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.

The Anatomy of an Appetite: Aging and Our Relationship to Food

The Anatomy of an Appetite: Aging and Our Relationship to Food

Many of life’s events involve food. From the grandest of celebrations to the smallest of gatherings, there is always a place for food. As an Aging Life Care Professional®, I recall a wonderful get together this care manager had organized to celebrate a client’s birthday, her ninetieth… I thought.  She so enjoyed her birthday cake. It was only after I re-did the math that I realized my enthusiasm was premature; Dorothy had another twelve months to go to before she reached her 90th year.

Dorothy took great pleasure in eating her birthday cake. But such enthusiasm for food is not shared by all adult seniors.  There are a variety of factors that may contribute to a decrease in appetite: the side effects of a medication, dentures that do not fit, loss of taste, feelings of loneliness as a senior sits down to a table for one and a myriad of medical conditions.  A wince as an older adult bites into an apple or a change in appetite after the start of a new medication are symptoms that may require a visit to the dentist or a call to the prescribing doctor.

The potential for resolving the nutritional problem described above are far more likely than the changes an adult senior experiences as the end of life approaches.  He or she may lessen their food intake and ultimately refuse all nourishment. Family members are justly concerned, confused and frequently feel guilty.  Often, they fear they are starving a loved one to death if food, liquid or some form of artificial nutrition is not provided.  For an adult senior with advanced dementia, the scenario is made more complex.  As the dementia progresses it impacts on that part of the brain that controls swallowing. The chance of choking increases. In either of these scenarios it is important to recognize as the end of life nears the body adjusts to the slowing down process and minimal amounts of nutrition or liquids are needed, if at all. Now the focus becomes comfort care. Moistening the mouth with a special sponge, applying lip balm or offering a small amount of water through a straw, teaspoon or syringe.

Aging Life Care Professionals understand that while parents may have left specific directives for no heroic measures, a daughter may find it too cruel to discontinue nourishment or fluids. A son may hope for a last-minute miracle or a spouse may feel that only time will dictate when to say the last good-bye.  As Aging Life Care Professionals, it is our role to hold the hand of our client and reach out our other hand to support the family in whatever their decision may be.


Miriam Zucker, LMSW, ACSW, C-ASWCM, is the founder of Directions in Aging based in New Rochelle, New York. For over two decades she has assisted families in customizing plans of care and developing effective strategies to meet the needs of older adults. She has recently been appointed to the board of directors of New Rochelle Cares, a non-for profit organization devoted to helping senior adults live safely and fully at home.

This blog is for informational purposes only and does not constitute, nor is it intended to be a substitute for, professional advice, diagnosis, or treatment. Information on this blog does not necessarily reflect official positions of the Aging Life Care Association® and is provided “as is” without warranty. Always consult with a qualified professional with any particular questions you may have regarding your or a family member’s needs.

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.

From Hospital to Home:  Post Hospital Syndrome

From Hospital to Home: Post Hospital Syndrome

Recently I addressed the Post-Acute Care Continuum in White Plains, New York. An organization whose goal is to educate and share best practices in post-acute care and care transitions. I was asked to speak about how geriatric care managers can help to ensure that patients return home and remain home beyond the initial 30-day period. Of course, we do not want our clients to return to the hospital at any time, but there is a reason for the specific 30 days.  In 2013, the United States Department of Health started to penalize hospitals for re-admission of patients within thirty days. The Department of Health wanted patients to be discharged responsibly with adequate follow-up care, hence this law was enacted.

Because of this act, the rate of 30-day re-admission has dropped from 20% to 17%. But often, while the reason for hospitalization has been addressed, the consequences of a hospitalization are just being felt when our clients return home. Dr. Harlan Krumholtz, MD of Yale-New Haven Hospital refers to this return as the Post Hospital Syndrome. He attributes this re-admission within 30 days to five major factors:

  1. Sleep deprivation: The patient is in a new environment. The illness combined with being in a different bed, in a different place will impact on cognitive and physical performance. A situation of perpetual jet lag has been created.
  2. Malnourishment: Certain tests and procedures require nothing by mouth for the day or evening prior. And if the test is cancelled and then rescheduled, another period goes by without nutrition. This results in protein-energy malnutrition. The consequences of such a scenario is that wound healing is impaired, there is a chance of increased infection and one’s immune system is compromised.
  3. Pain and discomfort: For any of us, especially those dealing with pain in the hospital environment, pain can lead to sleep disruption, mood disturbance, impaired cognitive functioning and may also impact on the immune system.
  4. Altering medications: Stopping one medication and adding another can have its impact on cognition and physical functioning: too much of a medication, too little, the wrong medication, an allergic reaction to a medication. A patient’s body becomes a roller coaster of experimentation in an effort to cure.
  5. Deconditioning: Time in bed for rest can put a patient at greater risk of accidents and falls. While physical therapy may take place in the hospital, Dr. Krumholtz questions if there is still too much inactivity. The result being once the patient returns home he or she is at greater risk for developing blood clots.

As discharge approaches, what must be done is a TOTAL evaluation of the patient. This evaluation should go beyond the reason for hospitalization. Attention must be given to sleep, nutrition, activity, strength and how all symptoms are treated and managed. As a geriatric care manager, it is my responsibility to observe, question and advocate for clients whose care has been entrusted to me.

A Doctor’s Simple Request

A Doctor’s Simple Request

In the last weeks of Helene’s life, she entered Calvary, a hospital devoted to end of life care or as Calvary likes to say, “where life continues.”  A short distance from her home in Pelham, New York and my office in New Rochelle, as her geriatric care manager, I visited regularly.  While I could easily acknowledge that my visits were to support her caregiver who was there daily, I also knew my final good-bye was not far off.

But before my good-bye came, there were conversations with clergy, the social worker, nurses and the sharing of information with the family. The reputation of Calvary has always been stellar so I was not surprised by their responsiveness to Helene’s needs and my queries.  What I was not prepared for was the request of her palliative care doctor. It was not medical history or questions about next of kin, but a simple request to see a picture of Helene in the years prior to her decline.  I could not think of a doctor, in almost three decades of practice who ever made such a request.

As my relationship with Helene had extended over seven years, I was beyond eager to share pictures and tell stories. The doctor was an enthusiastic listener.  There was the photo of a just finished visit to the beauty parlor, another of Helene showing me the house in which she once lived and one of her oldest grandchild standing proudly by her side. Her life as a magazine illustrator was also shared minus pictures.

As geriatric care managers, we are usually called into service when there is a life changing event. While our attention is focused on a presenting issue, we are always mindful that a lifetime preceded the current situation. Illness alone does not define the person. The doctor in his thoughtful gesture understood this and let me tell Helene’s story one last time. Sometimes I think it was for my benefit more than his. Nevertheless, his patient became a person and my good-bye, when it came a week later, was softened by his simple request.

Slow Medicine and Dr. Dennis McCullough

Slow Medicine and Dr. Dennis McCullough

It is not often I can write a blog in an hour. Usually it’s written, reviewed, accuracy checked and making sure I have made my client, who has provided me with a particular insight, indistinguishable from the message I am sharing.

This blog is different. There is nothing to cover up, on the contrary. In telling you of the recent and untimely death of Dr. Dennis McCullough, I am introducing you to the world of “Slow Medicine,” which he pioneered with the publication of his book, “My Mother, Your Mother” in 2008.  Regrettably, dying at the age of 72 he did not have the opportunity to put into practice what he encouraged. Or maybe it is not regrettable. He died a quick death, the result of a heart attack. Nothing prolonged and no heroic measures. He would have liked his death.

The essence of Slow Medicine is kind medicine. Less is more medicine. Often as spouses and adult children we feel compelled to do as much as we can to help a loved get better. Dr. McCullough has asked us to step back,  just minutely out of the box and ask ourselves this question:  by doing additional testing, surgical procedures, adding more medications are we really helping someone at the end of their life?  He faced this personally when his mother went from a nursing home to a hospice care center. Medications, other than those for pain were stopped.  It was here that her dignity took center light, with family and familiar caregivers close by. She was one of the sources for his book. The other being his own experience as a “vulnerable” patient for over a three year period.

I have touched ever so briefly on Slow Medicine. I think Dr. McCullough said it best in “My Mother, Your Mother.”  “Slow Medicine is not a plan for getting ready to die; it is a plan for understanding, for caring, and for living well in the time that is left.”

An untimely death, but an eternal message.