Geriatric Care Managers

Lately I noticed several people who have decided they are geriatric care managers, mostly based on their experiences with their own parents. They advertise as experts in caregiving or care management, and purport to help families find appropriate care for their aging loved ones.

This is extremely disturbing. The number of caregivers in the work place is sky rocketing, and will continue to grow.  Working caregivers, those with aging relatives, desperately need help. Many of them refuse promotions, reduce their work hours, or quit working altogether to take care of their frail family member. This will have a negative impact on their retirement years, as they will have less in savings, less in an IRA, and less Social Security income.

Currently the federal government is trying to reduce reimbursement for medical care by tinkering with Medicare, and many states are reducing what they pay for Medicaid. Options for eldercare are becoming scarce.  Families need real assistance with a wide range of age-related issues. They need hard information, not based on one person’s experience with their own  parents, but based on academic study of aging, continuing education in the field of aging, and years of experience with various types of age-related problems and situations.

I am a Professional Geriatric Care Manager. I hold a Master’s degree, I am licensed as a Professional Counselor, I am a Certified Gerontological Counselor, and I am a Care Manager, Certified. I have been in private practice since 1996, a member of the National Association of Professional Geriatric Care Managers since 1994, and started an internship in the field of geriatrics in 1989. There are only about 2,000 members of the professional organization (NAPGCM), http://www.caremanager.org. It is a growing field. We have already required credentialing of our members, and are working for more recognition of the profession, so that caregiving families will know where to turn for advice to real problems based on practical experience mixed with evidence based training.

The next time you are approached by someone who claims to be a geriatric care manager, ask about their credentials. It could make a difference in the quality of information you receive.

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Early Caregiving

My daughter had a relatively minor wrist surgery, and I went to stay with her for a few days during her initial recovery. The episode reminded me of the time I went to stay with my mother after she fell and broke her arm. This type of initially brief caregiving is often the way years of caregiving for an older relative begin, following a fall or surgery.

My daughter is a single mother with 2 young, very active, children. After her surgery, she needed help getting them off to school and picking them up while she could not drive, with meal preparation, and getting them to bed. She also needed prescriptions picked up, grocery shopping, help with getting dressed and bathing, and housekeeping and laundry done. When I left her house at the end of the week, I was guilt ridden. Me?! An experienced counselor of caregivers and staunch adversary of the guilt too often associated with caregiving. What happened?

My care receiver had ongoing care issues: no matter how much laundry I washed, there was more to be done. While her body healed, she would continue to have difficulty driving, getting the kids to school and herself to work; grocery shopping, meal preparation and meal clean ups would be challenging. The good part about this caregiving episode was that my daughter is young and will continue to improve and regain function, as opposed to older care receivers that may never recover. I, as her caregiver, felt guilty because of the obstacles she faced.

I realized anew what caregivers have learned: No matter how much you do, there is always more left that needs doing. At some point, caregivers must return to some parts of their own lives and leave their care receiver to cope, at least partially, with their losses. We cannot live someone else’s life, nor completely solve their problems. We can assist with physical losses and we can support them emotionally.

The solution to my guilt was to delegate. By the time I left her house, we had found rides to and from school for her kids, a co-worker would take her to work, I helped her grocery shop weekly, a neighbor prepared meals, and I continued to drive her to follow up medical appointments until she was okay to drive. Long time caregivers may find this helpful, too. During long term caregiving, it is imperative to “preserve the caregiver”, the caregiver must last as long as the care receiver. But as time goes by, the caregiver gets tired, no matter their good intentions. One way of coping is to identify resources that can assist with meeting care needs. A smart caregiver is not afraid to ask for help, and welcomes offers of assistance.

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Christmas with Dementia

Christmas with Dementia

Most types of dementia involve memory loss. This is probably the most frustrating part of caring for someone in the early stages, the constant repetitive questions and the surprising forgetting of what was just done or said. People with dementia may forget that the Christmas tree is up and be startled every time they see it. They wonder why the caregiver is changing their environment by adding decorations or cooking different foods. Unfortunately this seasonal changing of the environment and altering of familiar daily routine presents a difficult challenge to the person with dementia. They are most comfortable with everything being the same; the daily structure helps them feel secure and helps them cope with their cognitive losses.

At Christmas the caregiver wants to put up decorations, go to holiday meetings, wrap gifts, address cards and participate in familiar traditional holiday activities. To the person with dementia, these represent change from the routine and are can be very threatening . Some sort of holiday truce needs to be negotiated between care giver and care receiver.

Explanations should be offered only once. When the same question is asked repetitively, it indicates the dementia patient cannot cope with the answer; it doesn’t make sense to them.  After answering the question once, the practical caregiver might switch to a different type of response. One is to ask the care receiver something, such as ‘Which bow do you like best?’ or ‘Should this ornament go here or there?’ Another is to engage the care receiver in an activity. Ask them to help replace ribbon on a bolt or put stamps on cards.

One of my favorite leisure activities is coloring. Dover Publications has colorbooks printed on see-through paper (like thick tissue). Once colored, these can be placed on windows for a stained glass effect. In fact, they are called Stained Glass Coloring Books. (www.doverpublications.com) They have several different books with holiday themes, including Christmas, Easter and Halloween. This activity elevates a childhood familiar activity to an adult activity that can be displayed along with other decorations, or mailed to friends as gifts. I have some that are more than 25 years old, carefully saved from year to year.

Other holiday ideas are to cover styrofoam balls with nutmegs or colored pins, or put sprinkles on cookies, or shell nuts. Place a container with Christmas treats in areas that have been altered to make room for decorations, and let your care receiver have one whenever they go into that area. Care receivers must make concessions. You will probably not do everything you once did. But, in return, you will do some different things that might give the same pleasure.

While people with dementia have memory loss, they do not lose their capacity for emotions. They are particularly sensitive to their caregiver’s emotions. They may not appreciate the effort expended in decorations and baking, but they will definitely react negatively to their caregiver’s stress. The best gift you can give your care receiver, and the best for the caregiver, too, may be to eliminate many of the holiday-must-do’s, keep your stress level low, and enjoy hot chocolate and holiday music with your loved one.

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When Mom & Dad can no longer live at home

Since I work with ElderCare daily, I forget that most ordinary folk are unfamiliar with its challenges.  Most of us ignore articles about subjects that have no interest for us, like nursing home care or the cost of long term care. Once YOUR parent has a crisis, you develop a definite interest but don’t know where to go for information.  I’m starting a series of blogs about what you need to know when looking for Long Term Care (LTC). You can find plenty more information on my website, www.kaypaggi.com.

All too often the first sign of the impending need for LTC  is a medical crisis. A parent gets a poor diagnosis from a doctor, or falls and has surgery, or suffers a stroke. Until then, you and your parent happily ignore their accumulating years and continue with your lives as you have in the past. With this first crisis, your family is forced to realize some grim realities.  You need some information, fast!

Older adults who have been hospitalized due to a stroke or surgery can regain strength and mobility by short stays in rehab. I highly recommend that everyone age 75 and older go for a short stay in rehab before returning home after a hospitalization of more than 3 or 4 days. If they were sick enough to need to be hospitalized, they will have lost body strength during the days in the hospital. The therapists in rehab will help them regain function so they can return home safely.

Many older patients refuse this extra assistance because they want to go home.  They are frightened by the thought of going to a ‘nursing home.’ The percentage of older adults that are re-hospitalized after going home directly is appallingly high. Avoid this unnecessary second trip to the hospital by spending a few days in your friendly local rehab. You may have to request a rehab stay from your hospital physician; their job may be to keep costs down rather than to keep the patients safe following discharge.

Medicare does not pay for long term care. It is medical insurance, and good insurance at that. If your care receiver doesn’t have it, switch! But that’s going to be a future blog. Medicare does pay for some short term care in a rehabilitation facility. There are two types of rehab. One is a rehab-only facility, where treatment is fast paced and the stays are short, numbered in days, not weeks. The other is done in nursing communities.

Usually the hospital discharge worker gives the family a booklet and tells them to choose a facility. The family sometimes chooses the closest place to home, or the place that was used by a friend or relative in the past. A better solution is to use the Medicare.gov website.

From the main page, go to Facilities and Doctors, click on Compare Nursing Homes, and enter your area of the country. Here you can check on facilities by name, zip code, city or county. medicare uses a 5-star rating system, like the one used to rate hotels.

I warn you that Medicare is not always accurate. First, the ratings are done by people, who have differing opinions. 2nd, the criteria are not necessarily the same as the ones you might use. Last, Medicare is not updated often, so the staffing or ownership can change without the changes being reflected online. Use the Medicare site as a guideline, a starting point, not a decision maker. You still need to actually visit 2 or 3 facilities., and you must do this quickly while your care receiver is still in the hospital, so you can make arrangements for transfer when the elder is discharged.

One of the most important areas in determining quality of care is Staffing. It is also an area that is broken out in the ratings, so you can see the number of stars for Staffing. Possibly the most frequent complaint from patients in a facility is the length of wait time from the time they press the call button until someone comes to help. This is reflected in the Staffing rating. In order to go into a facility that has a higher staff-to-patient ratio, you may have to opt for a facility that is further from home. The average annual turnover rate in this industry is 300%. When you visit, ask how long the aides and CNA’s have worked there, or what their turnover rate is. The best facilities have staff members that have been there the longest.

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Waiting for Death

None of us leave this life alive; we all experience death. I am frustrated when I read an article about how a medical intervention “saves lives.” No intervention yet has saved anyone from dying; we all die. What medical interventions do is postpone death.

The process of dying differs from person to person. Most people want death to be as painless as possible, and their loved ones and caregivers do everything in their power to make it so. Knowing someone you love is dying is intensely frustrating. That is probably why so few people enroll in a hospice program. It may be comforting to the doctor and the family to feel like they are doing something, even if futile, to prevent (postpone) the dying.

My dog is 14 years old. In people time, she is about 100. She doesn’t see well, she doesn’t hear well, she doesn’t move around well. In the past 2 weeks, she has pretty much stopped eating and developed a limp; she moans when I pick her up. I know what is coming. I am a geriatric care manager. My clients are old, and I have been with them as they died. I know what is happening to them is happening to her. But knowing is different from experiencing it firsthand, around the clock, with a loved one, even a dog.

Against my own professional advice, I took my dog to the vet. I know there is nothing to be done. But I was hoping for a reprieve, a magic pill that would give me another few months with my furry friend. The vet, like most doctors, rose to the request for help. She started the dog on antibiotics, saying, “This dog is old; she probably has an infection somewhere.” She gave me appetite stimulant pills, pain pills, and steriods. All of these had to be forced down the poor dog’s throat, as she struggled against this invasion of her body. In spite of my best efforts, she refuses ice cream, turkey, baby food. The body shuts down as it dies, and she is not hungry. Eating, and the antibiotics, give her diarrhea.

I have made my peace. The medical interventions are gone. I cuddle her, I tell her I love her, I carry her outside and wash soiled towels. And I wait. Waiting for death is intensely frustrating and sad and necessary and loving.

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Invisible in the Nursing Home

Yesterday I took one of my clients to a new nursing community. It was a jarring experience for me. Thankfully, my client was pleased with the appearance and comfort of the new place. The stressors belonged to the caregiver, care provider, in this case, me.

I got there early to complete paperwork for the transfer from one place to another. The person I needed to talk to was in a meeting. I waited an hour and a half to find out that she had completed most of it herself, and sent it off to the family for a signature, so she did not need to see me, after all. My client is a DNR. Somehow the paperwork for that did not make the transfer; I was told to speak with the social worker. Nevermind, she is in a meeting. I was given a menu to fill out for my client, who is perfectly capable of reading and circling food items. No one had asked him. The client needs ongoing therapy to strengthen legs and arms. He needed to be evaluated by the therapy staff. They were busy; they would do it when they had time.

The client went happily off to lunch. I went to my office and steamed. Now I have experienced what client families have been telling me about for years. Other than sit with my client and watch to make sure that he was not excluded from anything, I was useless until the appropriate staff person decided to talk to me.

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