Working With A Geriatric-Care Manager

When you're exploring a foreign country, a guide who knows the terrain well can help immensely. That's just as true when entering the foreign territory of caregiving. Here, a geriatric-care manager can provide invaluable assistance for individuals and families facing challenging care decisions.

Geriatric-Care Managers come from diverse backgrounds, from nursing and social work to gerontology. These professionals can help navigate the tangles of family dynamics, round up medical care and necessary services, keep medical personnel on the same page, and cut through the baffling red tape of private businesses and government bureaucracies.

Some of the tasks geriatric-care managers routinely undertake include:

• Evaluating needs
• Connecting people to helpful services, senior housing, and long-term care facilities
•  Bringing families together to discuss options supportively
• Hiring and monitoring home care personnel
• Communicating with specialists, hospital and home care staff, and family members to coordinate care
• Alerting families to financial, medical, or legal problems and suggesting ways to circumvent difficulties
• Helping with a move to assisted living, a nursing home, an Alzheimer's care unit, or other facilities.

Some geriatric-care specialists focus on assisting older people. Others have expertise coordinating care and services for people of all ages with disabilities or debilitating illnesses.

Although working with a geriatric-care manager may be costly, such expertise can often save money and regrets, especially if you are scrambling to arrange care from afar. The cost of a geriatric-care manager is usually borne by the client or family, rarely by long-term care insurance. If you plan to work with a geriatric-care manager, be sure to get a written agreement outlining the scope of services offered and costs. This document can also help you decide which tasks, if any, might be undertaken by family and friends to save money.

To learn more about Geriatric-Care Managers, or to locate a Geriatric-Care Manager, contact the National Association of Professional Geriatric Care Managers at 520-881-8008 or www.caremanager.org.

For more on developing plans and effective strategies for the hard work of caregiving, buy Caregiver's Handbook, a Special Health Report from Harvard Medical School.

 Republished from: http://www.health.harvard.edu/

Updated: September 26, 2016

Originally published: February 2015

Column: How to fight for yourself at the hospital -
and avoid readmission

By Judith Graham, KAISER HEALTH NEWS I September 01, 2016

Everything initially went well with Barbara Charnes' surgery to fix a troublesome ankle. But after leaving the hospital, the 83-year-old soon found herself in a bad way.

Dazed by a bad response to anesthesia, the Denver resident stopped eating and drinking. Within days, she was dangerously weak, almost entirely immobile and alarmingly apathetic.

“I didn't see a way forward; I thought I was going to die, and I was OK with that,” Charnes remembered, thinking back to that awful time in the spring of 2015.

Her distraught husband didn't know what to do until a longtime friend - a neurologist -insisted that Charnes return to the hospital.

That's the kind of situation medical centers are trying hard to prevent. When hospitals readmit aging patients more often than average, they can face stiff government penalties.

But too often institutions don't take the reality of seniors' lives adequately into account, making it imperative that patients figure out how to advocate for themselves.

“People tell us over and over, ‘I wasn't at all prepared for what happened’ and ‘My needs weren't anticipated,” said Mary Naylor, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania.

It's a mistake to rely on hospital staff to ensure that things go smoothly; medical centers' interests - maximizing efficiency and payments, opening needed beds, avoiding penalties - are not necessarily your interests, such as recovering as well as possible, remaining independent and easing the burden on caregivers.

Instead, you and a family member, friend or caregiver need to be prepared to ask plenty of questions and push for answers.

Here's what doctors, health policy experts, geriatric care managers, older adults and caregivers recommend.

Start planning now

Planning for a transition home should begin as soon as you're admitted to the hospital, advised Connie McKenzie, who runs Firstat RN Care Management Services in Fort Lauderdale, Fla. You may be too ill to do this, so have someone you trust ask your physician how long you're likely to be hospitalized and whether you'll be sent home or to rehabilitation afterward.

Ask if a physical therapist can evaluate you or your loved one at the hospital. Can you get out of bed by yourself? Walk across the room? Then discuss what difficulties might arise back home. Will you be able to handle your own bathroom needs? Get dressed? Climb stairs? What kind of assistance will you require?

Request a consultation with a nutritionist. What kinds of foods will and won't you be able to eat? Does your diet need to change over the short term, or longer term?

Consider where you'll go next. If you or your loved one is going to need rehabilitation, now is the time to start researching facilities. Ask a hospital social worker for advice or, if you can afford it, hire a geriatric care manager (now called aging life care professionals) to walk you through your options.

Before being discharged

Don't wait to learn about the kind of care that will be required at home. Will a wound need to be dressed? A catheter need tending to? What's the best way to do this? Have a nurse show you, step by step, and then let you practice in front of her - several times, if that's what it takes.

Ann Williams watched a nurse give her 77-year-old mother a shot of Warfarin two years ago after being hospitalized for a dangerous blood clot. But when it was Williams' turn to give the injection on her own, she panicked.

“I'm not a medical professional. I've only given allergy shots to my cats,” she said.  Fortunately, Williams found a good instructional video on the Internet and watched it over and over.

Make sure you ask your doctor to sit down and walk you through what will happen next.  How soon might you or your loved one recover? What should you expect if things are going well? What should you do if things are going poorly? How will you know if a trip back to the hospital is necessary?

If the doctor or a nurse rushes you, don't be afraid to say, "Please slow down and repeat that” or “Can you be more specific?” or “Can you explain that using simple language?” said Dr. Suzanne Mitchell, an assistant professor of family medicine at Boston University's School of Medicine.

Getting ready to leave

Being discharged from a hospital can be overwhelming. Make sure you have someone with you to ask questions, take good notes and stand up for your interests - especially if you feel unprepared to leave the hospital in your current state, said Jullie Gray, a care manager with Aging Wisdom in Seattle.

This is the time to go over all the medications you'll be taking at home, if you haven't done so already. Bring in a complete list of all the prescriptions and over-the-counter medications you've been taking. You'll want to have your physician or a pharmacist go over the entire list to make sure there aren't duplicates or possibly dangerous interactions.  Some hospitals are filling new prescriptions before patients go home; take advantage of this service if you can. Or get a list of nearby pharmacies that can fill medication orders.

Find out if equipment that's been promised has been delivered. Will there be a hospital bed, a commode or a shower chair at home when you get there? How will you obtain other supplies that might be needed, such as disposable gloves or adult diapers? A useful checklist can be found at Next Step in Care, a program of the United Hospital Fund.

Will home health care nurses be coming to offer a helping hand? If so, has that been scheduled - and when? How often will the nurses come, and for what period of time?  What, exactly, will home health caregivers do and what other kinds of assistance will you need to arrange on your own? What will your insurance pay for?

Be sure to get contact information (phone numbers, cell phone numbers, email addresses) for the doctor who took care of you at the hospital, the person who arranged your discharge, a hospital social worker, the medical supply company and the home health agency. If something goes wrong, you'll want to know who to contact.

Don’t leave without securing a copy of your medical records and asking the hospital to send those records to your primary care doctor.

Back at home

Seeing your primary care doctor within two weeks should be a priority. “Even if a patient seems to be doing really well, having their doctor lay eyes on them is really important,” said Dr. Kerry Hildreth, an assistant professor of geriatrics at the University of Colorado School of Medicine.

When you call for an appointment, make sure you explain that you've just been in the hospital.

 Adjust your expectations. Up to one-third of people over 70 and half of those over 80 leave the hospital with more disabilities than when they arrived. Sometimes, seniors suffer from anxiety and depression after a traumatic illness; sometimes, they'll experience problems with memory and attention. Returning to normal may take time or a new normal may need to be established. A physical or occupational therapist can help, but you may have to ask the hospital or a home health agency to help arrange these visits. Often, they won’t offer.

It took a year for Barbara Charnes to stand up and begin walking after her ankle operation,  which was followed by two unexpected hospitalizations and stints in rehabilitation. For all the physical difficulties, the anguish of feeling like she'd never recover her sense of herself as an independent person was most difficult.

“I felt that my life, as I had known it, had ended," she said, "but gradually I found my way forward.”

‑ Kaiser Health News is eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the health care system. Visit khn.orglcolumnists to submit your requests or tips. KHN's coverage of late life and geriatric care is supported by The John A. Hartford Foundation.

Is It Worth Paying An Expert To Help You Navigate
The Health-Care System?

By JOSEPH F. COUGHLIN

There is a new cost in retirement and older age — navigating complexity. While managing finances in retirement can be a challenge — surviving the health-care and home-care system can make the most complex portfolio or financial advisor's Monte Carlo simulation look like a family board game.

When was the last time you had to go to the hospital? Had to organize the complexities of home care for a loved one? How well do you remember the experience? Parts of it are probably something of a blur. We're as helpless we can possibly be when sick, forced to give ourselves over into the hands of others. Sometimes, the best we can manage through the ordeal of illness is to simply try to keep our heads up.

Old age and chronic illness turn that period of vulnerability into a near-constant state of affairs. Often, older adults and their families can do but nothing but hope that they will be treated by the health-care system with their best interests in mind. Sometimes they won't be — not because doctors and nurses and therapists and administrative staff aren't doing the best work they possibly can to help patients, but because a hospital is a massive institution with an endless stream of work flowing through it, not just a place of healing, but an ever-whirring bureaucratic machine. Successfully navigating that complex system is critical to both your or a loved one's health outcomes as it is in managing the costs of health care.

The complexity of the health-care system plus our rapidly aging population has given rise to a new kind of health professional, the geriatric care manager (or GCM), now officially referred to as an Aging Life Care Professional. GCMs are advocates for older adults. They typically don't personally provide care themselves. Instead they collect and present information, help to design a care plan, and navigate the health care system to implement and facilitate that plan on behalf of the family that pays them. They are guides for families who must travel the sometimes-bumpy modern road of aging.

In this sense, a GCM is more like a lawyer or a financial advisor than a doctor. A GCM's value comes primarily from having a large repository of knowledge of a complex system, not necessarily any particular hands-on expertise. Further even from lawyers and financial advisors, there is no defined educational track (yet) for geriatric care management, and a GCM doesn't need a license (yet) to practice. Although experienced nurses appear to be leading the trek in the business of care coordination and management. Geriatric care management is part of the frontier of the burgeoning advanced service economy that is being driven by an aging population.

How much does navigation expertise cost? Effective expert knowledge never comes cheap. A GCM's time runs somewhere in the neighborhood of $125-$200 an hour. If you think of geriatric care management simply as help in picking out Dad's nursing home from a list, that may sound pretty steep, a luxury affordable only to those for whom money is no object. But there could soon come a time that navigating the depths of the health care system without a care manager will seem just as foolhardy as diving into the legal system without a lawyer.

GCMs work toward the holistic well-being of their older adult clients. At the same time, they provide a family with the information to make well-informed decisions about their elder's care. With the staggeringly high costs involved in making such choices, the difference between a well-informed and a clueless decision can be thousands of dollars, not to speak of the well-being of the care recipient.

Now for a one-question health care pop quiz: Do you know what a hospital case manager is? If you or your loved one winds up in a hospital bed, case managers are the ones who decide when you leave and where you'll go to next. They have the power to choose which rehab or assisted-living facility your parent will go to. Their number-one responsibility is to open up beds for the next round of sickly individuals.

They do their best to accommodate the specific needs of patients, but with the workload they face, it's inevitable that their recommendations will not always align with what the patient thinks is best, especially when that patient is an elderly adult with a difficult confluence of issues, preferences and needs.

This is just one example of why GCMs are so important, and perhaps one day will be indispensable. They represent the power of knowledge in a world where we live under the influence of large institutions and complex system that are sometimes too big for us to grasp – just when we may need them the most and ourselves too little for them to notice.

Reprinted from: http://www.marketwatch.com/story/is-it-worth-paying-an-expert-to-help-you-navigate-health-care-in-retirement-2016-08-12
Published: Aug 12, 2016 2:59 p.m. ET

Joseph F. Coughlin, PhD (coughlin@mit.edu) is Director of the Massachusetts Institute of Technology AgeLab. His research addresses how individuals, families, businesses and governments make decisions and plan for the new future of old age. 

The Decline of Tube Feeding for Dementia Patients

By Paula Span
THE NEW OLD AGE AUG. 29, 2016

Reprinted from: http://www.nytimes.com/

Dementia from Parkinson’s disease was taking its toll on Joan Jewell.

She could still respond to music, if a helper wheeled her to the Sunday concert at the Hebrew Rehabilitation Center in Boston, but she spent most of her time in bed. Sometimes she recognized family members; often she didn’t. She couldn’t say more than a few words. She had trouble swallowing.

Last year, her doctor pointed out that she was losing weight and that a feeding tube, surgically inserted through her abdominal wall, might help her regain a few pounds.

Her son James, who served as her surrogate decision maker, responded the way a growing number of family members do: He said no. The proportion of nursing home residents with advanced dementia who receive a feeding tube has dropped more than 50 percent, a new national study has found.

The researchers, analyzing federal nursing home data, reported that in 2000, nearly 12 percent of patients with this terminal condition had feeding tubes inserted within a year of developing eating problems. By 2014, the rate had fallen to less than 6 percent.

“It’s getting much less controversial” to decline a tube and rely on hand feeding, said Dr. Susan Mitchell, a geriatrician and senior scientist at the Harvard-affiliated Hebrew SeniorLife Institute for Aging Research. “This is becoming the prevailing wisdom.”

Dr. Mitchell has had a lot to do with that shift. As a young physician training in nursing homes, she wondered whether feeding tubes actually helped these bedbound elders. At the time, roughly a third of cognitively impaired nursing home residents were tube-fed.

She and a cadre of researchers, primarily from Harvard and Brown universities, have been methodically reporting their findings for 20 years, demonstrating in one article after another the drawbacks of artificial feeding for people in the final stages of dementia.

Change can come slowly in medicine, but it does come. In 2013, the American Geriatrics Society updated its recommendations against feeding tubes for older patients with advanced dementia. The Choosing Wisely campaign, which publishes lists of procedures and tests that patients and families should question, and the Alzheimer’s Association have taken similar positions.

Now, families and physicians seem to have gotten the sorrowful message: Dementia is a terminal disease. Eating and swallowing problems eventually plague almost everyone who has it. Feeding tubes don’t help. In fact, they can make matters worse.

Consider, first, how ill these patients are. Advanced dementia, as Dr. Mitchell and her colleagues define it, brings such profound memory loss that people don’t recognize family. They can’t speak more than five words. They’re incontinent. Sometimes they can’t turn over in bed unaided. “They’re dependent on others for all their day-to-day functions,” Dr. Mitchell said.

Even if an aide or relative patiently feeds them, “they may not know what to do with the food in their mouths.” When they try to swallow, they can aspirate food particles into their lungs and develop pneumonia. “For most people, that’s a very poor quality of life,” Dr. Mitchell said.

Feeding is such a primal activity, the first thing we do when someone is born and one of the last sources of pleasure as death approaches. Naturally, families can find it difficult to refuse a fairly minor surgical procedure that provides nutrition.

But a person no longer able to understand why a gastroenterologist is opening a small hole in her belly may find the insertion of a tube confusing and traumatic. The mush that flows through eliminates the taste of food and the social interaction of hand feeding.

Almost 20 percent of the time, the tube is blocked or dislodged within a year, requiring hospitalization. Dementia patients may also try to pull it out, leading to physical or chemical restraints (read: drugs).

Feeding tubes are also associated with an increased risk of pressure ulcers or bedsores, perhaps because they encourage inactivity or cause diarrhea; the ulcers heal more slowly than in people without tubes.

Perhaps the trade-off would be worth it to some families (since these patients can no longer make decisions themselves) if a feeding tube prolonged life. For others, that would be a good reason to refuse one.

As it turns out, though, feeding tubes don’t keep advanced dementia patients alive longer. Several studies led by Dr. Joan Teno, a geriatrician at the University of Washington who has often collaborated with Dr. Mitchell, show that they make no significant difference. After receiving a feeding tube, patients with advanced dementia lived a median of 165 days, and two-thirds died within a year.

Older adults nearing death still do receive feeding tubes, sometimes because families insist, sometimes because health care providers don’t offer enough information to help them decide. Stark racial differences persist: 3 percent of white nursing home residents with dementia had feeding tubes inserted in 2014, compared with 17.5 percent of black residents.

Feeding tubes remain more popular in certain kinds of nursing homes, too. For-profit nursing homes use them more than nonprofits, Dr. Mitchell’s research has shown, and bigger facilities more than small ones. In New England, fewer than 2 percent of residents are tube-fed. In parts of the South, the rate can run up to 10 times higher.

If you see such practices as indicators of a more aggressive approach to end-of-life care in general (Dr. Mitchell does), then you wonder if health care professionals spend more time talking to white families about their options. You wonder if higher Medicare reimbursement for tube-fed patients (and the labor costs of hand feeding) make nursing homes more apt to recommend tubes.

But more and more, you encounter people like the Jewells.

Joan Jewell had worked as a nurse in upstate New York and had cared for her husband as he died of Alzheimer’s disease. James Jewell, whom she encouraged to study medicine, is an internist at the nursing home where she lived.

Years before, when his mother could still contemplate such matters, “we had the what-if discussions,” Dr. Jewell told me.

Mrs. Jewell was clear. “She subscribed to the idea that quality of life was more important than being kept alive at all costs,” her son said. “And being able to do things for herself was part of her definition of quality of life.”

Despite her weight loss, then, he declined medical intervention. In February, Mrs. Jewell began refusing food altogether and soon slipped into a coma. Dr. Jewell and his children were with her when she died, at 89.

No Spouse, No Kids, No Caregiver: How to Prepare to Age Alone

A growing population of ‘elder orphans’ lack a built-in support system. What to do if you become one. 

By Anna Medaris Miller | Staff Writer Oct. 26, 2015, at 12:54 p.m.
Reprinted from www.health.usnews.com

When Carol Marak was in her 30s, she asked herself whose life she wanted: her brother's – the life of a successful and well-traveled businessman – or his wife's – the life of a woman whose career better accommodated raising three children.

The answer was a no-brainer: "My brother was in a position I wanted," says Marak, now a 64-year-old editor at SeniorCare.com who lives in Waco, Texas. Although she had been married and divorced earlier in life, at that point she had no kids and "made a very conscious decision" to keep it that way, she says.

Plenty of Marak's peers did the same thing. According to a 2012 study in The Gerontologist, about one-third of 45- to 63-year-olds are single, most of whom never married or are divorced. That's a whopping 50 percent increase since 1980, the study found. What's more, about 15 percent of 40- to 44-year-old women had no children in 2012 – up from about 10 percent in 1980, U.S. Census data shows. "My career was No. 1 in my life," says Marak, who worked in the technology industry for years.

But today, Marak and her single, childless contemporaries are facing a repercussion of their decision that never crossed their minds as 30-somethings: "How in the world will we take care of ourselves?" she asks.

Dr. Maria Torroella Carney, chief of geriatrics and palliative medicine at North Shore-LIJ Health System in New York, is asking the same thing. In research presented this year at The American Geriatric Society's annual meeting, Carney and her colleagues found that nearly one-quarter of Americans over age 65 are or may become physically or socially isolated and lack someone like a family member to care for them. Carney calls them "elder orphans."

"The risk of potentially finding yourself without a support system – because the majority of care provided as we get older is provided by family – may be increasing," she says.

The consequences are profound. According to Carney's work, older adults who consider themselves lonely are more likely to have trouble completing daily tasks, experience cognitive decline, develop coronary heart disease and even die. Those who are socially isolated are also at risk for medical complications, mental illness, mobility issues and health care access problems.

"You could be at a hospital setting at a time of crisis and could delay your treatment or care, and your wishes may not be respected [if you can't communicate them]," says Carney, also an associate professor at Hofstra North Shore-LIJ School of Medicine.

Take "Mr. HB," a 76-year-old New York man described in Carney's research as "a prototypical elder orphan." After attempting suicide, he arrived at a hospital with cuts on his wrist, bed sores, dehydration, malnutrition and depression. He lived alone and hadn't been in contact with any relatives in over a year. His treatment was complicated, the researchers report, in part because he was too delirious to make clear decisions or understand his options. He wound up at a nursing facility with plans to eventually be placed in long-term care.

But growing older without kids or a partner doesn't mean you're doomed – just as aging with kids and a partner doesn't mean all's clear. "We're all at risk for becoming isolated and becoming elder orphans," Carney says. You could outlive your spouse or even your children, find yourself living far from your family or wind up in the caretaker role yourself if a family member gets sick. Keep in mind that 69 percent of Americans will need long-term care, even though only 37 percent think they will, according to SeniorCare.com.

Plus, there's no way around the natural physical and mental declines that come with age. "Everybody has to prepare to live as independently as possible," Carney says. Here's how:

1. Speak up.

Marak wishes she had talked more with her friends and colleagues about her decision not to become a mom early on. That may have given her a jump-start on anticipating various problems and developing solutions to growing older while childless. She advises younger generations to  discuss their options openly with friends – married and single, men and women – before making a firm decision.

"We discuss our psychological issues with professionals. We discuss our money strategies with financial experts," Marak says. "Why not talk openly about family concerns and what it means to have or not have children? So many of us go into it with blinders on." 

2. Act early.
How early you start planning for your future health depends partly on your current condition – and your genes, says Bert Rahl, director of mental health services at the Benjamin Rose Institute on Aging. "If your ancestry is that people die early, you have to plan sooner and faster," he says.

But whether you come from a family of supercentenarians or people who have shorter life spans, it's never too soon​ to save for long-term care, whether it's by investing in a ​home, putting aside a stash for medical emergencies or "whatever you can do to have a nest egg," Marak says. "Life is serious, especially when you get old. Don't get to [a point]​ ​when you're 60 and now you're having to scramble to catch up."

Still not motivated? "Everybody wants some control in [their] life," Rahl says. "If you don't plan, what you're choosing to do is cede that control to somebody else – and the likelihood that they're going to have your best interests at heart is a losing proposition."

3. Make new friends and keep the old.​
Your social connections can help with practical health care needs, like driving you to the doctor when you're unable. But they also do something powerful: keep you alive, research suggests. In a 2012 study of over 2,100 adults age 50 and older, researchers found that the loneliest older adults were nearly twice as likely to die within six years than the least lonely – regardless of their health behaviors or social status.

Connections can also help ward off depression, which affects nearly 20 percent of the 65-and-older population, according the National Alliance on Mental Illness. "One of the things that keeps people from being depressed is to be connected," Rahl says. "The more social activities you have, the more friends, the more things you can do to keep your body and mind active – that's the best protection you have against mental illness."

4. Appoint a proxy.
Who is your most trusted friend or relative? "Identify somebody to help you if you're in a time of crisis, and revisit that periodically over your life," Carney suggests. Make sure that person knows your Social Security number, where you keep your insurance card, which medications you take – "the whole list of things somebody needs to know if they're going to help you," advises Dr. Robert Kane​, director of the University of Minnesota’s Center on Aging.

Before you start losing any cognitive capacities, consider designating that person as your durable power of attorney for health care, or ​the person who makes health care decisions for you when you're no longer able.

If no one comes to mind, hire an attorney who specializes in elder care law by asking around for recommendations or searching online​ for highly rated professionals. Unlike your friends, they have a license to defend and are well-versed in elder care issues. Most of the time, Rahl's found, "they're trustworthy and will do a good job for you."

5. Consider moving.

Marak is on a mission: "to create my life where I'm not transportation-dependent," she says. She's looking to move to a​ more walkable city, perhaps a college town where she's surrounded by young people and can stay engaged with activities like mentoring. She also hopes her future community is filled with other like-minded older adults who can look out for one another. "I want to … set up my life where I'm not living alone and isolated," she says.

Adjusting your living situation so that you can stay connected to others and get to, say, the grocery store or doctor's office is the right idea,​ says Carney, who cares for a group of nuns who live communally and has seen other adults create communities that act like "surrogate families," she says. "Think: Where do you want to live? What's most easy? How do you access things? How do you have a support system?"

6. Live well.
Marak is lucky: She's always loved eating healthy foods and walking – two ways to stay as healthy as possible at all ages. "Some of the foods that we eat are really, really bad for the body," she says. "That's one of the major causes of chronic conditions – and not exercising."

Keeping your brain sharp is also critical if you want to be able to make informed decisions about your health care, Rahl says. He suggests doing activities that challenge you – math problems if numbers trip you up, or crossword puzzles if words aren't your forte. "The old adage, 'If you don't use it, you lose it,' is 100 percent correct," he says.

5 out of 11 Signs Your Parent May Be Ready for Assisted Living
You can gather valuable information by looking for these clues

7. Around-the-House Signs
Look around the living areas. Sometimes the most obvious sign is hard to see because we become so used to it.

Look for:

Lots of clutter  An inability to throw anything away may be a sign of a neurological or physical issue. Obviously it’s more worrisome in a neatnik than in a chronic slob. Papers or pet toys all over the floor represent a tripping hazard.

Signs of lax housekeeping  Spills that haven’t been cleaned up are a common sign of dementia — the person lacks the follow-through to tidy. Keep an eye out for cobwebs, bathroom mold, thick dust or other signs of slackness. Physical limitations can mean your loved one needs housekeeping help or a living situation where this is taken care of for him or her.

Bathroom grime and clutter  A common scenario: Your loved one makes an effort to tidy up living areas but overlooks the bathroom. Or the guest bath is clean, but not the one the person uses all the time (the one off a bedroom, for example). Here you may see a truer picture of how your loved one is keeping up.

8. Pet-Care and Plant-Care Signs
Be sure to check out how the other living things in the home are faring. An ability to take care of pets and plants goes along with self-care.

Look for:

Plants that are dying, dead, or just gone  Most of us have seen plants go brown sometimes. Keep an eye out for chronic neglect, especially in a former plant-lover’s home.

Animals that don’t seem well tended   Common problems: dogs with long nails, cat litter boxes that haven’t been changed lately or dead fish in the fish tank. Poor pet grooming, overfeeding and underfeeding are other red flags.

9. Home-Maintenance Signs
Walk around the yard. Yard maintenance — or lack of it — can yield clues that your loved one isn’t faring as well at home alone anymore.

Look for:

Signs of neglect   Look for discolored siding or ceilings that might indicate a leak, gutters choked with leaves, broken windows or fences and dirty windows.

Newspapers in the bushes  Are papers being delivered but ignored? Sometimes people pick up those they can see on a driveway, but not ones that go off into the yard.

Mail piled up in the mailbox  Go out and check — it’s an indication that your loved one doesn’t even retrieve it regularly.

10. Signs from Friends and Others
Get the input of others who know your loved one in order to collect a fuller picture of reality. Gently probing about what others think isn’t nosy; you’re being loving, concerned, and proactive.

Look for:

Input from those in your loved one’s circle  Talk to old friends and close relatives to get their sense of how the person is faring. Listen for stories that hint that the person doesn’t get out much (“She doesn’t come over anymore.” “She quit book club.”). Pay attention to comments that indicate ongoing concerns (“Has he had that heart test yet?” “We were worried the day the ambulance came.”).

Medical insight  With appropriate permission, your loved one’s primary doctor may share your concerns about his or her patient’s safety at home — or may be able to alleviate those concerns or suggest where to get a home assessment.

A second opinion  A social worker or professional geriatric care manager visits older adults’ homes and does informal evaluations. While your loved one may initially resist the notion of a “total stranger” checking on them, try pitching it as a professional (and neutral) second opinion, or ask the doctor to “prescribe” it. Some people wind up sharing doubts or vulnerabilities with a sympathetic, experienced stranger that they’re loathe to admit to their own children or family.

11. Caregivers’ Signs
Finally, realize that some of the information you collect is intangible —it has to do with feelings and emotions, and the stress levels of everyone involved.

Look for:

How you’re doing  While this decision to remain in the home is not primarily about you — the son, daughter, grandchild, caregiver — your own exhaustion can be a good gauge of a decline in older adults’ ability to care for themselves. Keeping someone at home can require lots of hands-on support or care coordination, and this is time-consuming. If your loved one’s need for care is just plain wearing you out or if a spouse or children are feeling the collective strain of your caregiving activities, these are major signs that it’s time to start looking at other options.

Your loved one’s emotional state  Safety is crucial, of course, but so is emotional well-being. If someone living alone is riddled with anxieties or increasingly lonely, then that may tip the scales toward a move not solely based on health and safety reasons.

If your loved one has a full life, a close neighborhood and community connections and seems to be thriving, it’s worth exploring as many in-home care options as possible before raising stress levels by pressing a move from a beloved home.

If, on the other hand, your loved one is showing signs that living alone is a strain, it may be time for a talk. Broach the subject of where to live in a neutral way and you may find that your loved one harbors the same fears for current and future safety and security that you do. Find out what your loved one fears most about moving and about staying before launching into your own worries and what you think ought to be done.

Copyright Caring.com, 2013

Reprinted from: http://www.nextavenue.org/11-signs-might-time-assisted-living/ Article: 11 Signs Your Parent May Be Ready for Assisted Living  by Paula Spencer Scott; July 11, 2016; published on Caring.com

This is the second of 2 segments posted

Reprinted from: http://www.nytimes.com/interactive/2016/05/01/nyregion/living-with-alzheimers.html?_r=0

FRAYING AT THE EDGES Part 6
By N. R. KLEINFIELD

SHE WAS FOLDED into a chair in the living room, working her way through a cup of coffee. She sat arched toward her husband, the two of them talking through the afternoon’s changing light.

The apartment was a pin-neat one-bedroom, its windows offering sweet views that went a long ways. The black leather couch and rug were new. Her idea. She didn’t want Mr. Taylor stuck replacing tattered trappings once she could no longer pitch in. Everything with her was do it now.

Ms. Taylor told him: “I find when you can’t remember something but you feel something about it, you take your mind out of it and let your feelings get to it. If you get frustrated and angry, that’s the worst thing because you have this emotional interference. At Memory Works, they said a couple of weeks ago if it sounds like something or feels like something, say it. I was trying to find a word and I thought it felt like hamster, and I said it.”

“Makes sense,” Mr. Taylor said.

It happened that her days spanned strings of triumphs and losses, the ratio vacillating. “I totally forgot the gutter man was coming to Connecticut,” she said. “I wrote it down. But I forget to keep looking. I arranged for a man to come to replace a broken window and I was out. He was supposed to be there in five minutes. I was 20 minutes away. Fortunately he was late.”

Their toaster ovens differed in their two homes. The Connecticut one had no timer to shut it off. She would leave things in it. Once a bagel caught fire. They bought a model with a timer.

“It’s not just the two being different from each other,” she said. “It’s each one being different every day. Operating a car, finding the buttons, gets me mixed up. I can’t figure out how to turn on the air-conditioner. I’ll put my coffee down and go to the bathroom and come out and make coffee all over again. And then wonder, Where’s my mug?”

Applying her makeup, she would overlook an ingredient — the lipstick, say, or the rouge. There is a sequence, she said. She had problems with sequences.

Sometimes during glum moments — when she fumbled a task or lost something — she got down on herself. She would tell her husband, “We need to see a movie.”

Mr. Taylor was always the voluminous talker in the marriage, Ms. Taylor much more abstinent when it came to small talk. Now she spoke to everyone and struck up conversations with strangers, a new aspect of her personality. “I think I just unconsciously started doing it, and the response has been good,” she said.

Her husband looked at her appraisingly and said: “The governor is gone. You’re always coming home and telling me about all these people you met at the photo shop or something.”

“I’m not indiscreet,” she said, eyes widened. “I haven’t brought home any cats.”

“No, but you’re less inhibited than you used to be,” he said. “You do what you want to do, you say what you want to say. You’re not concerned about hurting other people’s feelings.”

“Oh gosh, I haven’t done that, have I?”

“Not that I know of.”

“Oh good.”

Mr. Taylor said: “You know your days are finite. And you’ve found interacting with strangers much more pleasurable than you thought possible.”

All in all, they were feeling upbeat.

He said: “I know this sounds really strange, but I don’t think Geri and I have had a better period in our marriage than right now. We’re much more dedicated to be with each other. The disease has brought that. Yes, it’s short-lived and there’s a sadness to that, but we’re not focused on that.”

She said, “We feel fortunate in the misfortune of this time.”

Darkness had come on. The city glimmered outside. She untwined herself from the chair and trundled into the kitchen to retrieve a plaque she wanted to show. Months ago, she had been fishing around an arts and crafts store, when her eye fastened on it. It read, “When I let go of what I am, I become what I might be.”

She had to have it. The disease had her wrestling with her self-identity as pieces of her disappeared. What kind of person was she if she couldn’t get names straight or make the oven work, forgot where she put that new blouse, forgot she even had a new blouse?

The plaque spoke to her, convincing her that she could build something else inside her, that she could unfasten herself from the past and not have it dominate the present. She said: “If you continue to think of who you were right up until the time you got Alzheimer’s, you will experience frustration, decline, failure, a lesser self. Not good company. I sometimes can’t complete a thought. I could feel bad about myself. If I have to measure up to what I was before I became this, I can’t. But if you let that go, then you are still becoming something. And it’s not necessarily a diminution of yourself. You must realize, it ain’t over.”

IF you have enjoyed these first 6 excerpts  from Fraying at the Edges, please read the entire piece at: http://www.nytimes.com/interactive/2016/05/01/nyregion/living-with-alzheimers.html?_r=0