Can Seniors Always Choose Their Own Fiduciary?

Chris Cooper — Mon, 21 Nov 2011 11:17:11 GMT

A fiduciary is a manager entrusted to control property of another and to act on behalf of and for the benefit of that individual. Special fiduciaries include personal representative (sometimes still called the executor or executrix), agent under a durable power of attorney document, a custodian of a Uniform Gifts (or Transfers) to Minors Act account, an investment advisor providing discretionary investment management, or a trustee under a trust arrangement. You select all of these fiduciaries, and you hire and fire them at will.

But there is a situation when you do not get to select your own fiduciary. This occurs when you are adjudicated to not have the capacity to handle your own affairs and/or are a danger to yourself and/or others. In this situation, a judge in a court of law (generally called a probate court) appoints someone to manage and control your property and/or to act on your behalf. Some states call this special fiduciary a guardian; in others states they are known as conservators.

As we live in a collection of 50 states, we have 50 different state laws that control how and when a guardian or conservator can be appointed. In general, a guardian or conservator is appointed in the following way: Someone, such as a family member, friend, or a government worker (for example, a social worker working under Adult Protective Services or some other agency that deals with mental health, children, and others with developmental disabilities) files an action in a probate court (or the court of competent jurisdiction) to have someone placed under conservatorship or guardianship. Both the person who needs to be conserved and the person bringing the legal action are represented by attorneys.

A probate judge then hears the case, witnesses and experts give testimony, and the person who is being sued for guardianship is also heard. The judge then makes a decision about whether or not to place the person under the court’s supervision, and, if necessary, names a fiduciary to manage affairs and/or to make living and healthcare decisions for the ward (the person needing to be conserved or placed under guardianship). State laws define a lack of capacity to handle one's affairs differently than having competency, so you will need to read more about your own state’s laws and the laws of your family member’s state of residency as to how all of this works. No two states are alike.

Even with good estate planning, naming an agent under a power of attorney document and/or trustee of a living trust, a guardian, or a conservator may still be necessary. In situations involving large estates, there have been many instances when a perfectly competent person may have wanted to be placed under guardianship or conservatorship. We have heard of the public fights in the courts here in the U.S. and in other countries where very rich persons have someone exerting undue influence on them in business matters (where we are talking about Fortune 500 or similar companies). The adult may not be able to make complex decisions because of someone’s outside influence, or because they are too emotionally involved to be objective as a director of a publicly held corporation (who also has a fiduciary duty to the shareholders). Other examples of undue influence can come from clergy, cults, criminals, family members, and abusers.

Another situation that may require guardianship or conservatorship is in the case of severe mental illness that causes a person to be a danger to themselves or others. Remember, earlier I said that agents under durable power of attorneys, trustees under living trusts, and others like these can be hired or fired at will. Sometimes, guardianship proceedings are brought to undo changes made to a will, trust, or other business decisions which could have been made under duress or are a detriment to the individual’s estate or to his person.

As you now see, guardianship and conservatorships are very public, and they can be embarrassing and expensive. We can reduce the need for guardianship and conservatorships by doing good estate planning. However, as you can see above, there are situations when the need for a guardianship or conservatorship is unavoidable. Many estate planning attorneys recommend that you name someone to act as your guardian or conservator in your durable power of attorney documents, so at least you have made some indication to the judge in the probate court as to whom you would like to serve in this very special position.

Chris Cooper, CFP®, is the owner of ElderCare Advocates, Inc. a geriatric care management and long-term-care consulting firm. He is also the owner and founder of Chris Cooper & Company, Inc., a fee-only financial planning firm that works with small business owner, persons preparing to retire, and the very elderly. Chris is a regular contributor to eCareDiary.com and was recently interviewed by eCareDiary’s co-founder, Susan Baida, regarding Empowering Family Caregivers. Chris has also on has appeared on CBS's Early Show, NBC's Today Show, and is a regularly featured guest on CNBC's Power Lunch. He is frequently quoted in The Wall Street Journal, USA Today, The New York Times, Kiplinger's Personal Finance, Money, and SmartMoney.

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What Seniors Can Learn from Falls!

Dr. Rein Tideiksaar — Mon, 14 Nov 2011 09:15:16 GMT

I speak with elders on a regular basis about falls and how to prevent them. Starting out, many elders (and their caregivers) have mistaken beliefs about falling. First, they think that falling is an important issue for older people but not for them. If I fall, I just get up and brush myself off. I never hurt myself. No big deal.

• The good news is that most falls do not result in injury. Only about 10% of falls experienced by older people will result in physical injury. However, when falling over and over again, the risk of injuring oneself is greatly increased. Falls can lead to hip fractures, spinal cord trauma, brain injury and other serious injuries, which can reduce one’s quality of life and ability to live independently. Falling is not limited to physical injury but can include social withdrawal, psychological trauma (i.e., fear of falling) and increased dependence requiring long-term nursing care. The bottom line? Falls are not benign! Falls are a big deal!

Second, too many elders still think that if they do fall, the best way to stop falling is to avoid physical activity, as much as possible.

• As a temporary fix, guarding against falls by avoiding activity may work, but over the long run this strategy often fails. Why? Because inactivity actually increases the risk of falling! With any cutback in activity, leg muscles quickly become weak and, as a result, the ability to keep balance and avoid falls diminishes greatly.

Because of these of false beliefs, fewer than half of all elders see a doctor after a fall. This is not good. Those who decline medical attention are far less likely to find out why they fell and, more importantly, to engage in preventive activities that that might prevent them from falling again.

For elders and their caregivers, falling should be a teachable moment; an opportunity to find out why the fall occurred and how to prevent another fall from happening. As well, it’s good time to address issues surrounding fears over another fall and what to do to in the event of a fall.

Finding the Source of Falling

Falling can be a sign or symptom of an underlying health problem; one that you may not even know about. For this reason, determining the cause of a fall begins with a visit to the doctor, even if no injury as occurred.

The Story of Your Fall

Your doctor will want to know the details of your fall so that he/she can understand what is causing them. To prepare, think about your last fall.

• When was the fall (date/time of day)?
• Where did the fall occur? Outdoors or indoors? If at home, in the bedroom, bathroom, kitchen, etc.?
• What were you doing before the fall? Walking, bending over/picking up something from the ground, reaching up, getting up from bed/chair or toilet, etc.?
• How did you feel just before you fell? Dizzy, weak, faint, etc.?
• How long were you down on the ground for?
• Did you experience any injuries?
• How did you get up? By yourself? Need assistance?
• Are you afraid or fearful of falling again?
• Have you experienced other falls in the past 3 months? If yes, try to supply descriptions about these events as well.
Additionally, the doctor will test your balance, vision, strength/flexibility and coordination, mental clarity, and medications. The results will determine your risk of falls and help design a specific plan to avoid falling again.

Avoiding Fear of Falling

Since the fall, are you afraid of falling again? Have you cut down on your activities as a result? If the answer is yes, you are not alone. Being fearful of falling and possible injury is a rational or ‘protective’ reaction, which tells us to me more cautious in our everyday activities. However, avoiding activity in hopes of avoiding a fall is not a rational response and, as stated previously, may contribute to the risk of balance loss and falling.

Fear of falling is typically associated with lack of confidence in accomplishing everyday tasks, such as getting in and out of the shower/bathtub, climbing stairs, walking to the bathroom at night, etc. Fear of falling can be minimized by:

• Engaging in exercises that increase muscle strength/balance and build confidence. Physical therapists are a good resource to help with a program that is appropriate for you.
• Using a cane or walker to support unsteady balance.
• Modifying unsafe environments. For instance, if the fall occurred in the bathroom while getting into the bathtub, installing grab bars and placing non-skid rubber strips on the tub bottom helps support balance/restore confidence.

What To Do If You Fall

Despite the best efforts to avoid falling, falls are unfortunately going to happen. Here are some tips if you fall:

• First of all, don’t panic. Try to remain calm/assess the situation. Take a few minutes to determine if you are hurt. Do not attempt to get up if you feel you are injured. Try the ‘wiggle check to ensure that you’re okay. While you're down, without moving your arms and legs, wiggle your fingers, then your toes. If you can't wiggle all your fingers/toes or if it's painful to do so, there could be some kind of nerve or bone injury.
• If you live alone, a fall alarm or PERS (Personal Emergency Response System) may be useful. This is a device worn as a neck pendent or wristwatch. In an event of a fall and inability to get up from the ground, the PERS can be used to send a signal to a family member or emergency service for help (I’ll have more to say about PERS in future blogs). Cell phones, with easy speed dial, can be used as an alternative to PERS.
• If you feel you are not injured and are able to get up, crawl to a strong and stable piece of furniture, like a chair, that you can use as a support to help pull yourself up.

Click here to get more information on Fall Prevention.

Rein Tideiksaar Ph.D., PA-C (or Dr Rein as he is commonly referred to) is the president of FallPrevent, LLC, Blackwood, NJ, a consulting company that provides educational, legal and marketing services related to fall prevention in the elderly. Dr Tideiksaar is a gerontologist (health care professional who specializes in working with elderly patients) and a geriatric physician's assistant. He has been active in the area of fall prevention for over 30 years, and has directed numerous research projects on falls and has developed fall prevention programs in the community, assisted living, home care, acute care hospital, and nursing facility setting. To learn more, check out the Dr’s professional profile on LinkedIn: http://www.linkedin.com/pub/dr-rein/6/759/592 If you have any questions about preventing falls, please feel free to e-mail Dr. Tideiksaar at drrein@verizon.net.

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Can Dementia-Caused Cognitive Damage be Reversed in Seniors?

Carole Larkin — Mon, 07 Nov 2011 13:44:09 GMT

As you age, some degree of difficulty recalling memories is considered normal.

However, more pronounced memory loss could indicate a serious problem, such as dementia (which includes Alzheimer’s disease). That’s why the occurrence of memory loss or other forms of cognitive impairment — such as difficulty with attention, language or other brain function — can be so alarming.

Although most types of dementia cannot be reversed, there are several forms that can be undone. Importantly, a wide array of commonly prescribed medications, especially certain antidepressants and pain medications, can cause cognitive impairment which may be reversed by stopping the drug. Unfortunately, this reversible cause is often over-looked. But new evidence is emerging that shines additional light onto this important drug-induced adverse event.

While medications are known to cause many unwanted side, many doctors fail to identify the drug as the culprit. In the elderly, adverse effects of medications are generally more pronounced. This is due to a host of factors, including increased sensitivity to a drug’s effects, slower rates of elimination from the body and consumption of multiple drugs at a time.

A well-known side effect of many drugs involves their effects (specifically interference) with one of the chemicals responsible for transmitting signals between nerve cells in our bodies, called "acetylcholine."

This "neurotransmitter" is vital for diverse array of nervous system functions from muscle movement to sweating to memory, so it is no surprise that interfere with it, or drugs with "anticholinergic" properties, can cause a host of symptoms (see Box).

Anticholinergic effects confused with early signs of dementia

Drugs with anticholinergic properties can cause delirium, but longerterm effects, which may be mistaken as the early signs of dementia, have not been studied as well for this class of drugs.

However, a recently published study specifically looked at this problem. The authors created a tool in which they rated many medications according to their anticholinergic properties on a scale of zero (no anticholinergic properties) to three (extremely anticholinergic; see Table). After adjusting for other factors that may account for cognitive decline, the authors noted a decrease on two measures of cognitive performance in men aged 65 and older. For each point on their scale, patients had a decrease of 0.8-percent on a cognitive test and 1.1-percent on a measure of routine activities one can perform for themselves (another measure of intact cognition).

Unfortunately, cognitive decline that is due to anticholinergic medications is often overlooked because most medications listed in the accompanying Table would not necessarily, alone, account for a striking decline in memory or other cognitive function. But, the cumulative impact of consuming multiple medications with anticholinergic effects may be significant, resulting in unnecessary distress among patients, families and physicians alike.

While these findings are only preliminary, they permit physicians and patients to semi-quantitatively account for the anticholinergic effects of a patient’s medications when the patient complains of memory and other cognitive problems.

If you are suffering from a troubling decline in one of your cognitive functions, the first thing you and your physician should do is take a look at your medication list. The answer may be as simple as changing to an alternative or stopping an offending drug or multiple drugs.

Full List of Anticholinergic Effects

Cognitive impairment
Delirium
Hallucinations
Rapid heart rate
Dry mouth
Constipation
Urinary retention(inability to urinate)
Decreased sweating/fever/overheating
Skin flushing & inability to sweat
Pupil dilation & difficulty with vision

Anticholinergic properties

Drugs with a score of 0 are not shown; a score of 3 indicates the strongest side effects.

Drug (BRAND NAME) Anticholinergic Score
Alprazolam (XANAX)* - 1
Amitriptyline (ELAVIL)* - 3
Atenolol (TENORMIN) - 1
Atropine* - 3
Baclofen (LIORESAL) - 2
Belladonna - 3
Benazepril (ETHEX, LOTENSIN)** - 1
Betaxolol (KERLONE) - 1
Bupropion (WELLBUTRIN)** - 1
Carbamazepine (CARBATROL, TEGRETOL) - 1
Carbidopa (SINEMET) - 1
Cetirizine (ZYRTEC)** - 2
Chlordiazepoxide (LIBRIUM)* - 1
Chlorpheniramine (ALERMINE,
CHLOR-TRIMETON)- 3
Chlorpromazine (THORAZINE)** - 3
Codeine - 1
Cyclobenzaprine (FLEXERIL)* - 1
Desipramine (NORPRAMIN) - 2
Dextromethorphan (BENYLIN, DELSYM)* - 1
Diazepam (VALIUM)* - 1
Diphenhydramine (BENADRYL,
DYTAN SUSPENSION, DYTAN-D SUSPENSION,
SOMINEX FORMULA) - 3
Doxepin (SINEQUAN)** - 3
Fexofenadine (ALLEGRA)** - 2
Fluoxetine (PROZAC)** - 1
Guaifenesin (MUCINEX, ROBITUSSIN)* - 1
Homatropine (ISOPTO HOMATROPINE) - 3
Hydrocodone - 2
Imipramine (TOFRANIL, TOFRANIL PM)** - 3
Ketorolac (TORADOL)* - 1
Loperamide (IMODIUM)** - 1
Loratadine (CLARITIN)** - 1
Metoclopramide (REGLAN)** - 3
Methadone (DOLOPHINE, METHADOSE)** - 2
Methocarbamol (ROBAXIN)* - 1
Metoprolol (LOPRESSOR, TOPROL XL) - 1
Morphine (AVINZA, KADIAN, MS CONTIN) - 1
Nefazodone (SERZONE)* - 1
Nortriptyline (AVENTYL, PAMELOR) - 3
Olanzapine (ZYPREXA)** - 1
Oxycodone (OXYCONTIN)** - 1
Paroxetine (PAXIL, PEXEVA)** - 2
Perphenazine (TRILAFON) - 2
Phenobarbital (LUMINAL, SOLFOTON)** - 1
Prochlorperazine (COMPAZINE)** - 2
Propantheline (PRO-BANTHINE) - 2
Propoxyphene (DARVON)* - 2
Quetiapine (SEROQUEL)** - 2
Ranitidine (ZANTAC) - 2
Risperidone (RISPERDAL)** - 1
Scopolamine (TRANSDERM-SCOP) - 3
Sertraline (ZOLOFT)** - 1
Thioridazine (MELLARIL)* - 3
Tolterodine (DETROL, DETROL LA)** - 3
Tramadol (ULTRAM)* - 2
Trandolapril (MAVIK)** - 1
Trazodone (DESYREL)** - 1
Triazolam (HALCION)* - 1
Trihexyphenidyl (ARTANE)* - 3
Venlafaxine (EFFEXOR, EFFEXOR XR)** - 1

* Do Not Use in Worst Pills, Best Pills

** Limited Use in Worst Pills, Best Pills

Click here to read Dr. Rein Tideiksaar’s article on how medications can increase the risk of falling.

Carole Larkin MA, CMC, CAEd, QDCS, EICS is a geriatric care manager who specializes in helping families with Alzheimer’s and related dementias issues. She also trains caregivers in home care companies, assisted livings, memory care communities, and nursing homes in dementia specific techniques for best care of dementia sufferers. Her company, ThirdAge Services LLC, is located in Dallas, TX.

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Caregiver Tips for a Stress-Free Family Holiday

Margery Pabst — Tue, 01 Nov 2011 12:30:44 GMT

Stress is a normal part of life and during the holidays, stress intensifies for all of us, but especially for caregivers. Everything from self care to patient care to family dynamics turns up the heat during the holidays. The successful caregiver takes a deep breath and approaches it all by dividing up issues and considering practical strategies before the big days on the calendar arrive.

I often start with my family history. Considering the following questions may avoid unnecessary stress when the family gathers.

-What long term alliances among and between family members exist? (For example, does Dad favor his oldest daughter?)
-What communication patterns exist among and between family members? (For example, are your two brothers always jockeying for who knows most about a given topic?)
-How does the family resolve its conflicts? (For example, do people get angry or is humor used to resolve issues?)
-What disagreements or historical events continue to impact the family? (For example, has divorce continued to play a part in family dynamics?)

Answering these questions and anticipating problems will go a long way toward avoiding sensitive issues. Here are some practical actions you can take:

-Identify topics that will promote harmony at the dinner table and beyond.
-Raise topics proactively to keep dinner table conversations focused on positive issues. You can be the facilitator of the conversation!
-Enlist support from family members to help keep conversation flowing.
-Avoid topics that create arguments.
-Draw up a seating chart to suit personalities and promote harmony.
-Determine the optimum time and duration for the family gathering. All day or several day family affairs have more potential for argument than shorter ones.

“What is best for our loved one?” is the key question for caregivers. For families caring for a loved one, ensuring the focus stays on patient needs will avoid squabbles about ‘what dad wants’ or ‘when is the best time to have dinner.’ Simply check in with your loved one to determine what is best for their healing and well being. This is a simple and often overlooked technique!

The holidays are not the best time to resolve financial and responsibility issues surrounding a loved one’s illness and family caregiving. If you are facing key decisions about such questions as “What is the budget?”, “Who will be the contact with the financial advisor?”, “Who will speak for the family?”, or “When do we tell Mom she can’t drive the car?”, try to determine those answers NOW BEFORE the holidays arrive in full force.

Finally, center your festivities around a few meaningful meals and activities. Don’t try elaborate meals or extended activities. Keeping it simple is a key to avoiding undue stress. Have two side dishes instead of five; decorate a five foot tree instead of a ten foot one; set the family gathering for four hours instead of eight.

I hope you have a wonderful holiday season full of positive memories for you and your family. Take pictures and roll that video recorder. Create stories and take walks. Most of all, congratulate yourself and your family on all the successes of the past year.

To get more caregiving-related information, click here.

Margery Pabst is the co-author of “Enrich Your Caregiving Journey”, a practical guide for the caregiver. She is eCareDiary’s caregiving expert and hosts a monthly radio program sponsored by eCareDiary, “Caregiver and Physician Conversations”. See this website or Margery’s website at www.pivotalcrossings.com for more details.

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What You Don't Know About Medicare Could Be Costing You!

Shannon Martin — Wed, 26 Oct 2011 10:50:35 GMT

October 15, 2011 through December 7, 2011 is this year’s Medicare Open Enrollment period. During this time, Medicare recipients can switch Medicare Part D programs (prescription drug coverage) or enroll or disenroll from a Medicare Advantage (MA) plan.

From January 1st-February 14th, those enrolled in a Medicare Advantage plan can also disenroll and switch back to regular Medicare (this is the only change that can be made during that period). It is worth each Medicare recipient’s or caregiver’s time to evaluate current Medicare coverage and consider alternatives based on his/her specific situation. Even if an individual’s current plan is appropriate, it is important to understand the coverage, how it works, and Medicare recipients’ rights.

During this time, an individual may be considering switching to a Medicare Advantage plan to save costs, or may be reviewing whether a current Medicare Advantage plan is still the best option. MA plans are an option to receive a number of the various Medicare benefits via a private insurer instead of the traditional program. Typically, these plans will have preferred providers or networks (or providers may not accept the coverage due to the reimbursement rates) and may require a primary care physician or have other restrictions. They may also include additional benefits such as eye or dental care or gym memberships, and the deductibles, co-pays, etc. are usually less expensive for the recipient. If a person is enrolled in a Medicare Advantage Plan and is not pleased with the plan/coverage and choices, there are several special enrollment periods, in addition to the annual periods, to make changes.

One issue many people encounter is the situation where they must get inpatient rehabilitation and do not like the facilities available under the plan for skilled nursing. The OEPI (Open Enrollment Period for Institutionalized Individuals) may help. Persons “institutionalized” (i.e. residing in or moving in and out of a skilled nursing facility and other eligible institutions) have a continual enrollment period. The person can disenroll from a Medicare Advantage plan while in the facility and return to regular Medicare (or a different MA if accepting enrollment) the beginning of the next month.

Additionally, there is what is known as the “trial period”, which is the first 12 months after someone signs up for a MA plan for the first time. During this time, he/she can choose to switch back to regular Medicare coverage (and get guaranteed issue on a Medigap plan). There are various other Special Enrollment periods, for situations such as moving, becoming eligible or losing coverage from an employer or other entity and plan contract violations. If a client feels they truly did not understand the coverage or were misled, it is worthwhile to contact Medicare or an attorney who specializes in this area about rights and appeals.

A major concern that is arising more often for Medicare recipients is the issue of inpatient hospitalization vs. observation status/outpatient stays. A doctor must write an order to admit you to the hospital as an inpatient, otherwise you are considered an outpatient. You may be considered an outpatient even if you have spent the night (or several) at the hospital receiving ER services, observation services, outpatient surgery, lab tests, x-rays, and more.

Medicare Part A covers inpatient services and comes with certain deductibles (in 2011, $1132 for total stay of days 1-60) whereas Medicare Part B covers outpatient services which may mean patients pay individually (typically with 20% copay after meeting the annual deductible) for various tests and services (this Medicare Fact Sheet outlines all of the copays, deductibles, etc.). Admission criteria relates to the intensity of service (IS) needed and the severity of your illness (SI). There are several medical necessity screening tools that Medicare and its contractors use to determine if a hospital admission is medically necessary. Ultimately it is up to the physician, however if the hospital is not being paid for inpatient admissions they will strenuously attempt to remedy that situation. Criteria must be met for Medicare to pay and they have been increasingly focused on costly hospital stays in reducing potentially unnecessary expenses.

The other major concern this brings up for patients is coverage of any inpatient rehabilitation needed after a hospitalization. Medicare will only pay for inpatient Skilled Nursing Services if you have been a hospital inpatient for at least 3 days in a row (not including the day of discharge). Observation services DO NOT meet the 3-day inpatient criteria, so if a patient or family did not understand the situation outlined above, it could mean unexpected out-of-pocket costs in the thousands. A hospital based rehabilitation program may be a consideration in this situation (hospital rehabilitation or long-term acute care hospitals are typically categorized as “hospital days” not skilled nursing days).

The importance of a proper understanding of Medicare benefits and options should not be overlooked. A Medicare Analysis and education about the process when turning 65 should be an integral part of pre-retirement planning. For current recipients, the enrollment periods provide an opportunity to ensure coverage is still most appropriate given the likelihood the individual’s health has changed and options have evolved.

Click here to get more Medicare-related information.

Shannon Martin, M.S.W., CMC, is Director of Communications at Aging Wisely, LLC (http://www.agingwisely.com), a professional care management and patient advocacy organization and EasyLiving, Inc. (www.easylivingfl.com), a licensed home care agency, in Clearwater, FL. Shannon served as adjunct professor at Eckerd College in St. Petersburg, FL, where she created a course on “Eldercare”. Prior in her career, Shannon served as social services director and admissions coordinator in an assisted living/skilled nursing facility and worked as a social worker and volunteer coordinator for a large hospice.

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Hospice or Palliative Care? : Choosing a Care Plan for Seniors

Chris Cooper — Wed, 19 Oct 2011 10:40:29 GMT

In the United States, hospice and palliative care represent two different aspects of care with a similar philosophy but different payment systems and location of services. Palliative care services are most often provided in acute care hospitals organized around an interdisciplinary consultation service with or without an acute inpatient palliative care ward. Palliative care may also be provided in the dying person's home as a "bridge" program between traditional U.S. home care services and hospice care, or in long-term care facilities. In contrast, over 80% of hospice care in the United States is provided in a patient's home with the remainder provided to patients residing in long-term care facilities or in free-standing hospice residential facilities.

Palliative care is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness. Non-hospice palliative care is not dependent on prognosis and is offered in conjunction with curative and all other appropriate forms of medical treatment.

Hospice in the United States has grown from a volunteer-led movement to improve care for people dying alone, isolated, or in hospitals to a significant part of the healthcare system, from both non-profit and for-profit providers. In 2008, 1.45 million individuals and their families received hospice care. Hospice is the only Medicare benefit that includes pharmaceuticals, medical equipment, 24-hour/seven-day-a-week access to care, and support for loved ones following a death. Hospice care is also covered by Medicaid and most private insurance plans. People in home-like hospice residences, nursing homes, assisted living facilities, veterans' facilities, hospitals, and prisons may also receive hospice care.

There is often confusion between the terms hospice and palliative care.

In the United States, hospice services and palliative care programs share similar goals of providing symptom relief and pain management. Non-hospice palliative care is appropriate for anyone with a serious, complex illness, whether they are expected to recover fully, to live with chronic illness for an extended time, or to experience disease progression. In contrast, although hospice care is also palliative, the term hospice applies to care administered towards the end of life.

Palliative care:
• Provides relief from pain and other distressing symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten or postpone death
• Integrates the psychological and spiritual aspects of patient care
• Offers a support system to help patients live as actively as possible
• Offers a support system to help the family cope
• Supports the needs of patients and their families
• Will enhance quality of life
• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy.

Under the Medicare Hospice Benefit (MHB), a patient signs off their Medicare Part A (hospital payment) and enrolls in the MHB with direct care provided by a Medicare-certified hospice agency. Under terms of the MHB, the hospice agency is responsible for the Plan of Care and may not bill the patient for services. The hospice agency, together with the patient's primary physician, is responsible for determining the Plan of Care.

Medicare does not pay for custodial care, and thus the room and board costs of an inpatient hospice are similar to the cost of a nursing home. Patients may elect to withdraw from the MHB and return to Medicare Part A and later re-enroll in hospice.

Hospice care is available in the later stages of Alzheimer’s disease and other dementias. Medicare may pay for hospice care when a person with a dementia:

1.) Reaches stage 7 of the disease process on the Functional Assessment Staging Scale (FAST Scale). This is when the person with dementia speaks 6 words or less.
2.) Is unable to ambulate (walk) without assistance
3.) Is unable to dress without assistance
4.) Is unable to bathe without assistance
5.) Is unable to maintain continence or bowel or bladder control

There are other signs and symptoms to be considered, such as aspiration pneumonia, urinary tract infections, and weight loss of 10% of more in the last six months.

Families who have questions and would like to know if there family member is eligible for hospice should call a local hospice organization and arrange for an assessment.

To read Chris Cooper’s article, Helping Elders Articulate their Long-Term Wishes, click here.

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Are There Gaping Holes in Your Caregiving Circle of Support?

Margery Pabst — Tue, 11 Oct 2011 10:43:50 GMT

If you’re like me, you have “FRIENDS” and then you have “friends”. Caregivers recognize the real, the capital letter “FRIENDS” quite quickly. As a caregiver said to me recently, “I had several friends who started out on the road with me in my early days of caregiving, but now there are fewer and fewer and I feel quite lonely sometimes.” Unfortunately, this story is one I hear often and one that I experienced first hand.

So how can we caregivers shore up our support and fill in the gaping holes in our circles of support? Building a circle of support in the first place, a circle that includes family, friends, and professionals like clergy and medical personnel is critical. As time goes on, some of these people will, as the comment above demonstrates, fall away from supporting you as they did in the beginning.

Consider, as you continue to build and replenish your circle, some of the following questions. As I write these questions, some of them seem obvious and yet, for me, it’s taken some effort to really put them into practice.

Do I have a person(s) who helps me laugh and who sees humor in the day to day living, working, and caregiving? Who can see humor in a torn medical patch or a half eaten meal? A friend who can is a FRIEND indeed! Is there someone who suggests a movie or is there to watch Saturday Night Live or a British comedy on PBS? Keep them close.

Do I have a person(s) who listens to my issues without jumping to judgment? We all have some friends who are ready to demonstrate why their problem is bigger, larger, more complicated and who are quick to say, “You should have done it this way.” You need “FRIENDS” who give you the time and space to talk.

Do I have a person(s) who understands why I feel the way I do without telling me not to feel that way? When I say, “I’m feeling guilty and not up to this today”, the real FRIEND will understand with comforting words like, “It’s ok to feel that way”. We don’t need people who tell us that we shouldn’t feel a certain way.

Do I have a person(s) with whom I can be vulnerable by sharing deepest fears, longings, disappointments, and successes? One of my dear friends confided to me, “I’m not sure I can do this much longer. The marriage is falling apart because my husband doesn’t appreciate how I care for him.” The real Friend will keep comments like this in confidence and will say, “I support you, so whatever you need, I’m there for you.”

Do I have a variety of friends/family members who represent a wide range of interests? Not having a wide range of friends with a variety of interests was one of the biggest mistakes I made. Enlarging your caring community to include a broader range of perspectives can help keep you in perspective. Seek out people who look at the world differently and have different interests, particularly interests that feed the soul like crafts, arts, gardening. I am not a gardener but I have FRIENDS who dig in the soil!

Filling your CIRCLE OF SUPPORT with “FRIENDS” is ongoing. I hope the questions posed in this article provide you with benchmarks for keeping your circle strong and supportive.

To get more information on enriching your caregiving experience, listen to Margery Pabst’s radio interview here.

Margery Pabst is the co-author of Enrich Your Caregiving Journey ,the winner of the 2010 “Caregiver Friendly Award”. Margery is eCareDiary’s caregiving expert. She writes for eCareDiary’s Expert Q/A and is the host of “Caregiver and Physician Conversations” (part of eCareDiary’s “Empowering Family Caregivers”) which airs the last Tuesday of each month at 2PM EDT. Margery also is the author of “Ask the Caregiving Coach” and is a national speaker on “Storytelling” and “Self-Care for Caregivers”. Find out more about Margery Pabst at www.pivotalcrossings.com.

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Fall-Proofing Your Home to Help a Senior with Alzheimer's

Dr. Rein Tideiksaar — Mon, 03 Oct 2011 12:15:33 GMT

People with Alzheimer’s disease (AD) are at serious risk for falls—and injury. At least half of all falls occur at home. The best way to deal with any threats to safety in the home is through prevention.—checking for hazards that frequently cause slips, trips or falls and eliminating as many potential trouble spots as possible.

The fundamental question to ask when assessing a home setting is, "How does the person's living environment help or hinder mobility?" The answer is best determined by observing both the individual’s everyday mobility and whether a particular area or furnishing is safe or hazardous.

Watch, for example, how the person with AD walks around the bedroom, bathroom and other locations during day and night; transfers on and off the bed, chairs and the toilet; and steps in and out of a bathtub and shower stall.

This assessment will help target potential hazards and necessary modifications. In addition, observing the individual’s mobility can also help determine his or her comprehension, judgment and other cognitive skills, providing even more insight into changes that may be essential.

These home safety tips will help:

Pathways
• When walking from one location to another, individuals with poor gait and balance often place their hands on walls, and chairs, tables, and other furnishings for support. Ensure that furnishings are stable enough to uphold the person.

• During walking, some individuals with AD keep their heads and eyes focused straight ahead, often causing them to collide with low objects in their path. Visual field restrictions contribute to this problem. For this reason, allow plenty of walking room by keeping “traffic lanes” free of furnishings, clutter and other obstacles.

Lighting
• In general, keep lights on in rooms that are walked through and make sure they are bright to avoid tripping over objects that are not easy to see. Consider a night light for dark passageways. During the day, open curtains and shades to let more sunlight in. Install extra lighting along the pathway from bedroom to bathroom, and by steps and stairways.

• Since someone may get up during the night to urinate, the route from the bed to the bathroom should be well-lit, as well as clear of objects. Use night lights to provide sufficient lighting. Be aware, however, that night lights can cast shadows and images that may lead to hallucinations and paranoia in some individuals.

• A person with AD may have difficulty adjusting to stark changes in lighting. Moving from bright to dark areas and vice versa, and sensitivity to bright lights can lead to a temporary loss of vision and promote confusion. Therefore, it is important to maintain uniform lighting levels.

Floor surfaces
• Avoid carpets, rugs and tiled floors that are patterned, such as checkered or floral designs, since they can interfere with depth perception and balance. Floor coverings should be solid in color.

• Remove loose throw rugs or place non-slip backing underneath them to prevent sliding. Use carpet tape to keep carpet edges from curling up.

Beds
• Since cognitive impairment may affect someone’s ability to safely transfer from one spot to another, it is critical to adjust a bed accordingly. Move a bed against the wall to prevent it from sliding away when the person gets up. A bed with wheels can be particularly hazardous; if there are wheels, make sure they are in a locked position.

• Elevated bed heights promote balance loss during transfers. Bed height is safe when the individual is able to sit on the edge of the mattress with both feet planted firmly on the floor.

• The floor surface along the bed should be slip-resistant to support safe transfers. If floor surfaces are slippery, have the individual wear traction-soled socks or slippers.

Chairs
• All chairs used by individuals with Alzheimer’s disease should be sturdy and have armrests, which provide leverage and balance support when getting up and sitting down.

• The stability of chairs is crucial for safety. A good test of chair stability is to grasp and lean into a chair, and slide and tilt it forward, backwards and sideways during sitting and rising.

Bathrooms
• Grab bars either attached to a toilet or wall, or elevated toilet seats can help someone sit down and get up. Bedside commodes are beneficial if toilets are inaccessible or difficult for an individual to use.

• During tub transfers, grab bars securely mounted on the tub wall or rim can supply support. All grab bars should be slip-resistant, color contrasted from the wall for visibility, and securely fixed to the studs of the wall for adequate support; regular towel bars are not designed for this purpose. Place non-skid adhesive strips on the top of sink edges to guard against hand slippage if these surfaces are used for balance support.

• A rubber mat or non-slip adhesive strips applied to the bathtub floor surface provide stable footing and visual cuing. Sometimes individuals with decreased depth perception view bathtub surfaces as "bottomless pits" and become fearful when entering.

• Bathtub benches and extended shower hoses can serve as useful devices to assure safe bathing.

In adapting the environment, remember that changes can be disruptive for individuals with AD and may produce anxiety that can intensify cognitive deficits. Therefore, as a rule of thumb, try to keep modifications to a minimum; the key is simplicity. Adjust only those features that clearly benefit the person’s mobility and decrease the risk of falls. If several changes are needed, gradually introduce them one at a time.

Individuals also may be unable to learn new tasks—such as using grab bars in the bathtub—or become frightened of new "gadgets.” So, after making modifications, always test to ensure that the alteration is indeed safe and beneficial. Fall-proofing a home is an ongoing process. As a person’s mobility changes over time, it is important to periodically reassess his or her abilities and the need for additional safety features to prevent falls.

To get more information on Fall Prevention and Alzheimer's, read Dr. Rein Tidekisaar's articles, "Is Falling an Early Indication of Alzheimer's" and "Alzheimer's & Falling: What's the Connection?".

Rein Tideiksaar Ph.D., PA-C (or Dr Rein as he is commonly referred to) is the president of FallPrevent, LLC, Blackwood, NJ, a consulting company that provides educational, legal and marketing services related to fall prevention in the elderly. Dr Tideiksaar is a gerontologist (health care professional who specializes in working with elderly patients) and a geriatric physician's assistant. He has been active in the area of fall prevention for over 30 years, and has directed numerous research projects on falls and has developed fall prevention programs in the community, assisted living, home care, acute care hospital, and nursing facility setting. To learn more, check out the Dr’s professional profile on LinkedIn: http://www.linkedin.com/pub/dr-rein/6/759/592 If you have any questions about preventing falls, please feel free to e-mail Dr. Tideiksaar at drrein@verizon.net

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Don't Give In to Dementia Denial! - Tips for Caregivers

Carole Larkin — Tue, 27 Sep 2011 10:52:38 GMT

You may be past denial -- Perhaps your sisters or brothers, mothers or fathers, cousins or friends (especially ones that don't often see your loved one with dementia) are in denial. People in denial about a loved one with dementia often say to themselves things like:

Denial:
• I’ve always looked to Dad for strength and guidance. I don’t know how I can handle things without him. The thought that I have to take care of him as well as myself is too terrifying for words.
• He’s the parent, I’m the child. It’s never been any other way and I don’t know how to change it.
• If I ignore it, it will just go away.
• He had a really good day today; maybe it’s not really as bad as I though. I’ll just wait until his behavior and memory get worse.
• He’s just having a bad day. He’ll be better tomorrow.
• If I admit that he has dementia then that means that I’ll probably get it too and I can’t face that.
• He made me promise that I would never put him in a nursing home. That’s where I’ll have to put him if he has Alzheimer’s, so I won’t admit that he has it.

Underneath the denial:
• Fear about the future. That’s really the underlying emotion behind the denial.
• It’s human to deny what we find unpleasant or frightening. But when it prevents us from seeing facts and facing their implication then it will not help our loved one or ourselves.

Consequences:
• Using denial as a coping strategy will always fail eventually.
• Denial will prevent the family from taking the steps possible to “get ahead” of all the issues to follow -- like starting medications that could prolong the patient at the highest levels possible for the longest time possible.
• Denial can prevent completion of legal forms allowing your loved one or your family to be in control of medical choices, property matters and inheritance issues.
• Denial will cause major lasting conflict within your family.
• Denial can cause unwanted outcomes. For example, your loved one could need nursing home care due to delayed care that could prevent the progression to the situation where only skilled nursing can care for them.
• Denial causes stress to the caregiver -- even to the point of a serious heart attack, stroke or other fatal event, leading to nursing home placement for your loved one anyway.

You can help your family member or friend in denial by:
• Telling them that it is OK to be fearful but that it does not help your loved one or the rest of the family.
• Help them to understand that fear is overruling logic.
• Explaining that denial or doing nothing is actually doing something; and that doing nothing is going to cause more pain to all involved.
• Helping them see that this is not about them and whether they will get the disease or not. Tell them that there is no relationship between helping your loved one and increasing the chances of getting the disease. It’s not contagious!
• Helping them see that it is not about them and the inconvenience to their daily life. This is about helping someone that they love have the best care possible.
• Letting them see that this is not about whether they like or dislike your loved one and that even if they don’t like the family member or friend, that helping is the right thing to do.
• Be kind, gentle and calm in approaching your family member or friend in denial. Anger will only cause them to dig their heels in deeper.
• Let your family member or friend in denial know that you will be there to support them through the time they are confronting their fear -- they are not alone.
• If you see that you are not making a dent in their denial, drop the subject. You can return to it another time.

Click here to read more articles related to Alzheimer’s and Dementia.

Carole Larkin MA, CMC, CAEd, QDCS, EICS is a geriatric care manager who specializes in helping families with Alzheimer’s and related dementias issues. She also trains caregivers in home care companies, assisted livings, memory care communities, and nursing homes in dementia specific techniques for best care of dementia sufferers. Her company, ThirdAge Services LLC, is located in Dallas, TX.

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Fitness Guru Jack LaLanne's Wife, Elaine LaLanne Talks About Healthy Aging Mission

Kim Harke — Mon, 26 Sep 2011 11:03:27 GMT

Caregivers hear it all the time. Exercise is good for them, and good for the elderly people they love.

The media brings frequent reminders from health experts that exercise prevents illnesses and raises energy levels. Exercise can also help alleviate or prevent depression and stress-related illnesses, which eCareDiary has reported as being prevalent among the elderly and those who care for them.

Thanks to the now decades-old fitness revolution, older adults have plenty of inspiration to change their bodies and lives. For example, bodybuilding champion Ernestine Shepherd, at 75, claims to feel thirty years younger than her true age. The credit goes to her grueling fitness regimen. Indeed, many doctors and scientists have dubbed exercise “the anti-aging pill”.

The benefits of exercise for older adults and stressed-out caregivers are indisputable. But tell that to the burned-out caregiver with a job and a teenager at home. Or to the elderly adult who lacks resources for fitness instruction or physical therapy.

A lack of time, energy, or access can make regular exercise seem like a luxury.

We asked Elaine LaLanne, owner of Befit Enterprises, and wife of the late fitness pioneer Jack LaLanne, about the role of fitness in healthy aging. Jack LaLanne maintained his vigorous workouts until his death this year at age 96. Elaine, who for decades made appearances on her husband’s famous show, keeps a regular fitness routine of her own – and looks great.

“When Jack passed away earlier this year, he was very concerned about seniors having good balance to help reduce falls, bone fractures and even deaths, so he created the Better Balance For Life Program,” Elaine told us.

The Better Balance for Life Program was designed by Jack LaLanne and two doctors, both of whom are experts in geriatrics.

“Better balance, better muscle tone, and strength with attention to our center of gravity can help prevent falls,” says Dr. Jeffrey Bourne, D.O., C.M.D., one of the program’s co-creators. “We know this is achievable for all people, even the frail elderly.”

Many caregivers are already helping an older adult with physical therapy or other exercises, especially when insurance fails to provide continuing services. But even if the doctor has not ordered a specific physical fitness program, a home-based exercise plan can prevent future accidents.

For caregivers, the strides made by the elderly person in their care through balance-building exercises can inspire new fitness habits. As they see their older relative improve in health and confidence, they may come to value the small steps they can make toward adding fitness to their own lives – even while caregiving. Little changes can help caregivers reap big health rewards.

The most important change a caregiver will make may be one of mindset. It is easy to assume that a fitness routine is only valuable if it includes at least 30 minutes of exercise a day. But the scientific evidence encourages finding fitness through smaller blocks of workout time. And smaller blocks of time may be easier for a caregiver to fit into his or her schedule.

For busy caregivers, or caregivers without access to an exercise class, a few brisk 10 minute walks per day can make the difference between keeping healthy or physically declining during the caregiving years. Strapping on the sneakers and making an extra loop around the grocery store, or walking from the farthest parking spot at work all add up.

Add in some strength building exercises at home a few days per week, and the busy caregiver may have taken all the time for fitness he or she needs – and deserves.

Specific information on adding it all up is available on the internet. Keeping your body healthy in 10 minute chunks of time is possible if you follow national guidelines such as those set forth by the Centers for Disease Control.

Depending on your lifestyle and where you live, opportunities for physical activity may be right outside your door, or even inside your house. Fitness programs from the National Institute on Aging are broken down by age group and list several exercise choices. The site explains the many activities that burn calories and build strength, not only in aerobics or tai chi classes, but even while doing chores around the house or yard.

Handling illness and physical declines, or taking on the caregiving role can make the “anti-aging pill” of exercise seem out of reach. But with a little information, and a bit of willpower, tiny steps really do add up.

eCareDiary reminds all readers to check with a physician before starting any exercise program for themselves or for an elderly person in their care.

To read more about caregiving, read Kim Harke’s article, Speak Up for the Care You Need, here.

Kim Harke is a health care technical writer specializing in compliance. She holds a Master’s in history from New York University.

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