**The following post is authored by Natalie Langley, MSW.  She is working on SCANS (for more on SCANS, please see Eric's blog by clicking here) and will be a 'guest blogger' from time to time.**

Moving older adults from their homes to assisted living can often be a challenging move and an adjustment; after all, any move is an adjustment for all of us and can create feelings of stress.  Assisted Living Facilities are designed for those who need extra help in their day to day lives, but do not require 24 hour skilled nursing care.  The older adults moving to an assisted living facility may feel they are losing their independence as they move to a place that will help them with their care or with household chores.   However, there are several things families can do to ensure their loved ones have a smooth move.   After determining the services they may need assistance with (dressing, bathing, housekeeping chores, etc), obtain a list of assisted living facilities nearby.  This list can be found at www.alfa.org or in a local phone book.  Include the older adult in this decision making process.  This will help to empower them and allow them to know they are a part of their health care decisions.  Next, schedule a time to view the assisted living home and take a tour.  Talk with the staff and the residents to see how they enjoy being there.  Pay attention to what is going on; do they have activities going on the main gathering room?  Do they ever go on outings or go shopping?  If so, how often?  Are the residents out and about or is it quiet in the building and many are in their rooms?  Ask to get a menu; what foods are served?  Do they have substitutes if there is something on the menu residents do not like?  For a complete checklist on things to ask and consider when visiting an assisted living facility, please go to the National Center for Assisted Living website at http://www.longtermcareliving.com/assess/al/assisted8.cfm. 

Once a place has been decided on, families can be involved in many ways to help make this a smooth transition for their loved one.  First, help with sorting, packing up boxes, labeling which room the box goes in, etc.  This will help reduce stress when moving day comes.  Listen to how they would like for you to help.  Stay positive and smile.  This will help ease the stress for the older adult.  If they sense you are nervous and stressed, they will pick up on that and may begin to feel that way if they are not already.  It is important to remember that these feelings usually will lessen after the move is complete and they begin to settle in.  Give them time to adjust.  Offer to help hang up pictures, etc. around their room to help make it “home-ier”.   Participate in activities with your loved one while there or eat dinner with them one evening.   Try to keep the routine consistent; if you always visited them on Sundays and Wednesdays when they lived at home, keep that schedule.  Remember, the person has not changed… only their address has.   For more information on assisted living facilities, please visit www.alfa.org.

I'm going to cheat just a little bit and pre-announce to my blog readers that SCANS Version 1.0 is about to go into production release. 

This is the Knowledge Repository Edition of SCANS.  It provides Health Care Managers at My Health Care Manager and our Affiliates with a comprehensive knowledge base of best practices in geriatric care. 

It contains information on all of the most common problem areas encountered when caring for aging parents.  More importantly it provides concrete geriatric care solutions, step by step actions, and powerful, practical tools for implementation.    Some examples of the issues addressed by SCANS include:

• Behavioral Issues
• Caregiver Support
• Cognitive Issues
• Family Communications
• Continence Problems
• Emotional Concerns
• Environmental Issues
• Information Management
• Intellectual Engagement
• Medication Management
• Nutritional Needs
• Pain Management
• Prevention/Wellness
• Provider Coordination
• Service Coordination
• Social Support
• Spiritual Well-being
• and many more

Our Director or Research, Jean Bandos, puts it this way:

"My Health Care Manager is in the process of developing an advanced technology Knowledge Management and Decision Support System that will change the way geriatric care management is delivered. This system is directly concerned with the caregiving challenges of the senior and their family ...  (this) Knowledge  management and Decision Support System will assist the Health Care Managers in delivering complete, comprehensive, and predictable services."

Our Research and Development team is particularly proud of delivering this first version to commercial use in less the 4 months of receiving a major grant from the Indiana 21st Century Research and Technology Fund of the Indiana Economic Development Corporation.

More advances are in the works...

Since I don’t have a healthcare background, I had a very limited understanding of physical therapy.  I thought it was only “prescribed” after an injury or surgery to help with rehabilitation.  I didn’t realize it could be “prescribed” to treat on-going issues often faced by seniors, such as loss of mobility or  balance deficiencies.

We became concerned when my Mother became increasingly unsteady on her feet and had difficulty getting up from a chair.  We thought these symptoms were signs of progressing disease or advancing age and “came with the territory.”  When we shareed these concerns with my Mother’s gerontologist, he ordered a physical therapy evaluation and three physical therapy sessions a week to increase her mobility.  My sister and I were thrilled to learn that exercises could help and that my Mother could be taught techniques to help her get in and out of the car and move around more safely and easily.

Mother has been attending her “exercise class” for about two weeks.  She told me she likes it and that they do most of their exercises while sitting in a chair… so it is not too difficult.  We are thrilled she is paying attention and participating.  Earlier this week, I took my Mother out to dinner.  We were seated in a long, low booth.  As we went to leave, I offered my hand to my Mother to help her up. She looked at me and shook her head and said “No, I need to use my legs.”  And I watched in amazement as she positioned her feet and pushed up with her legs and got out of the booth.  We both reacted with big smiles – because she had “done it herself.”

The My Health Care Manager's Client Portal serves as a communication platform for families caring for aging parents. It provides easy access to information like:

• Schedule of care events (e.g. medical appointments, therapy, geriatric care visits)
• Medical issues (e.g. Alzheimer's, arthritis, incontinence, congestive heart failure, diabetes, COPD)
• Health provider contact information and specialties
• Medication list including dosage, frequency, prescribing physician, and other specifics
• Recent Hospitalizations
• Client contact information
• Updates on key issues of aging such as Caregiving, Advanced Directives, Living Independently, Family Communications, Depression, and more
• Resources
• and more

It also supports secure, private interactivity with the Health Care Manager providing geriatric care for the family using tools like a discussion board, contact logs documenting visits and phone conversations, and posting of care goals like improving home safety, reducing isolation, improving depression, improving mobility, supporting treatment plans, and so on.

In addition to general communication sites like those mentioned in my previous post, family communications can be aided by a geriatric care manager.  The geriatric care manager is actively involved in the day to day care.  As such they often serve as a communication bridge between a variety of caregivers (such as home health providers, companion services, or home aids) and the family.

At My Health Care Manager our Health Care Managers use technology to help with this communication.  Some of this is done with simple reports or other outputs from our case management system that help to plan and organize the activities of the visiting agencies helping with eldercare.

A more advanced tool used by our Health Care Managers is the client portal.  This is a special purpose portal that allows authorized family members to view key data about their loved one.  It also provides a discussion board and other communication capabilities between the Health Care Manager and all the family members authorized to view information.  Caregivers can also provide updates regarding upcoming appointments or other events and even updates to the Personal Health Record such as prescription drug changes.    One of the favorite features for families is the posting of Contract Logs showing the most recent direct activities with the Health Care Manager and their loved one.  Instead of wondering what went on the doctors visit yesterday or relying on sketchy details from mom or dad the portal user can read the Health Care Manager's firsthand account.

This week, one of our fellow Health Care Managers, Jeannie Keenan, was interviewed and featured on the New York Times' New Old Age blog in a post titled "How to Make a Better Sandwich."  The article focuses on the "sandwich generation"- adults today caring for aging parents while also juggling work and their own families.

To read the article, click How to Make a Better Sandwich.

Years ago when I went away to college, I gave my Mother a small plaque with the following saying:

“Children hold their Mother’s hands for awhile and their hearts forever.”

This plaque has been carefully hung in 4-5 residences, following my Mother as she moved and downsized during the last 30 years.  Today, it has “pride of place” in her bedroom and hangs near the door. 

Yesterday, I was visiting and helping my Mother get dressed and ready for the day.  She noticed the plaque and said it should be revised to read “Mothers hold their children’s hands” and insisted that she would not know what to do if I wasn’t there to help her. Sadly, she recognizes that she is “slipping” and wonders aloud what is wrong with her.  She asks me why she can’t remember the day or date and why she can’t decide what to wear and why she can’t find her purse.  I reassure her that she is doing fine.  I tell her it is common to forget a few things when you get older and explain that the Doctor recently adjusted her medicines which could be causing some confusion and memory loss. 

Later, I can’t stop thinking about our conversation and realize that “role reversal” just doesn’t begin to describe the life of an adult caregiver.  Role reversal sounds so sensible and orderly….yet there is nothing sensible or orderly about caring for an aging parent.  This isn’t the natural order of things…or is it?  Many of my friends are caregivers for their parents too and we all agree that from our perspective…..role reversal is uncomfortable and difficult.   Some of our parents readily accept role reversal, yet others fight the switch at all costs fearing a loss of independence and control.  Role reversal doesn’t occur overnight, but creeps into our consciousness.  Until one day we realize that…. we are holding the hands of our parents and their hearts as well.

My friend recently asked me about recommendations for improving family communications about their aging parents through the use of technology.  Their family is struggling with keeping everyone current on their parent's situation and having a more even view of care required to keep them living independently. 

No surprise to most of you, this is a very common problem.  Typically the family member living nearby and providing help with aging parents every week has to convince the distant relatives that problem is emerging.  Occasionally, it even works the other way.  A visiting family member who hasn't seen mom or dad in a while can sometimes be struck by the a dramatic decline in cognitive ability, memory loss, or even overall health that has crept up on the local caregiver.

There are several good free tools for sharing information with your family.  Many people use Yahoo Groups  for this (to learn more click here).  It's free and easy to use, but to take full advantage of the portal family members must have a My Yahoo ID.  The Id is free, as well, but it's extra steps.  These groups can have restricted membership and other monitoring controls.  Without a Yahoo ID people can still participate in email communication through the group much like a classic list-serve.

Google has a similar tool (click here).  There are also a large variety of these with a more specific medical focus.

Jacqueline Marcell (author and former professor) recently posted on the web the top 10 eldercare recommendations.

1. Consider buying long-term care insurance.  Long-term care insurance can help cover home care services, visiting nurses, community programs like adult day services, and nursing home and assisted living expenses.
2. Consult an elder law attorney.  Elder law attorneys specialize in the needs of older adults and can provide guidance in estate planning, advance directives, and guardianship and conservatorship.
3. Utilize available resources, like the Alzheimer's Association or the Area Agency on Aging.
4. Review medications with your physicians.  Physicians should know all the prescriptions, OTC, supplements, and vitamins a senior is taking.  They can review the meds and determine if it is an appropriate and effective combination.
5. Consult a physician or other professional regarding mental health.  Some seniors experience depression, anxiety or behavioral issues with dementia.  A physician or professional can provide effective tips and interventions for caregivers.
6. If your loved one has dementia, learn how to effectively communicate with them (see some of my past blogs).
7. Validate feelings.  Validating and acknowledging how a senior feels about their health and overall situation instills a sense of comfort.
8. Utilize respite care services.  Adult day services and other community programs are a great way to provide social interaction for seniors while offering a break to caregivers.
9. Learn about your loved one's health conditions.  Educating oneself prepares caregivers for being effective advocates.
10. Take care of yourself!  (see some of my past blogs for information on how caregivers can take care of themselves).
    
    For more information, see healthcentral.com.

**The following post is authored by Natalie Langley, MSW, who came to us from the Alzheimer's Association.  She is working on SCANS (for more on SCANS, please see Eric's blog by clicking here) and will be a 'guest blogger' from time to time.**

Ever hear people call older adults “sweetie” or “honey”?  Working in health care settings before, I often heard staff using words such as these when talking to residents.  While most people have good intentions and they believe they are just being kind to residents when talking with them, research has now shown that talking to older adults with Alzheimer’s disease residing in nursing homes in a childlike manner are more likely to receive resistance from the residents. 

Colleagues at the University of Kansas School of Nursing have found there is a correlation between how nursing home staff communicate with residents who have dementia and residents’ subsequent resistance to care.  The researchers have coined the term “elderspeak” as talking to residents in an overly caring and controlling manner.  In addition, elderspeak is communicating to the residents similar to “baby talk” using such words as “Dearie” or “Sweetie”.  Research showed that the residents were more likely to cooperate with care when normal adult communication was used.   When nursing staff used elderspeak on the residents, behaviors such as grabbing objects, saying no, pulling away, screaming, hitting/kicking, and threatening were increased. 

Older adults are just that…adults- and should not be talked to as a child but rather in a respectful way just as you would carry on a conversation with any other adult.  They should still be treated with respect no matter their age or if they have Alzheimer’s disease.  Remember: They are a person first, before their disease.  If you have a loved one in the nursing home where you feel the staff is not being respectful of the resident and talking to him/her in a childlike manner, please speak with the staff at the nursing home about your concerns. 

This is going to be a greater challenge as more people are diagnosed with this horrible disease.  According to the new Facts and Figures released by the Alzheimer’s Association in 2008, it is estimated that there are currently 5.2 million Americans who have Alzheimer’s and by the year 2050 that number is expected to be 16 million.  It is important to educate health care professionals about how to speak with older adults now to help maintain a good quality of life as they move into their later years.  For more information on this study, please click here or go to http://www.alz.org/Icad/_icad_release_072808_8am_communication.asp.

We all plan – it is how we bring order to our lives and make sure the important things get done.  But when you are caring for a senior, even the most well crafted plans can’t solve all the problems.  Planning cannot stop a mental or physical decline.  Planning can’t stop a senior from having a bad day and upsetting the plans already in place.  Planning can’t ensure that what you think will happen …..will actually take place.  Planning can’t buffer your emotions when faced with a progressive disease such as Alzheimer’s.

So, why plan?  Why spend time and energy on something that won’t help?  Should we instead just take each day as it comes, with no thought to the future? 

My experience is that planning can help.  It can help a caregiver bring a little structure to a very challenging situation.  Planning can save time too.   And being proactive can ensure that potential solutions are explored ahead of time thereby reducing stress during a time of crisis.

Following are a few planning suggestions for caregivers:

• Create a list of all the important people in your parent’s life and include their phone numbers. For example:  all children and close relatives, neighbors, Doctors and health care providers, Assisted Living personnel, health insurance contact (and policy #’s), attorney, financial planner, minister, etc.  Carry this with you in your wallet.  Then when you need to call someone, you don’t lose time hunting for phone numbers. 
• Take the time you think it will do something and multiply by 2 or 3, depending on your parent’s physical and mental condition.  While it could take you a ½ hour to zip through the grocery store….it can take 3 times longer if accompanied by a senior who moves slowly or is confused about what to buy.
• Build good relationships with the people that care for your parent.  Take the time to meet the new Executive Director of the Assisted Living facility and introduce yourself to new staff members.  Be interested, engaged and respectful when dealing with your parent’s Doctor and their staff.
• Stay attuned to eldercare issues addressed in your local paper.  Is there a new Memory Care facility opening soon?  Have additional programs been added to the Senior Center?  Has the city added transportation options for seniors? 

Do you know of any communities that are not designated as a 55 and older community but it just seems they have naturally turned into that?  Those neighborhoods are becoming more and more common and are referred to as Naturally Occurring Retirement Communities or NORCs.  A NORC is community, neighborhood, apartment building, or street where the residents remain for years and “age in place”, allowing a naturally occurring retirement community to develop.  To “age in place” means to grow older in one location without having to move.  NORCs offer familiarity, feelings of independence, feelings of safety, and a comfortable environment  NORCs also tend to foster social gatherings, neighbors helping neighbors, neighborhood crime watches, and more accessible public transportation (as more and more people in the neighborhood utilize the transportation service, it will naturally develop a routine route in the neighborhood).

AARP reports that more than 80% of seniors wish to remain in their own home for the rest of their lives.  To age in place successfully, requires advanced planning regarding the senior's overall health care and well-being, home environment and safety planning, and preparation for aging-related changes.  A professional geriatric care manager can assist you in planning for aging in place.  For more information regarding aging in place, check out http://www.seniorresource.com.

Continuing from my last post...

2) Did you know that the default health care decision maker, under Indiana law, is a group of people?  Unless you have made out a designation of health care representative or have a legal guardian, your health care decisions can be made by your parents, your brothers and sisters, your spouse, and your adult children – AND THERE IS NO PRIORITY IN THAT GROUP.  In other words, they all have the same level of authority.  This can lead to problems or a stalemate.  Now think about what happens in a hospital or nursing home when there is a disagreement between family members about what health care decision to make for a person.  I can tell you that standard procedure in a hospital is to get the entire group together and try to mediate the dispute.  However, when you think about it, that is not what your advance directive says.  It does not say, if I cannot make a decision, mediate the dispute among anyone making a noise about it.  It says a specific person is named to make a decision when I cannot.  The designated health care representative may have to point out that they, and not the group, have the authority.

Please check next week for a third situation of how things can progress differently than planned with respect to advance directives.

Lots of questions are coming in about our latest major technology initiative - SCANS.  SCANS stands for Senior CAre Navigation System.  This is a development effort that has been underway for some time at My Health Care Manager.  The first full production release is due out in August.

We already use a complete set of Informatics tools to track, manage, and communicate with families regarding the issues faced by our senior clients and their caregivers.  SCANS goes to a whole new generation of support for our health care managers. 

The system provides a comprehensive set of geriatric care knowledge and decision support to our team in the field.  This includes a holistic, consumer-side view of the many issues faced by families grouped into 25 Care Categories.  All of the primary issues in each category are explored and specific solutions are recommend along with practical tools and actions steps for the caregiver.

This puts the best practices of the industry and a full time research team at the fingertips of health care managers and the families they help.

As you may have heard, actress Estelle Getty passed away earlier this week at the age of 84 from advanced Lewy Body Dementia.  Estelle was most widely known for her role as "Sophia" on the TV show The Golden Girls.  I remember watching that show when I was younger and even to this day, I continue to watch re-runs on TV....they still crack me up!  Sophia was the quick-witted, humorous 80-something golden girl.  She and 3 other ladies all lived together in a house in Miami.  I feel the show really did justice to the older adult population.  They showed independent women who were active in the community, had jobs, had a love life, and leaned on each other for support.  There are still stigmas today about older people like "they're bad drivers", "they're grouchy all the time", and "they don't have sex".  And, with a society trying so hard to not age, overcoming those stigmas becomes challenging.  However, I do feel that those stigmas are diminishing.  Even though The Golden Girls was filmed in the late 80s and 90s, what those ladies portrayed then is still real today.  The Baby Boomers today are active both physically and socially and are independent people who plan for the future.  As the years go on, the aging population will continue to grow and currently the number of people entering the workforce to work in geriatrics is not increasing.  I have always told my social work students to spend extra time with your grandparents and with their friends, or volunteer at an assisted living facility or nursing home.  Get to know these people- they have had very interesting lives and still enjoy life and activities that make them happy.  Some of my past patients and clients have made me a better person.  I will always work with this population, they are my passion.  As a nation, they are our future. 
Estelle was once asked in an interview what was the one thing that makes a person age well.  She simply stated humor...you have to have humor.

Several of us at My Health Care Manager share important eldercare information on our blogs each week, but this Saturday (July 26) at 11am ET, I will be live on the ‘Ask Mr. Eldercare’ internet radio show to share my perspectives and discuss the issues (click here to listen).  The host, Martin Sabel, and I will address the endemic problems of the health care system – and how geriatric care management can help seniors and their families make the most of the health care system and achieve the best quality of life possible.  If you are able to tune in at 11am ET (10am Central), you can call in to ask questions and share your thoughts or concerns.  If you’re unable to make it, you can listen to our conversation anytime by visiting the Mr. Eldercare show website by clicking here or visiting http://www.blogtalkradio.com/mreldercare and listening to the archived show.  Access to our previous blogs and additional eldercare information is through our website, www.myhealthcaremanager.com. 

As a follow up to my blog about safety issues with seniors, I found another important handout on Alzheimer's Disease and wandering.  It provides good information, tips, and resources.  Please check out In Search of the Alzheimer's Wanderer by Mark Warner.  Mark is also in charge of the Alzheimer's Daily News, a publication of the Ageless Design Research Foundation.  He sends daily emails regarding news and information about Alzheimer's Disease.  To subscribe to this free publication, check out his website at www.alznews.org.

Summertime is always great to be outdoors, but with the high temperatures, the risks of heat exhaustion and heat stroke are high.  Heat exhaution is caused by exposure to high temperatures and inadequate replacement of fluids.  Those most at risk for heat exhaustion are seniors, people with high blood pressure, and people who work outdoors the majority of the day.  Warning signs include:  heavy sweating, paleness, muscle cramps, tiredness, weakness, dizziness, headache, nausea/vomiting, and fainting.  The person's skin may be cool and wet, pulse may be fast and weak, and breathing may become fast and shallow.  If the person is not treated, it may progress to a heat stroke.  To help prevent heat exhaustion, have readily available cool, non-alcoholic beverages, stop and rest every 1-2 hours when outside, wear lightweight clothing, take a break in an air-conditioned area, take a cool shower/bath after being outdoors for a long period of time.  For more information, check out WebMD.com.

Much has been written about the requirements for executing advance directives such as powers of attorney, designation of a health care representative, living wills, arrangement for organ donation, and do not resuscitate orders.  Giving thought to any of these directives is a good idea in advance of the need for them - for seniors, their caregivers, and people of all ages.  Today I am thinking more about some of the things that can go wrong, or should I say go differently than anticipated with respect to advance directives.  For example:

1) The law in Indiana is that a designation of health care representative, more commonly known in other states as a health care power of attorney, is only effective when the principal is not able to make decisions.  Notice that in our documents the power to make decisions for someone else is usually prefaced by the words “whenever I am incapable of making my own health care decisions.”  That sounds clear enough, but in reality, a health care facility cannot practically decide, on a day to day basis when their patient is capable or not capable.  This tends to lead to a bias to ask the health care representative what care should be given, even when the principal is competent to make the decision.  It is the representative that may be paying the bills.  It is the representative who made the admission decision and has the most interaction with some of the staff. The point is that we must guard against allowing health care providers to always ask the representative.  It is the patient that should have input, if possible.


In my next couple of blog entries, I'll give more examples of how things can progress differently than expected...

An Alzheimer's patient once came to me after he had got out of his house and was found hours later in a ditch approximately 2 miles from his house.  Wandering is often a scary symptom of Alzheimer's disease and dementia.  It's confusing and scary for a senior who does not know where he/she is or where they are going; and is scary and worrisome for family caregivers.  Wandering can occur anytime but tends to increase in the late afternoon/early evening hours.  There are several things caregivers can do to keep their loved ones safe at home. 

Tip #1:  Use deadbolts on doors leading outside, place them high or low on doors
Tip #2:  Take locks off of bathroom and bedroom doors to avoid your loved one from locking themselves in
Tip #3:  As the sun starts to go down, close the blinds/curtains and turn lights on
Tip #4:  Install appliances that shut off automatically
Tip #5:  Keep toxins i.e. cleaners, bleach, poisons; and prescription medications in a safe, secure space
Tip #6:  Remove clutter from around the house
Tip #7:  Install a door alarm or place a motion sensor in your loved one's room at night to alert you when they are awake and moving
Tip #8:  Label doors, drawers, and cabinets; this is most helpful in the earlier stages

A professional geriatric care manager can help you in reviewing your home and finding assistance for home modifications.  For more tips and information, check out The Complete Guide to Alzheimer's-Proofing Your Home and home modification tips.

Summer is officially here... and the heat waves begin. Did you know that more people die from heat waves each year than from hurricanes, lightning, tornadoes, floods, and earthquakes combined?? (CDC)  As a caregiver or friend, how can you help keep your loved ones safe?

Older adults are particularly vulnerable to the effects of heat stress because the elderly do not adjust as well as younger persons to sudden changes in temperature.  Also, an older adult’s chronic illness may affect how his/her body responds to heat and many older adults take medications that impair the body’s ability to regulate its temperature or medications that inhibit perspiration.  

Heat stroke is the most serious heat-related illness. It occurs when the body becomes unable to control its temperature: the body's temperature rises rapidly, the body loses its ability to sweat, and it is unable to cool down. Body temperatures rise to 106°F or higher within 10 to 15 minutes. Heat stroke can cause death or permanent disability if emergency treatment is not provided.
Warning signs for heat stroke vary, but may include the following:

    - An extremely high body temperature (above 103°F)
    - Red, hot, and dry skin (no sweating)
    - Rapid, strong pulse
    - Throbbing headache
    - Dizziness
    - Nausea

According to the CDC, you can help protect elderly relatives and neighbors who are at risk by:

    - Visit him/her at least twice a day and watch them for signs of heat exhaustion or heat stroke
    - Take him/her to air-conditioned locations if they have transportation problems
    - Assist them in obtaining air-conditioning
    - Make sure older adults have access to an electric fan whenever possible.

Heat wave deaths can be prevented. For more information, visit these links:

http://www.hhs.gov/disasters/emergency/naturaldisasters/heat/index.html 

http://www.epa.gov/aging/resources/factsheets/index.htm#itdhpfehe