More on Falls and the Elderly

Learning more about fall prevention is key component to caring for an aging family member and supporting their quality of life.

First, Jane Gross at the New Old Age Blog, discusses the serious risk of falls for the elderly.

. . .Each year, nearly one-third of older adults experience a fall, and 20 to 30 percent of them wind up with moderate to severe injuries, ranging from broken teeth to broken hips. In 2005, the C.D.C. reports, 1.8 million elderly patients were treated in emergency rooms for non-fatal falls, and 15,800 died of their injuries.

Some 20 to 40 percent of those suffering a hip fracture will die within a year, researchers estimate, but even lesser injuries can precipitate a cascade of medical problems, the onset of severe disability, and the end of independent living and the beginning of round-the clock care.

She notes that there are many efforts underway to study prevention programs.

Meanwhile, Sarah Henry at Caring Currents wrote a post yesterday about the importance of geriatric care. She refers to a New Yorker article about a geriatrician who institutes a number of measures to prevent falls for his patient, after noting her high risk for a fall.

Aging Population Creates Space for More Eldercare Services

Two articles from newspapers in Minneapolis-St. Paul and Dallas discussed different eldercare services this week. Taken together they highlight how the growth in the elderly population in the United States is creating changes in how eldercare services are being offered, and how new business models are being created to perform these services.

The first article, from The Dallas Morning News, discusses home care agencies and in particular, the growth of franchises offering home care services.

Some 11,000 licensed home-care businesses served 7.6 million people last year, according to the American Association of Homes and Services for the Aging. And in-home aides are projected to be the second fastest-growing job over the next decade – the government forecasts a 50 percent increase, from 767,000 to 1.2 million jobs.

Though "mom and pop" businesses have dominated home care, entrepreneurs have propelled the recent growth by opening franchises to capitalize on the expected doubling of the older population by 2030.

Next, this article from the Star-Tribune focused on a company started by four nurses that provides eldercare assessments as well as managing ongoing care.

Two partners spend two hours or more on an assessment, Buelow said, speaking both to the senior and to family members. They spend 10 to 15 hours writing a report, which details a family's options for meeting a parent's needs.

The partners will conduct family meetings, sometimes including out-of-state siblings joining in on cellular phones, to go over the assessment and present the options . . .

Not Enough Facilities to Handle Dementia Patients in Maine

This article from the Bangor Daily News addresses the need for more facilities to handle dementia patients in the state of Maine.

Rick Erb, executive director of the Maine Health Care Association, which represents nursing homes in Maine, confirmed in a recent interview that the shortage of places for Mainers with difficult behavior has been a serious problem for several years and is likely to get worse as the population ages. Only three Maine nursing homes offer specialized long-term psychiatric units, he said, with higher levels of trained staff to handle aggressive patients and locked units to prevent residents from wandering. None of the three is north of Waterville or west of Gorham.

Erb said it’s up to the state to fund more of these high-level programs for Mainers with dementia.

“But right now, there is no movement toward creating more special units to deal with these psychological issues,” he said.

According to Diana Scully, director of the Office of Elder Services at the Maine Department of Health and Human Services, the state is well aware of the problem.

“There are long waiting lists” for admission to the three nursing homes with specialized psychiatric units, she said in a recent interview. “It’s hard for the existing facilities to address the need.”

But looking ahead, she said, state officials have yet to tackle the problem of ensuring that appropriate — and expensive — nursing home care is available for Maine baby boomers who develop difficult behavior related to dementia. Instead, the current focus is on increasing space for aging individuals in less-restrictive settings such as assisted living programs and boarding homes, as well as developing community-based support for families caring for their elderly relatives at home.

Scully acknowledged that it is not enough. “There will be more Alzheimer’s and other age-related dementias. We know we are going to need more options as people age,” she said.

Until those options are developed, waiting lists will continue to grow and hospitals will bear the burden.

Round-Up: Preventing Falls, Expressing Condolences, Respite Care, and More to Come

I’m still catching from a lovely August vacation, but wanting to share some articles that appeared in The New York Times while I was gone. Here Ohn Mar talks about a study examining ways to reduce falls among the elderly.

Falls among the elderly, a common source of injuries, have largely been considered inevitable. But a recent large-scale study shows that a combination of adjusting treatment, assessing risk and educating patients can substantially reduce serious falls.

The study, by Dr. Mary E. Tinetti and her colleagues at the Yale School of Medicine, compared two similar regions of Connecticut. For four years in the experimental region, the researchers asked clinicians to assess their patients’ risk of falls and to consider medication reduction and other prevention measures like strength training, vision adjustment and blood pressure treatment. The rate of serious falls by the elderly in that region was 11 percent less than that in the region that followed normal care.

That lower rate of falls translated to 1,800 fewer emergency visits by the elderly, the researchers said, saving more than $21 million in health care costs. The study was published July 17 in The New England Journal of Medicine.

In this essay, the vice chairman of medicine at Memorial Sloan-Kettering Cancer Center, Kent Sepkowitz, M.D., writes about doctors not expressing condolences.

Not long ago, soon after we put our pet dog to sleep, I received a handwritten note from our veterinarian expressing her condolences. The letter was not brief — she described my children’s fondness for little Rudy and how caring they were as his condition worsened. It was thoughtful and personalized, not something she had simply dashed off.

In contrast, during my 25 years of caring for humans I have written only a handful of similar notes to families after a loved one’s death.

Here, John Leland writes about respite care and the reluctance of caregivers to use the service for their ailing relatives.

In an aging population, nine million people take care of someone with Alzheimer’s or another form of dementia, and for many it is a responsibility without a break.

But as health professionals and the federal government have recognized the strain on these family members — including higher rates of depression, hypertension, diabetes, sleep disorder, heart disease and death — a growing number of facilities now offer short-term respite stays. In its simplest form, respite might be a home aide a few hours a week or use of an adult day care service. To caregivers at the end of their rope, real respite means a short time away — what for anyone else would be called a vacation.

Most caregivers do not take respite vacations because they see them as an admission of failure, or they worry that something will happen while they are away. A paradox of caring for an elderly relative is that the burden is so big, many feel they cannot share it.

Paula Spencer, a senior editor Caring.com, wrote about NYT’s respite care piece on their Caring Currents blog.

Every caregiver should know the key points:

1. Respite can save your health and your marriage.
2. Overnight options include in-home care and short-stay arrangements in nursing homes, assisted-living facilities, and "camps," such as one run by the Family Caregiver Alliance.
3. Using vacation respite isn't bad for the loved one with dementia.
4. Taking a vacation isn't a sign that you're a lousy caregiver.

That last point probably belongs first, and in all caps. There's such a pervasive misconception, deep in the psyche, that it isn't "right" to leave a loved one who needs care while you go off on holiday. "Most caregivers do not take respite vacations because they see them as an admission of failure or they worry something will happen while they are away," says the Times piece.

Examining Caregiving Among Florida's Minority Populations

An article in Washington's The Olympian newspaper discusses a two-year project run by the University of Miami's Center on Aging to evaluate the strain of caregiving on 200 minority caregivers in southern Florida. The project will feature an emphasis on using technology to connect caregivers, using video phones.

"People don't plan on becoming caregivers," said Dr. Sara Czaja, co-director of the center and principal investigator on the project. "It's something that just happens to them. It's not one size fits all. Culturally, we have different ideas about family, about caregiving - maybe technology can play a big role."

MAKING A CONNECTION

Part of the program involves connecting caregivers to others through video phones installed in their home. Through their video monitors, they can reach out to other caregivers, social workers or medical experts and watch pre-recorded videos about caregiving and Alzheimer's.

Profiles of Five Women Caregivers

This piece from the Rockford Woman (IL) magazine features the profiles of five women whose professional careers or personal lives involve caring for the elderly. Debra Adkins is the campus administrator for a facility that operates buildings ranging from independent living to a skilled nursing home on one campus. Teresa Colvin is a caregiver specialist for the Northwestern Illinois Area Agency on Aging. Beverly Bosselman is a certified hospice palliative care nursing assistant. Gloria Dawson is an author who wrote a book about caring for her mother and Shirley G. Sievers is a geriatric consultant and care manager.

Interview with a Geriatrician Trying to Revolutionize Nursing Homes

Caring.com posted an interview with Dr. Bill Thomas, a geriatrician who is working on a way to revamp nursing homes in the U.S. His current project is known as the Green House,

. . .groups of small, cozy homes that offer private bedrooms and baths, and "hearth rooms" with an open kitchen. Residents can eat when they want, sit by the fireplace, and take part in all house decisions. Meals are served around a big table, and some Green Houses bake bread or cookies daily and serve soup from a big tureen on the table to promote the feel (and scents) of home. There are now 41 Green Houses in ten states, but the Robert Wood Johnson Foundation recently provided a $15 million grant to Green Houses and the nonprofit group NCB Capital Impact to build more during the next five years.

Caring.com's features editor, Camille Peri, asks Dr. Thomas about the Green House concept and how it differs from the traditional nursing home facility.

How do Green Houses treat staff differently?

First off, the people who work with the elders in the Green Houses are called shahbazim. The shahbazim -- which comes from a Persian word meaning 'royal falcon' -- are what we call the midwives of elderhood. And here's the key: They work together as a team in a house and they are not part of the nursing department. The nurses are separate. So one thing we've done away with is the nursing assistant idea where, if you can't get a real nurse, you get a nursing assistant. We say that real hands-on care is so important and valuable that it has its own professional standing. And then the nurses, of course, also contribute a huge amount to the well-being of the elders. But the nurses and the shahbazim are partners, not bosses and workers.

Are long-term care residencies really necessary, or would it be better for people to take care of their parents at home?

There are nursing homes all around the world because there are millions and millions of people who need more care than their families can give them. As a geriatrician and a doctor, I have seen people go too far in care giving at home before they sought professional help much more often than I have seen people not go far enough. Many, many more people give up careers, income, job satisfaction, social life, their hobbies --give up so much to care for somebody they love at home. And I've seen that take a real toll on people's personal health and well-being.

So the issue I most often deal with is helping family caregivers realize: You've done more than anybody could ever expect you to do, and now it's time to bring in the professionals. And there's nothing wrong with that -- you've done what you can do. It's time to take the next step. Yet society layers on the guilt, and I don't approve of that.

My message to caregivers is: Don't give yourself over to guilt. The very fact that you're a reader at Caring.com -- that's like angel points in advance! So do the best you can, and when it's time to get more help, don't beat yourself up.

Addressing Diversity in Eldercare Populations

This article from RiseUP magazine discusses the changes the MetroHealth nursing home in Cleveland made to become more welcoming to increasing numbers of Hispanic patients. Changes included offering Spanish-language television, the ability to room with another Hispanic resident, and more Hispanic volunteers and Latin American foods.

The population of Hispanic seniors will grow the fastest, from just over 2 million in 2005 to 15 million in 2050. From 2006 to 2050, the percentage of African-American seniors will jump from 9 percent to 12 percent. And while Asian senior citizens currently make up about three percent of the elderly population, their numbers will more than double as early as 2040.

Experts say this diversity will have a deep impact on society — from the number of seniors with certain chronic conditions to the languages that health care workers speak; to the foods served at a day center to the ways and convince seniors to stay healthy.

A more diverse senior population is a plus for everyone, says Dilworth-Anderson, who is also the director of the Center for Aging and Diversity at the University of North Carolina.

For example, many black and Hispanic elders are cared for by a wide network of friends and family. Recognizing that tradition, doctors can make similar suggestions to ethnic groups that have not historically embraced that practice, Dilworth-Anderson says. “The richness of diversity can help us in problem solving.”

A report issued in March by the Federal Interagency Forum on Aging Related Statistics, which compiled data from 15 government agencies, found that, as a whole, today’s elderly are healthier and wealthier. But significant disparities remain, especially for blacks and Hispanics. The report found that almost 20 percent more black seniors than white seniors suffer from hypertension.

About 16 percent of white seniors are diabetic, while 29 percent of blacks and 25 percent of Hispanics have the disease.

“You’re going to have a larger percentage of minorities and still have an increase, in general, in the numbers of senior citizens,” says Dilworth-Anderson. Indeed, the total senior population is expected to jump from about 12 percent now to 20 percent by 2030.

The article also discusses how similar facilities are handling increasingly diverse populations, including the Long Life Adult Day Care Center in Bergen County, New Jersey, where Korean seniors meet every day.

Providing so-called “culturally sensitive,” care for the elderly is nothing new, but experts say it will be more important as the numbers of elderly minorities climb.

Wallace, associate director of UCLA School of Public Health, says many food programs for the elderly rely on government assistance, providing meals that are often far from ethnic. Even something as simple as getting rice at every meal — a feature that would make many Asian seniors more comfortable — can be a challenge.

“It’s simple things like, how you prepare chicken. Do you prepare it in a way that a Mexican senior would recognize? Or do you make chicken cacciatore from Italy.”

The questions are not trivial. Seniors who don’t eat well, don’t fare well, he says.

HFA's April 2009 national teleconference will focus on ways of understanding diversity and how cultural histories, traditions and beliefs can affect end of life care. Site coordinator registration will begin in late September.

Should Physicians Report Suspected Self-Neglect?

American Medical News, the newspaper of the American Medical Association, published an article for its ethics forum this week address the responsibility of a physician to report self-neglect in patients.

Older patients with chronic conditions can, over time, lose the ability to care for their own basic needs and safety. But how can physicians maintain respect for a patient's autonomy while assessing self-neglect?

In her conclusion, Lisa Gibbs, M.D., associate clinical professor of geriatrics at UC Irvine, concludes that physicians have a obligation to report self-neglect.

. . .physicians who see older patients -- or even patients living alone without family members or social support -- have an obligation to recognize and pursue explanations for signs and behavior that may signal self-neglect. Acting on these signals is not always comfortable -- particularly if patients' spouses or other family members are in the picture. But self-neglect exposes patients to greater risk for morbidity and mortality that can be avoided once it is recognized and managed. The physician's role is clear.

Eldercare Workers Receive Training in Understanding the Challenges of Aging

Some retirement and nursing home workers are receiving a three-hour training session that simulates the effects of aging for healthcare and eldercare workers, according to this New York Times article.

Along with 15 colleagues and a reporter, Mrs. Ramirez, a social worker at the facility, put on distorting glasses to blur her vision; stuffed cotton balls in her ears to reduce her hearing, and in her nose to dampen her sense of smell; and put on latex gloves with adhesive bands around the knuckles to impede her manual dexterity. Everyone put kernels of corn in their shoes to approximate the aches that come from losing fatty tissue.

They had become, in other words, virtual members of the 5.3 million Americans age 85 and older, the nation’s fastest-growing age group — the people the staff at the facility work with every day.

Broken Bones Aren't the Only Danger When an Elderly Person Falls

Anne Marie Valinoti, M.D., an internist in northern New Jersey, shared a case earlier this week in the New York Times. An 88-year-old woman had fallen and was alone on the floor for 15 hours when the family found her.

Although her family had called her while she was unable to rise, but she did not say she needed help because she didn't want to trouble them. This put her at risk for an extensive muscle injury. It highlights the need not only to try to prevent falls, but to talk with elderly relatives about the need to ask for help if they do fall.

Strain of Caregiving Considerable When Caregiver is Also a Single Parent

This article from The Journal News (NY) profiles one single mother's struggle to provide care for her mother.

Catherine Wilson sits down to work as a bookkeeper every night at 9, after her 80-year-old mother has settled into bed. She does her grocery shopping after midnight, no longer surprised to see others in the aisles at 2 a.m.

A 50-year-old mother of two teenagers, Wilson says she can instantly spot her fellow "caregivers," as they are known in the social-service pamphlets. They are struggling to meet the needs of an elder at home - medical appointments, prescriptions, and mental confusion, in her mother's case - while raising kids and trying to hold down a job.

"I've had unbelievable conversations in supermarkets," she said. "We have children, we have households, we have work responsibilities. We're still paying mortgages, and we're faced with a situation where we have to quit work."

The article features video of Wilson and her mother that illustrates the story. Thanks to Aging Parents Authority for sharing.

Idaho Improves Community and Home Based Care for State's Residents

Nice post from Joanne Kenen at The New Health Dialog Blog about Idaho's innovation in home based and community care.

Even Leslie Clement, Idaho's Medicaid Administrator, admitted that Idaho isn't usually regarded as a hotbed of social innovation, but the AARP was impressed enough with the state's achievements on keeping people out of nursing homes to make Clement one of the featured speakers at a recent luncheon and discussion on long-term care entitled "A Balancing Act: State Long-Term Care Reform." With good reason.

Most of us don't' want to end up in nursing homes. Too often, we don't have an alternative. Many states, Idaho among them, have been exploring ways to provide more home and community-based care. It's cheaper. And people prefer it.

Does Assisted Living Include Caregiving?

This post from caregiverslist.com discusses the variation in services offered by assisted living facilities. If you are researchers assisted living for a family member, you will want to ask about what eldercare services are offered, whether nursing care is available and for what cost, and whether the center can provide continuity of care at the same location.

Finding the right Assisted Living Community presents a complicated task because of all these dynamics. In addition, another type of assisted living is called "continuing care" and available at Continuing Care Retirement Communities. These communities usually require a large initial deposit (some seniors sell their home and use the proceeds to pay for this deposit) but guarantee the senior will be able to remain in the community as their care needs may change. Usually condos or townhouses, apartments and nursing centers are all located on the campus and the senior may move between them, as needed.

Bringing Home Mom and Dad

Newsweek prints a weekly "My Turn" essay from a reader. The July 21 edition is from Anne Kennedy Rickover, who writes about the decision she and her parents made to have them move closer to her home as they began to have more difficulty managing their daily activities. She describes the decision to ask her parents to move to her hometown as similar to the decision to have a child, requiring planning for a life-altering event.

I hadn't been pregnant in 20 years, but this was planned just as my previous pregnancies had been. For no logical reason, I woke up one day and knew that it was correct; my entire being knew it was precisely the right time. Of course, the clarity was subtly infiltrated with uncertainties and fears as soon as the decision was made.

When I woke up that morning a little more than a year ago, I knew it was time to ask my parents to move closer to me. By closer, I mean 1,300 miles closer—all the way from suburban Philadelphia to Lincoln, Neb. The logistics, both geographically and culturally, were overwhelming. The distance between the East Coast and the Midwest had never seemed so vast.

Preliminary Long-Term Care Opinion Leader Survey Results

The Commonwealth Fund and Brown University conducted a survey of long-term care leaders. Over 1100 respondents, including consumer advocates, providers, public officials, and policy experts, completed the survey between September 2007 and March 2008. The research objectives were described as:

• Assess the views of long-term care opinion leaders with regard to the current state of long-term care in the United States, the attributes of an ideal long-term care system, and potential areas and strategies for reform;


• Identify areas of agreement and disagreement about the nature of the long-term care problem across opinion leader type;


• Compare the views of national, state, private sector and research based long-term care opinion leaders vis-à-vis the character of suggested strategies for reform;


• Learn about the networks of long-term care opinion leaders and how knowledge and views regarding important long-term care issues diffuse among them;


• Compare views of long-term care opinion leaders to those of other health care opinion leaders and the general public that have emerged from previous surveys.

Among the findings, eighty-five percent ranked the workplace as one of the top three challenges facing long-term care, followed by financing (66%) and achieving quality (60%). More ranked nursing homes as fair or poor (53%) than other service types, including hospices (6%). They favored adopting savings incentives and adding a long-term care benefit to Medicare. Few had faith in consumer report cards to help people make informed choices. Read more by downloading the top-level findings.

Op-Ed on Long-Term Care Argues for an Advocate

Steve Jacob of the Star-Telegram (TX) wrote an op-ed piece at the end of June dealing with hurdles of providing long-term care for the elderly. Jacob includes figures from a number of recent studies and surveys to show the current state of long-term care in the United States. He discusses the challenges we need to face in order to improve long-term care options.

Long-term care (LTC) has few champions. David Stevenson, a Harvard Medical School professor, noted in a recent edition of the New England Journal of Medicine, that healthcare was mentioned more than 1,000 times during the 35 Democratic and Republican debates during the primaries. But almost nothing has been said about LTC, despite the fact that it comprises about 10 percent of healthcare spending.

LTC is more about social functioning than managing disease. The estimated 9.5 million Americans who require LTC need assistance with at least one activity of daily living (bathing, dressing, eating, toilet use and moving from one room to another) or instrumental activities of daily living (meal preparation, money and medication management, telephone use, light housework and food shopping).

Most LTC services are provided by relatively low-paid trained staff rather than physicians or registered nurses. It’s an intensely personal service, traditionally designed to keep people safe, clean and well-fed. The trend is toward maximizing patient self-sufficiency and independence.

Jacob makes a plea for greater government attention for long-term care solutions, concluding that ". . .along with Social Security and Medicare, long-term care is the third leg on the retirement security stool. It desperately needs a champion."

Round-Up: Travel Tips, Dementia Study, Hospice Music and the Perfect Conversation

Some articles, posts, and items of interest from around the web collected from the past couple weeks:

• The Caregiving Solutions blog offers tips about traveling with elders and the disabled. Preplanning is essential to the process and wellness coach Pamela Larsen Schroeder offers some good advice caregivers should think before their trip.


• From the Changing Aging blog - "HealthPartners’ research foundation and the Center for Spirituality and Healing at the University of Minnesota are recruiting participants through the summer for a study that will seek better means of stress management for people who are caregivers to a family member with dementia. To learn more or sign up, contact Dana McGree at 952-967-5031 or dana.a.mcgree@healthpartners.com."
  


• The Boston Globe offers a review of a new release of 'hospice music':
  

  The title of classical guitarist Marcia Feldman's new CD, released June 17, is "Between the Worlds." Perhaps no idea could better sum up the unique realm that Feldman's music inhabits. She is a hospice musician - a performer who plays tunes to soothe the dying. The worlds she refers to in the CD's title are those of life and death, and her music is designed specifically to ease the transition from one to the other.
  
  It's an unusual niche, to be sure, but one in which the Dedham resident has long felt comfortable. Trained in classical guitar and jazz vocals at Berklee College of Music, Feldman first began thinking about the connection between death and music when she lost her father 20 years ago. "His situation did not involve hospice care; he died suddenly," she said. "But something about the process of grieving for him made me think increasingly about the role music plays at our most troubling times."



• This blog features posts about two family members diagnosed with cancer, the mother and brother of the writer. This post describes the conversation between the brother and his oncologist.
  

  After discussing Craig’s report, Dr. F. gently began asking Craig questions about his quality of life, including how he feels compared to six weeks ago; if he’s happy with the chemo results thus far; and if he feels satisfied with his quality of life. He asked these calmly, and in a way that shaded his own opinion from that of Craig’s. Craig answered every question, with each response growing labored from sheer exhaustion. He said that he felt more tired than six weeks ago, when he felt he was more on the mend. He seems most distressed about his fatigue, which has prevented him from doing the things he loves, like reading, writing, and playing music. He said he can muster energy to do short activities, but even those are difficult; talking has become another short activity. Still, he feels he’s satisfied with his life (so far) and would like to continue. If I know my brother, he won’t be the one to say stop.
  
  It broke my heart to hear him speak about his life, a life that was so vibrant and so full of promise just six months earlier. That he’s had to discuss his own treatment, and consider his own mortality less than one week after burying Mom seems particularly cruel. But there’s never a good time for such a discussion, and Dr. F. did it perfectly. He ended the discussion by saying that if C were to say that he no longer wanted to continue with the medicine, he would view it as a reasonable statement. He also added that he sees a lot of cancer patients, and that C seems to be fighting hard to be where he is. He noted that he had hoped C would be in a better position symptomatically, and though there’s still a chance he may turn the corner, Sorafenib hasn’t really helped C in terms of enhancing his energy.

Eldercare Notes

A few articles and blog posts touching on eldercare topics from the past few weeks:

• An article from The Tennessean discussing building an in-law suite as a way to provide care for aging relatives in your own home. It discusses the advantages of having elders close by, but still maintaining privacy among the immediate family members. Thanks to the Gen-Between blog for sharing.
  
• The New Old Age blog, from The New York Times, continues full steam ahead with posts discussing what reporter Jane Gross wishes she has done differently when caring for her aging mother, and a post about a documentary, "The Sandwich Generation," which is being hosted on the AARP webiste.
• The blog Tender Loving Eldercare has a post about the role reversal experienced between parents and children and asks readers to share their stories.

Certain Drugs Increase Risk of Falling Among Elderly

University of North Carolina researchers say some prescription drugs that increase the risk of falling among older patients. The medications include common seizure drugs, antidepressants, and painkillers.

Falls are the leading cause of both fatal and nonfatal injuries in adults 65 and older. An estimated 300,000 hip fractures occur each year, often as a result of falling. Head injury is also a problem among adults who fall.

Adults who take four or more medications at a time are at highest risk for falling. But certain types of drugs can also make someone more prone to falling, said Susan Blalock, an associate professor at the U.N.C. Eshelman School of Pharmacy.

The complete list is available as a PDF here.

Physical Functioning Better Predictor of Death than Disease Among Elderly

The July 2008 issue of the American Journal of Public Health includes a study that shows that in people 80 and older, limits on a person's physical functioning are a better predictor of death within five years, than the presence of chronic diseases. The researchers, from the San Francisco VA Medical Center, looked at data from 19,430 participants from an ongoing National Institute on Aging. For those aged 50 to 59, chronic disease conditions were better indicators of mortality than functional measures. In older participants, the results shifted and functional limitations, became a better predictor.

Sei Lee, MD, MAS, a geriatrics researcher and assistant adjunct professor at UCSF believes there are two possible causes of the change.

The first is what he calls “a selection or survival effect.” For a younger person, he explains, high blood pressure or diabetes “can be a very bad thing, with a likelihood of very bad consequences. But if you’re 80, and you’ve lived with high blood pressure for 30 years, it’s possible that it just doesn’t mean the same thing to you as it does to the average person –– that your body has adjusted to it in some way. And so it won’t have nearly as much bearing on your chances of living another five years as your ability to walk down the block unaided or manage your own medications without help.”

Another potential reason has to do with the “trajectory of decline among our oldest subjects,” he says. Younger people are more likely to have a clear single cause of decline, he says, such as a heart attack or pneumonia. Older people, by contrast, are more likely to decline slowly, not as a result of one catastrophic event but “slowly, month by month, week by week, for no clear reason that you can put your finger on. Functional measures are much more likely to capture that trajectory of decline.”

Lee notes that functional status is known to be an important component of quality of life for older people. “Most older patients will tell you that they are more afraid of losing their independence than they are of dying,” he says.

As a follow up to the current study, Lee says that “even though self-reporting is well-known to be a valid indicator of health status, it would make sense to replicate this work with a larger sample and an objective data set such as formal medical records.”

If his results are validated, he says, “I would strongly advocate that functional status become a standard component of medical records. It would be an important tool for policy makers, clinicians, and patients.”

Use of a Fake Bus Stop to Keep Alzheimer's Patients Safe

Interesting item about senior centers in Germany that began using fake bus stops to keep Alzheimer's disease patients from wandering off. The patients wait at the stop to be taken home, and can be calmed by being invited to stop in for coffee while waiting for the bus. From the article, it is not clear if the centers would fit the description of a senior center or a nursing home in the U.S., but the idea has worked so well it is being replicated at other centers in Germany.

Deciding Whether to Age in Place

The Washington Post on Tuesday published a two-part piece about aging in place (or not). The first, from Rita Zeidner described the apprehension she felt when her parents, approaching 80, decided to move out of their home and into a retirement community. The second was written by her mother, Sylvia Zeidner. The daughter said that it took a few months for her to come to terms with her parents' decision, while her mother's view was that she and her husband were happy to be able to make the decision themselves.

As I see it, aging gracefully requires coming to terms with the cards we're dealt. And that's where timing comes in. Sooner or later my husband and I were going to have to move out of our home for health reasons. Choosing the right time meant doing it on our terms, not someone else's.

Practicing Slow Medicine in the Elderly

Last week’s New York Times ran an article about a medical approach known as “slow medicine.” Reporter Jane Gross examined use of the approach, which is based on research developed at the Dartmouth Medical School, at a New Hampshire retirement community. Slow medicine “encourages physicians to put on the brakes when considering care that may have high risks and limited rewards for the elderly, and it educates patients and families how to push back against emergency room trips and hospitalizations designed for those with treatable illnesses, not the inevitable erosion of advanced age.”

The article noted that like hospice care, slow medicine offers a philosophy of comfort, rather than cure. The approach is becoming more common in nursing homes, but is rare for elderly living at home or in other types of assisted living.

Aging in Place in York County Pennsylvania

HFA wants offer our readers a glimpse into the lives of the myriad of professionals who assist hospice patients, grieving families, the elderly, and their caregivers. People across many disciplines work to help those who are aging, grieving, and dying. We asked Heidi Kimmel, who works for the York County Area Agency on Aging, to share information about the organization and her job responsibilities. Last week, we also featured a profile on Pamela Gabbay, Program Director of the Mourning Star Center for grieving children. Look for more of these profiles in the months ahead.

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Heidi Kimmel

The York County Area Agency on Aging (YCAAA) has been meeting the needs of older adults in York County, PA since 1975. York County’s older population is the second fastest growing county in Pennsylvania, serving over 86,800 people age 60 and over. My title at the YCAAA is Aging Care Manager II. I received my Bachelor’s in Social Work from Millersville University in 1999. I’ve worked with the aging population in Maryland and Pennsylvania since 2000, mostly in skilled nursing facilities as a social worker helping with admissions or discharges. I am currently working towards my Masters in Social Work. I enjoy working with the aging population because most of my consumers and their families are very pleasant and cooperative. They are usually very helpful in gathering information that is needed to complete assessments for care they need and are grateful for the care they receive. Many of our consumers are empowered enough to direct their own care through our agency, although some of our consumers’ families have stepped up to the plate to take charge of their loved ones’ care.

YCAAA arranges for eligible clients to receive family caregiver support, adult day care, public transportation, in-home personal care and medical supplies. Using a sliding scale payment system depending on income, consumers may have to pay for a minimal or no amount of these services. Cost sharing allows people within a certain poverty level to receive services they would not be able to afford otherwise. YCAAA offers other no-cost services, such as home delivered meals, ombudsman and legal services, a friendly visitor program, senior community center, and a waiver program which helps clients stay at home longer. Other programs provide counseling on Medicare and related health insurance issues, and offer pharmaceutical assistance.

The YCAAA employs over 60 staff to meet the needs of York County’s older adults. Most state AAA’s are county level government agencies, such as York County, but some county AAA’s in the state are privately owned and operated or are non-profit agencies. YCAAA has three different departments with their own unique focus. Care Management is the largest department comprised of staff who take initial referrals, protective service staff who investigate elder abuse/neglect cases, community health nurse, care managers and care manager supervisors. There is also an Administrative Services department and Program Development department.

The York County area is home to a lot of elderly citizens in their 80s and 90s and so their children may also be considered elderly, as they may be in their 60s and 70s. Sometimes it’s challenging for those children to support their parents as they are also battling chronic and acute medical conditions of their own. Often the grandchildren have to step in at that point. It’s rewarding to see families come together to be a competent support system for their loved ones, whether it be finding a way to keep their loved one at home safely or making financial and medical decisions for them when they are no longer able.

Care Managers who come to our agency right out of college say they enjoy working here because they like the agency’s focus on the elderly population. Some feel good about being able to educate and advocate for older adults during their times of bio-psycho-social health stresses. Some may feel they are detectives as it is challenging to find out what the consumer really needs from what little data they or their caregivers are able or willing to tell the care manager. Other care managers get a good feeling out of the reciprocal relationship they have with their consumers as they tell their life stories filled with joys and hardships.

YCAAA has a high percentage of personnel who have been with the agency for 10-20+ years. They say they enjoy working with our agency because it’s flexible and family-friendly to the employee. They like being able to see the difference our agency makes in our elderly population. Unlike other county programs where consumers are court-mandated to participate, our staff feel we have a different atmosphere because the consumers seek us out for our services that can provide noticeable differences in their lifestyle.

Upon contacting your local Agency on Aging, you may notice they provide similar and different services depending in which county or state you reside. But you will be surprised by the types of services the Federal, State and Local governments have arranged in support of your elderly population. If they’re unable to provide what you’re looking for, they may have names and numbers of other government, private or non-profit agencies that fit you or your elderly loved ones needs. To find your local Agency on Aging, use the federal government’s Eldercare Locator website, http://www.eldercare.gov

Heidi Kimmel

Local Pennsylvania Paper Writes Caregiving Series

This three-part series from the Bucks County Courier Times focuses on caring for someone with Alzheimer's disease and dementia, by sharing one family's experiences. In the first article, writer Jo Ciavaglia talks about how Marjorie Jackson first noticed her mother was developing dementia, and the changes it brought while still undiagnosed. Next, she describes the mounting tasks Jackson begins handling for her mother as her symptoms worsen. It also discusses care options in Pennsylvania. The final article, deals with Jackson's placing her mother into a nursing home and the emotional difficulties of the transition.

Bloggers Discuss Caregiving Challenges

There are a couple of recent personal blog posts we wanted to share this week. First, this post discusses a difficult issue faced by aging parents caring for an adult disabled son. The blogger writes of his brother, who has Muscular Dystrophy and has been in a wheelchair for many years. A recent fall has made the poster question how long his parents can continue to provide care and how hard it will be to have that conversation.

Scott is a full grown man, and he doesn’t have the strength to help when he needs to be transfered from his wheelchair to the bed, or the tub, or his easy chair my dad set up to help his legs rest. And my dad turns 65 this year.

Dad has always been a big bear of a man, but he wont be able to lift Scott forever. . . Even though he needs professional semi-skilled care . . .we might could come up with some arrangement where my brother could be cared for in our homes.

But my parents are stubborn people, and it may sound funny coming from a 43 year old, but I don’t want to disobey them. I think that deep down, all of us, parents and children, know that a day is coming when the two able-bodied sons are going to have to sit down with the parents and say, “No disrespect, but you’re going to have to let it go and let us take over”. But for now, we have instead, this uneasy silence where we sons know what we have to say, but we don’t say it.

I think it’s going to take Scott telling them to let the brothers take over. Ironically, they’ll listen to him.

Thanks to the GenBetween blog for sharing. The second post, part of Virginia Cornue's series of posts on sandwich caregiving, discusses the guilt associated with making decisions about where and how your parents will receive care, and the challenges faced by those caring for young children along with aging parents.

Of all her 11 siblings, my mother was the only one who was in institutional care at the end of her life. This is something I still have not entirely reconciled. This in one of those it's not the right thing to do--not the right way to treat your elders values I hold. But it was the only practical thing to do. . .

. . .If I had been truely a Sandwich Generation participant...if I had had to care for her long distance, AND take care of an infant, go to grad school--commuting an hour or more each way, and teach parttime, do my share of the domestic chores, maintain some sort of marital and social life, I think, NO I know, I would have had not only a nervous breakdown but a physical one as well. . .

. . .More than a decade later, I still miss her daily. Her last days at The Oaks were as good as they could be. She, my model joyolgist, told me scatological nursing home jokes to lighten my heart. But I--I still don't feel right about how her last days ended. My Mom, however, would say differently to me. As is on her gravestone, she would say to me, "Do your best, honey."

Did I? Yes--given the circumstances. I guess that's all we can do in the long run.

Changes Seen in Nursing Home Usage by Blacks

Tuesday's Orlando Sentinel published an article about the increased use of nursing homes in the black community, both in Florida and around the country. This is a changing trend. In the 1970s, blacks were half as likely as whites to be in nursing homes. Today, they are more likely to be.

The increase of blacks in nursing homes is largely because of Medicare and Medicaid funding changes in the 1980s and 1990s, Smith said. Under the new rules, hospitals were encouraged to discharge patients to nursing homes. But nursing homes received less funding for residents who didn't need skilled care.

The change led to a proliferation of private assisted-living facilities that attracted whites who could afford them. But blacks, who traditionally have lower incomes, less health insurance and smaller retirement incomes, often don't have that option -- and end up in nursing homes where their care is paid for by Medicaid.

The article also states that although it is less expensive to provide community-based care in the home, demand for those programs has outpaced funding, and many services have waiting lists.

Reminder: PBS Series Caring for Your Parents Airs Tonight

On PBS tonight, Caring for Your Parent - check local listings here. About the program:

As the population ages, many adult children are grappling with an unprecedented social, cultural, economic, and personal revolution as they transition into the primary caregiver role for their aging parents. Produced, written, and directed by award-winning filmmaker Michael Kirk, Caring for Your Parents is a moving two-hour special that draws much-needed attention to this universal reality.

The first 90-minutes of Caring for Your Parents underscores today's struggle to keep parents at home, tensions between siblings, and the complexity of shifting caregiver roles through an intimate look at five American families. In the end, the documentary contends successful caregiving requires one primary ingredient‒love.

Immediately after the 90-minute broadcast, medical correspondent Dr. Art Ulene leads "A Conversation About Caring." This half-hour panel discussion offers concrete advice and guidance on how to start the conversation‒often the most difficult step in caregiving.

Caring for Your Parents is a Kirk Documentary Group, Ltd. Production for WGBH Boston. The executive producer is Laurie Donnelly. Major funding is provided by Harrah's Foundation. Additional funding by the Corporation for Public Broadcasting, a private corporation funded by the American people.

Cornell University's Aging Research Translator

The Aging Research Translator offers ". . .non-technical summaries of aging research published in peer-reviewed academic journals."

The ART website has been designed with community-based practitioners in mind. Community-based practitioners are the largest group of potential users of aging-related research, and the people most likely to apply the aging knowledge-base to the lives of real people. However, the location of research in university libraries and databases makes it difficult to access. Furthermore, the overly technical language of research articles can be an impediment. The ART website, developed by Cornell University researchers, attempts to address these challenges by posting summaries of aging research literature using non-technical language.

Thanks to Laurie Blanchard's long-term care blog for sharing this site.

GAO Report on Medicare Advantage Plans

The GAO recently published a report comparing traditional Medicare to Medicare Advantage plans (offered by private insurers.) U.S. News & World Report offers a synopsis of the report here. The original GAO report on Medicare Advantage, "Medicare Advantage: Increased Spending Relative to Medicare Fee-for-Service May Not Always Reduce Beneficiary Out-of-Pocket Costs," is available as a PDF.

New Emphasis on Treating the Elderly in Medical Schools

The Boston Globe reports that medical schools across the United States are increasing the focus on treating older patients. The article talks specifically about the programs at Brown University, Harvard, and UMass. From the article:

"By 2030, Americans age 65 and older are expected to account for about 20 percent of the nation's population, up from 12 percent now. Grants from two foundations and the Association of American Medical Colleges, awarded over the last eight years, have fueled the curriculum changes to meet the expected need for geriatric expertise."

The Impact of Depression on Treating Older Adults

We read two more articles of note from the January 2008 issue of the CDC's Preventing Chronic Disease journal, which address the impact of depression on the health of seniors. The first gives an overall view of the public health issues.

"Although public health is often conceptualized only as the prevention of physical illness, recent data suggest that mental illnesses are increasingly relevant to the mission of disease prevention and health promotion. Projections are that by 2020, depression will be second only to heart disease in its contribution to the global burden of disease as measured by disability-adjusted life years. Also, as the population ages, successive cohorts of older adults will account for increasingly larger segments of the U.S. population. We present the diagnostic criteria for, prevalence of, and risk factors for depressive disorders among older adults; the challenges of recognizing and treating depression in this population; the cost-effectiveness of relevant public health interventions; and the public health implications of these disorders."

The second looks more specifically at the challenges of treating depression in seniors.

"Depression is increasingly recognized as a significant public health problem among older adults. Because the condition is highly treatable and currently undertreated among community-based older adults, late-life depression is an appropriate focus for disease prevention programs. We report findings from a recent project to review the scientific literature for published reports about treatment for depression among community-dwelling older adults and to recommend the interventions with proven effectiveness. We also summarize the research findings related to each recommended intervention and describe the elements of each. To show the difficulties involved in translating research into practice, we describe real-world experiences in implementing these evidence-based interventions in various community settings. Because depression among older people is viewed more and more as a public health problem, we suggest that partnerships of providers, patients, and policy makers be forged to overcome challenges related to funding, training, and implementing treatments for this condition."

How Elders and Adult Children Discuss End-of-Life Preferences

This study appearing in the January 2008 issue of the CDC's Preventing Chronic Disease examines how adult children and elderly parents discuss end-of-life issues. Two researchers from the University of Georgia interviewed two groups, 15 older adults and 15 younger adults. The researches looked to answer the following questions.

1. How do elders express their EOLPP [end-of-life preparation and preferences] to their children?
2. Are their children receptive?
3. What are the barriers to this exchange of information?
4. What facilitates these discussions?
5. What differences emerge from examining the older and younger adults’ responses separately?
   

One of the research team's conclusions is that there is potential for health care and public health professionals to facilitate the dicussion about end-of-life preferences. They feel that this is a public health issue and offer the study as an initial step in understanding how children and their elderly parents approach the topic of dying.

New Study Examines Caregiving Among Gay Seniors

A study from the Journal of Gay & Lesbian Social Services questioned 199 lesbian, gay, and bisexual adults aged 40-85 about their history of giving and receiving care. The researchers from New York University and Pennsylvania State University, found that older gay adults create networks of caregivers to help support each other as they age. An excerpt from the article:

“These findings contradict old myths about elderly gay people leading lonely lives of quiet desperation,” said Dr. Robert-Jay Green, executive director of the Rockway Institute, a national center for LGBT research and public policy. “LGB seniors create vibrant communities of care that overcome the difficulties posed by discrimination or by greater levels of rejection from their biological families.”

Juggling Work and Elder Care

This article, originally appearing in the Investor's Business Daily, discusses how companies are handling elder care issues as more and more employees need to care for aging relatives. Offering flex time, referral services, and help lines are some examples of how businesses are managing.

During the Holidays, Check on Your Elderly Relatives and Friends

Here is a list of straight-forward, practical things to check for when visiting your aging family members and friends during the holiday season (from the blog, Taking Care of Mom at Home.)

Recent Court Decision Could Change Eldercare Options For Some in Maryland

The Baltimore Sun (Dec. 10) reports on a ruling by the Maryland Court of Special Appeals, stating that the state's standards for patients' inclusion in a Medicaid program were stricter than is allowed under federal law. The program is for designed to assist poorer seniors receive care in their homes or communities. An elderly woman daughter, whose mother had been turned down by the prgram, sued the state with the help of AARP and the Maryland Legal Aid Bureau. In Maryland, half the program is paid by the state, half by the federal government. Poorer states pay a lesser share of the costs. Only three states have waiting lists for the program, and Maryland's was the longest.

Eldercare and the Work/Life Balance

The New York Times Shifting Careers blog posted an interview with author Cali Williams Yost. Ms. Yost is a consultant on workplace flexibility, and offers some advice on preparing for eldercare issues.

Costs of Providing Elder Care Are Higher Than Previously Thought

The New York Times reports on the first in-depth study of the expenses Americans spend to care for aging parents or spouses. The study, conducted by the National Alliance for Caregiving, says those costs average $5,531 per year. According to the article, the report is being released today and will be part of a Capitol Hill briefing this week. The complete report (PDF) is available here.

Planning for Long-Term Care: With or Without the Help of Children

U.S. News & World Report offers this interview with author Alexis Abramson about how children can work with their parents to plan for eldercare, and the importance of an open dialogue.

What if you need to plan for your care and you do not have children? This article from The Seattle Times gives some good advice on finding professionals who can help.

New Social Networking Sites Cater to Caregivers

The New York Times (9/12/07) highlights the growth of social networking sites that cater to users older than the users of typical social networking sites such as Facebook and MySpace. These networking sites allow people to connect with others in their generation, share interests, and remain active.

Other websites help family members assisting aging loved ones. AGIS (AssistGuide Information Service) has a new website for family members looking for information and assistance with eldercare and other issues. The AGIS forums discuss topics such as caregiving, grief, Alzheimer's and dementia, and much more. These new websites address an aging population in two ways: by empowering seniors through social networking, and by assisting families in meeting the needs of their aging family members.