbor, Mich.
It’s not just adult children, of course. Caregiving can strain relationships inside the family and out. The mediator steps in to temper the situation, hash out misunderstandings and, perhaps most importantly, help head off estrangements, said Janet Mitchell, a co-founder of Elder Care Mediators in Fort Wayne, Ind., which has trained 80 elder mediators nationwide.
“A good mediator can delve right to the bottom of things, parse out the important issues and help the family deal with them,” said Ms. Rosenthal. “It’s different from therapy because it’s really about decision-making, not feelings and emotions.”
While there are no national statistics, elder mediators now practice in every state, charging clients from $150 to $500 an hour. And with no national standards, the practice differs from one mediator to the next.
Ms. Rosenthal, for example, chats privately with each side before bringing everyone together. This helps her understand each viewpoint, she said, and ensures each party will be given equal consideration during the mediation. Ms. Mitchell, on the other hand, first brings family members together, coaching them on how to communicate without hurting one another’s feelings. She uses Web cams in the mediation if one party can’t be present.
Elder care mediation can be tricky, as mediators must balance the opinions of many parties, not only adult children but in-laws, home aides, and sometimes grandchildren. “You’re trying to maintain neutrality and a little distance,” Ms. Rosenthal said, “but in this kind of mediation, you tend to favor the voice of the elderly person.”
A mediator generally should be trained in such subjects as the physical and mental effects of aging and how to communicate effectively with the elderly. But in a field with no national credentialing and no standard approach, potential clients should be wary before asking an outsider to sit in on a dispute.
Start with National Eldercare Mediation Network, founded by Ms. Mitchell, which posts profiles of elder mediators in all 50 states. Another Web site, Mediate.com, also allows prospective clients to search elder mediators by state.
Stepping in for Parent With Alzheimer’s
By Tara Siegel Bernard : NY Times : November 5, 2010
As my grandfather’s mind slipped away, first slowly, then quickly, as Alzheimer’s disease moved in, he tried to be reassuring. “I remember the important things,” he would tell us.
And he did. He may not have remembered that Barack Obama was president or that he just had a bowl of ice cream (my kindergartner nephew took full advantage), but he always remembered his family.
Money management was another matter. Early on in the disease, small red flags began to appear — failure to pay the association fees on the condominium in Florida, overpaid bills or repetitive trips to the A.T.M. Over time, he had to hand off most financial responsibilities to my mother and grandmother.
My grandfather was lucky enough to have relatives nearby who were able to gently intervene before the small mistakes escalated into something more serious, which is all too common.
But family members need to carefully consider how they approach their new role as financial caretaker. For adult children, this is the beginning of the role reversal. You may be stepping up to handle mundane tasks like paying the bills, but it’s also the time when you begin to think about your parent’s mortality, and perhaps your own.
For the person with encroaching dementia, the loss of autonomy can be devastating. “What often occurs is that the elder loses additional self-esteem, becomes more depressed and in turn becomes less active,” said Daniel C. Marson, a neuropsychologist at the University of Alabama at Birmingham.
And that’s why these matters must be handled delicately — and before a more serious financial unraveling occurs — whether the individual simply needs you to check in once a month, or you need to become the chief financial officer. Below are some strategies.
THE TALK
Discussing money matters with someone who is already dealing with diminished mental capacity can be challenging, though the conversation can unfold in many ways. It all depends on the family dynamics and the elder person’s level of impairment, personality and comfort level with financial issues, said Dr. Marson, who is also director of the university’s Alzheimer’s Disease Center.
In certain situations, the best place to start a dialogue may be in the doctor’s office. “Go to a health care professional who can be supportive and understand some of the dynamics going on, so that the conversation is structured around identifying something that is a need and that we don’t want to get any worse,” said Becky Bigio, director of the Senior Source program at Selfhelp Community Services in New York.
The needs of the person with dementia will change over time, which means the financial caretaker’s role will also need to evolve. It may help to follow a slow but natural progression. “Involvement may go from, ‘Do you have enough money to pay the bills?’ to ‘It’s O.K. to pay that bill,’ to ‘I’ll just pay the bills now,’” said Tom Davison, a financial planner in Columbus, Ohio, who has worked with several elderly people in his family and practice. “The changes may be fast or slow, but move at their pace.”
SAFETY MECHANISMS
There are also several ways to keep a watchful yet unobtrusive eye on a parent’s financial affairs, even if you don’t live nearby. Setting up automatic bill payments may be the most obvious way. For parents who want to continue paying the bills, allow them to write checks for services that won’t cause harm if the payment is late, and that you can easily remedy later.
Some major banks said they allowed customers to authorize a third party to receive statements — for mortgages, loans or credit cards — which makes it easy to spot a missed payment or unusual activity. (In some cases, the bank may require a power of attorney or notarized consent.) Long-term care insurers, like John Hancock and Genworth, also permit policyholders to have another person receive a notice if a bill is past due or if there is a lapse in coverage.
Other companies should follow that lead and make it easy to set up an automatic e-mail notification of a late notice.
LEGAL DOCUMENTS
Proper legal documents should also be in place. A durable power of attorney enables a person to step in and handle a parent’s financial affairs. Most banks are understandably wary of powers of attorney, given the room for fraud and abuse. So check with your institution about its requirements.
Opening a bank account in the name of a trust also gives one or more trustees decision-making and check-writing privileges. The same goes for anything else in a revocable living trust, where accounts and assets are titled to the trust. “Trusts like these can have two or more trustees at the same time and can be set up to operate individually or must act together — there’s all kinds of flexibility and can be written to respond to the particular circumstances of an individual,” Mr. Davison said. “Do they want checks and balances between an attorney and a kid? Want two kids to have to agree and both sign stuff?” Assets in the living trust have the added benefit of bypassing probate after the person dies.
It may be easier to simply add an adult child’s name to the account, but consult with an adviser to make sure it won’t interfere with the person’s estate plans.
SIMPLIFY AND SET ROUTINES
It’s less confusing for the financial caretaker and the elderly person to keep track of just a few accounts. So try to consolidate. Experts also recommend setting up routines and identifying the triggers that make the elderly person uneasy. For Mr. Davison’s elderly aunt, who had short-term memory loss, the trigger was the mail. As a former business manager who balanced her books to the penny, she was often overwhelmed when the mail arrived.
So Mr. Davison told her to open the mail every day and put it in a folder. Each weekend, he and his wife would visit and review the mail with his aunt, a routine that put her at ease. “See what the trigger points are, and try some ways to soften them,” he said. “You often can’t solve them, but you can soften them. And whatever was helpful three months ago may not be helpful now. It’s a progression.”
HIRING HELP
You obviously need to investigate any provider when dealing with the vulnerable and easily swindled, but there are several places to begin your search. AARP offers a money management program for lower-income people in some parts of the country, or, you can hire an accountant or another party to handle the finances. The American Association of Daily Money Managers is another option, and you can call to request someone who has experience with helping people with dementia.
There are also companies that cater to elderly people’s special needs. Wells Fargo Private Bank, which requires more than $1 million in investable assets, offers an Elder Services program. It will coordinate a variety of services, from dealing with medical claims, taking the cat to the veterinarian and paying the bills, while keeping a close eye on the accounts for fraudulent activities. The service is included in the bank’s investment management fees, which range from 0.80 to 2 percent of assets. Let’s hope we see more such services — and not just for the wealthy.
PLAN NOW
Ideally, all families should prepare for potential issues while everyone is still healthy. There are generally three questions families should answer, according to Ken Dychtwald, a gerontologist, psychologist and consultant. Who will handle the finances? What are the individual’s preferences on long-term care? And how will we pay for it?
“The biggest worry that people have about growing old is being a burden on their family,” Mr. Dychtwald said. “Ironically, if you don’t think about a game plan before it’s needed, then not only does it become a burden, but there is often damage that comes with it,” both financial and emotional.
My mother now says she believes the conversation about money matters should be a rite of passage of sorts, for everyone who reaches retirement. But it’s never too soon to have the talk.
By Tara Siegel Bernard : NY Times : November 5, 2010
As my grandfather’s mind slipped away, first slowly, then quickly, as Alzheimer’s disease moved in, he tried to be reassuring. “I remember the important things,” he would tell us.
And he did. He may not have remembered that Barack Obama was president or that he just had a bowl of ice cream (my kindergartner nephew took full advantage), but he always remembered his family.
Money management was another matter. Early on in the disease, small red flags began to appear — failure to pay the association fees on the condominium in Florida, overpaid bills or repetitive trips to the A.T.M. Over time, he had to hand off most financial responsibilities to my mother and grandmother.
My grandfather was lucky enough to have relatives nearby who were able to gently intervene before the small mistakes escalated into something more serious, which is all too common.
But family members need to carefully consider how they approach their new role as financial caretaker. For adult children, this is the beginning of the role reversal. You may be stepping up to handle mundane tasks like paying the bills, but it’s also the time when you begin to think about your parent’s mortality, and perhaps your own.
For the person with encroaching dementia, the loss of autonomy can be devastating. “What often occurs is that the elder loses additional self-esteem, becomes more depressed and in turn becomes less active,” said Daniel C. Marson, a neuropsychologist at the University of Alabama at Birmingham.
And that’s why these matters must be handled delicately — and before a more serious financial unraveling occurs — whether the individual simply needs you to check in once a month, or you need to become the chief financial officer. Below are some strategies.
THE TALK
Discussing money matters with someone who is already dealing with diminished mental capacity can be challenging, though the conversation can unfold in many ways. It all depends on the family dynamics and the elder person’s level of impairment, personality and comfort level with financial issues, said Dr. Marson, who is also director of the university’s Alzheimer’s Disease Center.
In certain situations, the best place to start a dialogue may be in the doctor’s office. “Go to a health care professional who can be supportive and understand some of the dynamics going on, so that the conversation is structured around identifying something that is a need and that we don’t want to get any worse,” said Becky Bigio, director of the Senior Source program at Selfhelp Community Services in New York.
The needs of the person with dementia will change over time, which means the financial caretaker’s role will also need to evolve. It may help to follow a slow but natural progression. “Involvement may go from, ‘Do you have enough money to pay the bills?’ to ‘It’s O.K. to pay that bill,’ to ‘I’ll just pay the bills now,’” said Tom Davison, a financial planner in Columbus, Ohio, who has worked with several elderly people in his family and practice. “The changes may be fast or slow, but move at their pace.”
SAFETY MECHANISMS
There are also several ways to keep a watchful yet unobtrusive eye on a parent’s financial affairs, even if you don’t live nearby. Setting up automatic bill payments may be the most obvious way. For parents who want to continue paying the bills, allow them to write checks for services that won’t cause harm if the payment is late, and that you can easily remedy later.
Some major banks said they allowed customers to authorize a third party to receive statements — for mortgages, loans or credit cards — which makes it easy to spot a missed payment or unusual activity. (In some cases, the bank may require a power of attorney or notarized consent.) Long-term care insurers, like John Hancock and Genworth, also permit policyholders to have another person receive a notice if a bill is past due or if there is a lapse in coverage.
Other companies should follow that lead and make it easy to set up an automatic e-mail notification of a late notice.
LEGAL DOCUMENTS
Proper legal documents should also be in place. A durable power of attorney enables a person to step in and handle a parent’s financial affairs. Most banks are understandably wary of powers of attorney, given the room for fraud and abuse. So check with your institution about its requirements.
Opening a bank account in the name of a trust also gives one or more trustees decision-making and check-writing privileges. The same goes for anything else in a revocable living trust, where accounts and assets are titled to the trust. “Trusts like these can have two or more trustees at the same time and can be set up to operate individually or must act together — there’s all kinds of flexibility and can be written to respond to the particular circumstances of an individual,” Mr. Davison said. “Do they want checks and balances between an attorney and a kid? Want two kids to have to agree and both sign stuff?” Assets in the living trust have the added benefit of bypassing probate after the person dies.
It may be easier to simply add an adult child’s name to the account, but consult with an adviser to make sure it won’t interfere with the person’s estate plans.
SIMPLIFY AND SET ROUTINES
It’s less confusing for the financial caretaker and the elderly person to keep track of just a few accounts. So try to consolidate. Experts also recommend setting up routines and identifying the triggers that make the elderly person uneasy. For Mr. Davison’s elderly aunt, who had short-term memory loss, the trigger was the mail. As a former business manager who balanced her books to the penny, she was often overwhelmed when the mail arrived.
So Mr. Davison told her to open the mail every day and put it in a folder. Each weekend, he and his wife would visit and review the mail with his aunt, a routine that put her at ease. “See what the trigger points are, and try some ways to soften them,” he said. “You often can’t solve them, but you can soften them. And whatever was helpful three months ago may not be helpful now. It’s a progression.”
HIRING HELP
You obviously need to investigate any provider when dealing with the vulnerable and easily swindled, but there are several places to begin your search. AARP offers a money management program for lower-income people in some parts of the country, or, you can hire an accountant or another party to handle the finances. The American Association of Daily Money Managers is another option, and you can call to request someone who has experience with helping people with dementia.
There are also companies that cater to elderly people’s special needs. Wells Fargo Private Bank, which requires more than $1 million in investable assets, offers an Elder Services program. It will coordinate a variety of services, from dealing with medical claims, taking the cat to the veterinarian and paying the bills, while keeping a close eye on the accounts for fraudulent activities. The service is included in the bank’s investment management fees, which range from 0.80 to 2 percent of assets. Let’s hope we see more such services — and not just for the wealthy.
PLAN NOW
Ideally, all families should prepare for potential issues while everyone is still healthy. There are generally three questions families should answer, according to Ken Dychtwald, a gerontologist, psychologist and consultant. Who will handle the finances? What are the individual’s preferences on long-term care? And how will we pay for it?
“The biggest worry that people have about growing old is being a burden on their family,” Mr. Dychtwald said. “Ironically, if you don’t think about a game plan before it’s needed, then not only does it become a burden, but there is often damage that comes with it,” both financial and emotional.
My mother now says she believes the conversation about money matters should be a rite of passage of sorts, for everyone who reaches retirement. But it’s never too soon to have the talk.
Caregiving as a ‘Roller-Coaster Ride From Hell’Jane E. Brody : NY Times : April 9, 2012
More than 40 million women are the primary caregivers for a sick person, very often the man they are married to. Caregiving, after all, is a wife’s expected role, and most accept it perforce as a duty that offers precious time to express love and wishes, settle financial and legal matters, and right past wrongs.
When a caregiving wife runs into a friend, acquaintance or even a relative, the most frequently asked question is, “How is he doing?” Far less often is an inquiry made about the wife, who may be struggling to juggle a job and child care as well as patient care.
Under the best of circumstances, she faces disruptions in her usual work and social life, sleep habits, exercise routine, household management and financial situation. In addition to a loss of intimacy, she may be saddled with such unglamorous tasks as cleaning up bathroom accidents, servicing medical equipment and fulfilling challenging dietary needs.
And as one expert put it, for some wives, caregiving is “a roller coaster ride from hell,” with each day bringing new challenges, demands and adjustments. What outsiders see as a gift, the wife may be experiencing as “a dirty little secret,” Diana B. Denholm wrote in “The Caregiving Wife’s Handbook,” recently published by Hunter House.
In an interview, Dr. Denholm, a psychotherapist in West Palm Beach, Fla., said that the challenge is especially acute when the marriage was a rocky one to begin with. Husbands who were abusive when they were healthy can become veritable tyrants when seriously or terminally ill, she learned from wives she interviewed.
Pushed to the Brink
For example, a waitress, mother of three and grandmother had been married for 46 years to the man who was the love of her life, but also verbally abusive. He developed colon cancer and severe diabetes and had a stroke.
“I’m so angry when others offer to help him, and he pretends he’s so strong and doesn’t need their help,” she told Dr. Denholm. “When they leave, he expects me to wait on him hand and foot while he screams at me. He expects me to wait on him like I’m his servant, even though I’m the sole support of the family and work long, hard hours.”
Another woman, a schoolteacher in her 50s married for 20 years to a man dying of emphysema, told Dr. Denholm: “What really frosts me is that he caused this with his smoking. Now I have to deal with the results. I really hate it when he turns down help from other people and gets himself into physical trouble. Then along with everything else I’m taking care of, I get stuck taking more care of him plus fixing whatever it was he tried to fix.
“I do feel guilty about wanting this to be over,” she added. “But how much more can I take?”
Even husbands who had been loving, thoughtful partners before a life-threatening illness stripped them of their usual roles and dignity can undergo personality shifts that prompt their wives to wonder, “Whatever happened to the man I married?”
Dr. Denholm herself served as caregiver for 11 1/2 years for a once athletic, robust, intelligent and loving husband who suffered a horrific succession of ailments that included colon cancer, congestive heart failure, kidney failure, severe arthritis, gout, urinary tract infections, blood clots, erratic blood pressure, ac hoking disorder and Parkinson’s disease.
While she said she was able to cope with most caregiving demands, they eventually made it impossible for her to maintain her professional life. And she confessed to one abject failure: an inability to persuade him to stop driving, which he continued to do until two days before he died.
“I finally took steps to protect myself,” she said. “I forbade him to drive my car, and I refused to ride with him when he was driving.”
It is no surprise when serious illness or severe pain results in feelings of anger, helplessness and depression, all the more so when the illness is terminal and the afflicted person loses his sense of self. After many years as “the man of the house,” the sick husband is once again a child who must be cared for, often by the very person he signed on to protect.
“For men in particular, their ego and sense of self can be hit very hard when they can no longer do what they used to do,” Dr. Denholm said. “It’s safe to take it out on someone you love, not because you don’t love her or respect her, but because it’s safe.”
Coping Techniques
In her book, Dr. Denholm discusses a series of coping strategies that she developed with her husband during his long illness. The most important of these is to adopt communication tools that avoid red flags, accusations and self-pity, and instead “create expectations, agreements and understandings, including some that may involve agreeing to disagree,” she said.
“Never start with, ‘We need to talk.’ Besides being a huge red flag to most men, the statement reflects your need, not your husband’s,” she wrote. “Always use an ‘I’ statement — ‘I need,’ ‘I want,’ ‘I’d like to.’ ” And if an issue is too emotionally charged to discuss with the patient, she suggested talking instead to someone you trust and respect.
One tool Dr. Denholm found to be especially helpful is to create written understandings, some of which may need to be modified as circumstances change. The understandings might involve finances, individual responsibilities or issues to be avoided.
For example, the waitress, whose husband refused to review finances with her, came to realize it was pointless to keep asking. Instead, she ended the screaming and arguing by going to the bank, the Social Security office, the Veterans Affairs office and even the Legal Aid Society to determine her rights regarding what she and her husband owned.
Also helpful, Dr. Denholm said, is to avoid “enabling behavior — doing something for someone else that they should be doing for themselves.”
She wrote, “Co-dependence is the single biggest cause of our deepest discomfort,” causing irritability, anger, excess work, stress, feelings of guilt, and fights with sick husbands and relatives. She warned caregiving wives against acquiring a “martyr complex” to make themselves feel more important.
“Co-dependent no more,” she said, “is healthier for everyone.”
Dr. Denholm also suggested that always “putting on a happy face” can be counterproductive. “If we keep a lot of information private, most people will have no idea how bad it might be behind our closed doors.” Better to ask for help when help is needed.
Tips to Ease the Burden of Caring for a Spouse
In “The Caregiving Wife’s Handbook,” Dr. Denholm lists 50 dos and don’ts to help make the task easier, including these:
More than 40 million women are the primary caregivers for a sick person, very often the man they are married to. Caregiving, after all, is a wife’s expected role, and most accept it perforce as a duty that offers precious time to express love and wishes, settle financial and legal matters, and right past wrongs.
When a caregiving wife runs into a friend, acquaintance or even a relative, the most frequently asked question is, “How is he doing?” Far less often is an inquiry made about the wife, who may be struggling to juggle a job and child care as well as patient care.
Under the best of circumstances, she faces disruptions in her usual work and social life, sleep habits, exercise routine, household management and financial situation. In addition to a loss of intimacy, she may be saddled with such unglamorous tasks as cleaning up bathroom accidents, servicing medical equipment and fulfilling challenging dietary needs.
And as one expert put it, for some wives, caregiving is “a roller coaster ride from hell,” with each day bringing new challenges, demands and adjustments. What outsiders see as a gift, the wife may be experiencing as “a dirty little secret,” Diana B. Denholm wrote in “The Caregiving Wife’s Handbook,” recently published by Hunter House.
In an interview, Dr. Denholm, a psychotherapist in West Palm Beach, Fla., said that the challenge is especially acute when the marriage was a rocky one to begin with. Husbands who were abusive when they were healthy can become veritable tyrants when seriously or terminally ill, she learned from wives she interviewed.
Pushed to the Brink
For example, a waitress, mother of three and grandmother had been married for 46 years to the man who was the love of her life, but also verbally abusive. He developed colon cancer and severe diabetes and had a stroke.
“I’m so angry when others offer to help him, and he pretends he’s so strong and doesn’t need their help,” she told Dr. Denholm. “When they leave, he expects me to wait on him hand and foot while he screams at me. He expects me to wait on him like I’m his servant, even though I’m the sole support of the family and work long, hard hours.”
Another woman, a schoolteacher in her 50s married for 20 years to a man dying of emphysema, told Dr. Denholm: “What really frosts me is that he caused this with his smoking. Now I have to deal with the results. I really hate it when he turns down help from other people and gets himself into physical trouble. Then along with everything else I’m taking care of, I get stuck taking more care of him plus fixing whatever it was he tried to fix.
“I do feel guilty about wanting this to be over,” she added. “But how much more can I take?”
Even husbands who had been loving, thoughtful partners before a life-threatening illness stripped them of their usual roles and dignity can undergo personality shifts that prompt their wives to wonder, “Whatever happened to the man I married?”
Dr. Denholm herself served as caregiver for 11 1/2 years for a once athletic, robust, intelligent and loving husband who suffered a horrific succession of ailments that included colon cancer, congestive heart failure, kidney failure, severe arthritis, gout, urinary tract infections, blood clots, erratic blood pressure, ac hoking disorder and Parkinson’s disease.
While she said she was able to cope with most caregiving demands, they eventually made it impossible for her to maintain her professional life. And she confessed to one abject failure: an inability to persuade him to stop driving, which he continued to do until two days before he died.
“I finally took steps to protect myself,” she said. “I forbade him to drive my car, and I refused to ride with him when he was driving.”
It is no surprise when serious illness or severe pain results in feelings of anger, helplessness and depression, all the more so when the illness is terminal and the afflicted person loses his sense of self. After many years as “the man of the house,” the sick husband is once again a child who must be cared for, often by the very person he signed on to protect.
“For men in particular, their ego and sense of self can be hit very hard when they can no longer do what they used to do,” Dr. Denholm said. “It’s safe to take it out on someone you love, not because you don’t love her or respect her, but because it’s safe.”
Coping Techniques
In her book, Dr. Denholm discusses a series of coping strategies that she developed with her husband during his long illness. The most important of these is to adopt communication tools that avoid red flags, accusations and self-pity, and instead “create expectations, agreements and understandings, including some that may involve agreeing to disagree,” she said.
“Never start with, ‘We need to talk.’ Besides being a huge red flag to most men, the statement reflects your need, not your husband’s,” she wrote. “Always use an ‘I’ statement — ‘I need,’ ‘I want,’ ‘I’d like to.’ ” And if an issue is too emotionally charged to discuss with the patient, she suggested talking instead to someone you trust and respect.
One tool Dr. Denholm found to be especially helpful is to create written understandings, some of which may need to be modified as circumstances change. The understandings might involve finances, individual responsibilities or issues to be avoided.
For example, the waitress, whose husband refused to review finances with her, came to realize it was pointless to keep asking. Instead, she ended the screaming and arguing by going to the bank, the Social Security office, the Veterans Affairs office and even the Legal Aid Society to determine her rights regarding what she and her husband owned.
Also helpful, Dr. Denholm said, is to avoid “enabling behavior — doing something for someone else that they should be doing for themselves.”
She wrote, “Co-dependence is the single biggest cause of our deepest discomfort,” causing irritability, anger, excess work, stress, feelings of guilt, and fights with sick husbands and relatives. She warned caregiving wives against acquiring a “martyr complex” to make themselves feel more important.
“Co-dependent no more,” she said, “is healthier for everyone.”
Dr. Denholm also suggested that always “putting on a happy face” can be counterproductive. “If we keep a lot of information private, most people will have no idea how bad it might be behind our closed doors.” Better to ask for help when help is needed.
Tips to Ease the Burden of Caring for a Spouse
In “The Caregiving Wife’s Handbook,” Dr. Denholm lists 50 dos and don’ts to help make the task easier, including these:
- Don’t let your husband take advantage of you or be abusive in any way.
- Ask for help when you need it.
- Don’t assume roles and jobs just because somebody thinks you should.
- Recognize that he’s the one who is ill, not you, and that your journeys will be different.
- Realize that sacrificing yourself completely will not make him well.
- Speak up for yourself and take a hard line on safety issues.
- See the humor in situations and try to laugh rather than criticize.
- Learn relaxation techniques.
- Give your husband a whistle, bell or call button to help him call you.
- Take advantage of the time remaining and have fun with your husband however you can.
- Have fun yourself, even if he can’t participate.
- Stay active and social, and spend time with people who make you feel better.
- Take care of yourself by eating well, exercising and arranging a way to get needed sleep.
- Take breaks and trips to visit friends, offering your husband care alternatives during your absence.
- Get help if you become depressed, feel excessively guilty or angry, or fear becoming abusive toward your husband.
- Protect yourself physically. Don’t try to catch your husband if he’s falling. If you are injured, you won’t be able to care for him.
Avoiding Surgery in the Elderly
By Paula Span : NY Times : January 25, 2013
It may take members of our parents’ generation (and our own) a long time to get over thinking of hospitals as refuges of safety and operating rooms as harbingers of better days ahead. But it’s gradually becoming clearer that for the very old and frail, and for nursing home residents in particular, hospitals are places to avoid whenever possible, and surgery can become a source of danger in itself.
Even operations considered fairly routine in younger patients, like appendectomies, become high-risk for nursing home residents. “Something about undergoing anesthesia, the surgery’s physiological assault on the body, impacts older people much more than we think,” said Dr. Emily Finlayson, a colorectal surgeon at the University of California, San Francisco, and lead author of a recent study published in The Annals of Surgery.
In fact, the study, which compared mortality risks and subsequent interventions for four types of major abdominal surgery, found that even compared with adults of similar age who had the same number of chronic illnesses — but who weren’t in institutions — nursing home residents fared sharply worse.
Bluntly put, surgery is much more likely to kill them.
Dr. Finlayson and her colleagues used national Medicare claims and nursing home surveys to identify nearly 71,000 nursing home residents who had surgery from 1999 through 2006. They compared them with more than a million elders who underwent the same four procedures but did not live in a nursing home. The researchers chose operations frequently performed on older adults: removal of an infected appendix (appendectomy), removal of an infected gallbladder (cholecystectomy), surgery for a bleeding ulcer in the upper part of the intestine, or surgery for noncancerous colon diseases like diverticulitis or colitis. These are painful conditions requiring immediate decisions, as opposed to diagnoses like breast or prostate cancer, in which a patient and his or her family can take a few days to figure out the best course.
Typically, Dr. Finlayson explained, the surgeon gets a call from the emergency room, frequently at 3 in the morning: an 85-year-old nursing home resident is being admitted with acute appendicitis. The response is almost always: Prepare the O.R.
But after an appendectomy, 12 percent of nursing home residents died, compared with 2 percent of Medicare recipients who weren’t in nursing homes. Gallbladder surgery was also more dangerous: an 11 percent mortality risk for nursing home residents, versus 3 percent in elders who weren’t institutionalized.
The risk of dying rose sharply for the other two operations. For colon surgery, it was nearly a third for nursing home residents, and 13 percent for others. Ulcer surgery proved the most dangerous; 42 percent of nursing home patients died, compared with 26 percent of others.
Even when the researchers matched these two groups of patients by age and by the number of other diseases they had, those in the nursing home group (and in this study that meant long-term residents, not those in temporary rehab) were significantly more likely to die in each case. Just by virtue of living in a nursing home, “they’ve demonstrated they don’t have the strength and mobility to live independently,” Dr. Finlayson said. “They don’t have the energy and vitality” — in doctorspeak, they lack “physiologic reserve.”
But even those who survived surgery — and they’re a majority, in some cases a large majority — weren’t out of the woods. Nursing home residents were far more likely to undergo “invasive interventions” afterward; they required mechanical ventilators for days to help them breathe, feeding tubes inserted in their abdomens when they couldn’t eat, venous catheterization (known as a central line) to monitor their hearts. Each of these painful procedures presents additional risks, of course.
We know that a substantial proportion of older people who enter hospitals will never fully regain their physical or mental capabilities, even when the illness that brought them there is successfully treated. (More on this syndrome later.) These interventions, which typically also keep people in bed, even though getting out of bed is critical to their recovery, may help explain why.
“Surgeons are very resistant to hearing this,” Dr. Finlayson said. “We’re focused on 30-day mortality. If patients leave the hospital alive, that’s success. We don’t see what happens three months down the road.”
So here’s a key question family members can ask before the surgeon starts scrubbing, especially if their older relative is frail enough to require nursing home care: Is there any alternative to surgery we could try?
“We think of appendicitis as a surgical disease — you take it out,” Dr. Finlayson said. “But if you get appendicitis in England, it’s often treated with antibiotics, whatever age you are.” Gallbladder attacks can also be treated with antibiotics, or sometimes with a drain inserted under local anesthesia. A stent inserted by a gastroenterologist can relieve a bowel obstruction.
In each case, the treatment is less of an assault than surgery with general anesthesia. And if it doesn’t work — if a 24-hour course of intravenous antibiotics, which can be administered in the nursing home, avoiding hospitalization, can’t overcome the infection — surgery remains an option.
It might take a confident surgeon (because invasive surgery can provide protection against lawsuits, even if it’s hard on patients) and a persistent family to pull off this alternative approach.
Surgeons, like most other physicians, are trained to save lives. “But with older patients, there’s less length of life to protect,” Dr. Finlayson pointed out. “So the other variables become way more important: maintaining cognitive status, living independently, caring for yourself. Quality of life.”
By Paula Span : NY Times : January 25, 2013
It may take members of our parents’ generation (and our own) a long time to get over thinking of hospitals as refuges of safety and operating rooms as harbingers of better days ahead. But it’s gradually becoming clearer that for the very old and frail, and for nursing home residents in particular, hospitals are places to avoid whenever possible, and surgery can become a source of danger in itself.
Even operations considered fairly routine in younger patients, like appendectomies, become high-risk for nursing home residents. “Something about undergoing anesthesia, the surgery’s physiological assault on the body, impacts older people much more than we think,” said Dr. Emily Finlayson, a colorectal surgeon at the University of California, San Francisco, and lead author of a recent study published in The Annals of Surgery.
In fact, the study, which compared mortality risks and subsequent interventions for four types of major abdominal surgery, found that even compared with adults of similar age who had the same number of chronic illnesses — but who weren’t in institutions — nursing home residents fared sharply worse.
Bluntly put, surgery is much more likely to kill them.
Dr. Finlayson and her colleagues used national Medicare claims and nursing home surveys to identify nearly 71,000 nursing home residents who had surgery from 1999 through 2006. They compared them with more than a million elders who underwent the same four procedures but did not live in a nursing home. The researchers chose operations frequently performed on older adults: removal of an infected appendix (appendectomy), removal of an infected gallbladder (cholecystectomy), surgery for a bleeding ulcer in the upper part of the intestine, or surgery for noncancerous colon diseases like diverticulitis or colitis. These are painful conditions requiring immediate decisions, as opposed to diagnoses like breast or prostate cancer, in which a patient and his or her family can take a few days to figure out the best course.
Typically, Dr. Finlayson explained, the surgeon gets a call from the emergency room, frequently at 3 in the morning: an 85-year-old nursing home resident is being admitted with acute appendicitis. The response is almost always: Prepare the O.R.
But after an appendectomy, 12 percent of nursing home residents died, compared with 2 percent of Medicare recipients who weren’t in nursing homes. Gallbladder surgery was also more dangerous: an 11 percent mortality risk for nursing home residents, versus 3 percent in elders who weren’t institutionalized.
The risk of dying rose sharply for the other two operations. For colon surgery, it was nearly a third for nursing home residents, and 13 percent for others. Ulcer surgery proved the most dangerous; 42 percent of nursing home patients died, compared with 26 percent of others.
Even when the researchers matched these two groups of patients by age and by the number of other diseases they had, those in the nursing home group (and in this study that meant long-term residents, not those in temporary rehab) were significantly more likely to die in each case. Just by virtue of living in a nursing home, “they’ve demonstrated they don’t have the strength and mobility to live independently,” Dr. Finlayson said. “They don’t have the energy and vitality” — in doctorspeak, they lack “physiologic reserve.”
But even those who survived surgery — and they’re a majority, in some cases a large majority — weren’t out of the woods. Nursing home residents were far more likely to undergo “invasive interventions” afterward; they required mechanical ventilators for days to help them breathe, feeding tubes inserted in their abdomens when they couldn’t eat, venous catheterization (known as a central line) to monitor their hearts. Each of these painful procedures presents additional risks, of course.
We know that a substantial proportion of older people who enter hospitals will never fully regain their physical or mental capabilities, even when the illness that brought them there is successfully treated. (More on this syndrome later.) These interventions, which typically also keep people in bed, even though getting out of bed is critical to their recovery, may help explain why.
“Surgeons are very resistant to hearing this,” Dr. Finlayson said. “We’re focused on 30-day mortality. If patients leave the hospital alive, that’s success. We don’t see what happens three months down the road.”
So here’s a key question family members can ask before the surgeon starts scrubbing, especially if their older relative is frail enough to require nursing home care: Is there any alternative to surgery we could try?
“We think of appendicitis as a surgical disease — you take it out,” Dr. Finlayson said. “But if you get appendicitis in England, it’s often treated with antibiotics, whatever age you are.” Gallbladder attacks can also be treated with antibiotics, or sometimes with a drain inserted under local anesthesia. A stent inserted by a gastroenterologist can relieve a bowel obstruction.
In each case, the treatment is less of an assault than surgery with general anesthesia. And if it doesn’t work — if a 24-hour course of intravenous antibiotics, which can be administered in the nursing home, avoiding hospitalization, can’t overcome the infection — surgery remains an option.
It might take a confident surgeon (because invasive surgery can provide protection against lawsuits, even if it’s hard on patients) and a persistent family to pull off this alternative approach.
Surgeons, like most other physicians, are trained to save lives. “But with older patients, there’s less length of life to protect,” Dr. Finlayson pointed out. “So the other variables become way more important: maintaining cognitive status, living independently, caring for yourself. Quality of life.”
