As a geriatric care manager  I have recognized  there are certain practice principles that are essential in my work. I was not aware of these teachings when I started my practice. But different scenarios have presented themselves again and again with these insights coming to the forefront regularly. I share them with you and hope you can incorporate them as you approach those you care about.

 1. SEE YOUR PARENTS IN THEIR PAST ROLES

They had a profession, proudly served in a world war, were little league coaches, won awards for their paintings, led Girl Scout Troops, volunteered, played the organ at the church, lived through the Great Depression. They have lost many of these roles, often without their consent. Sometimes this makes them angry and depressed. Guess who gets the brunt?

 2. WALK IN YOUR PARENTS SHOES

Three years ago the wheels they knew were on their car. Now those wheels are on a wheelchair which they may not even be able to maneuver by themselves.

 3. DON'T TALK IN FRONT OF YOUR PARENTS 

Don't assume your parents can't hear or don't understand what you are saying about them.  If you don't want them to hear something step into another room. How terrifying would it be for any of us to hear unpleasant news, understand it, and not be able to reply?

 4. REMOVE PRONOUNS WHEN YOU SPEAK OF YOUR PARENTS

 Repeatedly, I hear seniors referred to as "he" or "she". Mom is sitting across from the doctor, and it is as though she is not there. I have never heard of an illness that makes people invisible. When an older adult is in the presence of others, nouns and proper nouns give them the respect and dignity they deserve.

 5. IF YOUR PARENT DOESN'T THINK SHE HAS A PROBLEM OR IF HE KNOWS HE HAS A PROBLEM AND DOESN'T WANT TO CHANGE:

 1. It becomes your problem to figure out how YOU are going to deal with it.

 2. If they are not compelled to change, time will bring a solution, usually triggered by a catastrophic event. Sorry.

My learning journey as a geriatric care manager continues. The Quotable Teacher, says it best:  "For many learning is a spiral, where important themes are visited again and again, each time at a deeper, more penetrating level."

Recently, a daughter requested that, as an elder care consultant, I do a geriatric assessment of  her father. With a brief pause and a lowering of her voice, she asked that when I do the eldercare evaluation I streamline my time. See her father and give her a call regarding my observations and recommendations. No written report or putting resources into place. A single woman, she had been out of work for almost two years. I understood.

I did what she requested. Afterwards, I thought to myself, what would happen if she was offered a job in Texas or London and had to choose between leaving Westchester County, New York and her father or taking the job?  When opportunity knocks, there is a way to accept a new job offer and have the peace of mind of knowing the needs of mom and dad are addressed. Enter the professional geriatric care manager.

This profession started over 30 years ago as older adults transitioned from points north to warmer climates. Adult children were now at a distance from their aging parents. With these moves there were urgent calls from a mother  saying that dad had fallen. Or a call from the police informing an adult child that mom had driven thirty miles past her home and was disoriented as she weaved between lanes on the thruway.

With time, professional geriatric care management has expanded. Here in Westchester County, New York, as a geriatric care manager, I assist older adults who have chosen to remain, yes, in colder climates, in homes they have lived in for a life time. Accompanying parents to doctors' appointments, making sure there is food in the refrigerator, hiring and supervising caregivers, getting the "2AM call," seeing that the snow gets shoveled, buying an occasional refrigerator and  being the liaison to adult children who are living in the United States or abroad. These are all parts of my job description.

As a geriatric care manager, my weekly schedule takes me to a nursing home in New Rochelle, NY, my home base. The client I visit fought me vigorously the initial year she was there. She complained about being with "the crazies."  She told me about her idea of having zones at the nursing home that would separate the crazies from, well; I guess you would call the "non-crazies."  Except on rare occasions, time has deleted this idea from her mind.

Now more settled in the nursing home, I visit Evelyn a couple of times each week.  Last week, as I entered  the nursing home, and before I got to her room, I walked by a group of residents, most of them in wheelchairs.  As I passed them, I said "Hello." I didn't know any of them. But I knew why I said this.

I learned to say "Hello" many years ago from a seasoned social worker. The woman had spent years in the field of geriatrics. I was a newbie. Being with her was like; well... if I were a novice chef, it was learning to cook with Julia. If I wanted to discover the true meaning of love and compassion, it was like sitting with the Dalai Lama.  To me, she was the real thing.

What has stayed with me for more than two decades is what she astutely pointed out in a workshop she was conducting. The nursing home is the HOME of these residents.  As you would walk into anyone's  home you would say, "Hello and good-bye."  The nursing home is no different.

When I entered Evelyn's room I said, "Hello." When I left Evelyn, I said "good-bye." She was then  in the dining room along with approximately twelve other residents having dinner.  Reminiscent of  Richard Nixon's final salute, I reached the exit door, turned around, waved and, in a heightened voice, said "good night everybody."  Unfortunately, there is never much interaction going on at the small dining tables at which they sit. But my "good-night" prompted the residents to lift their heads and reply "good night."  Wouldn't you say the same if you were leaving someone's home?   

Thanks to the  teachings of a long ago mentor, this geriatric care manager was taught the very basics of good manners and basic kindness. And so I say "thank-you" to her. Wouldn't you say the same for a gift you have received?

As a geriatric care manager, I make regular visits throughout Westchester County, New York to those of my clients who reside in a nursing home or assisted living residence.  In this particular situation, after my nursing home visit, I followed up with an email to the family.

 I sent the email to Ruth's niece. Among other things, I told Janet her aunt remembers me vividly.  She recalls me as someone who was a part of her life when she lived in her Westchester apartment. So as sure as thunder follows lightening, whenever she sees me, she asks "when am I going home?"  A logical question. If I put her there, I can take her out.

 The truth is, neither her niece nor I am taking Ruth out of the nursing home. So when the questions start about her homecoming I must answer, with varying degrees of truth. Some speak the genuine truth others go around the truth and some are just therapeutic lies, otherwise known as "fiblets."  Whatever I say, Ruth forgets. She only remembers she wants to go home.

I have questioned  the social worker at the nursing home. Does Ruth ask them when she is going home? Negative. I'm the one who gets the interrogation. Not even with a mouth full of pizza, that I've brought her, will she stop asking me about going home to Pleasantville, New York. No, I did not make the name up for one to think there are magical qualities about this village that would warrant reconsidering our decision.

 When I left the nursing home, I could hear the aide trying to comfort Ruth. I asked her to be in the room so I could leave and Ruth would not be alone in her misery. It was an unpleasant ending.

 As a geriatric care manager I can intellectualize situations so as not to let my emotions override doing what is best for my clients.  I know it isn't safe for Ruth to be at home anymore. This is indisputable. What is debatable,  is whether, for the moment, my visits are helpful, even with two slices of pepperoni pizza. Maybe Ruth has to forget me before I can come back. I just don't know.

As both an elder care consultant and geriatric care manager, when I counsel adult children, I often ask them to see their parents in an historical context. Most often this relates to money. Specifically, I remind sons and daughters that their parents are products of the Depression. Their resistance and fear of spending money are grounded in the 1930's and follow them to this very day. An example: A client of long ago had an art collection worth many millions of dollars. I saw more Winslow Homers and Mary Cassatts in her home than chairs to sit in. Yet, when it came time to take a taxi from her Rye, New York home, here in Westchester County, to her grandson's birthday party in Pelham, New York, a ride of approximately 25 minutes, she refused to pay for a cab. It would be too expensive. The solution was that I put the cost of the cab ride on my credit card, and she handed the driver $10, thinking that was the cost (tip included) of the trip, when in reality it was just the tip.

The concept of historical context was again brought to me through the courtesy of You Tube. On the day prior to Thanksgiving, a high school classmate sent me an educational film produced in 1939. The goal of the cinematic verity was to teach children how to participate in a responsible manner in the preparation of the Thanksgiving feast.  Yes, it was humorous, but I was also seeing what was expected of children who were then around 10 years old and now, according to my calculations, in their early 80's.

As an elder care consultant, I can't say I have ever had to counsel a senior about his or her disappointment in their adult child reaching across the table for the drumstick or using the wrong fork for the salad. However, in the world of elder care, I will say I have a heightened understanding of the expectations of a time gone by.  And, I am appreciative of the culinary advances that have taken place since 1939. Perhaps those kids could have considered a meat thermometer for Mothers Day 1940.  That turkey looked way overcooked.

And now, on with the Happy Thanksgiving show:

http://www.youtube.com/watch?v=bW2uf2mNJ5Y

As a geriatric care manager, there are certain older adults who have been my clients for years. The longevity of the relationship has given me a baseline of what "their normal" is. I combine this with the observations of their caregivers and I have a pretty good idea of how they are doing. However, this combined concrete and intuitive knowing, becomes more challenging when a senior adult has dementia and is not able to verbalize how they are feeling.

To determine if an older adult is in pain, it becomes a more sensorial evaluation that I find myself doing. Partners Against Pain (www.partnersagainstpain.com) has outlined some indicators that something is not right:

Facial Expressions: Frowning, keeping one's eyes closed, blinking rapidly

Verbalizations/Vocalizations: Moaning, groaning, breathing nosily

Body Movements: Rigid or tense posture, fidgeting, gait or mobility changes

Behavioral Changes: Refusing food, stopping common routine, a change in the sleep/rest periods

Mental Status Changes: increased confusion and irritability

To try and localize where the pain is, it is best to observe when the above mentioned symptoms occur. Is it when an older adult is moving or when there is no movement? I also find it helpful to speak with the home health aide, especially if they are with the older adult on a daily basis. While the reasons for the pain can be many, I have found one of the most frequent causes for discomfort and pain to be constipation. For this reason, it is important that daily records be kept.

It's confession time. This elder care consultant tells lies. Why? Because I have to ensure the safety of  some of the older adults I help, while  lessening the anxiety of other seniors. This is especially true of those with dementia. My lies are called "fiblets" or "therapeutic lies."  "Thera" means to help. And that is the express purpose of these lies. Let me tell you about three of them.

Fiblet #1. Janet had one brother who lived in England. He died about ten years ago.  Janet has dementia. She had forgotten her brother had passed away. She asked if I would call him, maybe he would come and visit her. Would I tell her that  her brother passed away ten years ago and cause her the pain of hearing this "for the first time?" Of course not.  I told her Hans was on a business trip and would call once he returned. She took comfort in my answer and looked forward to his call.

Fiblet #2. Patricia had married at age 17. Her husband was considerably older and had taken care of everything. He died suddenly.  Her daughter contacted me shortly after his death. "Would you please teach my mother how to pay her bills?  She can never know that I am paying you to do this."  So we decided to tell Patricia Medicare was paying for my services (Medicare does not).  I met with Patricia three times. She was starting to get the hang of things and was so proud of herself, that she started telling her friends about this free Medicare service.  Fiblet goes frightfully wrong!  What was I going to say?  The story had a bittersweet ending. Patricia died seven weeks after her husband, but with the new confidence that she could pay her own bills.

Fiblet #3. Pauline had not left her home in over a year. With dementia, she felt safest in her apartment. Her brother consulted with me. How do I get my sister to move into an assisted living facility?  The following fiblet was successfully brought to fruition. A letter was formulated  to Pauline by moi, informing her there was a gas leak in the apartment house and that all tenants had to temporarily evacuate and would be housed in a local hotel, free of charge, until the condition was rectified. As the elder care consultant, I was assisted by personnel from the assisted living residence.  On the designated day, they picked up Pauline and brought her to the "hotel."

Truth. Within weeks Pauline got herself a boyfriend. She lived at the residence for over three years, never once asking when that gas leak would be repaired.

The call came early last weekend. Gwenn, who is usually talking in the here, the before and the future ( she wants to move to her ex husband's nursing home) was silent.  She was not responding to anything that was being said to her. As the nursing home orders dictate, "call the geriatric care manager for any emergencies," I was contacted. "We are sending Mrs. McCann to the hospital."

I took my folder with all of her vital information and was off to the hospital. They were right, Gwenn was silent. Until I arrived, all the hospital knew about her could be found on their electronic records and the documents the nursing home sent over. Gwenn lay on the gurney, helpless and vulnerable.  Hospitals and old people are not a good match.

We were lucky, it wasn't a busy morning in the ER. Blood work, a catheter inserted and an intravenous hook up happened pretty quickly.  Given the loud groans that came with an abdominal examination, a surgeon was called. Surgery as one is approaching a century of living, bothered me.  But first it was a CAT scan of her pelvis that they needed to do. "Are you sure you have to do this?" I asked. They were insistent. I contacted Gwenn's health care agents, informed them of her status, and they gave the consent. Waiting at the entry to the room where the CAT scan would be done, I decided to check the papers that accompanied Gwenn on the gurney. The papers had someone else's name and it was for an ultrasound of the abdomen....pregnancy problems. I pushed her back into the main ER room. Corrections and apologies followed and the procedure was done.

Gwenn was diagnosed with a severe urinary tract infection and was admitted to the hospital.  I accompanied her upstairs and reviewed with the charge nurse Gwenn's records.  I made sure she had a copy of Gwenn's health care proxy and  my number.  How strange it was to leave Gwenn without her reciprocal  reply to my, "Auf Wiedersehen." But I left the hospital knowing  I had done what a geriatric care manager is called upon to do...be the voice for the helpless, letting all around her know there is a vital person inside her silent exterior.

This geriatric care manager always wanted a sister, preferabably older. But, it was not meant to be. Instead, I have a wonderful younger brother.  Despite my unfulfilled wish, my status, if in name only, changed a little less than a year ago.

It began with a telephone call. A daughter, an only child, was at a loss as to how to help her elderly father. His answer to any of her well meaning suggestions, was "I'm fine." No amount of falls, forgetting to take medications or fender benders, would change his mind.  With no brothers or sisters, she looked to me, a geriatric care manager, for guidance.  "You've seen it all, how should I deal with my father?"

While I haven't "seen it all," I do know that being an only child in a care giver role can often be lonely. You do not have a sibling to turn to for  help, support or guidance . Guilt is prevalent because if something goes wrong, you know there is only one person to blame. There's mega physical exhaustion. Calls at all hours. You arrive home from accompanying dad to a doctor's appointment, only to turn back when a fall triggers an emergency visit to the hospital. Conversely, being an only child, you avoid the conflicts and disagreements about how best to care for dad. You can make choices without having to consult with siblings. There is  one vote... yours. No squabbles about who the co-signer will be at the bank.

But getting back to my status change. During the months that passed,  I provided the daughter with counseling, an empathetic ear and  reputable resources. All things a geriatric care manager does. One day, when her father was in the hospital, she called me with an update. She sounded exhausted and scared. I said to her I recognize how hard it is not to have a brother or sister at this time. "But, I do have a sister," she said to me. "I don't feel alone when I speak to you, I sleep better at night knowing that the decisions I am making are the right ones." So, in that moment, my wish came true. I have always said the role of a geriatric care manager brings with it many gifts. This is one I am not returning.

Here in Westchester County, New York, where my elder care consultation and care management practice is based, last month there was a  missing person's  alert for a woman with Alzheimer's Disease. One of her two daughter's stated, "I just want my mother back." 

Unfortunately this earnest and tearful request did not bring the hoped for result. A month after leaving the home she shared with one of  her daughter's, Betty Iannarelli's body was found.  Her daughters were loving and responsible caregivers. They had taken steps to insure their mother's safety should this very scenario happen.  She wore a medic alert bracelet with her name, medical and contact information. But this was not enough.  Her body was found near her home in Irvington, New York. The area, while remote, was in a  in a suburban part of Westchester County.

To prevent this tragic outcome from occurring to others, technology has stepped forward with Project Lifesaver.  Project Lifesaver works through a radio-frequency bracelet that the person with dementia wears. According to their web site, www.projectlifesaver.org, the hand or ankle bracelet emits a tracking signal.  Once the family or  caregiver realizes  the person is missing, a call is made to the Project Lifesaver number and an emergency team responds to the area from which the signal is received. The web site states that within 30 minutes from time of notification, the person is found.

In Westchester County, the service of Project Lifesaver is free. Additional information can be obtained by going to www.westchestergov.com. Go to senior programs and services, click on Project Lifesaver. For others beyond Westchester County, New York, contact your local Alzheimer's Association, Area Agency on Aging, or Project Lifesaver directly. 

"I don't know how you do the work you do." These very words were spoken to this geriatric care manager, a few months ago, when I accompanied an older adult to see her oncologist in White Plains, New York. Talk about doing the work you do.  He wasn't exactly working in a chocolate shop helping customers decide between nougats or truffles, dark chocolate or milk chocolate. In the next few minutes, I understood the reason for his comment. He told me about the frustrations he was facing with his father.

So why is it that certain of us in the field of elder care choose this profession and really like it?  In fact, some of us have a passion for it.  Recently, some of my colleagues responded to this inquiry. Here are a few of the responses:

"Seniors have a sense of heart to the lessons they learned over their lifetime. I am honored to have them share these lessons with me."

"What better way to garner wisdom and an understanding of our own future. It is such a privilege."

"Caring for the elderly is just one method of showing our appreciations for their contributions and ensuring that they live their golden years as happy and independently as possible."

"I have chosen to work with seniors because I discovered they were the undervalued audience."

For this geriatric care manager, simply put, in the giving, there is so much more that I receive. If a monetary value were to be put on the wisdom I have gained and the life lessons I have learned, Bill Gates and Warren Buffet would be asking me to join their Billionaires for Philanthropy.

As an eldercare consultant,  I am often asked to visit a client's home. Sometimes it is to discuss nursing homes, senior residences or the hiring of a home health aide or companion. On occasion,  the visit is a "pre visit" to start thinking about how the client's home can be adapted to meet his or her needs following a hip fracture or some medically altering situation that makes ambulation difficult.

If walking up or down stairs is of concern, often a location for a hospital bed can be found on the main floor. A commode can be situated, with a lattice screen for both privacy and dignity.  But, in some homes, especially split levels, there is usually not a bathroom on the living level.  Other homes may have a half bathroom which excludes a tub or a shower. Until now, this left sponge bathing as the only alternative in the absence of a shower. No longer! Announcing the portable shower stall.

According to their web site, www.shower-anywhere.com, the portable shower stall can be used anywhere in the house. A hose connects to a water source, kitchen faucet or otherwise.  The company claims, it takes a mere 60-90 minutes to install just using a screwdriver and wrenches. Sounds too easy. There are no modifications needed to existing plumbing. The economy shower stall is 34 inches square and 48 inches high. The deluxe unit has a rollout seat. Within the stall, there is a faucet, a  5 foot hose and  an automatic drain pump that discharges the waste water into the sink or other receptacle. Cost for the basic shower stall starts at $755 and the deluxe at $4,500.

While I am intrigued by this finding,  I have no vested interest in the company and I am sure there is more than one company offering such a product. I have had no feedback from a family who has used the shower.  Hence, I do not know if it is a bargain alternative to building or enlarging a bathroom or cause for filing an insurance claim for a flooded living room. At any rate, I believe if a piece of equipment can help to ease the stress of caring, it is at least worth a visit to the website.

As a geriatric care manger, receiving a call from an adult child to tell me of the death of a parent I have assisted, is not unusual. I feel honored and grateful to be remembered. Such was the case last night when I received a call from the daughter of a client I had helped a few years ago.  She called to tell me her father had died. I started to say, "I was sorry," but stopped. Without hesitation I wasn't sorry, in fact I was relieved, and  told his daughter so. Without pause, she agreed.

A little about Jack. Early in his life he had oral cancer that left him with slurred speech. An accomplished photographer, his speech would often leave people, who did not know him, thinking he had a drinking problem. Doctors talked over him, as if he was a negative that was never developed. How he hated this.

When I visited Jack, we had an agreement.  If there was something he said I could not understand, I would ask him to repeat it. His feelings were not hurt. On the contrary, he was happy to have someone to talk with who felt each word spoken was important. Often we would discuss interesting books each of  us had read.

In recent years, Jack had  a feeding tube inserted. A year  passed and more medical complications set in. Jack was not able to breathe on his own and was now in a nursing home on a ventilator. Unfortunately, he knew everything that was going on. One day he painstakingly  wrote a note to his daughters telling them to "get him out of here." He wasn't  talking about a reservation at the Hilton, it was the Quality Inn he wanted, eternal rest next to his wife. A sensitive doctor helped to make his request a reality.

During these last years, I heard and saw the black and white in Jack's life, the color was gone.  Jack had the quantity of his years, but not the quality. I hope he has found the peace and freedom he yearned for. And maybe he will send this geriatric care manager some photos of the Great Beyond, I'm really curious.

Some years ago, at our annual conference of the National Association of Professional Geriatric Care Managers, I was particularly impressed by a presentation by Dr. Dennis McCullough, author of "My Mother, Your Mother."  He espouses the philosophy of "slow medicine."  Simply put, there comes a time in an elder's life, when the focus of care goes from cure to comfort. We exchange the multitude of tests that can be performed to aggressively making the person comfortable. This can include control of pain,  providing oxygen so that breathing is not labored, and respecting the frail elder's refusal for food and liquid intake.

Another doctor, Dr. John Sloan has recently published a book expanding on this same topic. But before I explain his philosophy, let me list the primary signs that characterize frailty:

•   A slowing down of overall abilities.
•   A lack of interest in eating which results in weight loss.
•   A low activity level, unable to walk very far or not at all.
•   General fatigue. A person can sleep on and off all day and then sleep through    the night.
•   Loss of strength requiring the assistance of others.

Dr. Sloan's new book, "A Bitter Pill: How the Medical System is Failing the Elderly," talks about the need for medical treatment to be kinder in treating older adults. It gets back to Dr. McCullough's idea of slow medicine. However, Dr. Sloan goes beyond this concept and talks about functionality with regard to older adults. It is a strength based approach to frail elders. Building on those activities they can still do. It may be as simple as a call to a grandchild, sending a birthday card, sitting on the porch or singing a favorite song, listening to a favorite author. I recall wheeling a client to the piano. A retired music teacher, her fingers delicately touched the keys as she played a favorite piece by Brahms.

My experience as an elder care consultant, is that family members have an easier time accepting the concept of functionality. When it comes to withholding medical tests, a surgical procedure or accept a parent's refusal of food, these challenges are much harder for an adult child or spouse to say "no" to.  One of my goals is to help well-meaning families think about what their loved ones would want and determine whether the perceived outcome warrants the intervention. A sensitive task for a geriatric care manager, a complex decision for a family.

I do not profess to be a chauffeur, merely a geriatric care manager who, among other things,  accompanies her clients' to their doctors' appointments. Sometimes by ambulette, but more often in my car.

That was the scenario a month or so ago. I was taking Peggy to a doctor's appointment. She is a  new client, so I am not totally familiar with whom Peggy's IS.  You will see what I mean in a moment. I do know facts about her.  One is that she will not permit anybody by her side when she is walking.

This should have been my tip off, but it wasn't.  The keyword her is "independence." It is a word that is woven throughout the field of aging or just getting older. As we age the physical changes that occur, cause us to yield to new restrictions. Sometimes as a precaution, sometimes by necessity. However they come, nobody really likes them.

Back to Peggy.  Once in the car, Peggy had put on her seat belt. Often I am the one who does this. Another tip off.  Automatically, when we arrive at our destination, I will help my client to get out of the car.  With Peggy, I came around to her side and opened the door. She got angry, I mean Camaro red angry. "I can open my own door," she said to me. So what do you think I did?  That's right, I delicately closed the door, and invited Peggy to open it herself. Which she did. And while she did that, I stood there with one eye on a very fragrant lilac bush and my other eye on Peggy.

As a geriatric care manager, it is my responsibility to learn as much as I can about each of my clients. Not only the factual information, but about their personalities.  Especially, what triggers what. 

So accompanying  Peggy home,  I neither opened or closed the car door and all went well.  This geriatric care manager was not going to make the same mistake twice.  I also walked behind her.  So not only did I learn something about Peggy, but  now I know how Prince Philip must feel to walk those mandatory  steps behind his wife.  Now if I could only figure out what the Queen has in her pocketbook.

In addition to being an elder care consultant and geriatric are manager, I serve on the faculty of the Brookdale Center for Healthy Aging  and Longevity of Hunter College in New York City.  I teach a number of courses to students who are thinking of becoming geriatric care managers or who have an interest in a related field of aging. At the moment, I am teaching a course entitled, "End of Life".  Last week,  I introduced the course with a quote from a sociologist named Arthur Frank. At age 39 he suffered a heart attack and at age 40 was diagnosed with cancer. It was these two incidents that prompted him to write the book, At The Will of the Body,  published by Houghton Mifflin.

Below, I share his words with you because they are relevant, not only to older adults, but all of us. We never know when our number will come up on the roulette wheel of life. It is a reminder to value the present, the now.

"The ultimate value of illness is that it teaches us the value of being alive; this is why the ill are not just charity cases, but a presence to be valued. Illness and, ultimately, death remind us of living. "The way we look to a distant constellation / That's dying in a corner of the sky," Paul Simon sang. We look like a flicker of light. In the moment of that light going out, we learn that what counts is to keep it burning. Death is no enemy of life; it restores our sense of the value of living. Illness restores the sense of proportion that is lost when we take life for granted. To learn about value and proportion we need to honor illness, and ultimately to honor death. The Consolations of Vision."

While my expertise lies is in the field of elder care counseling  and geriatric care management,  I am diverting for the next few paragraphs.  If you were not invited to the Royal Wedding, there still may be a reason to visit London. It is the opening of the  Hyde Park Senior Playground.

A Ms. Madeline Elsdon, of the Kingsbridge Association, commented, "older people find indoor gyms intimidating and expensive and therefore aren't exercising enough." With that in mind, a  ribbon cutting ceremony was recently held for a specially designed playground for those over the age of 60. According to another  council leader, "60 is the new 30" (I'll buy that!). The fitness equipment is designed to provide "gentle exercise." that works the arms legs and upper body. Specifically, a cross-trainer, body-flexer, sit-up bench, flex wheel and a bike to improve strength, balance and flexibility.

If you are wondering if you will be excluded from the playground if you are under 60, don't worry, all are welcome.  I must add  another benefit not mentioned by our English neighbors. As an elder care consultant, I feel it is always necessary to challenge the social  isolation that can come with advancing years. What could be a better way to develop a new friendship than getting to know someone as you flex together?  Building muscles and acquaintances. A win win situation.

tags: seniors, senior playgrounds, senior exercise, elder care advisor  

For the last twelve years I have been the geriatric care manager for a gentleman who lives in Dobbs Ferry, New York. After all of these years of  helping Jim, and being in touch with his family, a strong and trusting relationship has developed. I appreciate their insights and they have respected my suggestions.

It is with this as a background, that  Peter, Jim's son,  asked me to meet him for a cup of coffee.  He was in from Boston. The purpose of Peter's meeting was to ask me a question: "What will the end be like for Dad?" Peter's father, a retired writer, was nearing the end stages of vascular dementia. While I don't read tea leaves (especially not in Starbucks), my experience has been that there are two scenarios that bring a person with dementia to their final rest.

The first scenario is a fall.  If the hip has been broken it will result in surgery. If a pelvis is broken, it is straight bed rest.  A stay of a few days in the hospital and then  home or to a nursing home for rehabilitation. It is during this time that if a  person remains in bed too long because of pain, fatigue or unwillingness to co-operate, there is a good chance that pneumonia will develop. The body's immune system becomes compromised and often the person cannot fight the pneumonia. It is the pneumonia that causes death.

The second scenario has to do with eating, or more appropriately, forgetting how to eat. Once in the mouth, food is moistened by secretions and chewed. The next step calls for the person to swallow the food. Herein lies the problem. The person  has forgotten how to swallow. The food may wind up  in the corner of the mouth or it may just rest in the mouth. It does not go any place. Other times, because of the difficulty swallowing, the food may wind up going into the lungs. A condition called aspiration pneumonia may develop, resulting in infection and ultimately in death.

I said to Peter my wish for his father was that he close his eyes and that he gently be transitioned to his new desk in the editorial heavens. Barring that, I told him that, as I have done for more than a decade as his father's geriatric care manager, I would continue to advocate for the right care. Sometimes the right care is pure comfort care minus the comfort food. 

tags: geriatric care manager, adult children, elder falls, pneumonia, comfort care, end of life

As a geriatric care manager, I oversee the care of certain of my clients who reside in long term care facilities.  Last week I visited Dorothy who lives in a  nursing home here in New Rochelle, New York. Recently, the social worker asked  if I would speak to her about her end of life wishes. Known as Advanced Directives or Do Not Resituate,  the document would guide medical intervention or lack of intervention if she was in cardiac or respiratory distress, needed a feeding tube or required dialysis treatment.

Dorothy had just recovered from a urinary track infection, and her thinking, which had been muddled from the infection, had now cleared up. The time was right. Rather than use the legal and medical words that she may not have understood, I put the question to her in very simplistic terms: "What do you want your doctor to do if your heart stops beating?"  She repeated my question  aloud and then said, "let me think about it."  Later I stopped by and she told me she didn't want anything done to her if her heart stopped beating.  I had the social worker come into her room, and she repeated her decision to him. Appropriate papers were signed. I was relieved that her wishes were documented. Now doctors would not be performing heroic measures because we had been remiss in addressing this subject or because she found answering this question just too tough.

Professor Dame Barbara Monroe, the Chief Executive at St. Christopher's Home in London, the birthplace of the hospice movement, recently presented a lecture on the importance of making one's end of life wishes known. While not having Buckingham Palace within eyes' view, I was in attendance by live feed for her presentation. There were three major points that she made:

 ·        Talk about death-then we can live until we die

·         Restore death as part of life

·         Courageous conversations are essential

As a geriatric care manager, there are certain tasks that are easier for me to do, than family members. This conversation was one of them. I think Dame Monroe would be proud of the two of us.  Now Dorothy can live until she dies, with the peace of mind of knowing if her heart stops beating, her wishes will be respected.  

tags: end of life, advance directives, geriatric care manager, DNR, nursing home, hospice

As a geriatric care manager, leaving families speechless is not one of my goals. On the contrary, counseling involves the exchange of ideas, thoughtful listening, the provision  of elder care information, and emotional understanding. But when the discussion turns to the assumed generosity of Medicare to pay for the ongoing services of a  home health aide and other skilled services, the response from families is... What??!!!   They are shocked.  An unrequested  moment of silence occurs that quickly changes to: Are you sure? Can you double check?  

I am sure. Simply put, Medicare will pay for a home health aide if there is a skilled need such as the services of a physical therapist or a nurse. A service that will help someone improve or get better.  The scenario is usually one where Dad is transitioning from the hospital or nursing home to home. Once home, a Certified Home Health Agency will send out a nurse to do an evaluation of Dad. Based on the assessment, services such as physical therapy and/or a nurse and other adjunct services will be put into place. During the time  these skilled services are in place, a home health aide often comes in a few days a week for three to four hours.  But once Dad has improved or has reached a point where he is no longer capable of improving, Medicare will no longer be in the picture. The therapist or nurse will give dad sufficient notice so that alternate plans can be made. The cost of home care then becomes an out of pocket expense or is paid for by Community Medicaid if dad's finances are limited or EISEP, a New York State assistance program.

And a final word of caution.  If dad is driving, and can't wait to get behind the wheel, may I strongly suggest  he refrain  until Medicare services have been terminated. As a geriatric care manager I have seen certified home health agencies prematurely end services. Why? Under Medicare guidelines, other than leaving the house for doctors' appointments or religious services, one must be homebound for help to be rendered. To learn more about Medicare guidelines go to: www.Medicare.gov. or consult, "Medicare and You-2011."  This publication is mailed at the beginning of each year to all Medicare recipients.

tags: geriatric care manager, home care, Medicare, counseling

Long before I became a professional geriatric care manager, I was a college student with a roommate from Nashville, Tennessee, so I know something about Southern hospitality. But the generosity of Southern Hospitality is a little too kind here in Westchester County, New York  when adult children ask me to, "just come on over, we won't tell dad you're coming." To which I reply, "if you want to see a relationship fail before it starts, this is a sure way."

In the field of elder care, having a parent or a spouse agree to an initial visit by a geriatric care manager or elder care consultant, can be a slow process. Schedule the appointment, cancel the appointment, dad says he doesn't need anyone, a wife says my husband can take care of me. And so it goes.

Getting back to the open door policy. Put yourself in dad's position.  Dad had fallen the day before. He was feeling sore and uncomfortable. Having assistance at home was an issue he was unwilling to accept before the fall. And, now in pain, the Avon Lady of geriatric care management was going to show up unannounced?  I don't think so.

I assured the adult children that I really wanted to help. But an unscheduled visit was not the way to go. I suggested they wait until dad felt better. As the pain lessens, there would be a decrease in his irritability and a better chance I could make it beyond the front door.

The strategy worked. The father's fall was the catalyst for him conceding that he could use some help. A few days later, with an agreed to appointment, I made it beyond the front door. We sat around the dining room table and worked out a plan of care that was acceptable to all.

Not every elder care scenario has a positive outcome. I was grateful to the daughter and son-in-law for listening to my initial recommendation of  waiting.  With understanding and patience, doors do open. Often it just takes time for them to open wide enough for me to get in.

I am a subscriber to, www.gratefulness.com. I think the name speaks for itself. The site  recently printed a poem by Joyce Holmes McAllister which brought me to the dance floor, albeit with new steps.

As a geriatric care manager, when I counsel families, I sometimes ask them to alter their expectations of a parent, spouse or a sibling. It is by altering these expectations, that they are able to see the positive and develop a strength based relationship with loved ones or even to find a source of connection with not so loved ones!  To find some pleasure in the dance of life that may previously have been overlooked.

So enjoy, as the tempo quickens and stereotypical images are pushed aside.

JITTERBUG

I will not dance the jitterbug: 
those trumpet sounds
and clarinets that once
could hold us in their grasp,
with syncopated blast,
are much too slow for me.
Too calm for my old aging feet,
that nineteen-forties beat – 
its rhythms seem predictable,
bygone swinging sounds
inside a calloused ear.

Don’t spin me out and then
pretend to let me go,
or whirl me like a top
while keeping me in tow.
For now I am too fast
and wild with age –
the thinning hair in flight
while brittle arches trap new tones
within old dancing bones.
Burning air is underfoot; 
I rise above the floor and fly.

You watch me from afar;
shake your head in disbelief, 
lift a labored foot or two,
attempt a lindy hop,
in slow motion. But I keep on –

too filled with speeding time to stop –
too full of sound to act my age.
“Come, be old and really fast
like me,” I beg. I grab you 
with a flying hand. “Come!
catch me if you can.”

– Joyce Holmes McAllister  

This is a math lesson from a mathematically challenged geriatric care manager. In school, pick any grade,  I was bad in math, I mean very bad. Geometry was the last tortuous class I took.   Angles, polygons, intersections,  prove the formulas. I could prove nothing, except that I couldn't understand what was being taught. But despite my dismal mathematical performance, I would like to present  a formula I know works. It has been developed over  22 years of  counseling adult children as both an elder care consultant and a professional geriatric care manager. Simply stated: LESS=MORE.

What do I mean?  Last week I received a call from a son living in Portland, Oregon. His parents live here in Westchester County, New York. He is an only child. He told me about his mother's advanced diabetes and the fact that she was caring for her husband who had mid stage  dementia.  Frequent conversations with his mother revolved around a list of  the "you shoulds, mom." Among the things he told his mother to do was to hire an aide to live-in and get someone to help her pay their bills.  For each item he mentioned, his mother had a reason why it wasn't necessary.  The son called me. He felt powerless and he was scared.

At the core of  my Less is More Theory, is developing a sensitivity to what a parent is experiencing. There are losses that can't be controlled: vision, mobility, the car keys. There is an historical consideration; living through the Depression. Money is not dispensed unless absolutely necessary. Independence is to be maintained, dignity is to remain intact.

From my office here in Westchester I tried to help George in Portland understand where his parents were coming from and why he was on the receiving end of his mother's rejections.  What he wanted to do for her was too much, too fast.  An aide for four hours  a day is far less threatening than someone moving in. Maybe he could pay some of their bills electronically.  

Overwhelming parents with advice and strongly worded suggestions will make them retreat and reject. Suggestions for their help must be sensitized and prioritized. Small steps, a turn to the left, a step back, two steps forward. The deviations are never standard, but the formula will work. The final proof will be in the progress.

My experience as both an elder care consultant and geriatric care manager, has taught me that older adults prefer to age in place rather than enter an assisted living residence or a nursing home. They want to bring home the nursing home. A bit clichéd, but home is where the heart is.  Of course, there are certain situations when a nursing home is necessary. Financial limitations, extensive skilled care that is needed,  behaviors related to Alzheimer's Disease or other dementias that put the older adult and family members at risk and the sheer exhaustion of being a caregiver.

Seniors staying at home with  home-care was the traditional method of care  here in New Rochelle and throughout Westchester County until 1994. It was around that time  that New York State started using a different calculator than mine, and came up with a new formula and consequent mandate. Specifically, if a senior, who was on Medicaid,  needed more than 6-8 hours of care a day, in most situations, they belonged in a nursing home. They felt this was more cost effective. I didn't understand it then and don't understand it now.

AARP doesn't understand this thinking either. It is reflected in a study they recently  commissioned that surveyed members residing in New York State. They found the majority of those New Yorkers who were  over the age of 50, "would prefer to receive long-term services at home versus going to a long-term care facility."  Only 3% wanted their health care services provided in a nursing home.

Although these results were of no surprise to me, I hope all levels of government will take this survey, and others like it, into serious consideration as they squabble over current health care reform and formulate future health care policy. With the precarious fiscal situation here in Westchester County, in New York State and  throughout the United States, taking the nursing out of nursing homes and bringing  it home to community-based care services, is both the practical and  compassionate way to go.

As I  assist older adults, this quote is always by my side. It is this geriatric care manager's gift of thought for the New Year: 

Old age is not a disease - it is strength and survivorship, triumph over all kinds of vicissitudes and disappointments, trials and illnesses.
-- Maggie Kuhn

This was your happy after story,  if you are open to what constitutes a happy union.  I have been Ann's geriatric care manager for the last three years. She never had children. Her husband, who became her ex-husband, who became her ex-husband with whom she cohabitated,  died this past Spring. The loss for Ann has been significant.

When I came on the scene, Bruce and Ann had been in ex-spouse, living together status, for over twelve years. I don't know all the reasons they divorced, but I clearly understood why they were now together. It was, among other things, Bruce's unimpaired cognitive status and Ann's eyes. Put another way, Bruce was legally blind and a clear thinker. Ann had her vision but was in the throws of dementia. Together they were a whole

They fought. Not physically, but there were verbal teases. Bruce knew just how to push Ann's buttons and Ann would respond by yelling at him to stop.  The time they enjoyed the most was when Bruce's (she was just Bruce's) aide  left, and  they would order their nightly  pizza pie and a liter of Coke. 

Bruce became ill in the early Spring. Into the hospital, rehab, home for three hours, back to the hospital, the nursing home again, the hospital again, and then to Calvary, a wonderful end of life hospital in the Bronx, not far from their Scarsdale, New York home. It was at Calvary that Bruce died.

"Why did he have to leave me?" Ann sadly asked me this week. I am not one to give clichéd answers, I like getting to the feelings beneath the statement. "You miss him don't you?" I responded. Without hesitation she said she did. She was lonely.  She was angry at  Bruce for his desertion, especially as Christmas approached.  I had seen Ann's anger before when she responded to  Bruce's verbal taunts, but this time it was different.  No more ribbing from Bruce, no more pizzas to be shared.

Experience as a geriatric care manager has taught me you  never know what goes on in someone's life until you get beyond the front door.  Married, divorced, and back together again?  Not even The Golden Girls  had an episode like this.

As I left Ann's home my thoughts went to Bruce for his perseverance in making his way back to Ann and to Ann for putting her pride to the side and opening her heart again. It was a happy union. Pizza for one just isn't the same as a whole pie.

Since 1988, when I started my geriatric care management practice here in New Rochelle, New York, I have seen a variety of approaches older adults take with their medications.  Here are six methodologies I have observed, and when appropriate, helped to rectify:

1. Seniors  who take their medications as prescribed

2. Seniors who take their medications as prescribed, sometimes

3. Seniors who earnestly try to take their medications, but varying amounts of pills fall to the floor

4. Seniors who say they take their medications but really don't

5. Seniors who believe they take their medications but don't

6. Seniors who plain out say they have no need for their prescribed medications and don't take them

Regardless of the profile, older adults are prescribed and take a lot of medications. Statistics range anywhere from 14-18 medications prescribed over the course of a year. According to data from  the American Society for Consultant Pharmacists, the elderly account for almost 13 percent of the United States population, but consume 34% of prescriptions. Further 28% of hospitalizations among seniors are due to adverse drug reactions.

 It is because of the unique medication-related needs of the senior population, that the above profession came into being. Such professionals are not widely known, but their impact can be significant. Of course, we have doctors and local pharmacists to advise us, but a senior care pharmacist will take an in depth look at the medications used by seniors and make sure the very problem the medication is trying to correct, is, not, in fact, making the condition worse.  These pharmacists have an understanding of what medications are most appropriate for seniors and which ones to stay away from. They know about appropriate dosing and the correct way to take the medication. They are well equipped to help in the resolution of medication induced problems.

 To learn more about Senior Care Pharmacists, visit their website: www.ascp.com. The site also provides a guide to finding  senior care pharmacists throughout the United States. 

An interesting company that I recently learned about, SeniorMed Consulting, www.myseniormed.com., provides both the services of  a senior care pharmacist plus an impressive "smart" pill box.

As a geriatric care manger I sometimes take on  the role  of  a race starter, similar to the ones  who drop the flag at Daytona or Indianapolis.   I evaluate an older adult, their long term care insurance policy and then  give the go ahead to make the claim. No doubt about it, each senior who has such a policy comes up a winner.   I think of  my client Hilda. A retired school teacher, she lived here in Larchmont, New York. She used up every last cent of her policy. Lucky for Hilda, not so lucky for MetLife.

These days, there must be just too many Hildas out there. It explains why Met Life (previously Traveler's Insurance) recently announced that at the end of December 2010 they would stop writing long term care policies. While diabetes, cancer and heart disease, remain the leading causes of death, the word CHRONIC is coming to center stage. So for many seniors who are policy holders, they are living longer, using their benefits and leaving less funds for the  investment portfolios of MetLife and other such companies. Who ever expected? Not MetLife or John Hancock for that matter.

Not very patriotic, but John Hancock is also asking state regulators to approve their request for an average increase of 40%.  Hancock did a study and found, from 1990-2010, the number of claims was much higher than they expected.  Like I said, CHRONIC is becoming  the pivotal word.  The Partnership to Fight Chronic Disease (http://www.fightchronicdisease.org) states that 75% of the nation's health care spending goes to treating these chronic diseases especially with the  new medical innovations that are emerging.

What is an older adult and their families (who may also be policy holders) to do about these increases? In an article appearing on September 30, 2010 in Kiplinger,  author Kimberly Lankford asked Marilee Driscoll, an expert on long-term insurance this question.  She recommends that if you can afford to keep the policy you should. If the cost is too high,  she suggests seeing if you can lessen the benefit period. So if the policy is a five year policy, see if it can be changed to a three year policy. What I found most interesting,  was Ms. Driscoll's comment that the average long term claim is for less than three years. Perhaps a fact to consider if you are thinking of buying long term care insurance. 

All dementia is not Alzheimer's Disease, but Alzheimer's Disease is a dementia. Confused? Many people are. That is why, when I counsel families I ask the question: "Has your mother had an evaluation for Alzheimer's Disease?" Sometimes there has been  no dementia evaluation.  Adult children or a spouse assume that all forgetfulness is Alzheimer's Disease.  "Not exactly", I say as gingerly as possible. I  deviate for a moment so we can effectively move forward.  I offer them the following explanation.

While Alzheimer's Disease (see www.alz.org/ for more information)  is the most common type of dementia, it effects over 5 million people in the United States, there are many other types of dementia.  To clarify, dementia is the umbrella term with more than fifty types of  memory loss  listed in this category. Here are five of the most common types of dementia:

VASCULAR DEMENTIA: caused by insufficient blood flow to the brain which can  cause transient ischemic attacks (TIA's) also called mini-strokes. These strokes last no more than five minutes with the average stroke being one minute.  Multiple mini-strokes can impact on cognition and result in dementia.

LEWY BODY DEMENTIA:  abnormal protein bodies, called Lewy bodies, appear in the nerve cells in the brain stem. The unique symptoms of this type of dementia  are, Parkinson's like activities, and fluctuating cognition ("Dad seems fine one day but the next day he doesn't know who I am"). See www.lbda.org for more information.

PARKINSONS DISEASE DEMENTIA: Parkinson's Disease in its later stages can effect cognitive functioning. The symptoms are similar to those described above, including tremors, muscle stiffness and reasoning (See www.lbda.org)

FRONTALTEMPROAL DEMENTIA: while there are multiple types of dementia in this category, Pick's Disease is the most common. The unique characteristic of this dementia is a noted change in personality which impacts on social skills. Lethargy is a common indicator, not wanting to get out of bed a sample behavior.  The personality changes come before the memory loss.

MILD COGNITIVE IMPAIRMENT: also called MCI can be a precursor to dementia. It  manifests itself  with difficulties with  judgment, memory and thinking.  Because a person can be aware of these changes, he/she may  respond by feeling  depressed, anxious and angry. Family members will also notice a change. However, these changes are not severe enough to impact on one's day-to-day  routine.

It is helpful to know the type of dementia, because it allows for the behaviors to be better understood and the treatments more targeted to the  particular diagnosis. While there are a number of excellent diagnostic centers here in Westchester County, The Burke Rehabilitation Center in White Plains, New York has been at the forefront of dementia diagnosis for over twenty-five years. 

Since 1985, when I started my career in elder care, I have often found myself inspired, motivated, humbled, stirred by the older adults I have helped. Yes, there are other adjectives not as positive, but they too are part of the continuum of helping.  

But back to the inspiring, please watch and listen to 107 year old Alice Herz-Sommer. There are no more words to write. The rest is up to each of us to learn.

 www.youtube.com/user/AliceTheFilm

A few weeks ago, I had the pleasure of attending the Cancer Support Team's  annual luncheon. This organization, based in Mamaroneck, New York was started by a physician whose wisdom went beyond the examining room. He realized that for patients and their families to effectively cope with a cancer diagnosis, they needed help in the home, transportation to treatment appointments and a support staff of nurses, social workers and community volunteers. Serving lower Westchester County, what makes this program so unique is that there is no charge for their services.

At the luncheon, I was seated next to a nurse with a specialty in hospice and palliative care. While I have understood the concept of hospice care, the definition of palliative care has always seemed a little vague to me. Wanting to gain a concrete understanding,  I shared with her the situation of one of my client's to whom I provide geriatric care management services.

A summary of my client. Ginger is in her mid nineties, the time when adult seniors start bragging about their age. The seventy year gap of Guess My Age, is now replaced with,  I'm Proud of my Age. She is not actively dying. She is contending with the infirmities  that come with age. She is legally blind and her memory is almost gone. But she has a strong heart, a pulse that is not missing a beat, and blood results that her doctor tells me are better than his.

Midway between the salad and main course, Madeline, the nurse, explained to me the principles of  palliative care. First, and most importantly, you don't have to be dying. The focus is on  improving the overall quality of a person's life. Palliative care can be provided while the person is being actively treated for an illness in their home or hospital. The team, which is made up of  a doctor, nurse, dietician, even a massage therapist, focus their attention on relieving pain and providing symptom management. Such symptoms, among others,  could be: difficulty with breathing, constipation, nausea and depression. In addition, part of the palliative care program offers emotional and concrete support to  families as they navigate the healthcare system and make difficult decisions.  Unlike hospice, where the total cost is assumed by Medicare, palliative care may not be fully covered by Medicare. It is important to discuss with the provider what costs are covered. Two sites to learn more about palliative care and providers are:  http://getpalliativecare.org  and http://www.nhpco.org.

By the time we reached dessert,  I felt the information that was shared would finally stick.  The more specific intent of palliative care is to provide support for a serious illness.  However, I felt a monthly visit from a palliative care nurse would supplement Ginger's well being by adding a medical dimension. After consulting with Ginger's family, they agreed to the visits.

The Cancer Support Team plays such an important role in our lower Westchester community. Now, by a chance seating,  it may serve  as the catalyst for enriching the quality of Ginger's life. Another reason to be grateful for all they do.

Choosing the right senior residence can be daunting.  A Livable Community? Independent living with additional help? Assisted living with care built in?  A Continuing Care Community?

 I will be teaching a class on this topic October 28, 2010 from 7-9 PM at:

 The Bronxville Adult School

Bronxville, New York

www.bronxvilleadultschool.org

914-793-4435

 I look forward to you joining me.

A geriatric care manager will often help  older adults make the transition from hospital to home. That was how I met Sophie, an 84 year old retired bookkeeper. She was being discharged from Sound Shore Medical Center, one of our local hospitals here in Southern Westchester County, New York.  With no immediate family, at the request of the discharge planner, I came to Sound Shore to meet Sophie and see if she would accept my services.  She agreed. From our first meeting until her death, her depression encased her.

So how did I know Sophie was depressed and not sad?  The answer lies in the definition. Sadness  has a time limitation, its transient. Often triggered by a life event, sadness weighs us down, but doesn't knock us out.  We are still able to function. With time, patience and understanding, the sadness lifts.

To experience depression is to feel an unbearable  heaviness.  One feels hopeless and helpless.  I have heard more than one person say to me  that the pain of depression is worse than any physical illness they have experienced. The American Psychiatric Association has put these feelings into a descriptive diagnostic text. Five or more of the following symptoms need to be present, in excess of  two weeks, for there to be a diagnosis of  clinical depression: 

·        A depressed mood

·        A diminished interest or pleasure   in daily activities

·        A significant increase or decrease in weight

·        Insomnia or hypersomnia

·        Agitation or significant withdrawal

·        Loss of energy

·        Feelings of worthlessness

·        Inability to concentrate

·        Recurrent thoughts of death, with or without suicidal plans

So getting back to Sophie's depression. How did I know she was depressed?  Her husband had died seven years ago. All remained unchanged at home since his death; his clothes, the watch on his desk he was repairing. Newspapers and magazines had piled up.  Sophie seldom left her house. Days moved  into nights and nights to days. Sophie's only interest was watching television. She never made her bed and her carpet had a layer of dust resting on top of it. She just didn't care. Other than paying her bills, there was little she allowed me to do. Doctors were a dirty word.

One day Sophie called me to say she was having severe stomach pains. She allowed me to call 911.  Although we will never know, her doctors' felt it was probably stomach or  ovarian cancer. Sophie really didn't care. Her only wish was to be kept comfortable and left alone. I respected both of these wishes. She died shortly after entering a nursing home. My sadness was transitional, her depression had enveloped her life.

Being an eldercare consultant and geriatric care manager, I have always felt that in the giving there is so much more that I receive. One of the greatest gifts is trust. For sure, it does not always happen. But at other times, with hearing, with listening, with a hug, with words spoken and other words understood but never spoken, a bond between geriatric care manager and senior adult gradually evolves. As Dora, who had a way with words once said to me, "I can feel in my belly button, I can talk to you."

Of little surprise, one of the hardest things to talk about is death, specifically a senior's desire to die. I have had some close encounters of the real kind with this topic.  "I've had enough,"  "I've lived long enough,"  "please God take me."  I don't shy away from these talks for it is truly an end of life discussion about living in the now.

So what is it that these candid wise men and women have had enough of? Let me be as honest and  precise as they have been with me:

• They mourn the loss of their independence. If they are not having their Depends changed or pulled up for them, then they are followed inside the bathroom or the caregiver is standing outside with her ear against the door.
• They perceive themselves as a burden to those they love. Their failing bodies are slowly stripping them of the ability to be and do.
• They are frustrated that they can no longer eat their favorite food; can't chew, can't feed themselves, can't taste, or a feeding  tube has totally taken away the pleasure of eating.
• They are irritated because their vision is limited or lost because of glaucoma, macular degeneration or diabetes. More likely to fall because of this vision loss, they are incensed because they are told  not to get up unless someone is always by their side.
• They are annoyed their hearing is diminished. The indignity of a hearing aid, the disappointment when the hearing loss is of a particular nature no hearing aid can help. Being in the moment and at the same time lost in it.
• They are frightened by the uncertainty of the day and the loneliness of the night. In and out of hospitals. Followed by rehabilitation in  strange places with aides that change with each shift.
• They are angry by the gradual fading of their mind. A disconnect from the world, a mind with no place to go but to be eaten up by plaques, tangles and strokes.

These are just some of the life processes these remarkable older adults  are enduring. It's why they say that living is worse than death.  In the practice of Mindfulness, we are often asked to put ourselves in the place of the other person. Do this simple exercise for just a moment.  What is your response?

 Informed choices is a primary goal for the geriatric care manager working with  older adults and their families. It can happen in many arenas: finding the right nursing home, elderlaw attorney, doctor, home care agency, even a dentist that will come to the house. Recently this process occurred as I helped a family decide whether independent living was appropriate for their parents.

 I use the word process with great care, for indeed, that is what happened over the course of a week. A devoted daughter and son-in-law, were greatly excited by a lovely independent living residence they had found for their parents. I was called in to close the deal. Not in a financial way, but to confirm that their choice was the right one.

 After a detailed history of both parents, and a visit to the senior residence, the lovely independent living apartment, wasn't looking so lovely to me. The esthetics were unquestionable, but could this residence truly meet the needs of John and Louisa? Louisa was in the mid-stage of dementia and John was frail, much of it brought on by the caregiving role he had assumed for all these years. The marketing team at the residence recognized what was going on, well sorta of, and felt the solution to the situation would be to use a home care agency to bridge those areas that would not be met by their independent living residence.

 For John and Louisa to fit into the mold of independent living, would require the assistance of home care aides. Here in Westchester County, New York the hourly rate is between $18-30 an hour. This would be a significant financial output to the already considerable amount they would have to pay for the pretty independent living residence.  But would their needs truly be met, even with a home health aide for eight or even ten hours a day? My answer was an unequivocally, NO.  The activities offered to a well senior are much different than those provided to a person with cognitive issues. The net result would be that Louisa would be shadowing John because her world does not exist in independent living.  As the consequence, how much could John's life improve?  Further, well seniors often stay at a distance from people they perceive as being different, ill mannered or odd. Growing up, we used to call it "having the coodies". Then, as now, it is mean and insensitive behavior. Finally, there would be continued calls to the adult children because of this mismatch. Instead of their stress being lessened by the transition,  they would be in the position of trying to correct something that should never have taken place.

 I am happy to say that John and Louisa are still in their home here in Westchester County. Their daughter and son-in-law recognized that pretty and lovely don't mean good and  right.  I suggested they visit some assisted living residences that were more appropriate for their parents.  I am grateful they took me up on my suggestion.  Housing transitions are challenging in the best of circumstances. But having a careful approach that takes into account all aspects of an older adult's being, has the greatest potential for success.

Recently, a colleague shared with me the invocation offered by Mary Maxwell at the annual conference of Home Instead, a senior companion service. She is a friend of the founders of the organization. Much has been written about the stress of  being a caregiver, but how about laughter within the context of aging and caregiving?

Laughter has many therapeutic values. It can help to relieve physical tension and stress leaving the body relaxed.  It boosts the immune system by decreasing stress hormones and increasing infection fighting antibodies. Laughter also has a way of releasing endorphins, a feel good chemical.  While the benefits of  these endorphins can  also be felt after exercising,  you don't have to go to the gym to reap these benefits (although you should!). Finally, laughter protects the heart. It increases the function of blood vessels and blood flow, which can help to protect against cardiovascular problems.

So without further ado, please laugh and enjoy:

 http://www.caregiverstress.com/2010/07/a-reminder-that-laughter-is-the-best-medicine

Recently I attended a memorial celebration. It was a beautiful summer's morning, the heat of the day had not yet arrived,  blossoming sunflowers were at their peak and a house was filled with people who came to lovingly recall a founding father of a summer community that has become a special part of my life.   

Sitting in the backyard of what was once Dan's home, and now the home of his daughter, were his children, grandchildren and great grandchildren and of course his friends. The latter were people who had known Dan in excess of forty years. The memories shared were varied; some funny, some touching, some that spoke of his talents and some with sentences that could only be completed with tears.

As  I listened to the tributes to Dan, the basic qualities he possessed helped me to understand why he was so admired and now so missed. Not surprisingly, they mirrored what MetLife (www.metlife.com) describes as the key components to a good life.  Let me share what respondents and researchers say are the significant factors that contribute to this quality of life:

• Being healthy
• Having a financial safety net (a safety net, not an armada )
• Having the time to do what is important
• Spending time with friends and family
• Having a sense of purpose in one's life
• Being able to focus on essential things and have a vision of the future

Dan, who lived into his late nineties was a retired postal worker. His eyesight had deteriorated over the years and at the time of his death he was blind. Now living in Colorado, he kept in regular contact with his life long friends.  In the assisted living residence he learned his way around the facility knowing how many steps he would have to ascend or descend to get to where he was going. He knew the arrival of his great granddaughter by the bounce in her step.  He questioned and listened tirelessly to his grandchildren, wanting to know everything about their professions. They were eager to share their lives with their grandfather and would talk in detail not realizing that the eventual silence on the other end was not Dan's, but a cell phone that had  gone dead. He enjoyed nothing more than going to Costco with his son for one of their mega Hebrew National hotdogs. He was still searching  for the right woman to complete his life.  

His daughter thanked me for coming. "You know Micki," she said to me, "my father was old but not elderly." Indeed he was. Later that day, as I thought about the celebration, the irony became as clear as the morning's sky. Dan's lack of sight did nothing to hinder his vision and ability to live a good life.

Thanks Dan, a life well lived and a lesson learned.

Last month, I was contacted by a family whose elderly mother had recently been transferred from a hospital here in Westchester County to a nursing home also in Westchester. While having dementia, Julia was not hospitalized for the dementia, but for pneumonia.   For reasons unknown, while in the hospital the medication which helped with her sleep was discontinued. She arrived at the nursing home exhausted from not having slept.

While people go to nursing homes for varied reasons, a short term stay is for the purpose of rehabilitation. Such was the case with Julia. But the door for rehabilitation only remains open as long as one is making progress. It is not closed immediately, but gradually starts to shut if the resident is not cooperative or stops making strides. The jargon for the latter is, plateauing. Kinda like reaching the top of a mountain, and you can't go any further.

Back to Julia. The head nurse had called in the psychiatrist to restart the medication. He put her on an extended release sleep prescription to help her sleep through the night. But the medication was doing more than that, its effects were extending into the day and interfering with her physical therapy.  The physical therapy department was ready to give her a wheelchair, wish her good luck and wave good-bye. Discharge was imminent.

It was at this juncture that I was called in. As a geriatric care manager, advocacy is part of the job description. In fact, it is high up on the list. The family was beyond frustration. Just two weeks prior Julia was awake and walking.  After getting a medical history, I asked if the physical therapy department knew about this sleep problem.  The family assumed the nursing department had spoken with them. I assumed otherwise. What would be lost by me reiterating  and discussing the current sleep situation with the director of physical therapy? With that, I excused myself, walked down the hall and spoke to the director.  I told her what she DIDN'T know. Julia's behavior was now understood in light of the prolonged effects of the sleep medication.  The discharge was cancelled. Within a few days, the appropriate medication dose was achieved.  Julia's lethargy lessened and her physical therapy continued for another ten days.

The role of advocacy, whether it be by family members or a geriatric care manager cannot be underestimated. Sometimes,  the thought that accompanies nursing home placement is that we are giving up the care and control of  a spouse or parent. On the contrary.  We can never relinquish this role. We must hold on tenaciously to this responsibility as to insure that a person's  life receives the care and attention it unquestionably deserves.

As a geriatric care manager and eldercare consultant, when I do an assessment of a senior adult, I ask many questions. Not only do I want to get a sense of the older person, but I want to know concrete information.  Current and past health status, work and social history, family relationships, all fall within this realm. I touch on the legal as well. Has someone been designated as Power of Attorney? Does the elder have a Living Will? A Health Care Proxy?

 It was the last of these questions that brought the surprising answer.  I was counseling  a daughter, helping her to evaluate whether it was time to bring Mom to Westchester County, here in New York from Florida. When I asked Pat if her mother had a Health Care Proxy, she told me she had Five Wishes. I was familiar with Five Wishes as a legal document, but never came across anyone who had chosen this directive in lieu of a Health Care Proxy. On the other hand, as the conception for this document originated in Florida, I shouldn't have been surprised.

To my way of thinking, Five Wishes  is a more compassionate and detailed way of letting others know how you want to be treated should you not be able to make decisions for yourself.  Recognized as a legal document in 42 states, it was created by the non-profit organization, Aging With Dignity, (www.agingwithdignity.org).  Although it shares the same goals as a Health Care Proxy, it gives people a greater opportunity to  describe their precise thoughts about health care decisions and beyond. It presents the person with the opportunity to use the written word to say those things too difficult to say in the moment or in the past. Apologies, forgiveness, acknowledging one's life long short comings, all have a place in Five Wishes.

So what are the Five Wishes?  Wish 1: This wish allows you to designate somebody to make your health decisions.  Wish 2: This wish deals with what kind of medical treatment you want and do not want.  It is at this juncture that Five Wishes becomes a unique document.   Wish 3: This wish encourages you to give direction as to how comfortable you want to be. Not only with regard to pain management, but such day to day things as bathing and grooming. Wish 4: This wish refers to how you want to be treated by other people. It lets one go beyond the obvious qualities of respect and proper care, to the role of clergy (if any) or visits from a family member  you have not spoken to in twenty years.  Wish 5: This wish lets other know such concrete things as what kind of funeral you want, hymns to be read. But more uniquely, as described above, it let's you make your peace with those who are important to you.

 I have described the Five Wishes within the context of the assessment I performed. But such planning, whether it be via a Health Care Proxy or the Five Wishes is the responsible thing to do, for all of us, at any age. It will be medical condition or crisis that will trigger the use of this document. Each of us needs to do our part, so those caring for us can responsibly step in to do their part as our advocate.

As a geriatric care manager, I often work hand-in-hand with families as they try to figure out how best to help  aging parents.  Peter, is a retired dentist caring for his elderly wife.  He is consumed by his devotion to her. His obsession is not healthy.  With his own physical problems, he is exhausted  to the point where  his stress level will ultimately impact on his ability to care for his spouse who has Lewy Body dementia.  I am trying to help Peter accept  that saying "No," is not a synonym for  "Bad Husband."

Ellen, another caregiver, has told me she is battling with the idea of sleeping with her mother each night. A devoted daughter residing in her mother's home, she is plagued by guilt. It happens often, but the intensity is greatest at night when she goes into her mother's room  to say good night.  Her mother, a senior well into her nineties, who is starting to have the physical maladies that come with nearly a century on this planet,  plaintively asks her daughter to sleep with her. "How much more time will I have with  my mother?" she asks me. "How can I say no?"  She looks to me with the hope that I will give my approval to her plan.  I don't. Instead, I ask her to look at what expectations are reasonable and those expectations  that exceed the boundaries of what is realistic.

So why is it that we can't say "No?"  We may be viewed as selfish, not caring, too self absorbed, too busy, not interested. All negatives. So we resort to saying "Yes," with significant consequences. Specifically over commitment that radiates to all parts of our being.

I am not suggesting that we always resort to "No". I am recommending that we evaluate the situation.  Sometimes it takes a concerned other, whether it be a geriatric care manager, a family member  or friend, to point out the consequences of keeping up this intensity of  involvement. An immune system can stay immune for just so long.

So the question is: when does one say "No", especially when saying "Yes" is so much easier? MayoClinic.Com in writing about this topic, outlines when saying "No" should be a consideration.   In contemplating  their four recommendations,  I believe  the care we take of ourselves will be  reflected  in a better quality of  help we provide to others.

1. "Focus on what matters most."  Determine what are your priorities. Sometimes this is best done in the company of others.

2. "Weigh the yes-to-stress ratio." If Ellen says "Yes" to her mother's request to spend the night with her, how is this going to effect her marriage or her ability to work effectively the next day if her mother is up during the night?

3. "Take the guilt out of the equation."  This is harder to do than telling children there is no Santa Claus!

4. "Sleep on it."  Often our sleep is already effected by numbers 1-3 above. But a little time does give us the opportunity to think about an important decision, gather additional information or  decide to wait for  a visit from a son or daughter to assist with a particularly difficult task.

Today I visited Annette in a nursing home. A spry senior, she is traveling the journey of dementia, knowing where she is one day and the next day totally someplace else.  Of  note,  I wore my June Cleaver, as in Leave it to Beaver, dress. For those of another age, this was a popular television program in the 50's and 60's.  It was the idealized American family living in the idealized American town. It was my reality show growing up.

 But getting back to June Cleaver.  Viewers would see June in her weekly dress, usually covered by the weekly apron as the meal time approached.  Today, my dress was a blue gingham check shirtwaist, belted, full skirt and a double strand necklace. It wasn't and will never be covered by an apron.  So why do I share this with you?  Let's get back to the nursing home, I entered  Annette's room and her first remark to me was, "that dress would make a nice shirt."  I was pleasantly surprised by her remark. Visual recognition, verbalizing what she was seeing and  perhaps a connection to an earlier time, had brought back the usually quiet Annette. Yes, Annette has dementia but in that brief sentence she was lucid with an eye for fashion.

 The Family Caregiver Alliance/ National Center for Caregiving (www.caregiver.org) talks about this  phenomenon  in one of their articles on dementia care giving.  Family members reluctantly accept the emotional fading of  a parent or spouse.  But then there is that occasional moment, when the person "returns," like Annette.  Or as a son said to me,   "dad is coming back."  Sometimes he stays a day, sometimes shorter. But he's there, talking about his family, vacations on Cape Cod, and his earlier life as a photographer. And then he's gone. A roller coaster ride that can weaken the strongest of us.  

 The loop dee loop of dementia and the moment of return. Last week while doing a consultation, an adult daughter told me how annoyed she would become  when her mother would either criticize or adjust the outfit she was wearing.  She then apologized as she started to cry.  Now her mother's  Alzheimer's disease had deprived her of  this once  annoying habit.... except for an instant. Her mother reached over  and  smoothed  the wrinkles that had formed on the back of her daughter's linen jacket.  A moment of  treasured return.

 So how do we view these once were moments of lucidity?  As just that, a word, an action, a smile, to be cherished. A reminder that under all the literal and figurative tangles of  dementia, there is still a person who remains and doesn't need a birthday to provide us with the best gift one could wish for.  

  As an elder care consultant and geriatric care manager,  I am often asked what it means to be old?  My answer is that  old is  defined by function not a numerical designation.  Take my cousin Sophia in California, a senior adult over 90 who is on the tennis court daily with a mind as strong as her swing.  Then take my client Albert (all names have been changed in my blogs), a few months over 65 and limited by a life long history of mental illness that manifests itself with ever constant somatic complaints that are real only to him. His life is centered around doctors' offices and emergency rooms. His interaction with me is limited to describing  his physical maladies. Are you surprised by either of these people?

 So where is the disconnect with understanding old?   Robert Butler, a foremost geriatric psychiatrist, who recently passed away, coined the phrase ageism.  He defined it as the stereotyping of individuals based solely on their age. For example, those granny glasses don't rest on every granny's nose and  it is not inevitable that every  older adult will develop Alzheimer's Disease.

 Presumptions and assumptions are two of the words that attach themselves to the mutated vision of aging. Let me share the story of my client Lorraine, a delightful 84 year old woman.  She is worldly, an avid reader, drives with acuity and has exquisite taste in the furnishings that surround her in her home.  She sounds pretty impressive and she is.  But when Lorraine starts to talk people start to hear her slurred speech. Cruel assumptions multiply faster than the words she utters. For starters, she has been called "drunk, demented and mindless." In medical situations, she becomes instantly invisible, as the medical professionals  turn from her and address her adult children. The flawed equation is: if you can't talk right, you can't think right. How far from the truth.  At an early age Lorraine was treated for jaw cancer with mega does of radiation.  Now, some forty plus  years later, the side effects of the radiation have caused this speech impediment.  This is a vibrant person that is not demented or drunk, she's just trying to rise above the unfair punches that sometimes accompany the aging process.

 Not all older people sit in rocking chairs, smell of urine or have dribble inching down the side of their mouths'. They work  into their eighties, deliver Meals on Wheels to those older than them, counsel other seniors on Medicare rights and play a mean game of tennis.

 The next time you are in the company of an adult senior, see them in their totality, their rich history, look for their strengths and don't fixate on their weaknesses. The life lessons they can teach us are infinite.

 Being in the field of geriatrics, and educated as a social worker, there is concept that I learned early on.   It is referred to as: conscious use of self.  It means  just what it says.  I'm supposed to think before saying or doing.  I'll leave the saying for another time, and focus on the doing or the not doing  as it relates to older adults and learned helplessness.

 What do I mean by learned helplessness?  It is "an induced feeling of powerlessness that often leads to real powerlessness."  The foundation of this definition is:  if you do for others what they can really do for themselves, you are going to either cultivate or contribute to the belief that they are incapable. Example, when I stop by Dorothy's apartment, do I say to Dot: would you like me to get you a glass of water?  Or, knowing that she is fully capable of getting her own glass of water, do I decide to walk with her to the kitchen and perhaps get a glass of water for myself while she gets hers?  Assuming Dottie can walk unassisted, if I bring her the water, then I am not giving her the opportunity to ambulate, to maintain her overall muscle tone and I may be planting certain self  doubts about her ability to do for herself.  This is especially true of women of a certain era who were on automatic pilot when it came to food preparation and service.  So doing for Dot, may not be the best way to help her maintain  her sense of self.  But,  unfortunately, sometimes we measure a positive outcome  by just that, the ability to do as much as we can for others. An erroneous hypothesis.

 This flawed assumption sometimes guides home health aides in their work.  The more they can do for their client, the better they are as an aide. What do I mean?  Alfred is a very capable and devoted aide to Jack.  At meal time, he will wheel Jack to the dining room table, tie his bib around his neck and put his favorite meal of meatballs and spaghetti in front of him.  Alfred will then start to feed Jack and Jack will call out, "let it go, give it to me."  With some interpretation Alfred and I have figured out this  meant, I want to feed myself.  Alfred has said to me he discouraged Jack from doing this because most of the meal  would wind up on his bib.  But such action, I explained to him, takes away from what Jack is expressing a desire to do. Is it more important that the meatball wind up in his mouth without Jack feeding himself or might Jack's self esteem be enhanced,  if he  picked up his fork, jabbed it into the meatball and got part of it to his mouth?  To my way of thinking, it is much easier to make another meatball than  return someone's sense of self worth, self-respect, and confidence.

 So let me present my equation:  LESS=MORE.  Within the boundaries of safety, the  less we do,  the greater is the opportunity for those we care  about to do for themselves. For Dorothy and Jack, their integrity remains anchored in a positive sense of themselves. What a wonderful gift we all have the ability to bestow.

As a geriatric care manager for more than twenty years, I have learned that the  logic of dementia, is that there is no logic. Or put another way, the illogical becomes the logical. No schedules, no timetables,  no calendars can forecast what will happen or when it's  going to happen.  It just happens. 

Take a recent occurrence with my client Richard. He is in the mid  stages of dementia and residing in an assisted living residence.  I was talking with the nurse about the change that was going to take  place with one of his medications.  Now Richard does not recognize  me despite the six years I have known him, he thinks the year is 1962 and believes he is living in a hotel.  While I feel strongly  about not discussing a person's health  or mental status in front of  him or her, I did not see anything inappropriate in talking to the nurse in front of Richard. In fact, I told him what we were discussing.  And then, similar to what is heard at the end of the 1812 Overture, when the cannons are fired and the tempo quickens to mirror the intensity of the blasts,  Richard verbally discharged with the same intensity. "I don't want to be on those medications, I don't want to be on any medications, I'm tired of taking medicine." 

 He sounded so logical. Yes, he probably is fed up with his world that no longer has any consistency or familiarity and is out of his control.  But then it is 1962 and Richard doesn't know me and doesn't know his family, and has to be told not to wash his hands in the toilet bowl.

 There is no logic, but there is a person in there. And in the moment what Richard was saying and feeling had to be validated and responded to. I entered his world, using  my best know how and tried to figure out how to respond. With logic, saying this medicine will help him?  Or join him with illogical logic.  "Okay Richard, I'll ask the nurse if you really need the medication."  The latter won out,  it gave Richard a momentary sense of being in control, of being heard......... of Being. 

While I know this is baseball season, I am discussing a strike out of a different nature.  It's not back to the bull pen,  it's leaving the assisted living facility or nursing home for  the hospital. This is one of the rules mandated by the New York State Department of Health in senior living residences. When an older adult is at risk to himself, hits another senior or a staff member he must be evaluated at a hospital.

 This is the play by play.  A client of mine, Paul,  a kindly gentleman in his mid eighties, recently started to display some unusual behavior.  He started to scream sporadically which got other residents to tell him to "shut up" or they started to scream along with him. Kinda like Sing Along With Mitch, for those of a certain age who remember the television program. His behavior became progressively more disruptive until one day he hit a resident. A call was made to the closest hospital that had a psychiatric unit, where he would be evaluated and the medications he was taking, which included an antidepressant and an anxiety medication, would be assessed.

 At the hospital, what should have happened did. They rounded each base by performing  blood and urine tests and doing a chest x-ray. These tests were done  to rule out, among other things, any infection. Infections, are notoriously known to cause a change in a person's behavior, especially older adults and particularly those with a dementia. Heightened confusion, belligerence and combative behavior  are very common characteristics. Tests showed Paul had a urinary tract infection (referred to as a UTI in the trade) and was immediately put on an appropriate antibiotic.  I say appropriate because not all antibiotics effectively treat a UTI.

 So, this really was a home run in the world of geriatrics.  The infection is now being treated.  In his sixth day of taking the medication,  Paul's usual behavior is returning, and there was no need to change his psychiatric medication cocktail.  Lesson learned, rule out any organic medical causes for  behavioral changes before making a change in psychiatric prescriptions.

Last week, a family was telling me about their elderly mother with Alzheimer's Disease. They started to describe her day to day behavior. But then brothers turned to sisters and sisters turned to brothers. Mom started to talk about their father, her dear Charlie, who died twenty years ago.  Okay, talk of someone you were been married to for fifty two years is not unusual. But poor Alice, in the throws of dementia, had resurrected Charlie from the grave.  He was back, she talked about the fact that he was at the machine shop and would be home later.  "But mom," they said, "Dad died twenty years ago." Shock and sadness overcame Alice. She had not remembered that her spouse had died.

Her children, with good intentions, thought they were being helpful in  reminding their mother that dad had died a long time ago.  The responsible thing to do, but not for someone with dementia.  In their world, everything that is new today, is also new tomorrow.  Can you imagine how Alice felt? The shock of learning that her husband died, albeit twenty years ago? People with Alzheimer's Disease, find it hard to retain information and learn new things. 

 It is for this reason that it is important not to correct someone who may base today's conversation on their life  of twenty or thirty years ago. Take the example of a client of  mine, an 86 year old retired music teacher who lived with her mother for many years. I visited her weekly in the nursing home,  usually around dinner time. At most of these visits, she would tell me that she would be leaving soon because her mother had dinner waiting for her.  Who was I to shatter this wonderful memory both of her mother and her cooking?  Instead, I entered her world and asked what she thought her mother was going to be making.  I gave her the opportunity to reminisce accompanied by her description of comfort food in its truest sense.

 Yes, it is upsetting and sometimes awkward as people we love and care for start talking in this manner. But the kindest gift we can give them  is not to contradict the reality of their world, but go along for the ride, wherever it may lead.  

I recently attended our National Association of Professional Geriatric Care Managers annual conference. While there were many exhibitors that lured me to their booth with bowls of my favorite Hershey Kisses, there was one display that drew my attention, not by what they offered with epicurean enticements, but what they were offering to seniors. It related to alerting families, geriatric care managers or other care givers that someone has fallen.

Now we are most familiar with that  famous women who has fallen and can't get up. While we are left to conjecture why she can't get up, the fact is that she could be lying on the floor for the night and beyond depending on what support systems are in place.

 In an article in 2006 in Morbidity and Mortality Weekly Report, about 30 percent  of adults age 65 and older will experience a fall that will cause injuries or deaths.  Not surprising, most hip fractures among older adults are caused by falls and in many cases, individuals will require nursing home care. Sometimes, what is promised to be short term rehabilitation winds up being a permanent  nursing home placement.

 Getting back to the exhibitor. As a geriatric care manager, I have found myself  counseling families in situations that are teetering on either having to bring help into the house, considering assisted living or depending on resources, a nursing home. A familiar concern is that an older adult will fall, and because of physical or cognitive impairment, cannot press the button to alert the family or the police.  That scenario may now have changed.  In describing this device to you, I preface my remarks with the fact that I have no financial interest in this company nor does the National Association's Code of Ethics allow a member to profit by discussing a product.

Put out by Lifline,  the senior wears a pendant and tradionally needs to press the pendant to notify others. Lifeline AutoAlert, uses a number of  variables, including height and acceleration of the person's movement, along with senors to measure changes. Combined, these elements are able to pick up on a senior's fall without them pressing the button. Within a  short period of time, calls are then made to designated individuals. Such a device, while new on the market, I believe warrants exploration.

 If all they say about the device is true, it provides an extra layer of security, especially for individuals who are disoriented, immobilized or unconscious.  For families having this peace of mind, may be better than whatever chocolates delicacies tickle your palate.

      As a geriatric care manager, I often take older adults to their doctors' appointments. This was the case  last week when I accompanied a client to his regular  appointment. Frustrated by her father's failing appetite, the daughter also joined us. The appointment, evolved into a quasi confessional by the daughter with the doctor offering forgiveness.  Her father, who is in the mid stages of dementia,  just doesn't have eating on his priority list. Like other seniors with dementia, the thermostat for eating too little or too much, is  broken.  The daughter told the doctor all the different techniques she was trying to get her father to eat. Nothing seemed to work, and she was feeling ineffective in her role as caregiver.  Inadequacy, guilt two very familiar words in the caregiver lexicon.

     As I was in the room when the daughter spoke to the doctor of her frustration, I was also there for his response. A seasoned geriatrician who genuinely understood the many frustrations felt by those wanting to do the best they can, his reply to her was short and to the point.  Don't judge yourself  by your father's willingness to eat. You are doing the best you can. That is all you can do. There are some parts of your father's being you cannot control.

     As he spoke these words, I thought to myself how often we judge ourselves only by a positive outcome.  In fact, it is other qualities like perseverance, patience, caring, and a sense of responsibility  that are the true determinants of the quality of the care we give.

     In the weeks leading up to Christmas, on my rounds as an elder care consultant, I could see and feel the merriment that was in the air and on the dance floor.  Whether in a nursing home or an assisted living residence, the music being played brought  a spontaneous sing along: lips moving, hands clapping, feet tapping and even a two step on the dance floor. For me, this was the true gift of the season.

     Research has indicated, that music has remarkable effects on the brain, especially on the mind of a person with dementia. Music provides the opportunity for recall and reminiscence. "Take Me Out to the Ball Game" is one such song that I sing with senior adults. It brings words to lips that have been silenced by the great brain robber. I have seen moods change, smiles take over faces and anxiety calmed. Association, connection....a better time.  The Dorsey Brothers, Benny Goodman the music of the 40's when the war ended and families were started and others reunited.

     Beyond the individual, music helps families in their interaction with one another.  It serves as a conduit for sharing experiences and enjoyment.  It reinforces bonds and helps to mend those that are fragile.  Differences take a backseat as  Kate Smith sings "God Bless America." Reminiscence comes forward.  The generations are merged as Elvis or Ethel (as in Merman) bring their respective memories to the foreground. Unity, stimulation, spoken and unspoken interaction, they are all the gifts of music.

     To take a phrase from a song, whose title fails me, "Why can't we have Christmas the whole year around?"  I believe there is enough magic of the season that can be carried throughout the year.  Take a few minutes to sing, it will soothe the soul,  lessen the stress, return the yesterdays to today.  A gift for all times.

Some weeks ago, the spouse of a dementia patient, asked that I visit him in a nearby nursing home. She wanted me to provide her with a geriatric consultation that would help her to decide whether her husband should remain in the nursing home or return to their home in New Rochelle. She was being tormented by this decision.  Her stamina, ability to sleep and eat were all being compromised.  Guilt and self expectation were mixing together to create a toxic level of perceived caregiver failure.

 I spent the initial part of the assessment in the nursing home coffee shop talking with the wife.  It was here I asked about her husband's past, his medical conditions and the triggering factor that brought him to the nursing home. A fall, a broken hip and now rehabilitation.

 While such a dilemma is a common one, it is not my reason for sharing this situation with you. It is what occurred when we went upstairs and I met Ted (not his given name).  Sitting in his wheelchair in the nursing home day room, his wife introduced us, no response. Again, the same introduction, the response, or lack of it,  was the same.  Having now known a little about his earlier life as a graphic artist, I asked him some questions that were relevant to his profession. I hoped by touching on the past it would evoke a response. He looked at both of us, and said nothing. Internally, my recommendations were starting to evolve given what his wife had shared with me and what I was observing. I wondered if he was aphasic, unable to talk. How would he make his needs known at home?  But then the A Hah  moment arrived. Ted's hearing aids had not been put in. The wife left us for a quick moment and returned with his hearing aids. A man who a moment ago, I was ready to think of as aphasic was now carrying on a conversation. 

 Given the demands of his care and his wife's exhaustion, I did not think a return home would be a prudent decision.  But more so, had  his wife, not observed that his hearing aids were missing,  part of my assessment would not only be erroneous, but, if circumstances were different, I might have  recommended that he not return home, but for the wrong reason.

Perhaps if I had asked some additional medical questions and if the nursing home had been more responsible, it  would have opened the doors for communication sooner.  I would like to think so.