I’m Jean Bandos, MSN, CNS, APRN, BC. I’m a gerontological clinical nurse specialist with vast experience in care management of the older adult. I’ve spent the majority of my career assisting the older adult and their families navigate the health care system. In my blog, I’ll share some eldercare resources and assist in spreading the word on “tips” for caregivers of aging parents.
To learn more about me, please visit our website.
Anyone who has dealt with an aging parent or a senior friend that has cognitive decline knows how hard it is to discuss those difficult topics such as driving, advance directives and/or their wishes to age in place. These conversations usually happen during a crisis situation, e.g. the senior has fallen and been admitted to the hospital,l or suddenly their car has a huge dent in the back end. As I discussed in my last blog, there is no easy way to begin discussions about the senior’s ability to drive when he/she has memory loss. It is even harder to conduct these conversations when you have not been involved with the senior on a routine basis. Whether it is regarding their driving ability or their end of life wishes, as an adult child you have to remember to preserve your parent’s dignity while assisting them to talk about their decisions.
If at all possible, do not have these conversations during a crisis. Plan a convenient time to have these conversations with your loved one. Remember that you want to keep the conversations positive- thinking of solutions; progressive- how the issue will be addressed over time; and productive- not argumentative. It is important to keep the senior engaged.
Decide beforehand who is best to conduct the conversation. This is a discussion for the family members, but a decision needs to be made. For instance, if it is regarding the senior’s driving skills, the person to deliver the message needs to be aware of how the senior is currently driving. Is the area of concern a one-time accident… or is it a daily roller coaster ride?
Decide on the best time to have these conversations. You want everyone to be calm, not filled with apprehension. You want it to be convenient for all of the people involved in the discussions. For instance, in regards to advance directives, you do not want to hold these discussion in a hospital room while waiting for surgery. The conversations regarding your parent’s wishes regarding durable power of attorney or health care representative should be held prior to any illness.
It is best to pick the topic of discussion and have it prior to the crisis. Regarding advance directives, the earlier you can have these conversations, the better. Everyone - no matter what age they are - needs to decide on their own health care decisions… especially their wishes if they become unable to make decisions for themselves. The financial power of attorney also needs to be decided before the senior has cognitive decline.
Develop a personal conversation plan for each topic that you would like to address and solicit professional support as needed. For example, if your parent has a relationship with a lawyer from drawing up their will, encourage your parent to talk with the lawyer about advance directives, including durable power of attorney. You may even help them set an appointment with their lawyer. Hopefully they will allow you to attend, but if not, ask them how it went and talk to them about your wishes.
There is no clear-cut right or wrong time to have these difficult conversations. The key thing to remember is to have the conversations before your parent is unable to have them.
Some good resources are Alzheimer’s Association’s website www.alz.org and the National Institute on Aging. Click here for the NIA’s Caregiver Guide for more tips on communication or visit http://www.nia.nih.gov/NR/rdonlyres/C2F11D41-E5FE-435D-9C9D-A3489319D4AD/6531/Caregiver_Guide307.pdf.
There is no easy way to confront your loved one about their driving skills – especially when they view it as their last means of independence. But yet we hear horror stories of older adults causing a terrible accidents. We wonder ‘will that be my parent? When do “I “ step in and take their keys?’ Then we ask questions and get answers like “just hide their car keys” or “tell them the car is in the shop and they will forget about driving!” You know, they don’t forget and they find those hidden keys…
Then we expect their physician to magically have the answer to this difficult decision. In reality, there are no easy decisions or ways to address this most difficult issue. But the Hartford Financial Services Group, Inc. and the MIT AgeLab conducted a research study and created a guide to help people dealing with this specific situation http://www.thehartford.com/alzheimers/.
The Hartford Brochure - “At the Crossroads” is a wonderful resource for anyone who is having conversations and/or thoughts about stopping a person with dementia from driving (http://www.thehartford.com/alzheimers/brochure.html). This guide was developed to assist people with dementia and their families prolong independence while encouraging safe driving. http://www.thehartford.com/alzheimers/
This guide provides suggestions for monitoring, limiting, and stopping driving while addressing the following areas:
• Why dementia and driving is a difficult issue
• Assessing concerns about driving behavior
• Monitoring driving behavior
• Easing the transition from driver to passenger
• Having positive and productive conversations
• Seeking help from outside sources
• Understanding how family relationships affect driving decisions
• Advice from caregivers who made this decision
The guide also covers many warning signs including but not limited to a decrease in confidence while driving; difficulty turning to see when backing up; easily distracted while driving; incorrect signaling; and scrapes or dents on the car, mailbox, or garage.
A key recommendation is to document and share with other family members and health care providers the frequency, type, and severity of accidents/incidents and any patterns of change. Remember that everyone has isolated incidents, but it is when there are patterns that conversations and decisions need to be made. However, if your loved one is confusing gas and break pedals or stopping in traffic for no apparent reason – it is time for immediate action.
These additional sites may also assist you:
You have documented your end of life wishes and informed your loved ones (click here for 5 Wishes advance directives accepted in 40 states). Now you have questions about finalizing your funeral plans. Where do you start?
First, you have to decide if you want the traditional full service funeral that usually involves a visitation (with the decision of open or closed casket), service, and transportation to the cemetery. Or do you want a direct burial or direct cremation (which occurs shortly after death)? If you do a direct cremation and/or burial, do you want a memorial service? Who would you like to plan the service? Remember, the service does not need to be at the time of cremation.
Once you have decided on your funeral plans, please discuss your wishes and any arrangements that you have finalized with your loved ones or with your attorney. The more documentation that you leave with your family, the easier it will be for them at the time of your death. There may be family members who would not abide by your wishes if they are not in writing - whether because of their religious beliefs or their own needs/beliefs. Some individuals who want to be cremated have family members who feel that if there is not a traditional visitation where you can say goodbye that there is no “closure” to the person’s life. Then there are those who do not want to see the body after death. By documenting your wishes, you will assist your family in abiding by and understanding your wishes.
Funeral providers are required by law to provide you with a price list of all services and charges that will be incurred. Many people prefer to prepay or designate a sum of money for payment of funeral expenses. Laws differ from state to state regarding protection of payments made directly to the funeral home. The Federal Trade Commission offers a list of questions to ask when you are considering funeral prepayment (click here or visit http://www.ftc.gov/bcp/conline/pubs/services/funeral.shtm). Websites such as the Better Business Bureau (click here to visit www.bbb.org) and Selected Independent Funeral Homes (click here to visit www.selectedfuneralhomes.org) can help guide you to reputable funeral providers.
Advance Directives and funeral planning are never easy topics to discuss... But having those difficult conversations and documenting your wishes will benefit not only you, but those you love.
Again, one great web site is the Federal Trade Commission's Consumer Guide to Funerals. It provides information regarding funeral planning, pricing of services, questions to ask, and information about your options. Click here to visit the site or go to http://www.ftc.gov/bcp/conline/pubs/services/funeral.shtm.
Do You Have Your Advance Directives Written??
Over the last months, I have had the opportunity to assist several families that were thrown into dealing with their loved one’s end of life wishes. Each family story is different, but the common theme was “the elder parent “ had not discussed nor written down his or her end of life wishes.
One father’s wishes were to not have CPR and to not return to the hospital if he had an exacerbation of congestive heart failure. From code status and hospital admission, these wishes sound easy. But since the elderly parent had not discussed these wishes with his health care providers and family, the family wasn’t able to fully advocate for his rights. When he had an exacerbation of his heart failure, the nursing home transferred him to the hospital. After being admitted, he had tests and treatments that prolonged his life. After several weeks, he died in the hospital. If he had discussed his wishes, named a health care representative, or created a living will, the family could have advocated for his wishes and prevented this last hospitalization.
It doesn’t matter what age you are… if you wait until the last days of your life to make others aware of your wishes, your wishes may not be carried out. Not because your loved ones don’t care, but because they will not have enough time to understand what you are requesting and be able to appropriately advocate for your rights. I cannot emphasize enough the importance of letting those close to you know your wishes and writing them down.
Have you had those conversations with your parents – with your children?
If these conversations do not happen, the end of life decisions become very difficult and many times will divide a family at a time when they should be together. Don’t let this be your family. Do your research- and ask the hard questions.
An excellent site to visit is Aging with Dignity. It will 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.
Another site is Partnership for Caring http://www.caringinfo.org/ and (1-800-989-9455). The Partnership for Caring has downloadable advance directives requirements for all 50 states, or one may call for advance directives documents.
There is never a good time – but anytime is the right time. Talk now.
National Healthcare Decisions Day aims to increase awareness about advance directives. While the initiative focuses on patients, all Americans should take the time to make their wishes known regarding health care. You should decide what treatments you do (or don’t) want to receive, and think about appointing someone to make these decisions and/or advocate on your behalf if you are incapacitated or unable to make your own decisions.
To find out more about National Healthcare Decisions Day, visit their website at www.nationalhealthcaredecisionsday.org.
National Healthcare Decisions Day is the perfect time for you to create your advance directives. My next post will focus on the importance of advance directives for individuals and their families.
See the Alzheimer’s Association’s website www.alz.org for more tips on communication.
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!
As the holidays come to a close, are you experiencing the holiday blues? Are your parents? While you where visiting your aging parents did you notice any signs of depression or mood changes? It is known that suicide rates increase over the holidays. But did you know that between 5% to 20% of persons over age 65 living in the community suffer from depression (2002, Primary Care Geriatrics)?
Depression is a common disorder among the elderly but is not a normal part of growing old. It is one of the diagnoses that continue to go untreated. There are many reasons for this, one being that physicians have the tendency to focus on illnesses affecting the body instead of the mind. Another key reason is that the older adult was taught to be independent and feel that they should take care of themselves and "their” problems. Your parent may feel that they should not “bother” their physician or you with their feelings of loneliness/depression. As the adult child, you may feel that you do not have the right to intrude on your parent’s privacy. But, if your parent has any of the common depressive symptoms such as irritability, frequent crying, loss of interest or pleasure, weight gain or loss (especially weight loss), insomnia, fatigue, decrease in ability to concentrate, feeling of hopelessness and/or suicidal thoughts, please assist him/her in making an appointment with his/her physician. If you can, go with them to the appointment and take a list of symptoms/ concerns to share with the physician. Reinforce that these depressive symptoms are treatable and that he/she deserve to feel better, to have more energy, and to continue to age in place.
One day I googled “depression in the elderly” and received 369,000 results- here are some resources that might assist in you in your search.
Resources:
The geriatric depressions scale is a self - administered scale that can measure depression in the elderly.
GERIATRIC DEPRESSION SCALE (GDS)
CHOOSE THE BEST ANSWER FOR HOW YOU FELT THIS PAST WEEK.
CIRCLE ONE (YES OR NO)
1. Are you basically satisfied with your life? Yes No
2. Have you dropped many of your activities and interests? Yes No
3. Do you feel that your life is empty? Yes No
4. Do you often get bored? Yes No
* 5. Are you hopeful about the future? Yes No
6. Are you bothered by thoughts you can't get out of your head? Yes No
* 7. Are you in good spirits most of the time? Yes No
8. Are you afraid that something bad is going to happen to you? Yes No
* 9. Do you feel happy most of the time? Yes No
10. Do you often feel helpless? Yes No
11. Do you often get restless and fidgety? Yes No
12. Do you prefer to stay at home, rather than going out and doing new things? Yes No
13. Do you frequently worry about the future? Yes No
14. Do you feel you have more problems with memory than most? Yes No
*15. Do you think it is wonderful to be alive now? Yes No
16. Do you often feel downhearted and blue? Yes No
17. Do you feel pretty worthless the way you are now? Yes No
18. Do you worry a lot about the past? Yes No
*19. Do you find life very exciting? Yes No
20. Is it hard for you to get started on new projects? Yes No
*21. Do you feel full of energy? Yes No
22. Do you feel that your situation is hopeless? Yes No
23. Do you think that most people are better off than you are? Yes No
24. Do you frequently get upset over little things? Yes No
25. Do you frequently feel like crying? Yes No
26. Do you have trouble concentrating? Yes No
*27. Do you enjoy getting up in the morning? Yes No
28. Do you prefer to avoid social gatherings? Yes No
*29. Is it easy for you to make decisions? Yes No
*30. Is your mind as clear as it used to be? Yes No
*Appropriate (nondepressed) answers = yes, all others= no... or count number of CAPITALIZED (depressed) answers
Score: _____ (Number of "depressed" answers)
Normal 5 +/- 4
Mildly depressed 15 +/- 6
Very depressed 23 +/- 5
________________________________________________________________
References:
1. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression rating scale: a preliminary
report. J Psych Res. 1983; 17:27.
2. Sheikh JI, Yesavage JA. Geriatric Depression Scale: recent evidence and development of a shorter version. Clin Gerontol.
1986; 5:165-172.
The Geriatric Depression Scale may be used freely for patient assessment according to the authors
http://depression.about.com/od/elderly/Elderly_Depression.htm
http://www.consultgerirn.org/topics/depression/want_to_know_more
http://nihseniorhealth.gov/depression/aboutdepression/01.html
The month of December is one of the most stressful times of the year and now you are the caregiver. You wonder how you will ever make it through this holiday season. Remember the most important thing is be kind to yourself. Take time to remember what is important to you. It could be simply preparing your favorite foods or holding on to that one tradition that brings a smile to your face. You do not need to do everything that everyone wants. Some tips for making it special for you and your loved one would be to invite people in small groups to your home, to dig out the old family photo albums and reminisce with him/her about special times from the past. Engage him/her “in a trip down memory lane” conversation. Tape the conversations, makes wonderful gifts for the grandchildren. Involve the family that is far away, set up a phone schedule so everyone gets to talk. Play soft music including some of the family’s favorite songs to help everyone relax. Simply take time to enjoy your time together.
Enjoy the season!
Additional resources for care giving are the Family Caregiver Alliance; http://www.caregiver.org/caregiver/ and the Alzheimer’s Association; www.alz.org
· An excellent resource regarding evidence based practice for nurses in clinical and educational settings is the Harford Institute for Geriatric Nursing, New York University College of Nursing http://www.consultgerirn.org/ . This site covers geriatric topics including but not limited to overviews, definitions, background information such as incidence, prevalence, assessments, assessment tools, and nursing care strategies. In dealing with fall prevention, as an example, the information that you will have access to is a general overview of falls, definitions, along with assessment tools and educational material. One tool that is shared is the Tinetti assessment tool for the older adults who can ambulate independently. The site also provides nursing care strategies, treatment protocols and management recommendations.
· Age related changes (such as altered visual acuity, decreased balance and muscle strength, hypotension, and changes in bladder function such as frequency and/or incontinence) increase the risk of falls. If you have a hospital based practice, you know that falls are the single largest category of incidents in an acute care setting and for people over 65 years of age, falls are responsible for one third of deaths (http://www.consultgerirn.org/).
· In dealing with the elder population, always remember to evaluate for the risk of falls and provide fall prevention education. Another resource for educational materials is the National Institute on Aging www.nihseniorhealth.gov .
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
http://www.nia.nih.gov/Alzheimers/Publications/caregiverguide.htm
Always try to remember to do you best to have enjoy the holidays and try to find some time for the holiday things you like to do.
I came across The Caregivers' Bible (Source unknown) and wanted to share it with you as the holidays are approaching.| 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 |
“Taking Steps to End Alzheimer’s” was extremely successful in Indianapolis. My Health Care Manager's Team stepped up and supported this event, not only financially but in the spirit of raising awareness. It is estimated that there are 4 million Americans with Alzheimer’s and that number is expected to grow dramatically impacting millions of caregivers across the country. What is one of the most important things for caregiver to do. You should identify Alzheimer’s disease as early as possible and take care of yourself. Remember the onset of the disease is gradual with loss of short-term memory, mood and/or personality changes. Your loved one may have difficulty finding the right word or not able to recognize objects, he/she may forget ordinary things like a pencil, turning off lights or the stove, closing windows, or locking the door. Be aware as a caregiver that this disease can cause emotional, psychological, and physical problems- causing social isolation for the caregiver as well as their loved one. Always remember, that to be able to take care of your loved one, you need first to take care of yourself. Identify your support network and stay connected with others. Several resources for caregivers are: The Alzheimer’s Association, www.alz.org ; education and referral center,s The Family Caregivers Alliance www.caregiver.org ; and the National Family Caregivers Association, www.nfcacares.org.
Eric Tinsley
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