When Parents Need Care

The Tipping Point: How Do I Know When My Parent Needs Advanced Care?

Recognizing and Managing Your Parent's Care Needs

By: Paula Tchirkow, MSW, LSW, ACSW

You’re home for the holidays, but something doesn't seem right. Your 83-year-old mother, usually meticulous about her hair and clothing, looks disheveled. There are stains on her sweater, and her hair hasn't been washed recently. More troubling, she seems to have lost weight since you visited a few months ago.

Always an independent woman, even after your father's death, she allays your fears by insisting that the cold weather got the best of her this year, and she's just a little behind in her chores. 

But when you check the refrigerator to grab to snack, you're startled by what you don't find. Aside from some milk, butter, and stale bread, there is little else in the refrigerator. A small stack of TV dinners sits in the freezer. Judging from the ice- encrusted boxes, you surmise they've been there a few months.

When questioned, your mother deflects your probe by talking about a hearty roast beef dinner she cooked "this week," which provided plenty of leftovers. But you can't find any evidence of the feast. In truth, the only thing in the kitchen that seems abundant is a towering pile of unopened mail.

The signs are there, if you are willing, and able, to read them. Your mother needs assistance.

It's natural for elderly adults, and their children, to be in denial about changing healthcare needs. No one wants to think about forfeiting independence, whether it's their autonomy or a loved one's. 

To be sure, many elderly adults and their spouses fight hard to mask the clues of a health breakdown, laughing off lapses in memory, or making excuses for a bad fall. Even without a charade, health and safety issues are not always easy to recognize, much less confront. 

This is always an unpleasant task, but the sooner you acknowledge and accept that a change in your parent's living situation is necessary, the better prepared you will be to manage the transition.

A Matter of Degrees

Some problems are easily fixed, and require little more than some forethought and ingenuity. For example, to ease minor depression brought on by loneliness, a caregiver can contact community or church volunteers that visit the elderly on a regular basis. Or bolster your mother’s memory by posting a pill-taking schedule on her refrigerator.

More complex problems, however, require additional consideration, and often the aid of professionals who have expertise in gerontology issues. 

To be sure, eldercare attorneys and geriatric care managers (GCMs) are a great resource of information, and often act as advocates for the elderly. More important, these professionals are adept at spotting the red flags that warn us that a change must made in a parent's care regime.

Some signals are crystal clear because they are punctuated by a crisis, like having to hospitalize your mother after a fall, or racing your father to the emergency room with chest pains. And in many cases, a parent's medical and safety needs will dictate whether your mother or father requires simple in-home assistance, or 24-hour critical care. 

But other signs are subtle: A mountain of unwashed laundry hidden in a bedroom, or example; or growing, yet unfounded, paranoia that is turning your once-active parent into a shut-in.

If you suspect problems, consider hiring a GCM to conduct an assessment of your parent's health and current situation. 

The GCM will also help you and your parent develop an objective care plan that fits the situation -- whether that's arranging for transportation to the grocery story, to managing all facets of placing your parent in a nursing home.

Review and Record

A GCM assessment is a thorough look at your parent's mental, physical, environmental, social and financial condition to determine their ability to remain safe while living alone. 

The assessment conclusions are valuable, mainly because the new information will help a GCM create a solid care plan. A good plan, says officials at the American Association of Retired People (AARP) "can result in fewer accidents and illnesses, a longer life, an improved quality of life and greater independence," for your parent.

Depending on the circumstances, assessments can range from three hours to several days. However all evaluations should include these basic areas of review: physical and mental health; medication use, activities of daily living; home and community safety; support system; appearance and hygiene; lifestyle; and finance.

The evaluation factors of the physical and mental health review should include any chronic conditions, such as diabetes or arthritis, or other diseases such as cancer or bladder control problems. 

The GCM should also be on the look out for other physical conditions, such as fractures, allergies, weight loss, blurred vision, hearing and balance problems or gum disease.

The mental health review should zero-in on psychiatric disorders, making note of a parent's treatment for depression, anxiety, Alzheimer or other types of dementia. 

Older adults should also be evaluated for their alertness, mood swings, disorientation, and forgetfulness. Even something as seemingly unimportant as a decrease in communication - such as a disinterest in reading, writing, taking telephone calls, or just conversation, should be noted. 

In addition, personal appearance should be evaluated in an effort to understand whether personal hygiene is becoming a problem.

Medication use should be evaluated on a basis of what drugs need to be taken, and the person's ability to take the medication as directed. 

Meanwhile, a review of daily living factors should take into consideration mobility, rising from a chair or toilet seat, shopping and prepare meals, or working around the house and drive safely. 

A GCM should also do a sweep of the neighborhood and home for safety hazards, to consider whether ramps or other adaptive aids are necessary. Indeed, the ability to avoid telephone and door-to-door frauds is also a safety concern, warns AARP.

A person's support system also should be detailed in a care plan, such as the names and contact information of family members, friends or neighbors that visit frequently or can provide assistance during an emergency. 

Don't forget to include a lifestyle review in the assessment. When creating a care plan, it's important to incorporate favorite activities and hobbies so the plan addresses the whole person. 

Favorite television and radio programs, musical instruments played, languages spoken, travel experiences, religious and spiritual background, accomplishments and social activities should be weaved into the plan.

Finally, a financial review should focus on short- and long-term considerations. Does your mother pay her bills on time, what is your father's monthly income, or how long will assets last? 

Insurance policies and legal documents should be reviewed also, to address issues such as, does your mother insurance plan cover in-home custodial care; does your father have a living will or trusts; and has the power of attorney been assigned?

The Next Step

Perhaps one of the most valuable services a GCM offers is expertise in managing your parent's transition away from total independence. The transition management is a delicate balance between physical and emotional issues, and having a guide to help navigate this potentially live-changing event often reduces anxiety --for you and your parent -- and keeps everyone focused on obtaining the best possible care.

Plans range in scope and goals, but should address both physical and emotional needs. 

If, for example, the plan calls for in-home adjustments, with the goal of making everyday living more simple and safe, think about the following: installing ramps or elevators where stairs present a problem; fitting bathrooms with grab bars, non-skid mats, night lights, and higher toilet seats; increasing the lighting to brighten dim areas of the house; placing often-used items within reach; clearing out clutter and loose wires-- and if possible, signing up your mom or dad for Tai Chi classes to improve their balance.

If warranted, consider arranging for in-home physical or occupational therapy to help speed a parent's recovery.

There are also tactical issues to address if your parent is moving from home to a long-term care facility. 

For example, make lists of all the required items that will be moved from home to the facility, and try to do as much as possible before admission. Have personal items set up in room when your parent arrives to help ease the transition. 

Make a second list with names and numbers of utilities and other services that have to be terminated, and send change of address notifications to assure that mail, as well as magazine and newspaper subscriptions, stay current. More important, make sure friends, family and neighbors receive change of address information to keep those cards and letters coming.

While tactical efforts smooth the mechanics of a transition, managing the emotional transition usually is more difficult and often draining. Advice from GCM on managing the emotional trauma typically focuses on two considerations: 

If your parent is still capable, involve him or her in every aspect of the decision making. Also, work hard to understand the transition from your parent's perspective.

Also bear in mind that fear of the unknown makes any situation more difficult, especially regarding a move from a home to a facility. Be proactive about keeping your parent informed, and answer questions thoroughly, and as often as they ask. 

Even if dementia is not the primary problem, the strain and confusion associated with moving into a long-term care facility can cause the elderly to forget. Make sure your mother or father is apprised of when the move is taking place, how it is going to happen (from home, the hospital, by ambulance, you will drive them), and who will be involved.

Also explain that the move might be sudden, as beds very often become available with very little warning. As a caregiver, arrange for your own support team that can be marshaled within 24-hours. Think through the admission day sequence and try to head-off confusion where you can.

To alleviate the anxiety associated with moving, you and your parent should spend some time at the facility before being admitted. This will help both of you become familiar with the staff and other residents, as well as become acclimated with the space. 

Try eating a few meals there, or participating in some activities before making the move. In some cases, a parent that's entering a new facility welcomes a "buddy" -- a current nursing home resident that acts as an orientation guide for the first few weeks. If your parent likes this idea, talk to the staff about arranging for a volunteer that would like to show your parent "the ropes."

If more than one family member is involved in the care of your parent, hold informal meeting, or phone each other to make sure everyone is updated on new developments. In addition, understand that even when siblings and other family members all agree that moving an elderly relative to a nursing home is the best option, everyone will handle the situation differently. 

There could be flare-ups of panic, guilt and anger that can easily deteriorate into arguments, and topple relationships. If troublesome issues about care or money seem to spin out of control, it may be best to call in a professional mediator, a family counselor or a GCM.

The best, first step to helping a parent remain safe and healthy is to recognize the warning signs before they fester and create a crisis. Yet identifying one sign doesn't necessarily mean that your parent needs immediate assistance. 

The more common occurrence is discovery of one red flag that leads to the detection of several others. When more than one of these red flags appears, it usually means your parent's care regime needs to be raised a notch. What should you look for? Here are some telltale signs:

• Unexpected discoveries. A talk with a neighbor, friend or minister often reveals mishaps that your mother doesn't discuss with you. For instance, that she suffers from fainting spells, repeated falls or perhaps has short-term memory lapses. Your mother could be trying to hide the truth, but it is just as likely that she doesn't recognize the danger or forgets the incident.
  
  

• Memory lapses. Don't be fooled by an elderly person's ability to remember things that happened 60 years ago -- such as what they wore to the high school prom. Even persons with significant dementia retain long-term memory. Memory loss can be a signal of chronic health problems, a chemical imbalance, or poor nutrition.
  
  

• Falls and in-home accidents increases. Falls can be a result of fragility, poor judgment, or a cluttered home. (Also, those damn scatter rugs that the elderly seem so fond of are dangerous, get rid of them.) Adapting a home to help an elderly person is a quick, easy answer.
  
  

• Empty cupboards and refrigerator, plus unexplained weight loss. This usually signals that your father is forgetting to eat or is unable to cook for himself. Also, reports from a doctor of anemia or dehydration could mean there is a nutrition issue.
  
  

• Piles of unopened mail. This includes unpaid bills, overdue notices, and un-cashed checks. It could mean that your mother is either overwhelmed by the constant inflow of mail, or can no longer differentiate between what is important, especially if there is memory loss. 
  
  Also look for rising bank account balances that could signal that she is not paying bills and letting direct deposit credits accumulate.
  
  

• Personal hygiene problems for normally meticulous individuals. This often happens after a hospitalization, but it can manifest at other times too. Some sure signs include stained clothing (can also stem from failing eyesight), wearing the same clothing (no clean clothes), going long periods without bathing. 
  
  Sometime, these symptoms are brought on by being physically unable to perform everyday tasks. However, other times, the problems are caused by memory lapses, such as forgetting how to work the washing machine.
  
  

• Behavior and mood change. Unexplained fear and paranoia, as well as chronic crying, all point to depression. However, older adults don't express the word "depression" because of the psychological stigma attached to the word. 
  
  They may instead talk about being "blue," "not right," "melancholy," or "afraid." A parent may also increase their complaints about physical ailments, becoming borderline hypochondriacs.
  
  

• Lack of interest in things she used to enjoy. Whether it's keeping house, going to the movies, playing bridge with friends, or reading mystery novels, if your mother seems to be dropping out of activities she used to enjoy, it could mean the start of a problem. 
  
  For one thing, she may not feel physically fit. Or, if she is cutting herself off from friends, it could mean that memory loss is making her feel awkward around her pals.
  
  

• Evidence of unsafe driving. You may notice problems with your father's driving while riding with him, or you may get reports from other family members or friends -- or worse, the police. Also, take note of an inordinate amount of dents and scratches on the car, which could signal impaired judgment. This is a sticky independence issue: proceed with caution.
  
  
  Paula Tchirkow is President of Pittsburgh-based Allegheny Geriatric Consultants which specializes in geriatric care management for aging parents and seniors planning for the future of their middle-aged children who have chronic illnesses. Paula is also a daughter of an elderly mother. Visit her website: www.caregivingadvice.com or reach her by email at Paula@caregivingadvice.com. 

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