Last week, I traveled from Indianapolis, IN to Litchfield, CT with my Mother to attend my sister’s wedding.  It was a long trip as we got to the airport early to deal with security, took a 2 hour flight to Newark and then rented a car and drove 3 hours to a Bed and Breakfast in Connecticut.  Along the way, we had to take our shoes off, give up our purses for a security inspection, and take escalators, elevators and a train in pursuit of a National rental car.  Everyone knows that traveling today is an exercise in both patience and logistics…b ut when you are accompanying a senior who is not steady on her feet and tends to be confused….. the patience/logistics requirements increase ten-fold.

Planning and advance preparation can help ease the journey.  In our case, I found it helpful to:

• Keep my Mother’s ticket and ID with mine, rather than risk her misplacing the paperwork.
• Consolidate all carry-on items in one bag (meds, jewelry, reading material), so there was less to keep track of during the trip.
• Dress for the security line….slip on shoes, no heavy jewelry, easy to remove jacket.
• Bring an extra sweater, as most airports are freezing.
• Pack snacks in case of airline delays, missed meals and long wait times.  The food court can be a long way from the assigned gate – a walk a senior is not up to.  If a senior has diabetes or a loss of mobility, packing snacks is essential to avoiding missed meals or long walks to the food court.
• Request a wheelchair or flag down a motorized cart to assist with transportation from gate to gate, if necessary.
• Stop when the senior gets tired and sit for a few minutes.  The airport pace is very difficult for a senior to keep up with.  This is especially true if your loved one has a loss of mobility.
• Limit information and do not provide it all at once – just focus on the next step and explain to the senior.  Discussing the entire itinerary i.e. we are catching a plane, then renting a car, then driving to Connecticut... is too overwhelming.
• Remember that the crowds, noise and fast pace of the airport can contribute to a senior’s confusion and anxiety.  Try to buffer them as much as possible by walking so that they are close to the wall and you are on the outside to take the bumps as people push past you.
• Be sensitive to their fears – dementia may cause even seasoned flyers to feel nervous about flying.
• Enlist help – ask someone else to accompany you to help with luggage, logistics and provide moral support.
• Enjoy the senior’s sense of wonder along the way – for them, a plane trip is a rare and exciting event. 

In summary, traveling with a senior should not be taken lightly.  Advance planning is key to ensuring a safe and stress-free trip for both caregivers and seniors alike. Be prepared, be patient and always remember that seniors will need extra special care and attention during the trip.

To make effective use of any set of tools you need to combine them with process.  In the case of caring for aging parents, the process is something you have to repeat over and over.  The situation changes, health conditions like diabetes or cognitive concerns change, needs and desires change, and all of these play in to the decisions about the next course of action.

At My Health Care Manager we have defined, detailed and implemented processes at all levels of service delivery - over 100 in all.  These include detailed flows, processing narratives, measures, entry and exit criteria, responsibility identification, and more.  At the core, however, these processes all revolve around this simple cycle.

If you are caring for a senior, consider adopting a process like this one and implementing changes in the top 3 (or fewer) areas of concern in each iteration.  Clearly, trying to change too many things at once can actually be counterproductive.  Any of us, especially if we're sick, depressed, or struggling with cognitive decline, can only impact a small number or areas at one time.

Understanding that this is a cycle with re-evaluation can help manage the sometimes overwhelmingly long list of things needing attention.

As we entered into spring, the presidential candidates continue the health care debate.  The real issue is that the US has an aging population.  By 2030, the number of adults age 65 and older will nearly double to 70 million. With twenty percent of the Medicare population having at least five chronic conditions (e.g. hypertension, diabetes, arthritis), the question remains: How do we care for these elders? 

Geriatrics is a growing specialty where physicians, nurses, social workers and other health care providers receive special training dedicated to improving the health, independence and quality of life of all older adults.  Geriatricians are physicians who are experts in caring for older persons; they are initially trained in family practice or internal medicine and then complete at least one additional year of fellowship training in geriatrics. They have the expertise to coordinate services among multiple specialty care providers.  For more information on the profession, visit the American Geriatrics Society website at http://www.americangeriatrics.org.

A geriatrician will coordinate a health assessment for older adults with the primary goal of encouraging and promoting wellness and independent function. The health assessment will include an interdisciplinary team approach to the physical, emotional, cognitive, functional, and medication status of the older adult.  If you would like to locate a physician in your area who is sensitive to the special needs of older adults, you can submit your request by completing a form on line located at http://www.healthinaging.org/public_education/physician_referral.php  or contact a geriatric care manager in your area.  To locate a local geriatric care manager, visit http://www.caremanager.org/.  In addition, telephonic geriatric care management services are now offered by My Health Care Manager.  To learn more, visit our website by clicking here.

Even though Mother was safe and secure in Independent Living (IL) in a Continuing Care Retirement Community (CCRC), we quickly realized that managing her prescription and over-the-counter (OTC) medicines was a challenge of its own.  With 10 prescription medicines and 4 OTCs, the variables of continuing supply with many expirations and prescription renewals combined with generic vs. brand names, dosages and time-of-day preferences were an overwhelming task for her … and her caregivers!  Fortunately, we devised a Weekly Schedule and medicine reconciliation program that allowed her to manage her own meds (with our assistance) that has now become a My Health Care Manager computer-based decision aid.  However, loading her pill tray every week and managing the time for her diabetes blood sugar tests and consumption of the pills became (and remains) an ongoing challenge.  Until becoming exposed to the issues of polypharmacy and older adults, I didn’t understand that normally-prescribed medicines and dosages affect many seniors differently – sometimes even causing symptoms such as confusion and loss of balance.  Even multiple medication regimes that were tolerated in the past can at any moment cause problems or unwanted symptoms.

When trying to get my hands around the multiple medications challenge, it became clear that no single health care provider had information on everything that was being taken by Mother.  Each knew what he or she had prescribed, but the rest of their knowledge was based on answers given to the common question, “What medicines are your taking?” at office visits.  Often confused over generic vs. brand names, dosages, and omitting OTC products, older adults often can’t be counted on to correctly answer this important question.  In developing My Health Care Manager’s suite of decision aids, we added a letter that the senior can choose to send to all of their health care providers (or only to the ones they designate). The letter lists the providers, their prescribed medicines, and any other OTC products being taken by the senior.  Several doctors have remarked that this simple summary of information is not available from any single source in our health care system.  You might try this important task on your own if you are immersed in eldercare.  We’ll have more on managing medicines in my next blog.

For the New Year I would like to share some resources and various sites that are useful whether you are looking for assistance in locating elder care services or trying to find specifics regarding geriatric health care.

Where you aware that the National Institute on Aging provides publications and other materials such as “Age Pages that address healthy aging, caregiving and specific topics such as dementia, diabetes and tips on medications.  Call 1-800-222-2225. or visit web www.nih.gov/nia.  Majority of their information is provided free of charge.  Other government sites are the Administration on Aging www.hhs.gov  or for the official governmental site for those who have Medicare http://www.medicare.gov

Some of the associations that share geriatric information are the American Association of Retired Persons  www.aarp.com   American Geriatrics Society , www.americangeriatrics.org and caregiver alliance www.caregiver.org

For end of life issues – Aging with Dignity is an excellent site to assist you in addressing those hard to discuss topics ( http://www.agingwithdignity.org). Aging with Dignity is a non-profit organization that was established to provide practical information, advice and legal tools you need to assist you in identifying and documenting your wishes and those of your loved ones.  The document called the “Five Wishes” is legally valid in 40 states  you can obtain a copy at http://www.agingwithdignity.org/5wishes.html

As we meet the challenges that 2008 will bring – I will continue to provide tips and resources to assist you in navigating the health care system and meeting the needs of your aging parents.   

Happy New Year!  

This week marks the 10th anniversary of the "Web Log" ... the genesis of the "Blog".  Of course, sharing ideas over the internet goes back to the dawn of the net itself.  The original idea of the then government sponsored network was to connect academic institutions and government agencies for the purpose of research and collaboration.

The Blog came along originally as a way to share information about where the "blogger" had been on the internet that day and what they had experience.  It quickly became an on-line diary of sorts.  This created the "stickiness" of the concept which since evolved in that dimension and many more.  

For My Health Care Manager the concept has been extended to caregivers helping aging parents and even seniors looking to improve the health and well-being.  Take a look at the blogs listed here - you'll find information on all of the most common heath challenges facing seniors and their families.  Some examples include falls, home safety, dementia, congestive heart failure, diabetes, and many more.

Having access to key thoughts on these challenges is valuable, but even more valuable is the key blogging concept of providing direct feedback to the author.  If you have a question of a comment on an article you've read, don't hesitate to use the "Comments" link right below the posting.  You can read comments and responses from others and best of all ask your question directly. 

If you don't see an article on the subject you're most interested in, post your question as a comment to the top entry in the Blog.  We'll answer the question in a future blog, comment, or email.

A recent study published in the Journal of the American Medical Association by John Robbins, M.D. et al identifies an algorithm for identifying the five year risk of a hip fracture in postmenopausal women.  While the study is limited to one gender and further studies are needed to assess the implications and use of the algorithm, it underscores the importance for seniors to remain vigilant in maintaining their mobility and maximizing their safety.

The factors affecting the 5 year risk are as follows: “age, self-reported health, weight, height, race/ethnicity, self-reported physical activity, history of fracture after age 54 years, parental hip fracture, current smoking, current corticosteroid use, and treated diabetes.” 

What can you do? 

• Be aware of the factors, and do your best to engage in health activities like remaining active, exercising, and refraining from smoking. 
• Do a home safety check.  Remove items like throw rugs that are easily tripped over, resulting in a fall, and possibly a fracture. 
• Check with your doctor to assess your risk for a hip fracture and work with him/her to decrease your risk.

For a home safety checklist from the CDC, please click here.
To read more about the study published in the JAMA, please click here.

If you live in a part of the country where season is changing to ice and snow, I am sure your are worried about that icy accident where you could fracture your hip. Just remember to be careful and do not take chances on icy and/or wet surfaces.  A simple fall can have a dramatic impact on your life.

But remember that falls happen everyday, even on beautiful days.  As you age, your sight, hearing, muscle strength, coordination and reflexes begin to change. You may notice that your balance may be off or that you lose mobility.  If you have diabetes or heart disease, your balance can be affected and some of the medications that you are taking can cause dizziness. Then there is Osteoporosis, where your bones become thin and break easily.  All of these things can contribute to your first fall- creating that change in your life that affects your overall well-being.  So how do you take care of yourself to remain active and maintain your quality of life?  Here are a few simple tips:  

Ø      Contact your doctor and ask him about Osteoporosis and a bone density test that will tell you how strong your bones really are or if you need medications to help strengthen your bones.  

Ø      Plan an exercise program that is right for you. Always talk with your doctor before beginning your exercise program  

Ø      Review your medications with your pharmacist and/or physician for any side effects. 

 Ø      Stand up slowly – this will prevent you from feeling faint if your blood pressure drops too quickly  

Ø      Wear shoes and socks (low-heeled shoes that fully support your feet).  

Ø      If you have handrails in your home, make sure they are safe and use them.  

Ø      Pick up your throw rugs.  

Ø      Don’t take chances.  

Ø      Make your home safe by making sure you have good lighting and keeping areas tidy.  

Ø      In your bedroom, put your telephone next to your bed.  

Ø      Keep night lights on.   

Some additional fall prevention resources are:  

Ø      The Older Consumers Safety Checklist is free by contacting the U.S. Consumer Product Safety commission at www.cpsc.gov  

Ø      National Institute on Aging provides Age Pages on osteoporosis, home safety and fall  prevention tips at www.nia.nih.gov    

Today, November 14, is World Diabetes Day- the first ever!  A resolution passed in December of 2006 by the United Nations created an annual United Nations Day for World Diabetes starting in 2007.  For more information on the day of recognition, please visit the World Diabetes Day homepage.

It just so happens that two recent studies have highlighted some of the issues affecting diabetics...

A diabetes study in the Journal of General Internal Medicine (set for the December issue) found that of diabetic seniors, 92% have at least one other chronic condition.  Even more worrisome: almost 50% have three or more other chronic medical conditions in addition to diabetes.  Seniors often make managing their other chronic conditions a priority and fail to properly manage their diabetes.  Many of the other conditions in seniors were triggered (or aggravated) at least in part by their diabetes.  The study stresses the importance of holistic care and taking a 'whole-person approach' to disease management. To read more about the study, click here.

For families, diabetes can affect multiple generations.  It's important to take preventative measures like eating a healthy diet and being active.  Once diagnosed with diabetes, it's important to take care of yourself!  A recent study in Australia suggested that more than 60% of those diagnosed with diabetes are wearing the wrong size shoe.  The wrong size of shoe could increase the chance of having foot problems, which (especially for diabetics) can even lead to amputation.  Please encourage those with diabetes in your family to have their feet properly measured to ensure they are wearing shoes the correct length AND width for their feet.  For more on this study, please click here.

It's important for seniors to work with their health care provider or geriatrician to manage their diabetes.  As the first study finds, many seniors have other chronic conditions in addition to diabetes.  For these seniors and their caregivers, a geriatric care manager or eldercare manager can partner with them and their other health care providers to approach their disease management in a more holistic fashion.

In my last blog, I focused on memory loss that is typically associated with aging. As we all know, aging starts as soon as we are born.  But did you realize that most older adults are healthy and engaged in normal activities. According to Hartford Institute for Geriatric Nursing approximately 78% of  65+ are healthy. For additional statistic and resources visit Hartford Institute for Geriatric Nursing’s new site http://www.consultgerirn.org/resources .   Today, I would like to talk about living a healthy lifestyle as we age. Genetics plays a pivotal role in our health outcomes but we need to acknowledge that environmental conditions and the quality of health care that one receives strongly influences the aging process. Aging is a combination of both genetic and environmental factors. Everyday we witness this. A person who has inherited high cholesterol from his/her parents but chooses to continue to smoke which impacts his/her risk factor for heart disease. This puts him/her at a risk for a heart attack. So what are some key behaviors for maintaining a healthy lifestyle while we age: not smoking, drinking alcohol in moderation, exercising, getting adequate rest, eating a diet high in fruits and vegetables, coping with stress, maintaining a positive outlook on life.  Another import component is to keep up with your health screenings.  It is not uncommon during a geriatric assessment to find out that breast cancer runs in a woman’s  family, the mother and sister both died for breast cancer, but the surviving sister who is 70 has not had a mammogram in years, even though Medicare pays for it.  It is important to always talk to your physician and schedule your necessary screens.     As a start, review the health care screening activities listed below.  You may want to use the following tool to keep track of your screening activities and share it with your physician.  

Recommendations		Date Completed
Yearly  **	Flu Vaccine
> 65  1 dose **	Pneumococcal Vaccine
1 booster dose q 10 yrs *	Tetanus Vaccine
> 60  -- 1 dose *	Shingles Vaccine
> 65  q 1 -2 yrs  *	Mammogram/Clinical Breast Exam
Q 3yrs  - can be stopped > 70 *	Pap Smear
At least 1 x after age 65 *	Bone Density Test
At least once in people with HTN or Hyperlipidemia *	Diabetes Mellitus Screening
If diabetic – q 3 mo	Hemoglobin A1c
Yearly if HTN, Diabetes etc. *	Eye Exam
Yearly *	Hearing  Exam
> 50 yearly then q 5yrs/10 years *	Colon Cancer Screening (FOBT, sigmoidoscopy/colonoscopy)
At least Yearly *	Blood Pressure Screen
> 65 screen  - q yr	PSA ( male)
Q 5 yrs/ more often if CAD, DM, PAD, or Prior Stroke	Lipid Disorder Screening
Other Screening Activites

 CDC Recommendations & US Preventive Services Task Force (USPSTF) * USPSTF (AGS: Geriatrics at Your Fingertips 2007)  Remember that a geriatric care manager can always assist in you assessing your dimension of well-being and in designing an action plan to maintain a healthy lifestyle while you age.    

With the Hollywood writers strike, some of those writers may be treating this time as a much-needed break from the daily grind, as they are only required to work 20 hours a week manning the picket lines.  Unfortunately, as most caregivers know, caring for aging parents is a full-time job.  And this is often on top of the full-time hours put in at a paying full-time job.  It can often be tiring, emotionally and financially draining, and very hard.

 

For family caregivers that are in need of a well-deserved respite, don’t hesitate to ask for help...  Don’t hesitate to take a well-deserved break!  Accept the help that your family and friends offer or hire outside help to give you a few hours (or a few days) of help each week.  Caregiver burnout is real – especially for working caregivers.  Understand that you must first take care of your own health, and that asking for help or accepting help may make you a better caregiver in the long run by reducing your stress levels and allowing you some respite.

 

Providing care for a loved one, organizing their health care and managing appointments, checking on their home safety, spending time with them to prevent isolation, AND doing all of the other duties that come with the territory is extremely time consuming, sometimes confusing, and sometimes stressful.  If you find yourself ‘in over your head’ or just needing some advice, you may consider enlisting the help of a geriatric care manager.  Geriatric care managers can help facilitate communication within your family, give you advice on avoiding caregiver burnout, and offer tips and tricks to help you manage the health conditions of your loved one (whether it be helpful ways to remind your mother with diabetes to check her blood sugar, tips on communicating with a senior suffering from Alzheimer’s, ways to improve your father’s quality of life or help manage your uncle’s arthritis, or a better way to manage the multiple medications prescribed to your grandmother).

Memory loss is typically the first sign of dementia, but what is dementia? When most people hear dementia they think of Alzheimer’s.  Alzheimer’s disease is the most common type of dementia. But there forms of dementia, such as vascular which affects approximately 15 -25% of dementias.  With vascular dementias the mental function is generally damaged by multiple small strokes and unlike Alzheimer’s, it usually appears suddenly.  Risk factors for vascular dementia include high blood pressure, high blood fat, diabetes, smoking, and old age. Vascular dementia is also more common in men than in women.

Dementia simply is that there is a problem with the brain that makes it hard for a person to remember, learn and communicate. As the dementia progresses the individual may have disruptive behavior and others. Remember with the first signs of memory loss, contact your primary care physician. If you are unsure of what questions to ask your physician, contact a geriatric care manager such as My Health Care Manager, www.myhealthcaremanager.com who will assist you in preparing for a discussion with your physician.   For more information on the types of dementia contact the American Geriatrics Society.  www.healthinaging.org . 

I remember when my mother was struggling with health problems toward the end of her life.  She had a half a dozen doctors and a league of other health providers all trying to help manage diabetes and congestive heart failure.  As a result she was on 28 prescription medications and supplements.  Mom understood how important it was to keep track of all these for her health care.  She carried a note paper hand written on both sides listing everything she was taking.  I watched her take it out and show each health provider in turn.  The problem was you’d have thought this little slip of paper was the Dead Sea scrolls.  She didn’t want to let it out of her sight because it was her only copy.  Being hand written in mom’s distinctive cursive, it was also a bit like reading ancient Aramaic.

 

With all the tools and technologies available today, we can do better.  Our aging parents should have a copy of their medications and other key medical information for every health provider they encounter.  This information should be printed clearly and verified.

Geriatric care managers can help collect and track this kind of information, and you can do it yourself, as well.  In the coming weeks I'll explore key components in building a Personal Health Record.  Such a record can make a dramatic difference in the quality of geriatric care.