Cowtown Eldercare

Tell Me That Story

2011-08-31T16:59:00.000-05:00

I had the pleasure of being a guest at a support group last night at a local assisted living community here in Fort Worth. I was the guest speaker, and I did a brief presentation on elderspeak, the topic of the last blog post.

We had a good discussion, but as most good discussions do, it took a turn, and we ended up talking about other things. One of the people in the group brought up an issue with her mother who has dementia. It seems that her mother keeps talking about "going home".

Going home can mean different things to people with dementia, and it can mean different things at different stages of dementia. In this case, this lady wants to go home to the state where she spent most of her life. Her daughter reported that she was considering taking her mom on the trip home, but was worried that the trip would be hard, because her mom is frail and in poor health. Before I could say anything, one of the other group members exclaimed "You can't take her home, that wouldn't be safe! Besides, you'd be doing it for yourself, not for her."

Good points, and certainly more meaningful coming from the other group member, who is dealing with similar issues. But what I was able to contribute to this person is the idea of redirecting her mother. It seems that her mother equates "home" with a time in her life when she was younger, healthier, and happier. I suggested that the daughter might want to talk to her mom about not being able to go home now, but let's talk about home. The daughter can ask her mom to tell her stories about home, and they can look through family photos of home they can reminisce about those happier times. The daughter can validate her mother's feelings that home was a happy place full of good memories. As mom begins to forget those longer term memories, things can shift, and the daughter can tell the stories.

Validating and redirecting is not hard to do, but it does take patience and empathy. When you think how scary it must be to not remember people or places, it can be a comfort when someone takes the time to listen to the stories you do remember, and who cares enough to remind you of the things you've forgotten.

Hey, Honey, How are We Doing Today?

2011-06-12T08:42:00.000-05:00

I know I've written about the topic of elderspeak before, but I think it's worth coming back to. For those of you who aren't familiar with the term, elderspeak is a way of speaking that many use when talking to older adults, especially older adults with dementia. Some characteristics include simple words, short sentences, using a high-pitched sing-song voice, the use of inappropriate endearments, and the use of "we", and it's not the royal "we". If you're having a hard time understanding what elderspeak sounds like, think about the way most of us talk to infants or pets.

Negative reactions to elderspeak include pushing, pulling, refusing to do tasks, grabbing at people or objects, screaming and yelling or crying. In research studies I've seen, people exhibit these behaviors at much higher rates in response to elderspeak when compared with silence, or interacting in a normal fashion.

Sadly, the message about elderspeak is one that a lot of people just aren't interested in. I was recently asked to do an in-service on the topic at an assisted living community. You would think that the people working directly with residents with dementia would want to learn any tips that might make their jobs easier, but you would think wrong. I had a pretty bored and uninterested audience, and no one owned up to feeling offended if someone talked to them like they were 5 months old.

There Ought To Be a Holiday

2011-04-25T07:03:00.000-05:00

I may have mentioned that I'm teaching a social work class on aging at UTA again this semester, and I've been thinking about tonight's lecture all week. The topic is caregiving. I don't know that I have much new to say about caregivers:

It's a hard job. You have to take care of yourself. If you get sick, you're no good to the care receiver. Take time for yourself.

As professionals, we all know what to say, and most caregivers have heard it over and over and over.

But here's a new message, something we don't talk about as much: If you know a caregiver, be intentional and do something FOR them.

Sometimes what that caregiver needs is a phone call, so they know someone is thinking about them. Sometimes that caregiver needs someone to come clean the house, without having to ask for it. Sometimes the caregiver needs someone to come take care of the care receiver for 2 hours so they can go shop without worrying. And what I know about so many caregivers is that they have a very difficult time asking for help. They feel like they are failing if they admit that they can't do it all.

So I challenge everyone who knows a caregiver to declare Caregiver's Day. It doesn't have to be to today, but it could be once a week or once a month. Do something for that caregiver to let them know they are not forgotten and they are not alone.

New Guidelines for Alzheimer's

2011-04-20T06:59:00.003-05:00

It was reported yesterday that there are new guidelines for Alzheimer's disease. The first article I read was in the New York Times, and I wrote about the guidelines on Katten & Benson's blog.

The most important part of the story, however, is lost in a short paragraph in the middle of the story. It was reported that Congress has introduced a bill that will create specific cost codes for Alzheimer's disease for Medicare. These codes would allow doctors to be paid for having discussions with family members and caregivers. This is significant, because as the article states, "keeping family members well-informed can result in better planning and care."

It is amazing to me that it has taken this long for this to be recognized. In the social work class I teach, we talked last week about setting goals. Professionals are really good at setting goals--our goals. We often forget that we need to be setting goals that are consistent with what our client/patient wants. This becomes difficult with that person with dementia, especially when they want to stay at home alone, when clearly that is no longer an option. I told my students that when working with dementia clients, the "client" at some point changes from the person with dementia, to the family/caregiver. At that point, we must then revise the goals. We still must address the person with dementia's goals, but the family/caregiver's goals often become primary.

I think allowing doctors to have these discussions with the family are a step in the right direction.

It Comes in Threes

2011-04-18T16:47:00.002-05:00

They say death comes in threes, and it certainly has yesterday and today.

Last night I learned that a client I have worked with for about 2-1/2 years died. This is definitely the worst part of my job--I get close to clients and their families, and then I lose them. Whenever I saw this client, he always, always asked me where I was traveling to next. We would spend a good part of any visit talking about where we had traveled, and now I won't have that to share with him. But I do have those happy memories, and that is what I cherish most about my job.

Today I learned that another older adult, someone in the community I have known for many years, died yesterday, too. I wasn't all that close to her, but she is someone I learned a lot from about aging and working with older adults. As her health failed, I saw her less frequently in a professional capacity, but more often as helper. I even recently helped her visit assisted living communities, and talked with her about her possible choices. Those of us who have worked in the aging community in Tarrant County have lost a friend and mentor.

The third death I learned about was through a facebook post from my brother, about a high school classmate. This person was a year behind me in school, but we were fairly well acquainted, although we had not seen each other since school. It's just always upsetting to learn about a contemporary's death--it reminds us of our mortality.

I hope that is it for awhile, but I guess there are at least a couple of funerals in my immediate future.

When Mom or Dad Doesn't Know You Anymore

2011-04-14T11:08:00.000-05:00

One of the hardest things about dementia is when Mom or Dad doesn't know you anymore. It doesn't matter that you've read The 36-Hour Day, or go to the local Alzheimer's symposium every year; it's just hard.

My Dad didn't have Alzheimer's, but at the end of his life, in the advanced stages of pancreatic cancer, he did not recognize me the last time I saw him alive. There is just no way to prepare for the first time that happens.

I just found a brand-new blog, My Father Doesn't Know Me Anymore, that addresses the many complex feelings that come with caring for a loved one with dementia. Finding the blog was accidental--I was looking at Katten & Benson's website statistics on Wordpress, and saw that we had been linked to on this blog. I followed the link out of curiosity, not sure what I'd find.

It turns out that the author is a client's daughter. I have worked with her and her father for about three years. As Lucy says in the blog, we have been through some ups and downs, but what relationship, even a professional one, doesn't have ups and downs? Lucy says some nice things about me and Steve Katten, the attorney I work for, but what I appreciate most about Lucy's blog is her honesty. She tells you what it is like to be a caregiver--the good, the bad, the ugly and the beautiful.

Lucy and her sister are some of the fiercest advocates for a parent I have ever met, and they are truly inspiring. I plan to read Lucy's blog on a regular basis, and I hope you do, too.

The Future of Medicaid

2011-04-04T16:29:00.000-05:00

I have been getting calls and emails from clients recently worried about Medicaid, and whether they need to start making other plans for their loved ones currently in nursing homes. I am at a loss about what to tell them.

On the one hand, it's hard for me to believe that the Legislature would actually make these cuts, and yet yesterday the Texas House of Representatives passed a draconian budget, including significant cuts to education and Medicaid. Texas nursing homes already lose about $12 per day for each Medicaid resident; cutting Medicaid payments would only increase that loss, and put many nursing homes out of business.

I am afraid there will be some serious cuts, and I fear that some nursing homes will close. I wonder how many legislators have family members on Medicaid in nursing homes. My guess is not too many. It's too easy to sit in a nice office in Austin and make life and death decisions, and make no mistake, people will die if these cuts go through.

I know we have to make some tough choices, and I know we have to live within our means, but I truly think many of the proposed budget cuts are just cutting off our noses to spite our faces. More people will go to the hospital, more people will be depressed, nursing home employees will lose their jobs, family members will lose their jobs. Where is the savings in that?

I'll appreciate any ideas you might have; better yet, send them to your legislator.

Foreign Territory

2011-03-23T07:20:00.000-05:00

It's been four years since I quit working in hospitals. I'm still pretty comfortable in hospitals, but it's easier now for me to see how foreign they are to everyone else. Even if you're just going to an outpatient surgery center for a minor procedure, like my Mom did this week, it can be a pretty overwhelming experience.

Mom was supposed to be at the center Monday morning at 9:00 for a 10:30 procedure. The phone rang at 7:40, and it was the center asking if we could be there at 8:30. Mom was still in the shower, but I told them, yes, we can be there close to 8:30. I'm thinking perhaps we'll be out sooner.

We get there at 8:35. Mom gets checked in, and we go to the waiting room. We wait. People get called back. We wait some more. More people get called back. We wait some more. At least the TV has the Today Show on, and not Fox News. And the volume is low, so it's easier to ignore. Finally, around 10:00 they call Mom back to prep for surgery. They let me go back about 20 minutes later.

In the room, it's cold. I wore jeans and a sleeved shirt, because I knew it would be cold (unlike the person I saw in a sleeveless velvet contraption over running pants, with a yellow mini skirt). I was still cold, though. Mom was cold too, and it seems the nurse didn't help Mom get ready, because the gripper socks they supplied were not on her feet, but on the table.

We wait another hour. The anesthesiologist comes in and asks questions. The surgical resident comes in and asks the same questions. The nurse anesthetist comes in and seems to be the only one who really knows what is going on. The surgeon himself comes in. She finally goes back for the procedure at 11:30. I wait in the waiting room some more. So much for being done sooner.

The procedure takes less than an hour, and she was not fully anesthetized for the procedure, so she's mostly awake when I'm allowed back. She's still kind of groggy, and not really understanding that she can't leave until her blood pressure and heart rate come down. The nurse never really tells me that's what is going on. I just know what to listen for, and I can mostly read the monitors. Finally, after about another 40 minutes, two different nurses adjusting the blood pressure cuff numerous times, there's a reading low enough. But the nurse is out at the desk. I know to go get her, and she literally comes running to see the reading and start turning all the monitors off. I wonder how many family members would just sit there and not get the nurse.

Anyway, we got home, and Mom is doing fine. I realize that I really don't like being in a hospital where I don't know anyone. It's easy to be spoiled when you get all kinds of professional courtesy. And I keep wondering about all the families I work with, and how helpless they feel, because they don't anyone, and they don't know hospitals work. And hospitals don't do much to make it easy.

Reverse Mortgages

2011-03-12T07:21:00.000-06:00

I sometimes have people ask my opinion about reverse mortgages, and I have to tell you, I'm not a fan. I think the number of people for whom a reverse mortgage is a truly good idea is extremely small, and for too many people I think they are downright dangerous products.

Now, in the spirit of full disclosure, I got a great deal on my house because it had a reverse mortgage, and the heirs were desperate to sell quickly so they could pay the reverse mortgage off, so I guess I would have to say a reverse mortgage was good for me, it just wasn't MY reverse mortgage.

Anyway, I bring all this up because the AARP has sued HUD over a rule change that is putting a small number of reverse mortgage holders under the threat of foreclosure. The New York Times has an excellent article on the story, which includes some great links of it's own to other sources of information on reverse mortgages.

I encourage everyone to read this article, and follow some of the links included, to learn more about reverse mortgages.

One Person's Trash is Another Person's Treasure

2011-03-09T07:16:00.000-06:00

Some of you may know that I've done some presentations on hoarding. I've recently been reading the book Stuff: Compulsive Hoarding and the Meaning of Things by Randy O. Frost and Gail Steketee. Frost and Steketee are the gurus of hoarding, and I think Randy Frost is a consultant on at least one of the popular hoarding shows on TV.

Any time I have done this presentation it seems that most people in the audience know someone they suspect is a hoarder, are related to someone who hoards, or they worry that they themselves are hoarders. Frost and Steketee report that between 2-5% of the population, or anywhere from 6-15 million people hoard. That's a lot of people with a lot of stuff.

I'm only part of the way through the book, but I'll share some tidbits:

Hoarding may not be as closely associated with Obsessive Compulsive Disorder (OCD) as once thought. Rather, it seems to be more characteristic of an Impulse Control Disorder (ICD), like kleptomania or compulsive gambling.
Hoarders often place high value on things that appear to be junk to the rest of us. They have difficulty distinguishing between things with true value and things that are trash.
Perfectionism appears to play a major role in hoarding.
Some studies have indicated a high correlation between compulsive gambling and hoarding.
There also seems to be a connection between possessions and a sense of security, with some people starting to hoard after suffering a severe trauma.

There's no doubt that this is a complex and difficult issue to deal with. I will keep you posted as I work my through this book.

A New Form of Assault

2011-01-26T07:04:00.000-06:00

Thanks to Robert Kraft (one of those facebook "friends" I don't actually know) for bringing this to my attention.

The New York Times has an excellent blog called the New Old Age. I don't get around to reading it often enough, but this recent entry is very thought provoking. The blogger writes about a recent study published in the Archives of Internal Medicine (the full article is only available by subscription). The study found that people with late dementia are frequently hospitalized too often, with medical symptoms and conditions that could have been treated in their nursing homes.

The study only looked at nursing home residents, and it found that over an 18 month period, 30% were hospitalized. Dr. Susan Mitchell, one of the researchers estimated that fully 75% of those hospitalizations could have been avoided.

So what's the problem? Dr. Susan Mitchell's comment: “Being in an emergency room where people are taking blood and putting in IVs in this crazy, noisy setting — it’s been described as an ‘assault,’ and I concur." If you don't know someone with late-stage dementia, allow me to describe someone I know.

This gentleman has been in an Alzheimer's care home for the last two years. He still recognizes me as someone he knows, but he has no idea how or why. He thinks he's known me for a very long time, but we have only known each other for a few years. He does not always remember his children's names. He is not able to carry on a conversation about anything, although he does still talk. It is reported that he eats a lot, but in the past year he has lost at least 30 pounds, and this over six foot tall man is wearing size small shirts.

Thankfully his family has him on hospice, so there won't be any unnecessary trips to the hospital, but how do you help someone in this state understand what is going on around them? How do you communicate to them what the IV is for? How do you keep this person calm without drugging them? And for what end? When we, as health care professionals or family members insist on sending someone like this to the ER to be treated for pneumonia, are we doing it for the patient, or are we doing it for us, whether it's to cover our backsides (in the case of a health care professional), or because we aren't ready to let a loved one go?

It does seem extreme in some ways to consider this kind of treatment assault, but once you have seen a frail, older adult, who doesn't know or understand what is going on, who only wants to be left in peace, being forced to stay in the hospital for aggressive treatment, you might agree that it is an assault. I happened to see a former colleague earlier this week, and when we worked together in a hospital he had one of these horrible situations. The patient was on a ventilator, he had multiple infections, he had pressure sores, he was on dialysis, and he was like this for MONTHS. His children would not let him go. It was so bad that there were nurses who refused to take care of him, because they felt it was assault. When his family finally agreed to take him off all the machines, he died before they got everything turned off.

We have to start talking about this. We are all going to die--that is one thing I am sure of.

New on the Alzheimer's Front

2011-01-21T06:51:00.000-06:00

According to a story in the New York Times, the FDA is getting closer to approving a scan that will help diagnose Alzheimer's disease. Right now, we can't definitively diagnose Alzheimer's disease until death, when an autopsy can be done. What a lot of people don't realize is that not only are there many types of dementia, but other treatable medical conditions mimic Alzheimer's.

Other types of dementia are related to vascular problems, such as having several small strokes, or Parkinson's disease. In these cases it might be possible to better treat the cause, especially with vascular dementia, to slow or stop the decline. Depression, which is very treatable, can also mimic the memory loss of Alzheimer's. Delirium is another condition that can look like Alzheimer's. Delirium is frequently caused by an infection, and infections are often successfully treated.

This is good news, because it gives doctors the potential to definitively rule Alzheimer's in or out, allowing them to properly focus their treatment. The article says full approval is still several months away, but it's certainly a great stride forward.

Growing Older But Not Up

2011-01-19T15:38:00.000-06:00

Thanks to Monica, one of the attorneys here at Katten & Benson, for sharing this great article about the oldest African American, Mississippi Winn. Miss Winn died recently at the young age of 113. Another amazing fact about her is that she was one of two known people left whose parents were likely born into slavery. Her niece said that even though she was 113, she thought she was young. Her family thinks one reason she lived as long as she did was because she just handled things as they came, of course, no husband or children might have been a factor as well.

I have my own Miss Winn story. Many years ago, when I still worked in the hospital, one of my patients was a nun, Sister Winifred. At the time that I knew her, she was 101. She was mostly deaf, and didn't see well, and she used to tell us that she figured God decided she had seen and heard enough.

She had been a teacher for many, many years, despite the fact that she did not really want to be a teacher. But she became a teacher anyway, because that is what the Church needed her to do, so she did it. Despite this, she had middle-aged, former students visit her in the hospital. I suspect teaching truly had been her calling, because she had clearly been beloved by many of her students.

The day I told her she was going to be discharged and would be able to return to her convent, she took my hand and said this to me: "I will pray for you every day for the rest of my life. I know that won't be long, but I will pray for you every day". She ended up living another three years. I never doubted that I was in her prayers.

Knowing her for even a short time was a gift I will always cherish. I hope all of you have the opportunity to be touched by a remarkable older adult.

Merry Christmas?

2010-12-22T08:33:00.000-06:00

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!

The Tracks of My Tears

2010-09-16T19:55:00.000-05:00

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.

More on Predicting Alzheimer's

2010-08-10T07:17:00.000-05:00

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.

Preclinical Alzheimer's ?

2010-07-14T06:48:00.000-05:00

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.

The Beers List

2010-07-06T10:04:00.000-05:00

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.

It's a Rainy Day Today

2010-07-05T07:43:00.000-05:00

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.

Hospital Delirium

2010-06-21T07:15:00.001-05:00

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.

Crazy?

2010-06-16T07:30:00.000-05:00

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.

What Happened?

2010-06-11T07:19:00.001-05:00

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!

Walking the Floors

2010-06-08T11:40:00.005-05:00

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.

Gotta Go, Gotta Go, Gotta Go Right Now

2010-05-30T08:34:00.014-05:00

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.

Raindrops Keep Fallin' On My Head

2010-05-29T09:07:00.009-05:00

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.

Can't Reach That

2010-05-28T06:58:00.005-05:00

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.

I'm Not Your Honey

2010-05-16T08:43:00.003-05:00

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.

Wandering through the Wilderness of Dementia

2010-05-05T10:34:00.003-05:00

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.

Common Bonds

2010-05-04T11:15:00.003-05:00

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.

Graying Caregivers

2010-04-25T09:13:00.001-05:00

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.

Letting Go of My Father - Magazine - The Atlantic

2010-04-18T15:14:00.001-05:00

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."

Observation vs. Admission

2010-04-08T11:18:00.003-05:00

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.

More Health Reform Updates

2010-04-07T14:24:00.002-05:00

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.

Health Care Reform and Medicare

2010-04-06T16:08:00.003-05:00

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 www.healthreform.gov.

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.

Here Come the Bugs

2010-03-09T07:17:00.004-06:00

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!

The ABCs of Social Work

2010-03-02T13:36:00.002-06:00

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;
Volunteer;
Watch out for the disenfranchised;
Xerox queens and kings;
Yearn for a better world for all;
Zoom around hospital corridors.

Dementia vs. Delirium

2010-03-01T09:30:00.002-06:00

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.

We All Need a Little Help From Our Friends

2010-01-20T10:17:00.004-06:00

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, www.familycaregiversonline.net, 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.

www.caremanager.org

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?

www.caremanager.org

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.

I Prefer Honeycrisps

2009-12-11T07:00:00.001-06:00

OK, you're probably wondering what the title means. Honeycrisps are my new favorite apple. They are crisp, with just the right balance of sweet and tart. I figure since I'm starting my teaching career soon, some might want to know what kind of apple I like.

Yes, I'm starting my teaching career soon. In January I will begin teaching a graduate level social work class at the University of Texas at Arlington School of Social Work. The class title is Direct Practice in Aging, kind of a specialty of mine.

I was pretty pleased to even learn such a class was being offered--I have long been frustrated that most schools of social work have dragged their feet on offering coursework on aging issues. I was even more pleased to be approached about teaching this course.

You can imagine that my Christmas vacation will now be spent reading the textbook and preparing lectures. My mind is already swirling with all the things I want to talk about; I just now need to start getting it all on PowerPoint!

This is a great opportunity to help teach others about the joy of working with older adults, and with luck some of these students will go on to provide services to older adults in our community. I will be pleased to see that happen.

Happy Thanksgiving

2009-11-25T06:51:00.001-06:00

Turkey Day is tomorrow, and I'm pondering the rituals of Thanksgiving.

When I worked at the Osteopathic Medical Center of Texas (The O), we always had a Thanksgiving dinner for the staff and patients. Staff would bring things, but we also had the patients help prepare parts of the dinner--this was a rehab unit, after all. I often offered to make, or help make, the turkey and dressing.

I have to admit that this offer was selfishly motivated, because I happen to think that my dressing is the best dressing around.

I remember one year we had a patient, an older African-American lady, and she and I had several conversations about dressing. We compared recipes, which were very similar, and we both believed that we made the best dressing ever.

When the day of our dinner rolled around, I made the turkey and dressing as usual. After the dinner, this lady made a point of telling me that my dressing was almost as good as hers--high praise, indeed!

Now, I also have to admit that my dressing isn't really my dressing. I learned at my Mother's side, she learned at her Mother's side...you get the picture. I owe a debt to all the women in my family who preceded me. And in my generation, it's not just the women who owe this debt. All of my brothers are good cooks, and some are even better cooks than I. They just can't make better dressing.

The Mystery of Medicare

2009-10-28T16:55:00.003-05:00

I've been thinking a lot about Medicare lately, partly because Medicare and the possibility of cuts have been in the news. I am certainly no expert on health care; smarter people than I are stymied by how to reform health care, including Medicare.

So I'm not going to talk about that.

I'm going to talk about what I know.

Open enrollment begins on November 15. For those of you not on Medicare, this means that this is the time when people on Medicare can change their Medicare Part D plans or their Medicare Advantage plans.

This is important because with my own mother we have been able to save money every year by switching her Medicare D plan. Each year the insurance companies change their formularies (lists of covered medications) and they can raise premiums or deductibles.

The easiest way to compare plans is to go to the Medicare website. You will need a list of prescription medications in order to get the best information. Once you enter the medication information, you will get the lengthy list (over 50 providers in North Texas) of different plans available. It is possible to even choose your preferred pharmacy and compare prices at different pharmacies.

There are some things you need to watch for.

If you have a Medicare Advantage plan that you like, DO NOT change your part D plan. If you choose a part D plan, you be dropped from your Advantage Plan. All Advantage plans have prescription drug benefits built into the plan.
If you have Tricare for Life, you probably don't need a part D plan, because you already have coverage with Tricare.
If you have coverage through a retirement plan, read your new options carefully. Some companies are only offering Advantage plans, and you might not want to sign up for one of those plans, because your doctors may not be providers.
If you are just now eligible for Medicare A and/or B, be sure to sign up for a part D plan. If you wait too long you might be penalized.

All of this information is available in Medicare and You 2010 publication.

Guess Who I'm Letting in My Home

2009-10-05T10:24:00.003-05:00

One of the most difficult decisions many older adults make is to allow caregivers into their home. But as hard as this decision is, I am beginning to think that choosing the right caregiver agency is even harder.

There are so many things to consider when choosing an agency. Cost is obviously a huge factor. Any way you look at it, paying for care is expensive. In the Fort Worth area, you can count on paying anywhere from $16-$24 an hour, and that is often with a four hour minimum. Some agencies will consider shorter minimums, but they might charge a higher hourly rate.

If round the clock care is needed, live-in care could be an option. Many agencies define live-in care based on whether the caregiver can sleep or not. If the caregiver can sleep, even getting up 3-4 times a night to provide assistance, this might qualify as live-in care. Of course, you then have to have a place for the caregiver to sleep, which in some situations might not be available. Live-in care is less expensive, usually in the $10-$12 dollar per hour range. Many times these caregivers are in the home for several days at a time, which can result in fewer caregivers.

If the caregiver is not able to get adequate sleep, the agency is probably going to insist on 24-hour care, which will usually be billed at the regular rate. You can expect however that the night time caregiver is awake all night long, and ready to provide assistance. Many agencies will try to have teams of 4-5 people on the care team in this situation, to minimize the number of people providing care.

In addition to having good, well-trained caregivers, it is also important to have a good relationship with the agency owner/administrator and other office staff. You are paying a lot of money for care, and it is reasonable to expect that when you call the office with a problem, you will get a quick response.

When choosing an agency, here are some questions you may want to consider asking:

Are the caregivers certified?
What kind of orientation and ongoing training do the caregivers receive?
How are problems resolved?
What kind of background checks are done?
How many clients do you have?
How many caregivers do you have?

Another source of information about caregiver agencies is the Department of Aging and Disability Services (DADS). They have a Long Term Care Quality Reporting System. At this website you can view information on recent complaints, not only for home care agencies but also for nursing homes and assisted living communities.

And finally, don't ignore your gut reaction. If you have a bad feeling after meeting with an agency owner or representative, pay attention. It might not be scientific, but these are people you will be dealing with on a regular basis, and if you don't like them, the relationship will probably not be a good one. There are enough other agencies out there that you should be able to find a good fit.

Outstanding Person and Ideas

2009-09-16T11:22:00.003-05:00

I had the good fortune to attend a dinner last night hosted by Senior Citizens Services of Greater Tarrant County. One of the many things Senior Citizens Services does is administer many of our local senior centers. One thing I learned at the dinner last night was that they served 260,000 congregate meals to older adults in Tarrant County last year.

The purpose of last night's dinner was to present the "Outstanding Citizen for Seniors" award. This year's honoree was Bob Schieffer, the CBS News Chief Washington Correspondent. For those of you who don't know, he is a fellow Texan, attended college here in Fort Worth at TCU, and worked for the Fort Worth Star-Telegram.

Mr. Schieffer has obviously attended many of these events, because he kept his remarks very short, but he made several important points that I wanted to share.

He talked about how things have changed since 9/11: that eight years ago, there was truly a feeling of bipartisanship in the nation's capital, and that as Americans we all came together in a time of need.

He talked about how in a 40 year career in Washington, DC he has never seen the level of acrimony as high as it is now. He very eloquently expressed my own feelings that guns at public rallies are inappropriate (at best); that signs calling our President a Nazi or worse are absolutely uncalled for; and that what we need is civil debate. Not name calling, not shouting each other down, not elected officials calling other elected officials liars.

Last night I was proud to be a Texan, and proud to be an American.

Fire! (Not)

2009-09-14T11:34:00.008-05:00

I had an exciting experience yesterday. I was in Chicago for a conference, staying in a nice hotel. I woke up a few minutes before 6:00 am to use the restroom. Before I got to the bathroom, some pretty loud beeping started, and I thought to myself, "Wow, that person has a really loud alarm in their room". Almost immediately I heard voices, which I thought was said person's really loud radio. After a couple of seconds when it didn't go off (because I figured if I could hear it, said person surely would and would have turned it off), I listened more closely, to hear this: "This is a fire emergency, please evacuate".

Not the way I wanted to start my day.

I poked my head out the door, as did a few others; we all looked at each other and said "Guess we need to go".

I threw on some clothes, grabbed my purse, my cell phone, and my laptop and headed down the stairs.

We all ended up staying outside for about 25 minutes.

The experience has made me think about a few things.

First, I'm glad I was only on the 3rd floor. I hate to think how the evacuation would have been if my mother, with her 2 bad knees had been traveling with me, and especially if we had been on the 12th floor. From now on, when traveling with Mom, I'm going to request the lowest floor possible. We never think this is going to happen, and despite all my years of emergency training in the hospital, I just never thought it would happen.

But I'm glad for all my years working in hospitals, because I knew what to do in a "fire emergency". I knew not to go to the elevator. While I did take a moment to change, it was only because my clothes for the day were already laid out. I only grabbed the laptop because it was stowed in it's bag and I could easily carry it, and I did these things because I had assessed the situation and did not smell any smoke on my floor.

Now, I learned today that there really wasn't a fire emergency. The person who sounded the alarm needed an ambulance, and thought that pulling the fire alarm would result in a quicker response. It may have, but I'm glad I'm not the one responsible for forcing a few hundred people to needlessly evacuate a hotel at 6:00 am.

I hope that everyone will take a few moments and think about their own disaster plans when traveling. It only takes a few minutes to review the fire evacuation maps posted in every hotel room. And if you ever wondered if a fire alarm would be taken seriously, I can tell you that it is in Chicago!

The Health Care Debate

2009-08-26T16:10:00.003-05:00

I read an interesting article this morning on the internet. The article is attributed to LiveScience.com. The headline read Health Care Debate Based on Total Lack of Logic, so of course I had to read it.

The crux of the article is that we are illogical (Mr. Spock has known that for 40 years). In the case of health care reform, each side starts with a conclusion, then works backward to find facts and data to support the conclusion. I know this to be true, because that's how I wrote an awful lot of my papers in graduate school. I'd write the paper, then go back to all the reference books to find supporting documentation to support my theory or hypothesis, instead of doing the research first. Today all you have to do is watch FOX or MSNBC to see this in action.

The article also made the point that the town hall meetings can promote even more rigid beliefs. Why? Because changing your mind about an idea can affect your sense of identity and sense of being part of a community.

So with that in mind, I think it might be helpful if we all take a step back, take a deep breath, and try to listen to the other side. Certainly each side of the debate has valid concerns and valid points that deserve to be heard.

Working With Older Adults

2009-08-24T15:11:00.002-05:00

One of my soap boxes, as anyone who knows me will tell you, is that there aren't enough people specializing in aging issues, whether they are social workers, doctors, or even home builders. Over the years I've been to a lot of seminars lamenting this fact; I've even given a few of those seminars.

Go into any social work/nursing/medical school class and ask students what they plan to specialize in, and almost unanimously the answer is families/children/pediatrics/babies. I have yet speak to any class of college students where someone admits they want to work with older adults.

And I was the same way when I was in graduate school. I was going to work with teenagers, and my first job out of graduate school was with Child Protective Services. The strange thing is, I'm not a "kid" person, and never have been.

My colleagues and I have all tried to figure out how we can make working with older adults more appealing, going so far as to offer paid stipends to social work interns, with some limited success. The research that has been done on the subject has shown that students who have had positive experiences with older adults are more likely to consider working with older adults. So I was intrigued to read this article in the New York Times today.

It's about a program where medical students actually live in a nursing home for a short period of time. The students are given a "diagnosis" and they are expected to receive care just as if they actually had the diagnosis. The students interviewed for the piece talked about how they came away with a much better understanding of the needs and experiences of nursing home residents, but they also feel they interact differently with all patients.

This sounds like a unique program, and one that would benefit all kinds of health care professionals and students.

Health Care Reform

2009-08-03T14:21:00.002-05:00

Much has been written lately about the proposed health care legislation, and I decided it was my turn to weigh in on the subject.

I will tell you up front that I have not read the entire 1000+ page bill. I have read one little part of it, and what I know from reading that part is that older adults will NOT be encouraged or forced to commit suicide. Neither will care be withheld from people at the end of their lives.

Let me explain what the bill does allow and encourage, and I'll use some examples.

In the last hospital where I worked, I worked in the intensive care unit. The patients there were really sick, and many died. There was one gentleman, who was only in his 60's, but with very serious end stage lung disease. He was on a ventilator, but he was alert and oriented. He knew he was not going to get better, and he knew the chances of coming off the ventilator were small. Sadly, no doctor was really forthcoming with this information; he just knew it to be true. When he did raise the issue with his doctors, they did at least confirm his suspicions. He then made the decision to stop the ventilator. I can't imaging how difficult a decision this was for him, but he had the courage to face the reality of his condition.

Conversely, there was another patient with the same diagnosis, although not as advanced. She was able to come off the ventilator, but she was actually told by her doctors that each time she went on the ventilator she risked not being able to come off of it. She refused to consider hospice, but she had no one to help care for her at home. She did not want to go to a nursing home. She was completely unrealistic about the course of her disease, despite having doctors who were very honest and realistic about her prognosis. She ended up going home, only to be re-hospitalized soon after and placed back on the ventilator. I heard that she died during that last hospitalization; I don't know if she ever came off the ventilator or not.

What do these two people have to do with health care reform? What the bill will do is require doctors to talk to their patients about advance directives. This is a good thing. The bill will also require doctors to talk to people with end stage diseases about hospice and palliative care; also a good thing.

Back in the early 1990s federal law began requiring hospitals to provide information to people about advance directives. Think about the last time you went to the hospital: a clerk probably gave you a brochure that told you about advance directives, and you probably threw it away. This is all the law requires currently.

Making serious end of life decisions is a conversation that we all need to have with our families and our doctors. When was the last time your doctor talked to you about what you want at the end of your life? I've never had a doctor talk to me about it.

Think back to the two patients I told you about. If their doctors had been having meaningful conversations with them about their disease process all along, perhaps if they had been encouraged by their doctors to talk to their families about end of life decisions, they might have both made different choices that would have allowed for more dignity and comfort at the very end of their lives.

Buyer Beware

2009-06-12T10:11:00.009-05:00

A colleague recently handed me a flyer she had received and asked if I knew anything about the service. Here are some of the claims made in the flyer:

Important Elder Law Update
Congress has passed legislation that standardizes entitlement provisions for persons 60 and over. These laws provide the following benefits:

Seniors may apply to completely avoid all probate and estate taxes
I don't even know what that means. The way it reads, it implies that there are probate taxes. There are not. If they mean that you can "apply" to avoid probate, they are wrong. You can't "apply" to avoid probate. You can plan to avoid probate.

In 2009, unless your estate is over 3 million dollars, there won't be any estate taxes anyway. Again, there is no "application" to complete to avoid estate taxes. If you have to pay estate taxes, you may be able to minimize the tax liability through proper planning.

Exempt assets from collection by government or nursing home if ill (with no need for nursing home insurance!)
I assume they are talking about paying for nursing home care. The government does not collect assets. Neither will the nursing home.

If you do not have long term care insurance and you need nursing home care, you can either pay privately for your care, or you can apply for Medicaid assistance. If you apply for Medicaid assistance, certain assets, like a homestead up to a certain value or one vehicle of any value are considered "exempt" (This is the rule in Texas. Medicaid rules vary from state to state). If the state pays for your nursing home care, they do have the right to recover expenses from your estate, this is the Medicaid estate recovery program. With proper planning, it may be possible to avoid estate recovery. Even so, the state isn't going to take your assets. They will file a claim against your probate estate, just like any other creditor.

The key is proper planning, done by qualified professionals. Many elder law attorneys are well versed in Medicaid laws, as well as estate tax planning. You would probably not let an electrician work on your plumbing system, so why would you let a someone with no credentials or questionable credentials give you tax planning or Medicaid planning advice?

I would also be cautious getting advice from someone whose main business appears to be selling financial products. Sometimes annuities are a perfectly fine financial product, but if an annuity won't mature until you're 114 years old (I have seen this, really), then it may not be the best product for you.

When I went to the website listed on the flyer, annuities figured prominently, as well as other financial products. There was no information on the "advisors", so there was no way to tell if they were Certified Financial Planners or if they held any other certification or designation.

I just don't think you can be too cautious when it comes to doing research on the folks who are going to help you plan for your retirement. If you need an elder law attorney, you can find one at www.naela.org. If you need a financial planner, you can find one at www.cfp.net. Another resource for a financial planner is the National Association of Personal Financial Planners.

It may be hard spending a little money for the right advice, but in the long run it could save you a bundle.

To Keep or Not to Keep

2009-06-04T15:24:00.004-05:00

Writing and keeping up with a blog is hard work. I find more often than not that I'll get an idea, even think about it for a bit, then just never get around to actually writing anything. I've been re-inspired this week, thanks to the daughter of a former client. She and I have had several emails about the blog, and networking, our facebook page, and networking, our website, and networking. But the thing she said that inspired me the most is that she feels the information I provide is easy to understand about practical topics.

Now that I'm inspired to write, what to write about...

...So, I'm going to muse a little bit about the issue of hoarding, because it's on my mind a lot lately, for more than one reason.

I learned a couple of years ago from my childhood best friend (I'll call her Ann) that her mother had become a hoarder. At the same time I also learned from Ann that her mother had been diagnosed with a rare form of cancer, and was not expected to live much longer. As we talked, I learned that Ann's mother, in an effort to control vermin, sprinkled Sevin dust everywhere in her house. Now, Sevin dust is a dangerous pesticide, and according to Ann, it was not possible to go anywhere in the home without coming into contact with Sevin dust, and her mother lived in it. It was no surprise to learn that the type of cancer her mother had has a strong correlation to chemical exposure. While no doctor had suggested the Sevin exposure caused the cancer, Ann, being in health care, firmly believed the exposure caused the cancer.

Around the same time I found out that a former neighbor also had a problem with hoarding. When her son went in and cleared out more than 20 trash bags full of her stuff, she basically disowned him. By her son's report, there wasn't even room on her bed for her to sleep, and her husband had all but left her.

I am currently working with a gentleman with similar issues, and his friends and family are struggling to help him deal with making the decision to move, which means sorting through a lifetime of belongings, and deciding what stays and what goes.

What I know about hoarding is that not enough is known about it. I went to a very informative presentation on hoarding at the American Society on Aging conference in March. The speakers reported that while hoarding has been commonly understood to be related to obsessive compulsive disorder, current research is finding a strong link to depression and dementia. Some researchers now believe that the changes in the brain that come with depression and dementia make it difficult for people to distinguish between "important" stuff and trash, so they just keep it all. Of course this is a major simplification, but it does make sense.

The other thing I learned is that for family to go in and just toss stuff out is often the worst way to deal with the problem, as my neighbor's son found out. Hoarders are often very attached to their stuff, even things that are obviously trash to the rest of us. When all that stuff is gone, the hoarder grieves, and I have heard of instances where psychiatric treatment was required, although that rarely repairs the damage done to the family relationships. We saw a film clip from the movie My Mother's Garden, which is a very poignant documentary about a family's struggle with this problem.

So how do you deal with it? It seems that often the best way to deal with the issue is to use a "good cop/bad cop" type of strategy.

The good cops are family members, friends, mental health professionals and other support systems. The bad cops can be code enforcement, law enforcement or Adult Protective Services (APS). Basically, the bad cops spell out why things need to be cleaned up and what will happen if it doesn't happen. The good cops then provide support, encouragement and assistance to help the hoarder maintain control of the situation while they clean things up. This is certainly a very labor intensive method, as my client's family and support system knows, but it can work.

Medicaid Unplugged

2009-05-04T17:07:00.005-05:00

No, I don't know all the answers you might have about Medicaid. I'm just way more tuned into Medicaid now because I'm doing more with Medicaid right now. I'm actually helping clients with their applications (for readers who are these clients, don't fret, I have LOTS of supervision).

Even though I've been listening in on Medicaid consultations for over 2 years, like anything else, you don't really pay attention until you actually need the information. Like now. And Medicaid is really complicated.

I'm also looking at my own family's situation in a new light. I know my Mom is getting really tired of me telling her "If you ever have to apply for Medicaid...", but what I know is that I don't want to have to do her Medicaid application. It will be one of those hard ones, and not just because it's Mom.

I marvel at some of the families I work with when they get the list of all of the documentation that's needed: months worth of bank statements, sometimes from years ago, copies of checks, copies of legal documents, copies of life insurance policies, etc., and then they actually send it to me. I'm not sure I could find all that documentation for myself, much less for my Mom.

Mom announced over the weekend that she had old bank statements that she needed to shred, and I told her "Keep at least 5 year's worth, in case you need to apply for Medicaid". She's keeping 7 year's worth for the IRS; who cares about the IRS?

I guess my point is, Medicaid is such a complicated animal, that if you or a loved one has even an inkling that Medicaid might be needed in the future, it's worth a visit to your friendly, neighborhood Medicaid specialist to learn a little bit about it. I'm thick in the middle of Medicaid every day, and the thought of being on the client side of the table makes my head hurt, and I know about this stuff!

If Katten & Benson is too far away or too difficult to get to, call us anyway, because we can refer you to someone more convenient who we know will do a good job for you.

Happy sorting and filing!

Medication Reminders

2009-04-09T15:34:00.003-05:00

Keeping track of medications can be hard, especially when you are on multiple medications, like so many older adults are. I wanted to make a couple of resources that I've learned about recently available.

For a lot of folks, pill minders aren't an option, because there isn't anyone to set the box up each week. I learned about this service, called DailyMedRx. They package all medications, including over the counter medications into pre-sorted into single dose packs. Each pack is then printed with the date and time the medication is to be taken. Now, I have not personally used the service, but it sounds like it could be a really great service for a lot of people.

Another useful site is e-pill Medication Reminders. They carry several different reminders, including ones that talk or vibrate. Again, these are great, but only as long as there is someone who can load them every week.

When choosing a medication reminder it's important to think about who will be using it. Someone told me recently about their client who had one of the really fancy ones, that's all computerized and has all the bells and whistles. This gentleman, who had dementia, had been an engineer, so of course he took the very expensive device apart, to see how it worked, and then he couldn't put it back together! I don't know what they ended up doing, but sometimes simpler is better.

There are also services that can provide monitoring, usually tied in with an emergency response system. One thing to remember with these is that you might know that the device opened at the proper time, and that the person even took the medications out, but you have no way of knowing that they actually took them.

These devices can be helpful for people in early stages of dementia, but as the dementia progresses they can often forget the purpose of the device. It's important to monitor how the person is understanding and using the reminder. I've actually seen a person take the pills out, say that they need to be taken, then put them on the table and forget about them.

Some of these products can be very helpful and can keep a person independent longer, just don't ever expect a device like these to be a substitute for real, live person.

Medically Complex Patients

2009-03-31T06:54:00.004-05:00

There was a great article today in the New York Times, http://tinyurl.com/cttxvp. The article talks about some of the issues involved in treating patients with multiple medical conditions, many of whom are age 65 or older.

One of the basic issues, which I had not really thought of before, is that almost no research has been done on medications. Lots of research is done on, say, diabetes medications, when diabetes is the only medical condition being treated. There is little to know research on diabetes medications when they are taken along with medications for heart disease, Alzheimer's disease, blood pressure, and high cholesterol.

What we know is that the more medications a patient takes, the greater the possibility of serious side effects, and the higher the risk of serious drug interactions. The way our health delivery system is fragmented, there are many patients who have a cardiologist prescribing one set of drugs, an internist prescribing other drugs, and then maybe an endocrinologist or a gastroenterologist also prescribing drugs. This often means that no one doctor is looking at the patient as a whole. This is further complicated by the fact that so few doctors are trained in geriatric issues.

The article suggests that at this point, patients are pretty much on their own, and must take responsibility themselves to stay informed about their medications and be proactive when talking to their doctors.

Little Known Facts About Medical Scans

2009-03-02T07:20:00.000-06:00

There was an interesting article in the New York Times http://tinyurl.com/bpl8fz today about medical scans. It seems that radiology centers are not required to be accredited, so there are no standards governing the quality of the scans being done.

According to the article, there is a great deal of discrepancy between good scans and bad scans, but insurers, including Medicare, pay the same price regardless of quality. In an example from the article, a woman had an MRI of her knee that was so bad the radiologist could not read it, but she went ahead and had surgery. The surgeon found no damage, and she still has knee pain. Her insurance company paid for the initial scan, but would not pay for a follow-up scan, and they paid for the unnecessary surgery.

Imaging centers can choose to be accredited by the American College of Radiology, which does requires that technicians be certified and provides standards for physicians. A new Medicare law was passed recently that will only allow Medicare to pay for scans at accredited centers, but this law does not go into effect until 2012.

Until there is more regulation, there is little for a health care consumer to do. The article does suggest however that consumers ask why the scan is needed, ask about the center's accreditation, ask about the technician's credentials, and ask how old the scanner is. Scanners more than 10 years old are much more likely to produce poor quality scans, because the technology has improved so much in the past 10 years.

Oops, Lost Again

2009-02-28T08:25:00.000-06:00

I had to go see a client in the hospital earlier this week, and even for me it was a somewhat daunting experience. The hospital is in Dallas, and it's large. Now on this particular trip I did go right to the hospital, thanks to my GPS. In the past I can see it; it's really big, then I can't see it, turn down a one way street; oh, there it is, but it's behind me, I have to turn around....now, finally there! So, anyway, I got there without incident this week.

It's a large complex, with multiple buildings, but I did at least know which building I was going to. I actually found a parking lot, with empty spaces, right across the street. The signs to the parking lot were OK, not great. My big issue was with the signs at street level. Why do they put the names of buildings 40 feet up on the top or side of the building? OK, I know it's so you can see it from the car, but what about when you are on the sidewalk? While I knew I was right across the street from the correct building, the only entrance that looked promising had a big sign that said "Physician Referral Service Only/No Hospital Entrance", so I kept walking. The next building was definitely not the building I needed (signage 40 feet up, but readable), so I backtracked, and went in the Physician Referral door to ask how to get to the hospital. Well, guess what? In the foyer of the Physician Referral office was an elevator to...you guessed it...the Hospital!

I found my client fairly easily from there, although once I got to the unit, which seemed circular in design, there were no signs at the entrance to tell which way the numbering went, so I pretty much made the circle looking for the room.

On the way in, I had observed that there was a skywalk from the hospital to the building across the street, which was adjacent to the parking lot where I had parked. In the elevator the floor with the skywalk was labeled, so I decided to go that way. Big mistake. I got off on the right floor, saw a sign with an arrow to the skywalk--but then never saw another sign and never found the skywalk. I could see it....Anyway, I walked from one area that was clearly patient rooms, then into an area that looked like it should be off limits to the likes of me. All gray walls and office doors and people in lab coats, but no one stopped me, and then ahead I saw more patient rooms, so I just kept going. I finally found some more elevators, got to the ground floor and out of the building, and saw I was on the other side of the building. So I had to go back in, go through the lobby, then finally out the way I came in.

As I was doing all this traipsing around, I kept thinking about my client's 80-something year old husband, who takes himself there every day to be with his wife. I'm sure he parks in the same place every day and follows the route that he knows will get him to his wife. But what if that parking lot is full? What if that particular elevator is out of service? What if they move her? I'm pretty comfortable wandering around hospitals, and I can read small, ambiguous signs and usally figure them out, but not every 65 year old, or 85 year old can. I only had one hospital employee ask me if I needed help, even though I passed dozens.

It's not just the emergency room that needs to be redesigned to accommodate older adults. Hospitals are often huge complexes, with remote parking lots, and as our population continues to age, they are going to have to be more proactive in serving this older population. I didn't see much being done about it when I worked in hospitals, and I don't see much evidence of it now when I go to hospitals.

In a few weeks I'm going with some friends and colleagues to Las Vegas, where we are doing a presentation at the American Society on Aging conference. We are going to teach people how to teach age sensitivity to others. This is just a first step. I hope some of you will consider joining me on this trip toward better accessibility for everyone.

ER Follow-Up

2009-02-19T11:19:00.000-06:00

Here is a comment I received from a colleague regarding my last post about the cutting edge ER in Maryland:

I spent Saturday morning in the emergency room at "Memorial Hospital" (the name has been changed to protect the guilty) because my ward had fallen and had cut her head. The nurse was awful insisting that she “settle down” so they could do the stitches. I kept telling the nurse that she has dementia and that her agitated stage was normal. I asked if they could give her something to sedate her. The nurse said they did not sedate patients for stitches and that she was just going to have to relax otherwise they would not be able to do anything. What an experience. Fortunately, the doctor came in, saw what was going on, had her sedated, an stitched her up. When we got her back to the nursing home, we discovered her hip was very swollen and bruised – something they did not see in the emergency room. Wish they had an emergency room like the one in the article she could have gone to.

One of the many things that is upsetting about this story is that my colleague is a social worker; she is someone who knows how to be an advocate, someone who "knows the system", and yet in this case had no influence at all with the nurse. If she can't get the professional in this instance to do what is right and best, how can someone without her skills and knowledge advocate for a loved one in a similar situation?

My initial response to my colleague was that this is the very reason I think all nurses and social workers, and really all health care workers, need mandatory training in geriatric issues. The nurse appears to have been more concerned with protocol than with listening to the patient or to the patient's guardian. This nurse's actions seemingly fly in the face of one of the basic tenets of medical ethics: Do no harm. Luckily for the patient, the ER doctor was able to place her needs ahead of protocol, and did what was necessary to make a frightening experience less so.

A Cutting Edge Emergency Room

2009-02-19T10:08:00.000-06:00

I was driving to work this morning, listening to NPR like I usually do, when a most interesting story came on. It was about an emergency room built especially for seniors, so of course I listened with extra interest ( you can find the text of the story at http://tinyurl.com/ce8oku).

This ER is at Holy Cross Hospital in Silver Spring, MD. One reason the hospital decided to build this special ER is because according to a federal survey, only infants go to emergency rooms at a higher rate than those over age 75. This was a new statistic to me, but not surprising. I do know that people over age 65 use other health care services at a much higher rate than the rest of us, so it only stands to reason that this is true of emergency rooms.

One quote from the story that had me cheering was made by geriatrician Bill Thomas, who helped design the ER. He said, "Good care for older people teaches us how to take good care of everybody." I could not agree more!

Where Shall We Go for Dinner?

2009-02-13T10:16:00.000-06:00

I am fortunate that my mother is still living; in fact, she lives with me. As she has gotten older, I see that certain things have become more difficult or challenging for her, and often times for me as well. And lest you think that because I work in the field of aging I cope with her changes any better than the rest of you, think again! It doesn't matter what your job is; if it involves your family, your knowledge and professionalism often just disappear.

One thing that we both enjoy is going out to eat, but it is also an activity that can be incredibly frustrating. Let me illustrate with a recent experience:

We got to the restaurant, and there were actually some handicapped parking spaces available, so we parked. The parking lot had something of an uphill slope, and we had to walk to the end of the walkway to get to the ramp, than up a steep ramp to enter the restaurant. Mom has bad knees, so she had to hang on while we negotiated all this.

Once inside the restaurant, the hostess started to take us all the way to the back of the restaurant, so she obviously did not notice Mom's trouble with mobility. I had to ask if we could sit some place closer to the front, and she was able to accommodate this; not all hostesses will. We received our menus, but the combination of dark, romantic lighting and small print made the menus difficult to read. There was of course music playing, but I can't really say that it was background music. It was front and center music, and because Mom is hard of hearing, it made conversation difficult. I'm not sure when restaurants decided that diners don't need to talk to each other, but I think it coincided with the prevalence of cell phones and blue tooth technology.

The practical result is that there are some restaurants we just don't go to anymore. Many are simply too loud to allow an enjoyable experience. Some only have booths, which are difficult for Mom to slide in and out of. Dining out should be a pleasant experience, but I find it frustrating when I have to analyze every potential restaurant for barriers.

I have a brother who manages a restaurant, and he tells me that he is constantly struggling with the owner over lighting and music volume. I think until we all start doing our part to educate restaurant managers and owners of these issues, and on a constant basis, we won't see much change.

Life Care Planning

2009-02-06T11:05:00.001-06:00

I am approaching my second anniversary with Katten & Benson, an elder law firm in Fort Worth. When I came to work here, I had never heard of life care planning in the context of an elder law firm.

Life care planning as I knew it was a concept I was more familiar with in rehabilitation settings. An example is the young person who suffers a spinal cord injury in a car accident. Depending on the exact injury, there are certain medical issues that can be anticipated, such as recurrent urinary tract infections, possible skin breakdown, or shoulder problems if the person is able to transfer independently. There are also known equipment needs: a custom wheelchair and seating system, catheter supplies, a wheelchair van, etc. Even durable equipment like the wheelchair or van will have to be replaced every few years due to normal wear and tear. The life care planner considers all these needs and helps the client manage the settlement so that the goods and services required are paid for by the settlement, for the rest of the client's lifetime.

Life care planning in an elder law firm, it turned out, is not much different. Rather than working with people who have had traumatic injuries, we are working with people who have chronic medical conditions, such as dementia, Parkinson's, diabetes or heart disease, and we try to anticipate the needs and get goods and services in place.

Now, let's think about everything that might happen if you are diagnosed with Alzheimer's disease. From a legal standpoint, you certainly want to make sure your estate planning is in order. If you've done estate planning, we review it to make sure it's what you want. Powers of attorney are particularly important , because you want to make sure you have identified the people you want to handle financial and medical decisions. You might even want to take the additional step of designating a potential guardian, in the event guardianship is needed as the disease progresses.

A good financial review and Medicaid planning might also be needed. If you have limited income or assets, it's a good idea to know what will need to be done in order to qualify for Medicaid. Medicaid is complicated, and an attorney will best be able to advise you about issues like gifting, estate recovery, and protecting assets for a community spouse.

As an Elder Care Coordinator it's not my job to provide care, but it is my job to help you get care. The options can be overwhelming: Do I need help at home? What kind of help is available, and who pays for it? When do I need to consider assisted living? What will happen to my spouse? Is the doctor listening to me, and do I really understand what the doctor is telling me? These are all things I can help with.

It can be reassuring to know that you have someone you can call and talk to about a variety of topics. Sometimes I'm going to validate your thinking, and other times I will have to tell you it's time to consider something different. And sometimes I'll just sit with you and be supportive, so you know that you're not alone.

It's Never Too Early to Plan

2009-01-27T14:53:00.000-06:00

Back in the early '90's I went on a wonderful sailing vacation in the British Virgin Islands with a group of friends. We spent time researching charter companies, we researched the islands themselves, we planned menus and even took groceries with us. Once there, we shopped again for provisions, we read maps and charts, and we plotted the course for our two weeks in the islands. Before we ever got there, we knew we wanted to go to Foxy's on Jost Van Dyke, Cane Garden Bay, made famous by Jimmy Buffett, and the Baths on Virgin Gorda.

All in all, we probably spent more time planning for and anticipating this vacation than we actually spent on the vacation. I suspect many of you have had similar experiences, whether it's a vacation trip to Disney World or a camping trip to Big Bend.

I bring this up because I heard somewhere recently that many people spend more time planning a vacation than they spend either on planning for retirement, for later life health issues, or how to manage finances in later life.

This was something I had never thought of before, but as I have been thinking about it, I'm sure there is a lot of truth to the statement. One thing I have learned is that it is never too early to plan for anything, especially something as important as retirement, which has a huge impact on quality of life. Another thing I have learned is to plan for the worst, and hope for the best.

As part of a Life Care Planning Law Firm, this is what I help people do. The Life Care Planning concept is designed to help the older adult with a chronic disease process plan for the future. Traditionally, we have dealt with chronic illness as a series of reactions. We feel bad, the doctor prescribes medicine, we get worse, we go to the hospital, maybe we have surgery, maybe we go home; and the cycle starts over again. Too often the patient is a passive participant in this process, with little input or decision making capacity. My goal is to help people take responsibility for their health and health care needs, and to become a more active participant in the decision-making process.

In future posts I'll give some examples of how this new way of planning has been able to help people.

The American Way

2009-01-20T16:31:00.000-06:00

There was an article in the New York Times today titled "A Front-Row Seat as a Health Care System Goes Awry" (http://tinyurl.com/7y8urf). The article is an interview with Dr. Robert L. Martensen, a former ER doctor. Dr. Martensen has written a book called “A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era.” I have not read the book yet, but I will be interested to see what his reflections are.

One thing he does talk about in this interview is the American way of dying. I have seen what he talks about far too many times, and I'm glad to see that at least one doctor recognizes the disservice that happens too often as patients and families face end of life issues. Dr. Martensen talks in the interview about doing ethics consults where there is no hope of recovery, and yet the doctors involved are reluctant to tell families this, in the name of keeping hope alive.

I will never forget the family I worked with some years ago. I don't even remember the initial problem that brought their mother to the hospital, but by the time she reached my unit she had several systems failing. This was shortly after HIPAA was enacted, and up to that point no one had talked to the family at all about what their mother's condition or prognosis was. When I took the intiative and talked to them about her condition, they were so relieved that someone was finally talking to them they didn't even care it was bad news.

A few days later, the physician agreed that a hospice referral was for the best, and I ended up having to talk to family about this over the telephone. While the way I had to deliver the information was less than ideal, the family was just glad that someone was finally telling them what to expect and what needed to happen next. I was able to get her transferred to an inpatient hospice unit, and as happens so often, she died just a few hours after getting there.

Dr. Martensen feels that doctors should be realistic, and I agree completely. I have seen 91 year old people put on dialysis, and people with end stage lung disease put on ventilators. I know that it is hard to tell people that there is nothing more than can be done, other than comfort measures; I've had to do it. I have also seen how hospice can be a tremendous support for patients and families, and how it can allow people to have the good death that Dr. Mortensen talks about.

It is my hope that as we start looking at ways to repair our broken health care system, we can work to make sure that more people have the option of a good death made available to them.

There's No Place Like Home

2009-01-18T20:08:00.000-06:00

One of the hardest things I do is help people make the decision to leave home and move to a nursing home, assisted living or retirement community. "Home" is obviously so much more than the roof over our heads. For some, home is where families were raised, with all the good and bad times that families go through. For others, home is where a husband or wife died, and the surviving spouse fears they will lose memories if they leave the house. Home is where all our stuff is; where we know which floor boards creak and how long the water has to run before it gets hot.

I've wondered before if this decision will be easier for people like me, who lived in a dorm, then went on to live in multiple apartments and living situations while in college and graduate school; but I guess deep down I don't really think it will be. I work with people who were career military and lived in barracks as well as all over the world, and they all struggle with the idea of leaving wherever home is now.

I do think that familiarity will make most changes a little easier. I and many of my colleagues are familiar with retirement and assisted living, so we may have a little easier time choosing that if and when the time comes. I was only half joking when I told my college roommate the next move was to assisted living!

I think the best thing we can do when we are helping an older adult with this decision is to try and help with the fear. Offer to take them to visit communities before they need to move. Most communities offer free lunch, and many will even let the prospective resident stay in a guest room for a few days to see what it's like. Encourage them to talk about the fears, and understand that they will experience grief at giving up their home and all that it represents. And always recognize that the decision is hard. It usually means a loss of independence or control, which is never easy. If possible, start the conversation before the move is even needed. It's a difficult conversation to start, but it will make the decision a bit easier when the time comes.

Greetings from Cowtown

2009-01-16T17:02:00.000-06:00

To quote a friend of a friend, I never thought I'd be hip enough or cool enough to start my own blog. But here I am, starting my own blog. It seems that things have been guiding to me do this, so I finally decided to take the plunge and get started.

I am a social worker, and for almost two years I have worked for Katten & Benson, a law firm in Fort Worth specializing in elder issues. Now, a social worker in a law firm is a rare thing, indeed, but Steve Katten is a pretty rare lawyer. He is one of two Certified Elder Law Attorneys (CELA) in Tarrant County, and as he tells it, he realized some time ago that many of his clients needed more than the legal services he could provide, and that's where I come in.

While I have a title, Elder Care Coordinator, all you social workers out there know that titles in our business don't really mean anything. We do it all, or at least it feels that way many days! I have regular clients that I see through our Life Care Planning program, and I will talk more about that concept in the future. I also field questions from many other clients on issues like choosing nursing homes, or understanding their Medicare benefits.

One of my passions as long as I have worked with older adults is education, and helping people have the knowledge they need to make the best and most well-informed decisions possible, and that's why I decided to start blogging. I hope that as I run into situations and write about them, you will glean a little knowledge and understanding about growing older, caring for aging parents or loved ones, and navigating our crazy health care and public benefits systems. I don't know how often I'll post, but I hope that you'll check back often and see what's going on here in Cowtown.