Wednesday, December 22, 2010

Merry Christmas?

I knew it had been a long time since I had posted anything, but I didn't realize how long. Clearly it's been a busy autumn, and now it's only four days until Christmas. The presents are bought and most are wrapped and under the tree, but I still have baking to do, and a house to clean up before my youngest brother and his family arrive from North Carolina. They'll be here for more than a week, and while I will love having them here, there will be no restful time during this holiday season. I've given myself a pass on Christmas cards this year, but somehow it's hard to let that go.

I did want to share this intriguing blog post I just read from the New York Times about parent-child relationships. A gerontologist at Cornell University did some research and found that parents will talk about having a favorite child, and how that sometimes influences who the chosen caregiver is. Kind of interesting reading, not sure what I think about it.

Anyway, I do hope everyone has a Merry Christmas, a Happy Hanukkah, a festive Kwanzaa, and  a safe and Happy New Year!

Thursday, September 16, 2010

The Tracks of My Tears

I've been thinking a lot about end of life issues lately. Partly because we talked about it in class this week, partly because the 27th anniversary of my Dad's death was earlier this month, and partly because I'm going to 2 funerals in the next few days

The funerals are the worst part of middle age, as far as I'm concerned. Although I bet it gets worse when it's my friends who are dying, and not their parents.

During this week's lecture, and then with a facebook chat with a friend, I've had the opportunity to think and talk about the fact that we don't do grief and mourning well in this country.

We're lucky if we get 3 days off when someone in the immediate family dies, and if it's a cousin or an aunt or uncle, we're fortunate if we can take the few hours it might take to go to a local funeral. Once the funeral is over, well, that's all she wrote. We are expected to go back to work and get on with our lives like nothing happened. I read an article that popped up on Yahoo this week, and Michelle Williams (she was married to Heath Ledger) was talking about hard it was after he died. She made the comment that in Victorian times we got to wear black, then gray, then mauve, then pink, as we moved through the mourning period. Today there is no acceptable outward manifestation of our grief, and I think that's a shame.

The other thing that's gone the way of Victorian times is the vocabulary of grief. We don't know what to say to each other when we grieve. Platitudes like "He's in Heaven now with his Dad" (said to my mother when my 22 year old brother died) can cause more pain than comfort to some. My Dad was only 50 when he died, so Mom's response was that both of them were too young to be dead. As one friend pointed out, after his father's death, getting syrupy sympathy cards only made him dread more cards, and his father was still dead as a doornail.

I know that I struggle with knowing what to say, what to do, how to comfort those who are in pain. And looking back at the times I've been in mourning, it's hard to say what helped the most. Except I know my friends showing up at the funeral meant a lot, my friends making me go to baseball games I didn't care about meant a lot (during my Dad's illness--thanks, Roger), and my friends who pulled me forward and out of the daze of grief meant a lot. It wasn't so much what anyone said, but absolutely what they did.

Tuesday, August 10, 2010

More on Predicting Alzheimer's

Here is a followup story to my last post: Spinal Fluid Test is Found to Predict Alzheimer's.

The good thing is that the research is moving quickly on Alzheimer's disease. The number one predictor for developing Alzheimer's is age, with over 20% of women over age 85 developing the disease (2010 Alzheimer's Disease Facts and Figures). And face it, age is not a risk factor we can control. We can eat right, exercise, and do all the crossword puzzles imaginable, but if we're lucky, we'll all age.

I still have qualms, though, about doing spinal taps on people. The article indicates that it isn't as risky a procedure as it once was, but then it goes on to say that most internists and family doctors aren't experienced with the procedure. It was suggested in the article that spinal tap centers could be established, but you know, I have mixed feelings about that. It's just one more silo in an already too fragmented health care delivery system.

The other, probably bigger issue for me is one of ethics. Again, who decides? One doctor in the article suggested it should be a decision made between a doctor and the patient. But can my health plan force or strongly encourage me to have the test? If I want the test, will my insurance company pay for it? If I test positive, will I lose my coverage? Will my provider then pay for early treatment?

If I decide to have the test today, what other kind of ramifications will it have for me? I just purchased long term care insurance, but I'll bet I would have been denied if I had tested positive. Will future employers not hire me?

I think the research is good, but at this point I think that's where it needs to stay--in the realm of controlled research. That's not to say I won't change my mind in the future, I probably will. But I don't want us rushing in to something without really thinking through the long term ramifications for every day people, and making sure that new technology and procedures don't make an already terrible diagnosis even more terrible.

Wednesday, July 14, 2010

Preclinical Alzheimer's ?

An article in the New York Times today reports that medical experts are recommending new guidelines to diagnose Alzheimer's dementia earlier. We're pretty sure the disease starts 10-20 years before people become symptomatic, in fact I was at a seminar yesterday and heard that very statement. But I view this news with trepidation.

The experts propose using MRI scans (expensive), PET scans (even more expensive), and biomarker testing (not even that common, and certainly expensive) to determine if a person "preclinical Alzheimer's". Some of the reasons given for diagnosing earlier is so that the disease can be treated. Except that there aren't any drugs on the market yet that will do that. Aricept and Namenda can only do so much, and as far as I can tell, they might not be effective in this particular instance.

Another reason given is that it will give people the chance to make plans and get their affairs in order. Except most don't do that now. It's rare that we have someone come in and say they've just been diagnosed and they want to do or review their estate planning and talk about when they might need a guardian. Of course I want people to do that, but I don't think many people in their 50's will do that if that faced with a diagnosis of "preclinical Alzheimer's".

I invite you to share your thoughts about this news. Me, I'm going to be chewing on it a while.

Tuesday, July 6, 2010

The Beers List

Just to clarify, I'm not going to talk about Shiner Bock, Rahr Ugly Pug or Corona today.

In my last couple of posts I've talked about some of the negative effects medications can have on older adults. I was pretty unhappy that the nurse at the orthopedic surgeon's office told Mom to take Benadryl, and when we told Mom's geriatrician later in the week, she too was pretty unhappy. In fact, she said she would talk to the surgeon personally.

But like that nurse, I'm sure many of you have never heard of the negative side effects of Benadryl, a common, over the counter medication. One resource available, at least to know which medications have potential negative side effects, is the Beers List (originally published in the Archives of Internal Medicine).

Now, my intent here is not to encourage everyone to go out and question every single prescription prescribed for older adults. Doctors often have to weigh the risks and benefits of a medication. Most people are going to take a strong chemotherapy drug for cancer, despite potentially toxic side effects. The issue is that even common drugs like Benadryl can have really nasty side effects in older adults, that younger people don't have, and too many medical professionals don't know that. So, use the Beers list as a resource, and be sure to talk to your doctor about why a particular medication is prescribed, so you can be an informed consumer.

Monday, July 5, 2010

It's a Rainy Day Today

It's raining this morning. Not really earth shattering news, except that it's almost July in Texas, a time when rain is a scarce commodity.

Something I often talk to the adult children of my clients about is how they can encourage their parents to spend money for care. I talk about how their parents saved all this money "for a rainy day" (see, there is a connection), and yet the parents don't recognize that it's not only raining, but it's a storm out there. But my clients aren't the only ones who don't see the rain.

As professionals, doctors, nurses, social workers and other health care providers have often failed to recognize the storm warnings. Today there is an excellent article in the New York Times  about the need to prepare for more care for older adults. This is something I've talked about before. There just aren't enough health care professionals being trained in the very specific care needs of older adults.

Just as an example, I've been to two doctor's appointments with my mother recently, one to her orthopedic surgeon, and one to her geriatrician. Mom has been having trouble sleeping since her surgery, and the nurse at the surgeon's office told Mom to take Benadryl to help her sleep. After the appointment I told Mom she was not going to take Benadryl because of the potentially negative side effects this medication has in older adults (seizures and hallucinations, to name two). Now, I chose not to argue with the nurse, and I'm sure some will criticize me for missing the teachable moment, but this is a nurse that I had gotten off on the wrong foot with, and I suspected she would not take kindly to my interference.

But this is a perfect example of how someone in a medical practice catering to mostly older adults is not properly trained. Luckily, Mom has me to tell what is OK and not OK, but I'm not a medical person, I just happen to know a little more than some. I wonder sometimes how many like Mom have followed this nurse's advice, and had a bad drug reaction, which might have resulted in a hospitalization.

I guess the moral here is that we all need to find ways to encourage young people to fall in love with the idea of working with older adults, and do what we can to support those who already do. Geriatricians are among the lowest paid doctors out there, yet they are the ones who spend the most time with their patients, and that should be rewarded.

Monday, June 21, 2010

Hospital Delirium

If you have an older parent or other family member, read this article in the New York Times.

The article is about hospital delirium, which sadly happens all too often to older adults in the hospital. About one third of all hospital patients over 70 develop delirium, which is frequently misdiagnosed. No one is exactly sure why so many patients develop delirium, but it can be caused by improper medication use. Sadly, many doctors do not understand that older people do not tolerate medication dosages that younger people tolerate, so they are given the typical dose, then, when delirium develops, they are restrained, and medicated, to deal with the agitated behaviors. Some other causes of delirium include lack of sleep (hospitals are noisy 24 hours a day, 7 days a week), not making the older person's glasses or hearing aides available, and changing rooms. I worked in one hospital where patients were moved from room to another constantly, which resulted in different nurses, different case managers, new roommates, and we wonder then why they become delirious.

Wednesday, June 16, 2010


I had an interesting experience last weekend, although not a unique experience. I have a friend and colleague who is a private professional guardian. She is the guardian for several people, and she gets appointed guardian in situations where the Ward does not have anyone to act as guardian.

One of her Wards is a woman I'll Mae. Mae has dementia, and according to my friend, Mae is not a pleasant person. Mae has children, but they don't want anything to do with her.

My friend called me last Saturday, asking a big favor. It seems that Mae was at a local hospital, having been sent there by her nursing home because she injured one of her caregivers. The hospital medicated her with her some pretty strong anti-psychotic medication, deemed her medically stable, and was putting her in the ambulance to return to the nursing home. The nursing home was refusing to allow Mae to come back without a private sitter in place, for the protection of their staff. And my friend was out of state at a wedding.

For those who are my facebook friends, that's why I spent Sunday afternoon at the psychiatric emergency room at John Peter Smith Hospital.

My friend was able to find a sitter who could stay with Mae Saturday, and she did return to the nursing home. My friend also engaged a private duty service to take over on Sunday, but by Sunday morning Mae had injured the Saturday sitter, and had continued to hurt nursing home staff. The nursing home was done, and insisted that she leave.

Again, long distance and over the phone, my friend arranged for law enforcement and emergency medical responders to take Mae to the psych. ER at JPS. She called me when she could not locate Mae anywhere in the hospital system.

We eventually found Mae in the regular ER, because she had complained of chest pain while on the way to the hospital. She was absolutely calm and non-threatening when I found her. She was mean, but not violent. I stayed with her until we got her admitted to the psychiatric unit.

My friend cut her trip short to come back to Fort Worth for a couple of days to get Mae situated in an Alzheimer's facility that I helped her locate, and she's leaving again today to finish the rest of her vacation. So I might yet be called out again to help with Mae.

Some of you reading this may identify with this situation. Our medical system has no good way to deal with those people with dementia who also have behavior issues, including violent and aggressive behaviors. There is something inherently wrong with having police take a frail, 76 year old woman to be involuntarily committed to a psychiatric unit. Regular hospitals are unable to provide the medication management required in a situation like this, and a guardian has no legal authority to admit a Ward to a psychiatric hospital. The nursing home clearly had no idea how to manage the behavior, and Alzheimer's units like the one Mae went to yesterday, where they do know how to manage the behavior are incredibly expensive (over $5000 a month). Mae is lucky she can afford to live there.

I don't know what the answer is, but we are going to have to find a better solution, because the numbers of people with dementia will only grow as the population continues to grow older. I'd love to hear any ideas.

Friday, June 11, 2010

What Happened?

OK, I know you're wondering what happened.

I got bored.

I am one of those people who changes wallpaper and screensavers on a regular basis. So when I saw that there were new template designs, and picture backgrounds, I just couldn't resist.

I would have preferred it if there had been a longhorn--you know, for Cowtown, but the powers that be at Google apparently don't see the charm in cattle; I guess they've never been to Texas.

So, I settled for rocks. Lest you think they aren't relevant, think again. The journey we are all on can be rocky and treacherous and beautiful. And I hope that some of what you learn here helps you along on that journey, so that you miss the more dangerous passages, but still experience the excitement and beauty.

Here's to the next leg of the journey--wherever it is!

Tuesday, June 8, 2010

Walking the Floors

Mobility. However you are mobile, it's important to do it safely.

Of course most people are familiar with canes and walkers, but not a lot of people ever get the proper training in how to use these devices. I worked with physical therapists long enough to know that those walkers with 4 wheels and hand-brakes that everyone seems to have in assisted living are not all that safe. If a person has trouble with memory, they might forget to lock the brakes, and if they have trouble with sequencing, they might not be able to use the brakes properly. Because they have 4 wheels, they move faster, so the person might not be able to keep up.

My best advice: see a physical therapist to find out what will work best for you, and to make sure you know how to use your equipment properly.

Other safety tips:

  • Get rid of all the throw rugs. Even large rugs can be a problem, because we had one that would not stay in place, and this resulted in Mom's fall last Fall.
  • Make sure cords of any ilk (extension, phone, cable, computer) are out of the way. If you can shorten them and attach them to the wall, even better.
  • Promptly clean up spills, and pay special attention to greasy or slick spills. I had my own fall a couple of years ago when some greasy food was not properly cleaned up. The floor looked clean, but it was still very slick, and falling in front of 50 people was as bruising to the ego as it was to my knees.
  • Make sure furniture is placed so that there are wide pathways to accommodate a walker if one is used. Remember that furniture walking is never a safe option.
  • Nightlights are your friends. There are lots of varieties, so you should be able to find the right type for every location.
  • Carry a phone with you, or even better, install an emergency response system ("I've fallen and I can't get up"), so you can get help if you do fall.
These are just a few ideas to make mobility safer.

Sunday, May 30, 2010

Gotta Go, Gotta Go, Gotta Go Right Now

We're rounding out bathroom safety today. Obviously grab bars around the toilet are helpful, but some bathrooms are just not set up for that, if there's a tub on one side and a pedestal sink on the other side, so then what do you do?

You add something called a versa-frame. You can see here that this item is just an aluminum frame that fits to the existing toilet. The legs can be raised or lowered, and this provides arms the person can use to help push up from the toilet. This item costs around $50, but I've never seen them at a big box store. You'll have to order it online or get it at a medical equipment company.

Most toilets are low, sitting only about 15" from the floor, making it difficult to get up if you have a bum knee or hip. Replacing your toilet with a 17" model is one option, but an expensive option. You can get a toilet for around $115, but if you don't know how to install it yourself, you'll have to pay a plumber for the installation. One option is to add a toilet seat riser. This particular model locks (don't ask me how), and can also be purchased with arms. Not always the most stable option, and can be problematic if there's a man in the house. But at $50, it's less expensive than replacing the toilet.

For a lot of situations, a bedside commode is a solution. If a person can't walk to the bathroom, a bedside commode can be placed wherever the person needs it. The bucket is removable for ease of emptying. The bedside commode can also be used over the toilet. In this photo the bucket is removed, and the splash guard is left in place, so this could then be placed over the toilet. Then, if needed, the bucket can be replaced and the bedside commode placed by the bed at night. Bedside commodes come in wider widths than the one pictured here for wider people. There is still some Medicare coverage for bedside commodes, so be sure to check with your medical equipment provider for details. If you pay out of pocket, cost will be $150-200, depending on the type.

Saturday, May 29, 2010

Raindrops Keep Fallin' On My Head

On to bathing safety!

If you're not able to safely get in the tub for a bath, or to stand to shower anymore, then you need to consider adjusting things to make showering safer. Grab bars are often the first line of defense in this instance, and the first thing I did in my house for my mother.

You can see that this grab bar is placed so Mom has something to hold onto as she is bending over to turn the water on. This is also the bar she uses when she actually lifts her legs over to get into the tub. Fortunately, the handyman who installed the grab bars was able to anchor this grab bar into the studs on both ends, so it is easily able to withstand a great deal of weight.

This bar is for stability while standing and showering. It is longer, allowing for something to hold onto from almost any point in the tub. Grab bars come in all shapes, sizes and finishes. I believe the ones I installed are 2 and 3 feet long, and are brushed nickel. They were fairly inexpensive, around $25 each.

You can get grab bars in white plastic, polished chrome, you can even find designer grab bars that match your fixtures, of course you'll pay more for these. Grab bars are readily available in stores like Lowe's or Home Depot, and you'll find them in the plumbing section. Medical equipment companies also carry them, and they are comparable in price to the big box stores. I was really fortunate to find a great handyman through the medical equipment company I used for some other things. He installed the grab bars in about 20 minutes, and it only cost $50.

There is a lot of variety when it comes to bath/shower chairs. This one is molded plastic. The legs snap in place, and they can be adjusted by turning them. There is an optional back, that we have chosen not to use. It's lightweight, but very durable, and can hold up to 400 pounds. Also note the tub mat in place, to provide a less slick surface for feet and chair legs.

When looking at a tub bench it is important to remember to measure your tub width. I knew my tub was on the narrow side, so I made sure to measure it, and I'm glad I did. The first bench I looked at, which was a little less expensive than this one was a little too wide to fit all four legs squarely and evenly on the bottom of the tub, which is crucial for safety. You want to make sure the legs aren't on the curve of the tub. And be sure to measure front and back legs, because the other bench I looked at had about a half inch difference in width from front to back.

Weight limit is another consideration. It does seem that most of the benches I looked at are now automatically super-sized, accommodating 300 pounds or higher. This was not always the case, because back when I worked in the hospital we usually had to specify when we needed something to accommodate more than 200 pounds.

When I priced the benches in the big box store, they were twice what I paid for this bench at the medical equipment company, and with nowhere near the selection of the medical equipment company.

The last item we got for the tub was the hand held shower. This type is inexpensive--only $18 at the big box hardware store, and even better, it just screws on to the existing pipe. No special tools, no plumber. It even came with a little aluminum tape. You can spend a lot more if you want, but if you think the need is only temporary, this is really all you need. It makes showering while sitting more pleasant, because you don't have to have the shower pounding in your face, and since you can't move to let the shower hit different body parts, the shower can do all the moving.

Hopefully this has given you some good pointers for making bathing a safe and still pleasurable experience. We'll tackle the rest of the bathroom next.

Friday, May 28, 2010

Can't Reach That

Thanks to Mom, who was discharged from rehab this week for inspiring this post.

After we left the hospital, we made a stop at an unnamed big box home improvement store so I could get a hand-held shower and to price a bath chair. Got the hand-held shower, but the bath chairs were more expensive than the ones I had seen online. As I was telling Mom this, she said, "You know, you should go to the Senior Centers and do talks about this. I know there are a lot of ladies at the Senior Center who need this kind of stuff, but they don't know about it."

So, since there's so much of this stuff, also known as adaptive equipment, out there, I'll probably break it down into several posts. Today we'll talk about a "hip kit", which pretty cool, although that's not why it's hip.

When folks have had hip replacement or surgery to repair a broken hip, they are often placed on hip precautions: no crossing the legs, bending more than 90 degrees, other things that I can't remember right now. The result is that you can't reach things on the floor, like things you've dropped, or your feet. That's where the hip kit comes in.

The item at the top is a reacher. Pretty self explanatory. One nifty feature, that's hard to see, is a magnetized pin near the tip, in case you drop a safety pin or some other small, metal object.

The next items are the yellow long-handled shoe horn and the long handled bath sponge. Pretty clear what those are for, and how to use them. The sponge makes a pretty good scratcher, too, as Mom has discovered since her incision itches.

The white cylinder looking thing is a sock-aide, and Mom loves hers. This one looks like a rigid one, made out of hard plastic, they also make soft ones out of fabric and probably cardboard or something. What you do is put your sock on the cylinder, then undo the straps (in this picture they're not fully extended) and hold one in each hand. Then you drop the cylinder on the floor, put your foot into it, and then pull the cylinder out with the cords, and oila! Your sock is on! (To my OT friend Denise, hard to describe in words only how this works).

The last item is called a dressing stick. I've never known many people who actually used them, but you can see that there are different types of hooks on each end, so useful for hooking things.

You can buy each item separately, but they are less expensive when you purchase them in the hip kit. They are readily available at multiple places online, and also at most medical equipment companies. Medicare will not pay for any of this, but a kit will cost anywhere from $30-40, depending on the store. My local medical equipment company charges a bit less than most of the ones I found online.

Next stop--the bathroom.

Sunday, May 16, 2010

I'm Not Your Honey

It's always eye opening, being on the other side.

Mom had knee replacement surgery last Tuesday, so this week I've been the patient's daughter, not the professional medical social worker-geriatric care manager. I have to tell you, I haven't been so impressed with what I've observed. But, one thing that has been reinforced, is that the folks I worked with at the Osteopathic Medical Center of Texas RehabCenter were an exceptional lot--so a big shout out to all of you! I wish you were taking care of Mom.

One of my biggest complaints is all the "elderspeak" (In "Sweetie" and "Dear", a Hurt for the Elderly, New York Times, October 6, 2008).

I am not your honey/sugar/sweetie/dear. Neither is my Mother. We have names. You can call me Kim, her name is Mildred.

Unfortunately, the comments to the New York Times article aren't available, but back in 2008 when I originally found the article, I read the comments. This is a very divisive topic. People who use elderspeak feel very strongly about it. To them, they are being comforting and nice and pleasant. To the people who hate elderspeak, it's condescending, impersonal and lazy.

After this week I have become aware of how much more prevalent elderspeak has become. Almost every nurse and aide who I have observed interact with my Mother has used it. I can't really tell if it bothers her, but it bothers me. They don't know her. How can she be their "honey"? And I know I'm not your "sweetie".

So please, take that extra 5 seconds to look at the chart, and use our names. Don't depersonalize us, or assume an intimacy or affection that isn't there.

Wednesday, May 5, 2010

Wandering through the Wilderness of Dementia

A good article in the New York Times today, More With Dementia Wander From Home. I have known a few families who have been extremely proactive in dealing with wandering, placing door locks up high, making sure the person with dementia is registered with the Safe Return program, even placing alarms and cameras around the house.

More often, however, families never get around to doing anything. The burden of caregiving, especially for people with dementia, can be so great, it's impossible to think about more than the current crisis.

But we all need to be aware of this danger. When we have children, we spend a lot of time and effort baby-proofing our homes; now we have to worry about dementia-proofing our parents' homes.

Tuesday, May 4, 2010

Common Bonds

I had the opportunity to attend a college reunion this past weekend. Before I go any farther, I do need to point out that I was an undergraduate at UT Austin from 1978-1982. (I know that might shock those of you who think I am much younger than that).

So, many of the people I saw last weekend I have not seen in 30 years or more. Mostly everyone was a little grayer and/or wrinkled. A lot weighed a little more than they did 30 years ago, and a few weighed considerably less than they did 30 years ago. Amazingly, we've all pretty much grown up and become a decidedly respectable lot, with spouses, children, mortgages, good jobs, and still doing oodles of volunteer work, which is what brought us together 30 years ago in Alpha Phi Omega, a national service fraternity.

I also discovered another common denominator with many of my former school mates this weekend--many of us care for our aging parents. I heard variations throughout the weekend, "I moved back to Texas to take care of Mom" or "My in-laws had to move in with us" or "I had to put my Dad in assisted living because he has Alzheimer's."

It put the article from a couple of posts ago in even greater perspective--we are an often silent and unknown group. Employers don't often recognize us, even our friends don't always know the pressure we face, when we are pulled to the future by our children, nieces and nephews, and yet the needs of our parents keep us firmly rooted in the here and now.

I salute all of you who do this work, and now that we've found each other after all these years, I know that we'll support each other in this latest endeavor, just like we all supported each other 30 years ago through boy/girlfriends and break-ups and all the travails of young adulthood.

Sunday, April 25, 2010

Graying Caregivers

My last post was about a middle-aged son caring for his older father. I think I've written before (or if I haven't, I guess I should) about the fact that the average age of nurses and social workers is increasing (we're a decidedly middle-aged lot).

Here is a good article about paid caregivers getting (and being) older themselves. It's a trend that will likely continue, as the population continues to age; as older women find they must continue to work past retirement; as the pay for professional caregivers remains low; for too many other reasons to list here.

Sunday, April 18, 2010

Letting Go of My Father - Magazine - The Atlantic

Letting Go of My Father - Magazine - The Atlantic

Here is an article that I think is just too important not to share. I don't think it's enough to say that being a caregiver is hard work. It is a job that is almost impossible to do in some circumstances. Jonathan Rauch of the The Atlantic writes very poignantly about his experience as a caregiver, and argues that caregivers are invisible in our society. He writes, "There should be no need for anyone to go through this alone, and no glory in trying."

Thursday, April 8, 2010

Observation vs. Admission

For those who don't know, traditional Medicare will cover a short time (up to 100 days) in a skilled nursing facility. In order to qualify for this benefit, a person has to have a three day (midnight) stay in the hospital, and have a medical or rehab need.

This benefit is a lifesaver for many families. Hospital lengths of stay have been getting shorter and shorter, so sometimes when Mom or Dad has been hospitalized due to an accident or planned surgery, they need a bit more time somewhere before they go home, and this has usually been the local skilled nursing facility.

Something that is happening with increasing frequency is people going to the emergency room and never actually being admitted to the hospital, even if they are in the hospital for 3, 4 or more days. If you are wondering how that can be, let me tell you in a word--observation.

It is possible to spend days in the hospital without ever actually being admitted, and this has been a hot topic this week in a list serve I belong to. Geriatric care managers from all parts of the country are running into this problem, and it is a problem for older adults, because in more and more instances they don't find out that they were never admitted to the hospital until after they have spent time in the skilled facility (sometimes to the tune of $375/day) and get the bill, because Medicare tells them, correctly, that they did not meet the admission criteria.

The reasons this is happening are varied, and as is usually the case, boils down to money. Hospitals are under great pressure to decrease inappropriate admissions--when the person doesn't really need to be in the hospital; AND they get penalized for re-admissions--when a patient is discharged, only to show up back in the ER a few days later. So, instead of admitting people, they just "observe" them, sometimes for days.

So, the moral of this story: if a loved one is hospitalized (especially an older adult), make sure you know their admission status. If the doctor doesn't know, and don't be surprised if he doesn't, ask the case manager, because she usually will. It's better to bug the people at the hospital about admission status than it is to run the risk of a hefty skilled nursing bill.

Wednesday, April 7, 2010

More Health Reform Updates

I got my hands on some more information about the Health Care Reform Bill; this comes from the Kaiser Family Foundation. These benefits will be available in 2010:
  • Medicare beneficiaries will receive a $250 rebate when they reach the doughnut hole in 2010. I reported earlier that the doughnut hole will be phased out, and this will occur by 2020.
  • Medicare coverage will be expanded to individuals who have been exposed to environmental hazards in areas subject to an emergency declaration made as of June 17, 2009, and who have developed certain health conditions.
These are benefits that will be available in 2011:
  • A national, voluntary insurance program for purchasing community living assistance services and supports (CLASS) has been established. My understanding is that this is basically long term care insurance.
  • Medicare Advantage plans will be prohibited from imposing higher cost-sharing requirements for some approved benefits than is required under traditional Medicare.
  • Freeze the income threshold for income-related Medicare B premiums for 2011-2019 at current levels, and reduce Medicare D premium subsidies for those with incomes above $85,000/individual and $170,000/couple.
There are more changes that will affect Medicare that will be phased in beyond 2011, but I'll cover some of these in later posts.

Tuesday, April 6, 2010

Health Care Reform and Medicare

OK, folks, I'm gonna try and tackle health care reform, but only as it will affect Medicare and Medicare beneficiaries (sorry, everyone else).

First, let me tell you it's kind of hard to find objective, unbiased information. What I know is that almost everyone has a very strong opinion about this topic, but my intent here today is just to state what changes we can expect. It's too soon to know how things will end up, and with anything of this scale, there are sure to be unintended consequences, good and bad.

Most of this information is taken from the website

  • Subsidies to Medicare Advantage plans will be reduced. Some years ago, in an effort to move more Medicare beneficiaries into Advantage plans, Medicare paid these private insurance companies higher rates to offer plans. This idea never really took off in Texas; Secure Horizons is still the largest and most well-known Advantage plan in North Texas. My suspicion is that reducing these subsidies will result in some of the smaller plans going away. Since we don't have that many smaller plans in North Texas, there may not be much effect, but who knows?
  • Closing the doughnut hole. If you have Medicare D, you probably know about the doughnut hole. This will be phased out over several years, and in the meantime, beneficiaries will get a 50% discount on brand name medications while they are in the doughnut hole.
  • Free preventative services. Deductibles and co-payments will be eliminated on preventative services like colonoscopies. This will hopefully encourage beneficiaries to use these services, therefore allowing problems to be identified early, when they are treatable.
This is just a start. I will continue to look for information and share it as I find it.

Tuesday, March 9, 2010

Here Come the Bugs

Here is an excellent discussion on hospital infection rates in today's New York Times, Doctor Leads Quest for Safer Ways to Care for Patients.

I remember a situation back when I worked in the hospital. We had a patient with a bad wound, and the resident would go in, remove the dressing without washing her hands first OR putting gloves on. She'd then go on to do things to the wound, then leave--again, never washing her hands before going to the chart to write her note.

Our therapy team finally approached the resident and told her she was going to have to start washing her hands before and after seeing this patient. She was shocked that a bunch of lowly therapists and social workers would dare confront her on this issue, and told us she was the RESIDENT and knew better. When we threatened to get the infection control nurse involved, she backed down and started washing her hands.

I've also seen a nurse fool with a patient's IV, again with no gloves, get blood all over her hands, and go on to the next patient without washing her hands.

So, you are well within your rights to always ask medical personnel to wash their hands and put gloves on before they do anything to you. And don't even get me started on neckties!

Tuesday, March 2, 2010

The ABCs of Social Work

March is Social Work Month, so in case you're not sure what we do (no, we don't plan social activities, at least not all the time), here is my version of the ABCs of Social Work.

As Social Workers, we:

Advocate for marginalized people;
Bend over backwards to get the job done;
Create services where none existed before;
Deliver meals to people at home;
Educate others on social issues;
Field all kinds of unusual questions;
Grief counselors;
Hear every side of every story;
Insist on client confidentiality;
Jump to action;
Know how to network;
Love what we do;
Mend broken hearts;
Never say never;
Observe everything;
Play with kids;
Quick to add our voices to a cause;
Refer, refer, refer;
Solicit donations;
Teach parenting skills to teenage parents;
Unify neighborhoods;
Watch out for the disenfranchised;
Xerox queens and kings;
Yearn for a better world for all;
Zoom around hospital corridors.

Monday, March 1, 2010

Dementia vs. Delirium

I thought it might be a good idea to review dementia and delirium (it helps that it's something I'll be addressing in class soon).

If you don't remember what dementia is (no pun intended), it is a syndrome that includes many cognitive deficits that include memory problems. Most people are familiar with Alzheimer's type dementia, but dementia can also be caused by vascular problems, Parkinson's disease, substance abuse, as well as other causes.

While the different types of dementia do look a little different from each other, in general there is a gradual decline in memory and thinking ability.

Delirium, on the other hand, is an acute, or sudden onset of change in consciousness that can't be explained by a pre-existing dementia. Delirium can change or fluctuate over the course of a day, and can include changes in sleep patterns.

Even people with dementia can experience delirium; if a person with dementia demonstrates a rapid change in behavior or memory, delirium should be ruled out.

So what can cause delirium? There are several medical conditions that can cause delirium, including urinary tract infections, pneumonia, or even a mild heart attack. Medications can also cause symptoms of delirium.

Any time you see a sudden change in mental status of an older adult, be sure to consider some of the causes of delirium, and seek medical treatment.

Wednesday, January 20, 2010

We All Need a Little Help From Our Friends

I was asked recently by a colleague to write a newsletter article on Geriatric Care Management, and I realized this is a topic I haven't even written about here. So, not only did I get a newsletter article out on the topic, I also have a blog post.

My colleague, Zanda Hilger, is a busy, busy lady who does lots of teaching, counseling and consulting on aging issues here in Fort Worth. She has a website,, that is full of information. I encourage everyone to go check it out. And like me, Zanda is a caregiver, so she "gets it".

Being a caregiver is hard work. There is no other way to say it. Many of the people I see on a daily basis have jobs, spouses, children, and now they have the worry of having to provide increasing amounts of time devoted to parents or grandparents whose health is failing, who are functionally able to do less, and who need more and more assistance. It’s no wonder so many caregivers are fatigued and depressed and overwhelmed.

Sadly, little in our current health care delivery system is designed to make caring for older adults easy. Services are sporadic, care is fragmented, and it can feel like you need a PhD in bureaucratese to understand an insurance explanation of benefits.

For some, the assistance of a geriatric care manager (GCM) can be a life saver. A professional Geriatric Care Manager is someone who helps families who are caring for older relatives. GCMs can be especially helpful if the caregiver lives in another city or state from the family member needing help.

Many GCMs are trained and experienced in any of several fields related to care management, including nursing, gerontology, social work, or psychology, with a specialized focus on aging and elder care.

Unfortunately, most services provided by Geriatric Care Managers have to be paid out of pocket and can average $75.00 per hour. Medicare and Medicaid do not cover care management services. Some long term care insurance policies do provide some coverage, so be sure to explore that if your loved one has this type of policy.

Some of the services a GCM can provide include:

  • Conducting care-planning assessments to identify problems and to provide solutions.
  • Screen, arrange, and monitor in-home help or other services, including assistance in hiring a qualified caregiver for home care.
  • Provide short- or long-term eldercare assistance for those engaged in local or long distance caregiving.
  • Review financial, legal, or medical issues and offer referrals to geriatric specialists.
  • Provide crisis intervention.
  • Act as a liaison to families at a distance, overseeing care, and quickly alerting families to problems – especially important when families are engaged in long distance caregiving for a loved one.
  • Assist with moving an older person to or from a retirement complex, assisted care home, or nursing home.
  • Provide consumer education and advocacy.
  • Offer eldercare counseling and support.

When talking to a GCM, there are some questions to be sure and ask:

  • What are your professional credentials?
  • Are you licensed in your profession?
  • Are you a member of the National Association of Professional Geriatric Care Managers?
  • How long have you been providing care management services?
  • Are you available for emergencies?
  • Does your company also provide home care services?
  • How do you communicate information to me?
  • What are your fees? (These should be provided to the consumer/responsible party in writing prior to services starting.)
  • Can you provide me with references?

Finding and hiring a care manager can make the hard work of being a caregiver a little less so. A care manager can be there to help understand the medical complexities so you can make informed decisions. They can help unravel insurance. Care managers will be connected to many service providers in your community, and they will be able to do a lot of the leg work and research so you can find the best care available for your loved one.