End of Life Decisions: A Broken Promise

End of Life Decisions: A Broken Promise

As a geriatric care manager, in the early part of my journey with senior adults and their families, I ask about advanced directives: a living will, power of attorney and a health care proxy. There will be one of three responses: 1. No, my mother refuses to talk about these documents. 2. We are planning to go to an attorney or 3. Yes, there has been a designated POA and health care agent.

If you fall into the number three category, it may be with relief that you have these documents in place. As the health care agent, you have had the “discussion” and understand the wishes of the person you will represent. You are certain that you can march forward through the complexities of end of life decision making. Yet for some, when the time arrives, that confidence becomes clouded by doubt. It’s not unusual. Such was the case for Lorraine, Anne’s daughter.

Anne, my client of nearly five years, confided in me with weekly regularity that she wanted to die. She knew she was losing her memory and was humiliated by what was happening. Other indignities followed. An extremely anxious person, the only comfort she took was that Lorraine knew her wishes and would do right by her.

Lorraine did not visit her mother with any frequency despite living just over the Westchester County border in Connecticut, a thirty-minute trip. Watching these meager visits and equally few telephone calls, I was sure that when Anne’s doctor called Lorraine to suggest hospice care, she would readily agree. To my surprise, Lorraine would not acquiesce. She acknowledged to me that she knew what she was supposed to do as her mother’s agent. The problem was she could not bring herself to make those final decisions about stopping advanced medical treatment, nutrition, and hydration. “Who am I to make those decisions?” she said to me. I wondered, was it unspoken hope or unease?

Anne lingered with time becoming the final decision-maker. In the days before Anne’s death, I said to Lorraine, with no suggestion of judgment, that she would carry with her whatever decision she made. I recognized that those who generously take on the role of health care agent do so with a full heart. But sometimes, good intentions can be superseded by last-minute questioning. Doubt fogs the road we thought we could readily take.

ADL’s and IADL’s: The Alphabet of Assessing an Adult Senior

ADL’s and IADL’s: The Alphabet of Assessing an Adult Senior

Where does this geriatric care manager start when a family is eager to help an aging parent?  The answer is an assessment. It is a bevy of questions that are asked to determine how best to approach the issues at hand. Some of the questions I ask are unique to the situation, but others are basic: Activities of Daily Living aka ADL’s and Instrumental Activities of Daily Living aka IADL.

Activities of Daily Living tell about an adult senior’s ability for self-care. Is a parent able to feed herself? This does not include preparing a meal or even chewing or swallowing the food, it is bringing food to one’s mouth. Dress and undressing without assistance, from underwear to shirt and tie.  Toileting: is the older adult able to ambulate independently or with a walker or wheelchair to the toilet?  Transferring:  can the person independently move from one place to another, from a bed to a chair?  Personal hygiene: can an older person bathe themselves, brush their hair, their teeth?

While the Activities of daily living provide a gauge as to whether an adult can live safely on their own, the Instrumental Activities of Daily Living, are also of important consideration. IADL’s include the ability to manage money this would include paying bills in a timely manner. The ability to go grocery shopping or to use a food delivery service. Getting to and from doctors’ appointments.  Household chores including doing laundry, hand washed or otherwise, and selective house cleaning.

Beyond these two significant areas, an assessment will look at the finances of the older adult to determine if there can be alternate living arrangements or home care paid for privately or thru an entitlement program. Knowing about family support within the geographic area in which the older adult resides is important. The role that can be played by adult children living at a distance. The physical, emotional and cognitive conditions the senior may be confronting, and the ability to take the corresponding medications responsibly. The “story” of the senior’s life. Personality traits, occupation, significant events that may influence how best to approach a parent. Who might it be in the family or beyond the family that may have the greatest chance of influencing the senior?

By combining responses to ADL’s, IADL’s, and the topics discussed above, this geriatric care manager can help families take the first step to bringing a parent to a healthier and safer way of living.  To this end, health care directives and a power of attorney should be in place to ensure that next steps can be taken without complications.

Nurturing the Nurturer: The Use of Doll Therapy for Older Adults

Nurturing the Nurturer: The Use of Doll Therapy for Older Adults

As Aging Life Care Professionals®, when we are asked to assist with securing placement in a nursing home, there are many questions we ask beyond the physical and cognitive conditions that are prompting the move. Primary among those questions is: what was mom or dad’s occupation? Those families who have parents in their mid-eighties and beyond often reply by giving dad’s occupation and the fact that mom was a homemaker.

Remembrances of lifelong professions can be retained long after actual employment or the responsibilities of raising a family have ceased.  Take Gene, a retired fireman who had been diagnosed with dementia.  On the day he arrived at the nursing home, being the conscientious firefighter he once was, he spotted a fire extinguisher and was headed straight to his job. Fortunately, his daughter positioned herself to block his access.

For mothers and wives of this era, the role of family nurturer is often rooted in the person. This is not to say that fathers have not played prominent roles, but for mothers or other women that have been employed in caregiving roles, it is not a job that finished at five. In later years, should there be cognitive loss accompanied by agitation we, as Aging Life Care Professionals, look to guide the family in ways to lessen the anxiety their loved one may be experiencing. Nonpharmacological approaches are preferable. One such method is doll therapy.

Doll therapy is just what it says. It is providing a person with a doll, that she/he can hold, cuddle, talk to, even dress and undress.  The latter helping with finger dexterity and hand-eye coordination. The doll can give a person a sense of comfort and purpose with the goal being redirecting the anxiety and bringing a parent to a sense of calm and contentment. Beyond this, a doll can be a starting point for reminiscence, asking a parent to recall their days as a new parent, bearing in mind that it is the long-term memory that is most vivid.

Research studies have shown both increased happiness and increased social interaction using doll therapy. But doll therapy is not without controversy. Some feel the dignity of a parent is compromised using a doll.  Other concerns are that dolls are demeaning and infantilize older adults. A passerby may look at a person with a doll and remark that the senior looks “cute” holding a doll. Not the way a relative wants their spouse or parent to be perceived.

As Aging Life Care Professionals, our approach is a person-centered one. To each client, we bring a toolbox of suggestions, techniques and resources. While the use of doll therapy is one such example, we customize the guidance, recognizing the unique needs of each client while working together with families to ensure practical and realistic outcomes.

Can an Adult Senior Remain at Home? …That is the Question

Can an Adult Senior Remain at Home? …That is the Question

As an eldercare consultant, I am familiar with the statistic that close to 90% of adult seniors, have expressed a desire to remain in their homes for as long as possible. The terminology in the world of eldercare is “aging in place.”

My lack of surprise about aging at home, while corroborated by AARP, has its source in the adult children who visit my office frustrated that their parents feel there is no compelling reason for them to move out of their house. A typical scenario as described by a son or daughter: no bathroom or only a half bathroom on the main floor, stairs that must be ascended or descended to get to the kitchen, no direct access to the outside without holding on to a hand rail that is unstable accompanied by a walkway that is crumbling, nonstop repairs both large and small.

Sitting across from these adult children, I understand their unease. They are often wakeful at night, distracted at work, consumed with the responsibilities of calling the plumber, roofer or making sure a path has been shoveled after a snowstorm.  I also know from talking with adult seniors the comfort that comes with continuing to reside in a lifelong home. Change is never easy or welcomed.  So, what’s an eldercare consultant to do?

For this consultant, the major consideration is safety. There is no compromise on this issue. To ensure this safety there are three necessary requirements. First, the willingness of a parent to agree to whatever modifications should be made to the house. First, the readiness of the parent to accept home care if necessary and first, the financial wherewithal and/or community support services to achieve these outcomes.  Yes, they are all number one priorities.

To this end, I frequently visit the parents in their home. Often, mom and dad need to be heard and understood, with a focus on empathy. Once they know I understand their situation, it is easier to start to effect change. The secret is small steps. With each step, it is validating their willingness to undertake necessary changes. That validation provides the incentive for the next step until a safe living environment is accomplished.

But please don’t think I come with a magic wand. Sometimes the ideal, or even close to it, becomes unachievable. It may be the staunch autonomy of a parent or it is the symbiotic relationship of husband and wife who create such a strong wall (yes, this one is achievable), that adult children, the family favorite, or even this eldercare consultant cannot convince them that they are putting their safety at risk. Then Father Time steps in and removes aging at home as a choice. A fall, noncompliance with medication, or one of those all too frequent storms we’ve been having here in Westchester County, may result in a whole new aging in place definition and destination.

A Flower and a Shower: Caring for Someone with Dementia

A Flower and a Shower: Caring for Someone with Dementia

Several years ago, I put a new bathroom in our new home. When it came time for the shower, I described to the salesman the type of showerhead I was looking for. “It’s called a sunflower,” he said and off we went to the display.

To this geriatric care manager, the notion of a sunflower showerhead, AKA a rainfall showerhead, suggests something very soothing. But enough about what I imagine. From a practical point of view, a shower for a person with Alzheimer’s Disease can sometimes take on an entirely different aura. Why can bathing be such a challenging task?

For some, it is the loss of independence. A caregiver or a family member is now either in the bathroom or outside the door. Privacy is trumped in the name of safety. Especially challenging when the aide is female and her client a male. Also, the person with dementia may not recognize that something is wrong, and becomes agitated, even belligerent. Why are all these people telling me what to do?  The senses may also contribute to this encounter. The water streaming out of the showerhead or the spigot, can be frightening to the person with dementia. Even the sound of the water can be unsettling. Stepping into a bathtub may bring a fear of falling.

The following strategies may help to reduce the stress of bathing:

  1. Choose the right time of day. If the person is experiencing sun downing, mornings may be the preferable time.
  2. Use a strength based approach. Have the person help in the bathing process as much as possible.
  3. If a person is resistant to a bath, try bringing in some favorite music or say something like: “a short bath and then a big scoop of strawberry ice-cream.” A reward system works well.
  4. Know thy self. If you have had a long day, put off the bath.
  5. If these strategies fail, try some non-rinse body soap and shampoo.

The explanations for why a person resists bathing is as varied as the person. By exploring various techniques combined with the acceptance that what is not achievable today may be resolved tomorrow or the next day, brings a degree of calm to an otherwise unsettling illness.

Besides the Queen, Every Woman Needs a Pocketbook

Besides the Queen, Every Woman Needs a Pocketbook

At one moment or another, we have all wondered what the Queen of England carries in her pocketbook.  Certainly, she does not need a driver’s license, a credit card or loose change for parking.  But there it is, firmly implanted in her hand.  For our female clients, the necessity of that pocketbook is also a must. But perhaps for different reasons.

Let me tell you about Madeline. She has mid-stage dementia. One day, as she left her home for a doctor’s appointment, she realized she had forgotten her pocketbook. I was the designated driver, and I could hear her ask for her pocketbook as she descended the steps from her home. Lillian, the caregiver said, “you don’t need your pocketbook.” My window went down and I told Lillian to go back inside and get Madeline’s pocketbook. I knew it was only going to be a matter of time before Madeline asked for it.

So why does a person who is not going to actively use her pocketbook need it?  There are 5 reasons as I see it:

Because a lady has always carried a pocketbook.

Because a woman feels secure when she holds it in her hand or sees it on her walker.

Because even with dementia, a lady may want to reapply her lipstick or check her hair.

Because a woman wants to feel in charge, as she always has, and pull out a few dollars and treat everyone to ice-cream.

Because we, as care managers, care givers and family have a responsibility to help “the Madeleines” retain their dignity, even when they don’t recognize something is missing.

This geriatric care manager thinks of each of her female clients as royalty. And as such, while her handbag may not match her outfit, each lady will surely have one firmly clutched in her hand or placed in the basket of her walker when she leaves her house to greet the world.