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I have been away from this blog this summer, in part because I’ve been on a circuit of visits to older relatives: my parents, my father-in-law, and my aunt and uncle. At each stop, there was plenty to think about in terms of everyday challenges for people in their eighties and early nineties. As we are starting to feel our own aging, many of us at mid-life also face worries about our aging parents and other relatives and wonder whether they need help and how to begin.
If they live long enough, older adults experience reductions in strength, coordination, eyesight, hearing, memory or mobility, through a combination of aging and the effects of chronic conditions. By the time people are in their mid-to-late eighties, and sometimes earlier, independence in daily activities may begin to be compromised, especially in activities that health care providers and researchers call instrumental activities of daily living (IADL’s), like preparing meals, shopping, driving or using public transportation, handling finances, and cleaning. These are differentiated from more basic activities of daily living (ADL’s), which include personal tasks such as bathing, getting dressed, toileting, and eating.
Family members can have a hard time deciding when to step in and when to leave well enough alone for aging relatives. Often the facts of the situation aren’t dramatic or obvious. But subtle changes that occur over time can gradually make independent functioning a little bit more difficult or more risky. We get the nagging feeling that things just aren’t the same and that maybe something should be done.
Of course, your parent or parents may already be pro-active in getting help. But often, older people themselves may not be sure whether they need help or what they could use. They may not be aware that services exist or that family members might be available to assist. It's a good place to start by raising the subject, "Do you think you could use a little more help...?"
Assessing the situation with older parents long distance can be an especially vexing challenge. Signs that all may not be well include any obvious change during phone calls: more evidence of confusion or forgetting, more worries or complaints, or more silences. Any of these suggest the living situation may be getting more stressful or that something else might be wrong, from the early stages of dementia to a case of depression.
An older person who does not have much to say in response to “What did you do today?” may have limited mobility and increasing social isolation. When older people are less able to walk comfortably and surely, they begin to decrease their life-space outside to very few excursions and inside to a small area of the home. They may no longer be climbing stairs, walking down a long hallway, or even rising from the chair very often.
If you learn of a fall, a common cause of injuries for older people, you will want to ask where the fall occurred and at what time of day or night. Was the older person trying to reach something? Was he drinking or mixing medications and alcohol preceding the fall? Could there have been a problem with dehydration or malnourishment (which would cause dizziness or fainting)? Was she wearing appropriate footwear or using the cane/walker? Did small throw rugs or floor mats trip him up?
It is usually easier to get a good assessment of the situation in person. A visit provides an immediate impression of the older person’s condition and you can size up your family member’s weight, mobility, grooming, demeanor, and mood. Red flags to look for in the house or apartment include lack of fresh food in the refrigerator or cupboards, trash that has not been emptied for too long, lots of dirty dishes or laundry piled up, pets that are not receiving needed attention, or signs of poorly managed incontinence.
If you are not nearby, you might consider using the services of a local Geriatric Care Manager (see listing of suggested resources below) to go to the home and do a professional assessment with your older family member.
Major changes in functioning may necessitate moving to a more secure living environment where there is access to care and services. But much of “long-term care” takes place in people’s homes, rather than in institutions, including services ordered by physicians such as Physical Therapy and Occupational Therapy. And many older people may be able to manage to stay in their homes with just a little more help with everyday and periodic tasks.
Some of the most common needs for someone who is “aging in place” include help with meal planning and grocery shopping, doing errands, scheduling and getting to medical appointments (including to the eye doctor, podiatrist, dentist, and other infrequent visits), medication management, changing the bedding, doing laundry, and periodic household cleaning and seasonal chores. Even sorting and managing the mail can become a surprisingly real burden for older people.
Once families identify that there are unmet needs, they may be able to manage informally, for example by visiting more often, checking in more often, making a regular date to get groceries, or arranging for someone to clean or help with other chores. It is a good idea to share concerns and the needs you see with other family members, even those who don’t live nearby; enlist neighbors where possible, and talk with the older person all along the way so he is given a voice in planning. Your parent may also have ideas about other resources you may not be aware of.
When strictly informal help from family or friends is not possible or not sufficient, other options to get started with helping an older relative include the following:
• Each state has a Department on Aging and regional Area Agencies on Aging (AoA) which can offer you referrals to a variety of services, some means-tested (only available to low-income elders) and some freely available to anyone over 60 or 65. For instance, Meals-on-Wheels for in-home hot lunch delivery is available in almost every community in the U.S. and offered on a very low-cost or donation basis. To find your state Department of Aging, check here: http://aoa.gov/AoARoot/AoA_Programs/OAA/How_To_Find/Agencies/find_agenc…
• Another great starting point to find local services for seniors and lots of helpful information is here: www.eldercare.gov. This website has a link for a list of Federal government online resources for senior health, housing, and benefits, information for caregivers, and, most importantly, a way to find services by city or zip code.
• The older person’s Primary Care Physician can assess many aspects of the person’s health and functioning and can give him or her referrals to other professional evaluations, e.g. to a physical therapy evaluation in the event that walking or balance has become an issue, or to a neurologist, psychiatrist, or other medical specialist for other concerns. The crème de la crème of medical professionals for older adults is a Geriatrician, a medical doctor specializing in issues of old age. Large hospitals offer a geriatric assessment team for complex concerns of older adults.
• If the older person was recently hospitalized, you can contact the hospital’s discharge planners/social work department for advice and referrals even if the older person has already returned home.
• A Geriatric Care Manager, usually an RN or an MSW social worker, can be hired through a private agency to assess the older person’s needs and the home environment. Unless this is arranged through a low-income service, there will be an hourly charge to do the assessment, but some of the services they suggest may be covered by insurance or may be available for low or no cost to older adults. You can locate a certified Geriatric Care Manager through this website: www.caremanager.org
• Home Health Agencies (often for-profit) and Visiting Nurse Associations (usually non-profit) provide in-home nursing assistants and companions for older and disabled people, billing available insurance and private pay resources. These agencies vary in the level of assessments they perform: some send a Geriatric Care Manager to carefully assess the situation in the home, while others simply send workers for whatever services and hours you request. Like temporary employment agencies, these agencies collect a higher hourly rate than they pay their personnel, but they also do all the screening, insuring, supervising, and scheduling of their workers.
• The Alzheimer’s Association (www.alz.org) has a multitude of resources for families with a loved one who has dementia—online information, local support groups and referrals to services. Other organizations devoted to specific conditions affecting older people, such as Parkinson’s and arthritis, have their own informative websites, support groups and referral resources, as well.
This is just a partial list of things to think about and resources to explore. In my next blog post, I will discuss some of the common relationship and emotional issues that can accompany this process of arranging for help for older family members.
