To Stay at Home or Not to Stay at Home

George Shaw 4 copy

– By George Shaw
Most individuals, if given the choice, would prefer to stay in their own home later in life – even as their needs for care progress. There are a number of different home health care options for those who wish to “age in place,” yet depending on the actual level of care that is required, this option can become quite costly – especially if assistance is needed around the clock.

Some of the issues to consider when making the decision to remain at home or move into a senior care facility include cost and location. Proximity to family and other loved ones is certainly a primary factor in making this decision – regardless of whether these individuals will be the actual caregivers.

Certainly, we all enjoy our independence. It is great to be able to do the things that we want to do when we choose to do them. But for some who are getting older, physical mobility and / or cognitive impairments may make it difficult to live an independent lifestyle without the assistance of others.

While in the past, seniors with physical or mental impairments had no other choice but to move to a skilled nursing home, today there are many types of living arrangement options that are available. These can include:

Retirement Communities – As the group of baby boomers who are retiring continues to increase, there are a number of new retirement communities being developed across the country. These living arrangements typically consist of apartments or condos for those who can live independently, and they oftentimes provide amenities such as swimming pools, golf courses, tennis courts, and a myriad of planned social activities.

Assisted Care Living Facilities – Assisted care living facilities are ideal for those who can do most things independently, but they may need some assistance with basic daily activities such as bathing or dressing. These facilities typically consist of apartment type arrangements with a common eating area and planned activities.

Continuing Care Retirement Communities – Continuing Care Retirement Communities, or CCRCs, are a relatively new type of living arrangement for seniors that consist of independent condos, assisted living quarters, and skilled nursing services, whereby the residents may move to different areas as their needs for care progress. These communities are ideal for seniors as they can stay in one area, even if they develop a need for additional assistance. These are also a great option for married couples as both individuals may reside in the same location, even if one needs a higher level of care.

In terms of expenses, in many cases, the cost of care in a facility or at home may be covered under a long-term care insurance policy. Today’s insurance plans have become quite flexible in their payment options for the many different care choices that are now available to seniors.

Be Prepared

Girlscoutth

As a boomer who married late in life, has no children, and who will probably outlive her husband who is older than she is and is presently battling cancer, I fall in the category of the 40% who will probably end up in a nursing home.  Well, maybe not since I have a community of friends who may pull together to create an environment where we can all age together, providing each other the social and emotional support we may need and pooling our resources to take care of our physical needs.

[by the way this picture is of a girl scout, not me, although I was a girl scout for a couple of years. I am using this picture to reflect the girl scout motto, "Be Prepared." That explained, back to my entry.....]

I am hopeful.  These friends have been very forthcoming and helpful with my circumstances with my husband.  Since we are all aging at the same time, we may recognize the need to be pro-active in preparing for our twilight years, which is the point of this article.

Mostly, we boomers, especially at this age, are not really thinking about the time when we may become more frail.  The fact is, we are very much not prepared for that time in our lives.  At this stage, we are probably loosing parents and possibly friends or spouses.  But we are still thinking about hiking with friends or traveling rather than being fed by somebody else or having a portable commode next to our beds.

But, and I can’t repeat this enough, now is the time to contemplate where and how we want to be spending those last years or months because NOW is when we can do something about putting everything in place.

According to presentations at the 4th Annual Symposium on Policy and Health, the complexities of family structures in today’s society does not lend itself to the traditional forms of caregiving for the elderly within the family units.  Presently, families perform about 75 percent of elderly care. This can be anything from running errands to full-time caregiving.  We are the group that is doing this caregiving.  But with the out of the box way we have proceeded with our lives,  we need to ask ourselves who will be taking care of us when we need that help?

Then there are the sub-groups such as the LGBT (lesbian, gay, bisexual and transgender) who may have a more difficult time with care in their more frail years.  Recent research suggests that LGBT seniors are more prone to isolation and psychological distress than their heterosexual peers. Researchers at the University of California Los Angeles’ Center for Health Policy Research reported in a study that half of Californian gay and bisexual men aged 50 to 70 live alone, compared with only 13.4 percent of straight men. More than one in four lesbian and bisexual women in California live alone as well.

Studies show that ethnic minorities rely on family members much more than their white counterparts.  But they are also less likely to seek outside help through social services or the medical establishment. According to studies provided by the American Psychological Association:

Studies show that ethnic minority caregivers provide more care than their White counterparts and report worse physical health than White caregivers (McCann et al, 2000). Several studies have found that African American caregivers experience less stress and depression and garner greater rewards from caregiving than White caregivers (Cuellar, 2002; Haley et al, 2004). Hispanic and Asian American caregivers, however, exhibit more depression than white caregivers (Haley et al, 2004).

Being boomers, we may end up causing a paradigm shift in how we approach our twilight years.  We may even affect how our society looks at the aging process.  We may develop creative ways of approaching support systems to serve our needs as we become more frail.  But unless we focus on this question now, we may end up in a nursing home, with strangers [sometimes -- when they are not being pulled in 20 different directions] responding to our needs.

Anyone for the idea of a Commune for the Aging?

Nursing Homes as De Facto Psychiatric Institutions

Assorted Medicine Pills in Caps

[Continuation of blog on anti-psychotic drugs for the elderly 2011]

“….within three months of admission, 70 percent or more of nursing home residents are on at least one medication with psychoactive properties and 15 to 20 percent are on four or more,” according to a study that was done by the University of Florida in 2010 and reported by Aging Today.  The study also noted that most residents who are admitted to nursing homes come without a history of either psychiatric diagnoses or treatment.

Although dementia does strike some older individuals as a “side effect” of aging, there is more and more acknowledgement that a lot of dementia-like symptoms are caused by the interactions of drugs.

According to a study done by the citizen advocacy group, Public Citizens, Worstpills.org (http://www.worstpills.org/includes/page.cfm?op_id=459):

“As people age, they become more susceptible to delirium and dementia** caused by drugs. This is known as drug-induced cognitive impairment, and it is an important syndrome to recognize….

Both in the hospital and office settings, drug-induced cognitive impairment is often overlooked [emphasis added] and attributed to an underlying medical illness or merely to “old age,” when it is actually a side-effect of a drug. In many cases, the reason for prescribing the culprit drug is questionable, or the cognitive impairment is related to taking multiple drugs at once.”

A study done in 1990 by Barry Rovner, et al which appeared in an issue of International Psychogeriatrics found that there was a high prevalence of mental health problems in nursing homes, so much so, that they concluded that nursing homes “can be viewed as de facto psychiatric institutions.”

Dr. Gary Oberlender, a Specialist in Geriatric Medicine, has done many evaluations of older individuals who have been diagnosed with dementia.  He concludes that:

“…..cognitive decline in a senior does not necessarily mean that the person has Alzheimer’s disease, or even that the person has dementia. There are many potential causes for why a senior might have memory loss, disorientation, trouble concentrating, loss of interest, or any of the other common manifestations of cognitive decline.

It is important to recognize that for many seniors, the ability to think clearly and maintain normal cognitive function is a very fragile thing. For some seniors, cognitive performance is the weakest link in their chain. It is the first thing to become impaired when faced with a stressful situation. Any physical, emotional, or even environmental stress can tip the balance and push them over the cognitive cliff.”

One can easily imagine the stress that an elderly person might feel when being moved from their home into a strange situation with strange people manipulating them physically (helping them change and bathe, cleaning them, etc.), surrounded by strangers and eating unfamiliar foods, having to follow a whole schedule that might be different from the one that they had been living.

Dr. Oberlender continues:

“Drug side effects or the onset of depression manifesting as cognitive decline are very common in seniors — more common than the general public or even many health care providers appreciate.

Other potential causes for cognitive decline in seniors include impaired hearing or not listening (these are two different things!); anxiety; vitamin B-12 deficiency; stroke or poor blood flow to the brain; thyroid disease; anemia; poorly controlled diabetes, hypertension, or heart disease; and inadequate nutrition.

None of these are causes of dementia but any one of them can cause a senior to experience significant cognitive decline and look for all the world as if they have dementia! Furthermore, almost all of these potential causes has the potential to be reversed,(emphasis added) which in turn would improve or totally reverse the cognitive decline.”

PSYCHIATRIC PROFILE OF NURSING HOME RESIDENTS

The Rovner, et al study found that there were  “three main categories of residents with psychiatric problems in nursing homes: Those with serious mental illness, those with dementia and behavioral problems, and those who are anxious or depressed.”  The last category, according to the study, is caused by “reduced functioning caused by medical problems and difficulties adjusting to nursing home life.”  Interestingly, there does not seem to have been further exploration done to see whether the second category, ie dementia and behavioral problems, might not be caused by the same reasons.

CULPRITS

There are three drugs regularly prescribed that have side effects that can cause dementia like symptoms:

Benzodiazepines:  These are tranquilizers and sleeping pills which are often prescribed for anxiety, to sedate chronically ill patients, or patients that are planning to undergo surgery.  They are highly addictive and there is a withdrawal that does occur if stopped.

“People who take benzodiazepines chronically for anxiety, which is not recommended, can also develop more chronic cognitive impairment. Furthermore, because addiction to benzodiazepines is common, stopping them abruptly can result in a withdrawal syndrome similar to what is seen with alcohol withdrawal, including sweating, agitation, confusion, hallucinations and even seizures.”

One can see that these combinations are in and of themselves not great but if a patient does not recognize that certain symptoms they are experiencing are being caused by the medication or from withdrawals by stopping the medication, they end up being caught in a cycle of pills and counter-pills to try and alleviate the symptoms.

Opiates: We know that opiates can cause delirium and fogginess of thinking.  They are used quite regularly to alleviate pain of any kind — from a sports injury to cancer.  As with Benzodiazepines, their effectiveness diminishes with use.  The response is to increase the dosage, which increases the symptoms.   Opiates can cause delirium and the more chronic cognitive changes seen in dementia.

Tricyclic antidepressants:  Although an older version of anti-depressant, they continue to be used for severe depression and also for pain symptoms, particularly neuropathy.

Since cognitive impairment symptoms are generally attributable to these three drugs, we need to ask how these drugs might affect an older person.

[Continue on Health Care or Mis-Care to come out next week]

© Yvonne Behrens, M.Ed  2011

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