By Guest Writer: Ruth Rogers

Every year, many senior citizens have a fall.  Not all of the falls are devastating, but many of them are. Falls can cause broken or fractured bones, loss of motor function and independence, and even death. Unfortunately, many people just accept this as a normal aspect of aging. Fortunately, there are many ways to prevent senior citizens from falling so they can maintain their independence.

There are many reasons that falls increase with age. To begin with, failing eyesight can cause a person to misjudge stairs and curbs, even when they are in a familiar location. Regular eye checks and screenings will alert you to issues with your loved one’s eyesight and help to keep them safe. Wearing  glasses is another way to prevent falls from poor eyesight. Even though your loved one might only be walking from their bed to the bathroom in the middle of the night, make sure to remind them to turn on the lights and put on their glasses.

Another way to prevent falls from vision problems is to remove trip hazards throughout the house. When caregiving, remember to check the home thoroughly for dangling cords or clutter that might be dangerous.

Even small changes like eating a better diet can help eyesight. Dark leafy veggies, fish oil, and vitamins E, A, and C are perfect for protecting  eye health.

Exercise is another way to reduce eye problems. Hardening of the arteries can lead to high blood pressure which can affect eyesight. Diabetes is another risk factor for reduced eyesight. Exercise can help with heart disease risks as well as circulation problems, which can greatly reduce the associated risk of sight loss.

Smoking is the second largest reason for the development of macular degeneration, so quitting smoking now will not only do wonders for the heart and blood flow, the skin tone and a lessened risk of cancer, but will also lower their risk of damage to your eyesight.

Balance exercises are also encouraged to lessen the risk of a fall. Have your loved one try balancing on one foot and then the other for a few moments.  Make sure that there is a table or chair nearby in case they are a bit wobbly, but you will find that just a little bit of practice will help to restore their balance and to safeguard you from a dangerous fall.

The process of aging is already tough on the eyes as they are less able to produce tears and the lenses are not as clear as they once were. Focusing can become difficult and sensitivity to glare increases. All of these factors add up to the increased risk of a fall and it is vital that your loved one does all that they can to preserve their eyesight so that they can avoid a fall.

Look for a family practitioner or general practice physician to be the primary care physician for your loved one. General and family practitioners are trained to treat all aspects of a person’s health and well-being even though they have not specialized in a specific field. They treat the elderly as well as newborns, children and adults for everything from a splinter to a more serious illness.

Health Insurance Coverage

Choosing a doctor can be based upon several factors. One of the first aspects to look at is whether or not the patient’s health coverage is accepted by the physician being considered.  Most physicians will accept Medicare but it’s important to determine whether or not they will accept Medicaid and/or the supplemental policy if one is available.  If the doctor will accept the health coverage, the next thing to look at is accessibility.

Location and Accessibility

It is important to choose a doctor whose office is located close enough to be easily accessed for routine care and emergencies. If the elderly loved one is homebound, a physician who understands this and is willing to work around this detail to provide care is ideal.

Physicians can order home health nurses to draw blood, administer injections, take vitals signs and other basic medical procedures then report to the doctor. These procedures would normally be done at the doctor’s office, but when dealing with a homebound patient, getting them into the office may be a problem.

In addition, when transporting an elderly homebound loved one, distance to the doctor’s office can play a part in the convenience of the location. Determine if the time spent driving and the distance to and from a doctor’s office makes the doctor in question an acceptable choice for your loved one’s needs. If the doctor requires that your loved one must been seen at the office frequently, then distance can be an important factor when choosing the physician.

Office Hours

When choosing a doctor there are a few important questions about the doctor’s schedule that you should ask. What kind of office hours does the doctor hold? Do they have evening or weekend hours? How can you get in touch with them when the office is closed? Are the physicians who cover the “on-call” hours acceptible to you?

Hospital Choices

Most doctors have privileges at specific hospitals. When choosing a doctor, it is important to find out which hospital or hospitals the doctor has privileges at. This is the same hospital the patient would go to for emergency care, tests and surgeries in most cases. The size, location and reputation of the hospital may play a large role in your decision to choose or not choose a specific doctor.  Some towns and cities have specialty hospitals for certain conditions.  If your loved one has a condition that is treated by one of these specialty hospitals, it is important to determine if the primary physician has priviledges there.

Personality

Even the most qualified and credentialed doctor may not be the best choice for your loved one’s personal physician if their personality clashes with yours. You’ll probably want to choose a doctor that you genuinely like and feel comfortable with. Remember that you will need to be working closely with this person to advocate for the best health care for your loved one.  Imagine my surprise when I asked my father’s physician if he might be discharged in the afternoon only to hear him say “What part of HE WILL BE DISCHARGED TOMORROW MORNING did you not understand?”  However, there are also surgeons that I have worked with in the past who had terrible bed-side manners yet they are the ones with whom I would have trusted my life.

Choose a doctor who will take the time to speak with you as you advocate for your loved one’s health care. The doctor should be willing to listen to your concerns and answer your questions to your satisfaction. Remember, you are hiring them and paying them for their time.  The days of the primadonna physician OUGHT to be over.

Another consideration is the physician’s staff.

Do you like the physician’s staff? Are the doctor’s employees personable, respectful and pleasant? If you find receptionists, nurses and other staff members to be rude, then perhaps you should consider other physicians. These are the people you will be working with to schedule appointments, update prescriptions and access patient information. If you find them difficult to work with initially, it might improve over time but don’t expect it to automatically occur.

Ask the doctor if they have a Family Nurse Practitioner or a Physician’s Assistant in practice with them. These medical professionals assist doctors in caring for patients in many private practices. Decide if this is acceptable to you for your loved one’s care. If not, then you may need to continue looking or specify in the patient records that care must be provided by the doctor.  Keep in mind though that Nurse Practitioners and Physician’s Assistants generally have more time to spend with the patient and are trained to be patient advocates.  They are also often more accessible.

Making the Choice

After taking all of these factors into consideration, decide which physician you would like to care for your loved one. Schedule a new patient appointment and commit to making the new relationship work.

It wasn’t until I began looking at them as a means of respite care placement for my father that I learned of their costs.  In my father’s case, the daily respite cost was $220 but the monthly cost would have been over $5000.00 for a semi-private room.  This rate did not include medications or transportation to medical appointments. (Rates seem to vary between $4000.00 and $7500.00 per month depending upon the residence.)   None of these facilities accepted Medi-Care and private insurances don’t cover such things.  A couple of them stated that if a person were 2 guarantee private payment for 3 years, then they would not “evict” the resident once their money was gone.  At that time, they would then accept Medicaid reimbursement. 

Recently I have read several articles about assisted living facilities being available mostly in areas of higher income.  In areas of lower income, rural areas and in areas where minorities live (and all 3 of these are equivalent to areas of lower mean income), there are less available assisted living facilities.

In a study at Brown University, a conclusion was made that hispanics would be more likely to use nursing homes than assisted living facilities because they at more likely to be at the lower end of the socio economic scale and did not have the money.  Because of lack of money, they were more likely to be placed in nursing homes with less than desirable facilities, receiving less than adequate care which sent them back to the hospital and began a downward spiral.

I think that another reason that there are fewer assisted living facilities in areas where hispanics live is that their culture has the tradition of elder care being handled by the adult children of the family in a home setting.  My best friend’s mother took care of both her mother and aunt in her home until she was physically unable to do so anymore.

Assisted living facilities vary tremendously; they can contain a myriad of amenities and consist of private apartments with a nurse on duty 24 hours a day or at the other end of the spectrum, they can be closer to a nursing home environment with semi-private areas that consist of 2 beds in a room with a television set.

Assisted living homes are not the right choice for everyone.  Unless a facility has a special unit  (and many are opting to include these), dementia patients should not be placed there.  Sometimes patients have medical conditions that are too complicated for this type of living arrangement, as well.

Nursing homes don’t have much variation.  In MY words, they are simply sad places where lonely people live out their final days. 

In between, there are skilled nursing facilities, but in most instances, these are temporary placements until the “patient” can either be returned home or to a more permanent placement in a different facility.

I’m concerned about what will happen when the aging population runs out of money to pay for these expensive assisted living homes.  At between $ 50,000 and $90,000 per year, who will be able to live there long?  Our elders were a little more prepared but I don’t believe that the baby boomer generation has prepared themselves well enough to be able to cover even a year of living there.  And now that many boomers are upside down on their mortgages, selling their home won’t help to pay for that care.  Not many of us have long term care insurance either. (And in reality, how can long term care insurance continue to exist when almost ALL of us will need it at some point?)

I also think that with health reform, more families are going to be responsible for the care of their elders.  Hospitals will discharge elder patients sooner and before they are able to care for themselves.  This is happening even now !  I literally had to beg that my father be admitted to help remove the 12 pounds of fluid that had accumulated in his legs due to congestive heart failure.  Sure…..they’ll put a defibrillator in an 86 year old man with dementia (because insurance will pay for THAT)  but when it comes to managing the care of that man post procedure, they’ll leave it to the family.   (And they won’t discuss end-of-life care…but that’s a whole other issue.)

Already, a big portion (17% of employees in south Florida, according to a recent study)* are having to leave the work force in order to care for their aging loved ones and another 15% have cut their hours. 

During the past year, as we have experienced a financial crisis, more family members are gathering together under one roof in order to make ends meet.  Do you think that we will return to the days of Leave it to Beaver and Father Knows Best where Moms become the caregivers for the family while Dads return to providing the financial contribution?

In a study reported by Deborah B. Gentry, it was determined that nearly 40% of adult children acting as caregivers had serious conflicts with one or more siblings regarding the care of their parents.  Many times, this was due to the lack of participation of one of the siblings, arguements over finances or disagreements on where Mom or Dad should live.  With a help of a mediator, these issues can be sorted out in a private, non-threatening setting where the family (including the parents) meets together.

Eldercare mediators have taken classes in this type of mediation.  They may be nurses, social workers, gerontologists or they may also be attorneys themselves.  (If they are attorneys, they do not practice law during the  mediation service.)

What does an eldercare mediator do?

• they are a neutral 3 rd party who helps with decision-making processes
• they help clear up misunderstandings within the family by knowing the right questions to ask
• they provide for expression of feelings and yet, keep the family on tract
• they help the family heal hurts, avoid blame and self-pity
• they help the family consider as many options as possible
• they provide for future modification of the decisions made

Mediators do NOT:

• Make any of the decisions themselves
• Provide family therapy
• Practice law

Who is involved in the meeting?

• Parents and siblings should be present.  The meeting may also include spouses, grandchildren, other close relatives, close family friends, caregivers, medical providers, pastoral leaders and lawyers.

What is discussed at the meeting?

This is up to the family members but some ideas for discussion include living arrangements and possible assistance for the parent(s), driving ability, end-of-life provisions, financial concerns, trust and estate issues, division of responsibility amongst the siblings, etc.

The advantages of hiring a mediator are that parents (or spouse) must give permission for the meeting to take place, thereby maintaining their dignity and autonomy by being involved as much as possible.  Also, if help is needed, financial and task responsibilities can be divided up equally among the children (siblings) or a care contract for a sibling that volunteers to be the primary caregiver can be discussed.  Obstacles are more easily overcome when using a mediator who can keep the family focused on the goal of caring for the parent (or spouse) in the best possible way.  Family relationships are also improved because everyone is kept in the loop.  Those siblings who are unable to attend due to physical constraints can participate by telephone or even on the internet.

The cost of an eldercare mediator is about $100.00 – $300.00 per hour but is a good investment in maintaining or building family unity and working to provide a good outcome for your aging parent(s) or loved ones.

Eldercare mediators can be found through state and local Area Agencies on Aging, attorneys specializing in elder law, geriatric care managers, Alzheimer’s Association (especially support groups) and the health department.

Ironically, I know exactly what I didn’t know in my dream.  I know that I have a lot of guilt over the circumstances of his death .  He wasn’t treated well at the hospital; I HATED seeing him propped up in a chair.  I wasn’t there when he passed away in the middle of the night.  Nobody was.  I wish I could change that and therefore I go over and over it in my mind, trying to rewrite the past but realizing that it is impossible to do so. 

According to Dr. Vickie Rackner, author and keynote speaker, “Guilt is a pain that tells you there’s a mismatch between the person you’d like to be and the person you were in that moment.”  At “that moment”, I would have liked to have been the person who stayed at the bedside 24/7 and the person who KNEW to argue for hospice care and kept my father at home .  I regret that I wasn’t.

Dr. Rackner also states that regret and guilt are distant cousins.  Certainly they are related because regret often leads to guilt.

In the book, “The Emotional survival Guide for Caregivers” by Alexis Abramson, Barry J. Jacobs, PsyD states that when a loved one dies, guilt is the 2nd most predominant feeling in a former caregivers’ experience.  There is guilt that they didn’t do enough, guilt that they are now “free” of the burden of caregiving, guilt that they have their own life back.  This guilt can last 6 months or even longer. It comes and goes but is eventually replaced by the knowledge that the disease process and God’s plan were the biggest factors overall.

Guilt is a part of all aspects of caregiving.  Caregivers are often overburdened and torn between what they need to accomplish for their employer, their spouse, their family and their care recipient.  What was NOT accomplished often leads to feelings of guilt. ( I missed the soccer game; I missed spending quiet time with my spouse; I ran in, dropped off groceries, and ran out of my Mother’s house without stopping to chat at length.)  When I was caregiving for my father, I would often feel bad that I didn’t make the time to sit with him and play cribbage or watch T.V. as often as he wished I would.  There was just too much to do.  We DID play Cribbage at least 2 hours almost every night but as he always said “I have all day !”  He did; I didn’t.

Anger can also lead to feelings of guilt.  We feel badly about being angry that we are stressed, overwhelmed, over-worked, tired, etc., so then we feel guilty which leads to anger back to guilt and more anger….a never-ending circle.  Guilt will also cause us not to take care of ourselves, perhaps because we believe we don’t deserve the care  – which of course, will lead to anger, to guilt…and you get the picture.

In order to get rid of the guilt, it is important to acknowledge that feelings are JUST feelings, nothing more.  You must forgive yourself for your imperfections.  You are only human and no human is perfect.

While you cannot change events or all of the activities in your caregiving role, you CAN change your feelings about them and you may be able to change some of the actual activities themselves.  For instance, if you are finding it difficult to have any quality time with your care recipient because you are too busy doing chores, hire some of them out.  (If expense is a problem, The Area Agency on Aging has a scholarship program for a certain number of hours per month where caregivers can do light housework).  (Meals on Wheels may be available in your area to deliver some hot food to your loved one or perhaps your church may have a program.) When you are able to spend some time with your loved one, you can get to (RE)know them better, and enjoy them.

In the last couple of years, there has been a lot of talk surrounding the book The Secret and the laws of attraction.  Part of that philosophy involves a change in the way you look at the world and your role in it.  You CAN change the way you perceive your caregiving role from one of burden to one of gratitude for the experience.  Changing your perception will cause you to (consciously or subconsciously) change your actions in order to align the two with each other.

You must remember that it is absolutely imperative to take care of yourself and to continue to enjoy life.  Do not feel guilty about those things that you do just for yourself (I’m speaking in moderation, of course).  They will make you a happier person to be around. Do not become a matyr; it does nobody any good. 

So how does this all relate to my dream and my feelings of guilt ?  As I thought it through, I decided that I did the best that I could with the knowledge that I had at the time, so I forgave myself .  I had cared for my father in my home up until the last week and a half of his life and I am proud and grateful that I was able to do that.

With the holidays approaching, I wanted to mention something else that Dr. Vicky Rackner stated.  “Consider giving yourself a holiday gift.  Forgive yourself for one choice that brought you guilt.  Forgive one other person for one action that disappointed you.  Forgive the world for the bolt of unfairness that stood between you and an old dream.”

I hope that you can do that.

Gary’s article can be found immediately below.

“Coumadin^®, available generically as warfarin, has been widely used to reduce the risk of stroke for well over 50 years. Dwight Eisenhower, Richard Nixon and George Bush senior were all taking Coumadin during their active years of former Presidency. Despite millions of prescriptions written annually for this medication, practical, easy to use information remains a challenge.

One of the most common and historical needs of managing warfarin is diet, specifically, dietary vitamin K. Physicians use warfarin to increase the bleeding time in patients at risk for developing unwanted blood clots. The goal is to prolong the bleeding just time enough to prevent clot formation where it isn’t needed (the heart and lungs for example) but allow clotting to take place for normal blood vessel bleeding repair. While warfarin prolongs your bleeding time, dietary vitamin K increases the body’s natural ability to form clots.

The simple blood test called an INR test measures that active anti-clotting effect of warfarin. The higher the dose of warfarin, the more potent or longer the blood takes to clot. A diet high in vitamin K can reduce the effect of warfarin and lower the number of the blood test result. For this reason, it is important for patients to keep a consistent intake of dietary vitamin K to help maintain safe levels of protection warfarin provides without interfering too much.

It is difficult to monitor vitamin K intake when food and beverage labels do not provide this information and the FDA does not require it. While professionals teach vitamin K is abundant in leafy green vegetables – there are many hidden sources patients and their care givers need to know about. Salad dressings and some mayonnaise are good examples.

The vitamin K registry

An easy to use, extensive vitamin K database is available for patients and their family. The vitamin K diary allows you to simply type the first few letters of a food or beverage you’re interested in and a menu of products is displayed listing the serving size and the amount of vitamin K. The vitamin K registry can help you keep balance and choice in your diet. A printable version is also available to assist in creating grocery lists for the Coumadin patient.

The vitamin K diary

The vitamin K diary is an interactive resource for patients or caregivers to keep track of vitamin K intake. While using of the vitamin K registry as a source guide, the vitamin K diary allows the user to record the vitamin K (listed in micrograms) consumed for each meal. The diary, offered as a word document, calculates the total daily and weekly intake of vitamin K. The vitamin K diary is best used 7 days prior to the patient’s blood test to best evaluate the effect of diet and shared with the patient’s healthcare provider.

For other helpful resources on maintaining your quality of life, visit www.PTINR.com  ”

With that in mind, we must be proactive in trying to reduce the odds of delirium occurring when our aging parent or loved-one becomes a hospital patient.

By taking the following ten steps, you may be able to reduce the risk of delirium:

1. Bring  a complete list of all medications (and their dosages), as well as a list of all over-the-counter medicines to the hospital with the patient.  It may help to bring the medication bottles as well.
2. Prepare a “medical information sheet” listing all allergies, names and phone numbers of physicians, the name of the patient’s usual pharmacy and all known medical conditions. If you have any reports such as CT scan results, recent lab tests or notes from a recent doctor visit, bring those too.
3. Bring glasses, hearing aids (and extra batteries), and dentures to the hospital. Older persons do better if they can see, hear and eat.
4. Bring in a few familiar objects from home. Things such as family photos or favorite photos in an album, a pillow, a favorite comforter or blanket for the bed, rosary beads, a beloved book and relaxation tapes can be quite comforting.
5. Help orient the patient throughout the day. Speak in a calm, reassuring tone of voice and tell the patient where he is and why he is there.
6. When giving instructions, state one fact or simple task at a time. Do not overwhelm or over stimulate the patient.
7. Massage can be soothing for some patients, but remember that for others, it can be over-stimulating. 
8. Stay with the hospitalized patient as much as possible. During an acute episode of delirium, relatives or perhaps friends should try to arrange shifts so someone can be present around the clock.  If family is not close, and it is affordable, ask about having a “sitter” present. 
9. If you detect new signs that could indicate delirium — confusion, memory problems, personality changes — it is important to discuss these with the nurses or physicians as soon as you can. Family members are often the first to notice subtle changes.
10. Find out more about delirium. The American Psychiatric Association’s “Patient and Family Guide to Understanding and Identifying Delirium” is available on line.

Adapted from The Hospital Elder Life Program 2007

I also wanted to introduce you to the QAS website because they have some great teaching articles about vitamin K (a vitamin that should be limited when receiving Coumadin therapy) and also about some other medications that should be avoided during therapy.  He will discuss those more in later posts.

So without further adieu……

There is good news for patients taking Coumadin^® (warfarin)!

The good news for patients, family members and those who care for a loved-one taking Coumadin® (warfarin) came March 19, 2008 when Medicare announced coverage for patients to test their blood in the privacy of their home. The policy extends benefits to Medicare beneficiaries who have been taking warfarin for at least 90 days for any of the following reasons: atrial fibrillation, mechanical heart valve replacement, or venous thromboembolism (DVT/ PE).  

What is patient self-testing?

Patient self-testing allows patients taking warfarin to test their blood at home with a small finger-stick sample of blood – not too different for diabetic patients who check their blood for insulin levels.

Coumadin^® is a medication that requires a small sample of blood to measure the effect of prolonging the bleeding time designed to prevent dangerous blood clot development. Medicare and many private insurance company’s provide reimbursement for up to, but not more frequent, than weekly home testing to reduce bleeding risks.

Home INR testing however, requires a physician’s prescription for one of the FDA-approved, small, hand-held monitors and for testing supplies. The monitor and testing supplies are not available in retail pharmacies but can be obtained through specialty distributors such as Quality Assured Services, Inc. (QAS).  QAS is a Medicare and private insurance company that distributes, trains, and communicates patient’s home test results to the patient’s physicians.   

Who is a candidate for home INR testing?

Patients who are motivated, with a desire to improve their control of warfarin and reducing the risk of side effects are good candidates for home INR testing. The test is simple to perform by the patient or a caregiver.

How home INR testing works

Home INR testing enables patients to test more frequently than monthly, in the comfort of their home, resulting in better warfarin control and therefore improved safety. Home testing results may be phoned in through a secure 800# provided through the distributor of the monitor. Testing strips are shipped directly to the patient’s home at no additional charge.

Weekly testing is a testing frequency that has been proven superior in clinical studies. Testing weekly evaluates the effect of patients: diet, overall health, metabolism of Coumadin^® and interaction of other medications. Patients or care providers simply phone each home test result into their physician’s office or online service.

How to get started

Patients or caregivers can have many of their questions answered by visiting home INR testing. Specialty pharmacy providers such as QAS, Inc. provide full-service assistance including insurance, clinical and technical support at no charge to the patient.