Depression in the Elderly

By Estee Bienstock, R.N.

Depression affects more than 20 percent of our elderly population, aged 65 and older (U.S. Department of Health and Human Services, 2009). For many, depression presents initially late in life. Depression in older persons is closely associated with illness or injury and can cause great suffering for the individual and the family.

Feeling down from time to time, due to life struggles, is normal. Depression, on the other hand, is a REAL medical condition in which a person has feelings of sadness, loss of motivation, and lack of self-confidence. The feelings of hopelessness and helplessness prevent one from enjoying everyday life and affects overall daily functioning. There is a loss of interest, even in one’s family, friends, work or social activities. Depression is often described as “living in a black hole.” Getting through the day can be overwhelming.

There are many reasons why our treasured elderly family members experience depression. These include:

• Loss of a close family member (spouse) or friend
• Chronic pain or illness
• Difficulty with mobilization
• Frustration with memory loss
• Difficulty adapting to life changes (i.e., moving residence)
• Reaction to an illness
• Side effects of medication

Depression varies from person to person and the symptoms are varied. Women have a greater risk of depression than men. Women tend to have feelings of guilt. Deprivation of sleep is frequently a problem. Women tend to either lose weight or gain weight. When men suffer from depression, they often see it as a sign of weakness. They tend to be more aggressive, angry, violent and reckless. Men have a higher suicide rate. (U.S. Department of Health and Human Services, 2009)

Other symptoms people may have when suffering from depression include:

• Loss of interest in activities of daily living such as social interactions, work, family gatherings
• Pessimism
• Disturbed sleep patterns
• Irritability, agitation, and restlessness; loss of energy, feelings of fatigue
• Self loathing, feelings of worthlessness; frequent crying
• Decreased concentration, difficulty focusing, unable to make decisions,
  memory loss
• Headaches, gastrointestinal disturbances, muscle aches, and weakness
• Abnormal thoughts about death

Depression can be difficult to identify in the elderly and is often untreated because many people think that depression symptoms are a normal part of aging or a natural reaction to chronic illness, loss, or dramatic changes in social transition. Contrary to popular belief, depression is not part of the normal aging process. Many elderly people and their families do not recognize the symptoms of depression, are not aware that it is a medical illness, and are not familiar with treatments. It is natural to feel grief in the face of major life changes, such as leaving a home of many years or losing a loved one. Sadness and anguish, natural responses to major life changes, are normal, temporary reactions to the inevitable losses and hardships of life. However, depression is a medical disorder that continues for prolonged periods. Depression requires professional treatment to reduce the intensity and duration of the condition.

Deteriorating health, a sense of isolation and hopelessness, and difficulty adjusting to new life circumstances often combine to create untenable living situations for the elderly. Suicide in our elderly population far exceeds the general population as a whole.

Fortunately, the treatment prognosis for depression is good. Once diagnosed, 80 percent of clinically depressed individuals can be effectively treated. Medication is effective for a majority of people with depression and the elderly respond the same way. (Adams et al, 2007) Medications can be combined with supportive psychotherapy or cognitive behavioral therapy to improve effectiveness. Psychosocial treatment plays an essential role in the care of older patients who lack social support or lack coping skills to deal with their life situations.

Suggestions for activities for skill building with the elderly patient with depression include:

• Utilize music as a distraction from worries and an assist for relaxation; try it as a sleep aid before bedtime
• Organize interactions with pets as a relief from loneliness; ask friends or neighbors to visit with their pets regularly
• As a focus for new growth, assist the patient with nurturing a seedling
• Select readings as a stimulant for conversations about feelings
• Encourage reminiscence and sharing of recollections for posterity to increase feelings of self-worth

Caregiver skills that are important to nurturing our elderly patients with depression include:

• LISTEN
• Be patient
• Acknowledge the sadness
• Resist giving advice, but hone your listening skills
• Do not pass judgment
• Promote realistic expectations

Deteriorating health and advancing age present problems for the patient and their loved ones. Issues associated with depression can lead to family conflicts, even more isolation, financial strain, abuse of drugs or alcohol, and thoughts of suicide. Depression, left untreated, prevents elderly loved ones from enjoying life as they have in the past.

A strong support system is often helpful to both the caregiver and the senior person’s well being. Find sources of help for caregiver tasks. Contact family, friends, neighbors, church/synagogue, workplace, Area Agency on Aging or other organizations. Keep looking!

Family physicians can have a significant impact on the health and well-being of the elderly and their caregivers. Family physicians can educate caregivers on behavioral management techniques and coping strategies. By providing the holistic approach to care for patients and caregivers, family physicians can help prepare families for the many phases of this challenging role and allow the patients to feel safe with their dignity left intact.

Raleigh Geriatric Care Management, www.rgcmgmt.com

Is it Elder Abuse?

By Hilary Wright

Abuse isn’t happening just to toddlers and young children, but is becoming more common among the senior citizens in this country. Unable to take care of themselves, they must rely on a professional or family caregiver to help them from day to day. If you have a loved one who must depend on care from someone other than yourself, you may want to know the tell-tale signs of the many forms of abuse that they may be afflicted with. 

Sometimes, an elder may report an incident of physical abuse; however, they often won’t, so you’ll need to look for other behavioral and emotional signs, like depression or withdrawal from family and friends, changes in behavior, i.e., mood swings or appearing frightened and teary eyed. Sometimes, the abusers themselves will give clues to possible abuse by their refusal to take the elder to the doctor when needed, by not allowing family and friends to see the abused person alone, by giving explanations which are found to be inconsistent with the abuse symptoms.  They may have bite marks and scratches themselves, from an elder fighting back.

Signs of physical abuse:

• Cuts, lacerations, welt marks (a possible sign of using restraints)

• Burn marks from cigarettes

• Malnutrition or dehydration

• Hair loss from someone grabbing/pulling hair

• Sores on the body, open wounds

• Weight gain or weight loss

• Poor skin conditions

• Unexplained injuries, such as fractures and breaks

• Bruises, scratches, bite marks, finger prints

• Frequent trips to the emergency room

• Black eyes, broken fingernails

• Over or under medicated

As much as people don’t want to think about it, sexual abuse does occur among the elderly. It’s considered sexual abuse when something happens either without their consent or when an elderly person is incapable of making such a decision on their own. Physical signs of sexual abuse may include:

• Bruises around the breast or genital area

• Cuts or lacerations around the breast or genital area

• Clothes with blood stains or tear marks

• Soreness around breast, genital, or anal areas

• Difficulty with walking or sitting

Some older people may report sexual assault, while others may withdraw from family and friends, flinch at certain quick movements, or be frightened by the opposite gender. The abuser will usually have a story that will not match the physical or emotional evidence noted by family members, and they will generally not allow family or friends into the home or to be around the abused person alone.

Not all abuse can be seen with the naked eye. There’s also emotional and psychological abuse that occurs when a person is demeaning and dehumanizing to another person. Psychological and emotional abuse can also make someone withdraw into depression or even deny that anything bad is actually taking place. You may catch the abuser talking down to the person, calling them hurtful names, and begin to withdraw the elder from visiting with family and friends.

Behavioral signs of psychological abuse:

• Continuously emotionally upset or disturbed

• Nervous behavior and a repetition to their actions

• Negative attitude

• Agitation or anger

• Rocking back and forth, sucking their thumb, or even biting (themselves or others)

Financial abuse occurs when a caregiver takes advantage of an elderly person financially, either through stealing money, lying about how much the elder needs for certain care, or cashing the elder’s checks without permission.

Signs of financial abuse:

• Caregiver withholds money from the elder

• Checks are cashed without permission of the elder

• Personal belongings begin to disappear

• Power of Attorney begins to be misused

• Caregiver isn’t actually providing the services that are needed

• Elders aren’t taken to the doctor when needed

• You notice unusual items being charged on a credit card

• You notice the elderly person requesting a transfer of assets or funds

• There’s sudden and abrupt changes in a will

• They are not aware of where all their money has gone

• Suddenly, they are unable to pay their bills

• They are unable to buy clothes, food, and other necessities

• You notice withdrawals of a lot of money at the same time or within the same week

Another form of abuse is neglect and abandonment, occurring when an elderly person isn’t being cared for properly, like not being fed, bathed, or properly medicated.  Ignoring an elder is also considered a form of neglect and abandonment, because the caregiver refuses to give them any sort of care. The signs of neglect and abandonment can sometimes be noticed with a simple inspection of a loved one, where you may see things like untreated sores or bed sores, malnutrition and/or dehydration, unsanitary living conditions, or dirty bed linens and clothes. You may also notice a strong odor coming from a loved one, due to the lack of continual hygiene, or obvious weight loss or weight gain. Sometimes an elder will actually begin begging you for food, or tell you they have some medical or dental need that hasn’t been tended to.

Although it’s no excuse, caregiver abuse, either by a family member or by a professional, often occurs due to caregiver burnout, caregiver stress, substance abuse, emotional and mental issues of their own, economic conditions or living arrangements. This doesn’t mean that all caregivers are abusers, because very few are; but it’s better to be informed and educated for the safety of your loved one. If it’s a family member who is a caregiver for someone disabled or elderly, you can take some preventative measures in order to prevent it from occurring, or to at least notice it at the very earliest stages. Educate yourself on the signs and symptoms of caregiver stress; make sure the caregiver is receiving help from others, so they don’t have to do everything on their own, which can quickly lead to caregiver burnout; and investigate other living arrangements, in order to take an elderly loved one out of a toxic, ultimately unsafe environment. Elderly people don’t have to be a target for others, especially by those who are supposed to care for them. Older people can also take some important steps on their own in order to make sure they remain safe from abuse of all kinds:

• Don’t live with a family member who is or has been abusive in the past.

• Speak to friends often, especially when you feel as though you are being taken advantage of.

• Review your will. If changes are made, be sure it is because you want them to take place, not because of pressure from family members.

• Have friends and/or neighbors visit you often.

• Seek legal advice when making decisions.

• Have your Social Security or pension check deposited directly into your account.

• Speak directly to your attorney first before signing a Power of Attorney.

• Don’t sign anything until you’ve read it. If you have difficulty understanding the legal terms, make sure to seek out an attorney and have them explain it to you.

Older Adults and Alcohol

A national 2008 survey found that about 40 percent of adults ages 65 and older drink alcohol. Older adults can experience a variety of problems from drinking alcohol, especially those who: • Take certain medications • Have health problems • Drink heavily There are special considerations facing older adults who drink, including: Increased Sensitivity to Alcohol Aging can lower the body’s tolerance for alcohol. Older adults generally experience the effects of alcohol more quickly than when they were younger. This puts older adults at higher risks for falls, car crashes, and other unintentional injuries that may result from drinking. Increased Health Problems Certain health problems are common in older adults. Heavy drinking can make these problems worse, including: • Diabetes • High blood pressure • Congestive heart failure • Liver problems • Osteoporosis • Memory problems • Mood disorders Bad Interactions with Medications Many prescription and over-the-counter medications, as well as herbal remedies can be dangerous or even deadly when mixed with alcohol. Medications that can interact badly with alcohol include: • Aspirin • Acetaminophen • Cold and allergy medicine • Cough syrup • Sleeping pills • Pain medication • Anxiety or depression medicine Drinking Guidelines for Older Adults Adults over age 65 who are healthy and do not take medications should not have more than: • 3 drinks on a given day • 7 drinks in a week Drinking more than these amounts puts people at risk of serious alcohol problems. If you have a health problem or take certain medications, you may need to drink less or not at all. Source: NIH National Institute on Alcohol Abuse and Alcoholism

Laughter is the Best Medicine

By  Helen Hunter, ACSW, LSW

When was the last time you had a really good laugh? The scientific definition of laughing is a “successive, rhythmic, spasmodic expiration with open glottis and vibration of the vocal cords, often accompanied by baring of the teeth and facial expression”. That doesn’t begin to tell the story of what laughing does for us, however. The bottom line is that laughing is medically beneficial. Laughter establishes or restores a positive emotional climate and a sense of connection between two people. In fact, some researchers believe that the major function of laughter is to bring people together – the more social a person is and the more social support a person receives, the more likely that laughter will result from that social connection. Mutual laughter and play are an essential component of strong, healthy relationships. By making a conscious effort to incorporate more humor and play into your daily interactions, you can improve the quality of your relationships. What are the Physical Effects of Laughing? Laughing makes people feel good for a reason. Studies have shown that laughter boosts the immune system and triggers the release of pleasure-inducing neurochemicals in the brain. The immune system, which contains special cells that are responsible for defending the body against infection, have been shown to increase during the act of laughing. In the central nervous system, the brain releases powerful endorphins as a result of laughing. Endorphins are natural, morphine-like compounds that raise the pain threshold, produce sedation and induce euphoria (commonly called a “natural high”). In other words, we feel better when we laugh because endorphins reduce physical and mental pain. While this may be a wonderful feeling, laughing has other benefits as well: During a laugh, respiration, heart rate and blood pressure temporarily rise. This causes oxygen to surge through the bloodstream that then results in lower blood pressure. Laughter improves the function of blood vessels and increases blood flow, which can help protect against a heart attack and other cardiovascular problems. Laughter reduces pain and allows toleration of discomfort. Laughter reduces blood sugar levels, increasing glucose tolerance in diabetics and non-diabetics alike. Laughter relaxes the whole body, relieving tension and stress. It has been shown that following a good, hearty laugh, muscles in the body are relaxed for up to 45 minutes afterward. Laughing burns calories – laughter is sometimes referred to as “inner jogging”. A hearty laugh gives the muscles of the face, chest, shoulders, stomach and diaphragm a good workout. Laughter also helps to create a positive mood. It allows the expression of happiness and the release of anxiety. Humor eases tension and is a great antidote to a stressful situation. Laughter is often seen as a temporary vacation from everyday problems, bringing us to a paradise in which worries do not exist. Humor and laughter are natural safety valves that shut off certain hormones that are released during stressful situations. In fact, your sense of humor is one of the most powerful tools you have to make certain that your daily mood and emotional state support good health. Here are some ways to bring more humor and laughter into your life: Smile: Smiling is the beginning of laughter. Like laughter, it’s contagious. When you look at someone or see something even mildly pleasing, practice smiling! Count your blessings: Literally make a list. The simple act of considering the good things in your life will distance you from negative thoughts that are a barrier to humor and laughter! When you hear laughter, move toward it: People are very happy to share something funny because it gives them an opportunity to laugh again and feel the humor in it. When individuals hear laughter, they seek it out and ask “What’s funny?” Spend time with fun, playful people: These are people who laugh easily, both at themselves and at life’s absurdities and who routinely find humor in everyday events. Their playful point of view and laughter are contagious!! Bring humor into conversations: Ask people: What’s the funniest thing that happened to you today? This week? In your life? Laugh at yourself: Share your embarrassing moments. Attempt to laugh at situations rather than bemoan them: Look for the humor in a bad situation, the irony and absurdity of life. This will help improve your mood and the mood of those around you. Surround yourself with reminders to lighten up: Keep a toy on your desk or in your car. Put up a funny poster in your office. Choose a computer screensaver that makes you laugh. Frame photos of you and your family having fun. Keep things in perspective: Many things are beyond our control, so make the best of a situation and find the positive in the situation. Deal with stress: Stress is major impediment to humor and laughter. Pay attention to children and emulate them: They are the experts on playing, taking life lightly and laughing!! Here is a simple prescription for a healthy life: Thirty minutes of exercise at least 3 times a week, and 15 minutes of laughter on a daily basis!! The bottom line – laughter may just be the best medicine on the market today!

Who’s Most Likely to Feel Caregiver Stress?

~Paula Spencer Scott

Does caregiving actually cause stress? Some surprising new research says no, the real source of the stress lies within the person, not the situation.

After looking at more than 1,200 female caregiving twins, Peter Vitaliano, professor of psychiatry and psychology at the University of Washington, concluded that how stressful caregiving is for you psychologically is more a matter of your genes and your upbringing. Caregiving itself does not cause stress, he says. This new study appears in the Annals of Behavioral Medicine.

Who’s most at risk, according to this research? People who:

• Have a history of depression. “Like putting salt in a wound,” says Vitaliano.
• Grew up with parents who showed a lot of avoidance and fear in response to big stressors (like losing a job).
• Lack resources to help them cope, like social support and finances.

The study also found that caregiving can cause anxiety, which is in turn linked to depression.

This all may sound like splitting hairs. Though this research confirms Vitaliano’s earlier work debunking a causal connection between caregiving and stress, it flies a bit in the face of many, many other studies that link them. There’s even a name for it: caregiver stress syndrome.

This study didn’t specifically look at Alzheimer’s caregiving, whose duration and unique challenges can wear down even the best-adjusted family member. I wonder, would the results look different?

Bottom line: It doesn’t strike me as terribly helpful to be told your stress is the fault of your genes or your family history. If you’re feeling it, you’re feeling it. It’s nobody’s fault — the real question is what to do about it.

File this info in the nice-to-know category. Then go hide in the bathroom for a little deep breathing, a few bites of dark chocolate, and a wish for some respite time to come your way this week.

Should You Tell a “Fiblet” to a Parent With Dementia?

From our earliest days we are taught never to lie, especially to our mother or father. However, a recent survey of aging experts reveals that telling a “fiblet” can actually be therapeutic when adult children are faced with telling painful truths to aging parents who have a cognitive impairment such as Alzheimer’s disease.

The National Association of Professional Geriatric Care Managers (NAPGCM) recently surveyed 285 professional geriatric care managers about the most common and difficult situations faced by families who are helping aging parents. Geriatric care managers help these families deal with some of the most sensitive and challenging issues.

More than 90 percent of the professional geriatric care managers surveyed said they have used or recommended the “fiblet” strategy to relieve stress and anxiety and protect the self-esteem of an elderly person. The situation cited most by experts in the survey as an appropriate and helpful use of a “fiblet” is when a senior is refusing clearly needed care or assistance at their home. For example, telling an aging parent with Alzheimer’s that a paid caregiver is coming to their home for their spouse’s benefit or for another concrete role can help the elder maintain pride and reduce anxiety.

The following were identified by care managers as situations when it can actually be therapeutic to tell a “fiblet” to an aging parent:

• When they are refusing needed care and assistance at home. Telling them the caregiver is there for their spouse’s benefit or for another concrete role can help them maintain pride and reduce anxiety (identified by 83 percent of those surveyed).
• When they can no longer safely drive, yet insist on doing so. Telling them their car is in the shop getting repaired can reduce confrontations (68 percent).
• When knowing the cost of in-home care prevents them from accepting the needed service (68 percent).
• When it would only cause worry and stress to tell them about family problems they can’t solve, e.g., unemployment, financial upheaval, divorce, drug abuse, incarceration (64 percent).

According to the National Institutes of Health, as many as 5 million of the 43 million Americans age 65 and older may have Alzheimer’s disease, and another 1.8 million people have some other form of dementia. Americans feel increasingly challenged by the need to communicate difficult information to aging family members with dementia.

“A therapeutic ‘fiblet’ is just that—it is therapeutic because it calms and reassures, reduces anxiety and protects self-esteem,” said NAPGCM President Emily Saltz. She added, “You would use a ‘fiblet’ only with parents who have a cognitive impairment such as Alzheimer’s disease.”

Geriatric Care Managers Share Their Experiences

As part of the survey, geriatric care managers were asked to provide comments about their own experiences in recommending the use of a “fiblet.” A universal theme of the comments was that family members should navigate this clearly delicate area with help from a support group or from an experienced professional care manager. Care managers also stressed that one should only use a “fiblet” to protect and support a family member rather than for personal benefit or gain.

The following are from among more than 200 stories collected through the survey about geriatric care managers’ experiences of using a “fiblet” in the course of their practices:

• “I’ve used therapeutic ‘fiblets’ in many instances, but probably (most often) when the death of a loved one is beyond a person’s capacity to understand. For example, if a person is looking for a deceased loved one, I tell them that I haven’t seen that person today but when I do, I’ll tell them that the person is looking for them. This serves to validate their experience and provide reassurance that someone cares.”
• “When an adult son was diagnosed with cancer, the decision was made to not inform his frail, memory-impaired nursing home-bound father of the diagnosis. At the same time, the son increased his visits to his father during treatment, as he had more free time available for visits. The son and father enjoyed more time together without stressing the father with a scary diagnosis.”
• “A client wanted to see their mother who had passed away many years ago. Instead of telling her that her mother had died and causing her to grieve again, we told her she was out and would return later. She accepted that and went on with her day.”

Source: The National Association of Professional Geriatric Care Managers (NAPGCM). NAPGCM was formed in 1985 to advance dignified care for older adults and their families. Geriatric care managers are professionals who have extensive training and experience working with older people, people with disabilities and families who need assistance with caregiving issues. For more information, visit http://www.caremanager.org. –

Raleigh Geriatric Care Management in Raleigh, NC  www.rgcmgmt.com

Spouses Who are Caregivers

by Kathy Birkett

Family caregivers usually are fulfilled by their choice in life to provide much needed care for a loved one who needs that care.

Often we begin caring for our children and then seem to naturally progress to our parents, grandparents or in-laws who may have entered a phase where some level of care from others is required.

It may be something that begins in a small way, such as bringing them food now and then or helping with things around the house. It can quickly progress to more and more tasks and supervision, all the way up to hands on care.

Sometimes, despite all our care and best efforts, it becomes necessary to transition our loved ones in a facility where they can receive more skilled care than we can provide.

Aging in place is a goal for most of us and our senior loved ones and we as caregivers try to do everything we can possibly do to help them make this dream a reality. We will help them create the right living environment with simple modifications and big renovations or even finding a more appropriate home in which to age in place.

Caregivers’ Challenges

Unfortunately, every day is not always the best day. There will be harder days than others, crises that arise along the way including injury and hospitalization. Let’s not forget the occasional (or all too frequent) disagreement about even the littlest thing that soon gets smoothed over when we remember why we are all together.

Caregiver burnout is a reality that we all face. Getting an extra hand, recognizing that we can’t do it all by ourselves day in and day out, can help. Finding respite when you can and an outlet for your feelings will help you be a caregiver longer and better.

I recently came across an interesting poll that found caregiver stress has increased from an interesting source.

Caregivers Who Are Spouses

The Associated Press – NORC Center for Public Affairs Research recently published the results of a recent poll that asked approximately 1400 family caregivers questions resulting in some surprising answers.

They found that most Americans are counting on their families to provide care for them as they age, as they have been doing themselves for other relatives or friends. Unfortunately, not many of us are planning well for our own long term care. We can readily tell you where and how we want our funeral to happen and probably have already made plans and payments for that but we can’t tell you about our goals for day to day care before that happens.

We can’t talk about what kind of a facility we might consider, where we would want to get help, what our care wishes would be, and more importantly have probably not executed any advance directives stipulating our wishes.

This poll found that eight out of ten people found caregiving to be a positive experience but one that is also extremely difficult.

The most stress is being reported by spouses who are now caregivers — not children providing care to parents or grandparents as might be thought. Spouses did promise to care for each other in sickness and in health but find this promise to be stressful to deliver.

Struggling Spouses

Spouses express the struggle that they experience when their relationship changes from companion to caregiver. They deal with not only stress but anger and frustration. It can be hard when hands-on care over grooming, feeding, wound care and other duties are taken on that were once done by nurses now are their responsibility.

While some spousal caregivers report that their marriage is strengthened by their caregiving commitment, which is a welcome outcome in the face of other stressors, spouses were more likely to report that caregiving weakened their relationship with their partner and placed an added burden on their finances.

It is reported that only about 30 percent of those over 40 who may be likely to care for a loved one in the next five years feel prepared to do so. Spouses tend to be older caregivers than those caring for parents and that could make the caregiving more physically challenging as well. The average age of a spousal caregiver is 67, compared to 58 for those caring for parents.

How to Identify and Overcome Caregiver Stress

If you begin to recognize signs that you are having what could be an overwhelming amount of stress that could be harming your health or ability to care for your spouse then it is time to take action.

• Recognize signs of stress – being tired all the time, having difficulty sleeping, feeling unappreciated with no one to talk to or care about you, feeling depressed or hopeless, not ever feeling like there is a good day, feeling like your own life is not worth living, being ill yourself, crying often or you begin isolating yourself from others.

• Begin taking time for yourself – sometimes you need to call someone to give you an hour, an afternoon, a day or a weekend off. There are people you can call, such as family members, volunteers from faith based organizations, organizations, home health agencies or friends. Just being alone, taking a breather, shopping, lunch with a friend, sleeping late or seeing a movie can mean a lot to your personal and emotional well-being.

• Get a medical checkup – schedule a doctor visit for yourself. Get your preventive health checkup or immunizations to help keep you well. You can’t help others if you are not well.

• Talk to someone – go to a support group locally or online, talk with a member of the clergy, find a friend, or keep a journal so that you can express your feelings and allow yourself to move on past those feelings.

Being a caregiver whether to your spouse, mother, aunt or grandfather not to mention caring for your own children and household will always cause moments of stress. Remember the importance of what you do every day. You are right where you are supposed to be!

Being able to recognize, though, that burnout might be lurking but you can overcome it in order to be the best caregiver possible is the first step in staying well. One smile is all the thanks you need to provide the love and care your spouse or family member needs.

Raleigh Geriatric Care Management in Raleigh, NC  www.rgcmgmt.com

Long Distance Caregiving

Carol O’dell

If you’re a long-distance caregiver, then you know the drill. You call all the time. You coordinate care from 400 miles away. You spend long weekends or vacation time visiting your loved one and hoping before you open that door that they’re OK. Worry comes with long-distance caregiving, and so does guilt, but you try really hard to make it work — and you dread the day that won’t be enough.

You are not alone. According to a recent Caring.com poll, nearly one-third of all caregivers do not live with or, in many cases, even near their loved ones. Here’s a look at a few challenges long-distance caregivers face, and tips to help manage care from afar.

Feeling emotionally connected to your family members.

Sometimes phone calls or visits filled with doctor appointments and home chores don’t allow for heart-to-heart talks. As much as there is to cover, make the time to just sit for a few minutes and allow a natural conversation to emerge.

Set up a weekly phone-chat date for the times that you’re apart. Have it at a time when you both can look forward to it and nothing competes. After you discuss some of your “to-do” list items, begin to share something personal about your own life. Ask their advice on something — anything — from the color shoes you should wear to your cousin’s wedding to whether you should get a bigger car. Let them feel as if they’re a part of your life as well.

Getting shut out.

Many long-distance caregivers, particularly those helping someone with moderate to severe dementia, find that their visits actually aggravate their loved ones — who are confused and want to “go home” or don’t understand why you keep calling them “Dad.”

Remind yourself that you’re not just there to visit. You’re there to make sure Mom or Dad are being cared for properly. (Having a loved one with moderate to severe dementia increases the likelihood that he or she is living in a care facility.) Stay out of sight if you have to, but visit the staff, have lunch in the cafeteria, and walk the grounds. Talk to the people your loved one interacts with to find out how he or she is doing. It’s painful not to be able to connect, but remember that you’re still needed.

Knowing your loved one is safe and appropriately cared for.

Audrey Adelson, author of “Long-Distance Caregiving,” writes, “Often, long-distance caregivers obtain important information from their elder or secondhand from family members who have spoken with a member of their loved one’s treatment team. This makes it difficult to get a clear understanding of what is really going on.” How do you stay in the loop when you’re not in the area?

How to manage? By having lots of eyes. Whether you coordinate care for your loved one in his or her home or an assisted living facility, start to connect with those who interact with your loved one. Call after an appointment and ask how it went. Let them know you plan to be involved, and be sure to send a thank-you card or friendly e-mail.

Managing insurance and financial needs or making sure you can trust those who do.

Trust is a big issue for long-distance caregivers. When you don’t have people who genuinely care for your loved one and communicate with you about what’s going on, then you begin to worry, and worry, and worry.

Take the time to find professionals who can assist you and your loved one. It’s worth the time and effort. Hire an elder law attorney to make sure their financial assets are protected, or check into local resources designed for seniors and their family’s needs.

Make a plan for whatever comes next.

Long-distance caregivers dread getting “the call.” Whether it’s from a concerned neighbor or from the ER at 4 a.m., it’s difficult to know what to plan for when anything could happen. Try to laugh (or scream, or sob) when all of your planning and hard work takes a dive and you have to come up with a new plan. Change is inevitable, and when we fight that it that causes us pain.

Play “what if.” Come up with the three possible scenarios — a fall, a worsening of a condition or ailment, or a refusal to move even when that’s needed. How will you handle it? Can you go ahead and do some online searches? Can you connect with other caregivers and ask how they handled a big change and ask how it’s going now? It’s easier to face the “what ifs” when you know that somehow, some way, you will get through.

Being a long-distance caregiver comes with challenges you never thought you’d have to face. Sometimes you have to let go, just a little, of all that you can’t control. Caregiving isn’t easy, and there aren’t always solutions, so grab your rearview mirror the next time you’re in your car and look at yourself and say, “You’re doing the best you can.”

For a loved one living in Raleigh, NC, contact Raleigh Geriatric Care Management to assist with your family member. www.rgcmgmt.comRaleigh ,NC

Remember the Studebaker? Reminiscing as Therapy for Your Parents

By  Paula Tchirkow, MSW, LSW, ACSW

Not again? You’ve heard that story about Sunday trips in the big black Studebaker at least 100 times. But you sit politely as your elderly mother recalls her grandfather’s rumble seat, running boards, chrome grill and overflowing picnic basket. It’s likely that your mother has not forgotten that she told you the story before. And she’s not just shooting the breeze or living in the past. Your elderly parent is bolstering her self esteem by reminiscing. Like many older adults, she is engaging in an important psychological process called “life cycle review,” and it’s healthy. Encouraging an older adult to reminisce is one of the easiest and most effective techniques you can use to boost their confidence and brighten their mood. In fact, it’s virtually foolproof as a method of combating mild depression or loneliness. Go ahead, give it a try. Next time the Studebaker story comes up, engage your mother. Ask her how many people fit in the car? Did it have a rag top? How fast did it go? What were the roads like back then? And what exactly was in that picnic basket? The vivid connection to a time when your mother or father felt more alive, happier, successful, and useful reassures them that they weren’t always in their current physical and mental state. Reminiscing helps older adults review past accomplishments and activities, thereby giving them a renewed sense of fulfillment about their life. Although most people tend to focus on good memories, life cycle review can also help older family members become comfortable with the past. That is, the technique gives older adults an opportunity to admit and accept the parts of their lives that didn’t go as well as expected. Both the reckoning process, and the acknowledgement of happier times, clears up minor depression, reverses feelings of isolation, and helps parents get back into a rhythm of positive reinforcement that boosts physical and mental well being. To be sure, the benefits of storytelling and review are greatly underestimated. To discover how valuable life cycle review can be for older adults, here are 10 tips to help you get the process started: On your next visit, quickly survey the home for an object to spark a conversation. For example, a cookbook may start the person talking about a favorite recipe or holiday. A piece of antique furniture, nick-knacks, old records, needlepoint projects, a piece of clothing, even a dish towel has worked as a catalyst for conversation. Visit the attic. If you’re not having luck with the items that are in plain view, don’t be shy about taking a trip to the attic or basement to dig out old photos, cards and letters, maybe a wedding dress. Personal props such as these can trigger a flood of memories and conversations. Use scents. Without fail, certain smells bring back memories almost instantaneously. That may be because the sense of smell is the most primitive of our senses, and the last to fail. Even older adults suffering from advance stages of dementia usually respond to smells, albeit not verbally. For instance, their eyes may brighten or a smile may appear when they get a whiff of cinnamon, wildflowers, fresh baked goods, peppermint, or coffee. Create reminiscing cards. Browse magazines, newspapers, or the Internet to find images of items that you know will prompt a conversation, such as scenes from the Depression Era, amusement parks from a parent’s childhood, places they visited on vacation. Paste the pictures onto pieces of cardboard and build a catalog of visual aids. The cards can be use by family members or healthcare workers who look after your parent. Don’t shrink from the unhappy memories. Recounting less-than-perfect events can be cathartic. Reflection doesn’t always have to be rosy, and often unlocking long-forgotten disappointments is uplifting. It’s a way for older adults to get worn-out burdens off their chest. For instance, you may hear from an older widow, that if she had to do it all over again, she would not have married her husband. They key is to let people freely express doubts and fears about the past, and validate—don’t judge—those feelings. Interestingly, and sort of magically, we all become less inhibited about expressing feelings as we get older. So don’t shut out the more sobering events for fear that it might depress your parent – the exercise will likely raise their spirits. Do it on the phone, in person, or on the Internet if your parent is computer savvy. These reminiscing sessions can take the form of a 15 minute phone conversation; an hour-long respite over tea, maybe a look through a photo album after Christmas dinner. There is no set length of time or frequency that is ideal. The amount of time you spend recollecting is case specific, and usually depends on the attention span of the older person. Encourage in-home health aids or the staff at healthcare facilities to use the technique too. It’s a great alternative to stale topics, like the weather. For parents that live in care facilities, create a personal history poster to hang over their bed. In that way, healthcare workers can refer to the poster when they visit the room. Include things like your parent’s nickname, former profession, how they met their spouse, the names of their children, grandchildren and pets, hobbies, favorite movies, songs, or books, towns and cities where they lived, or any other piece of personal trivia that will guide the staff into a rewarding conversation. Aside from prompting conversation, the fun facts help the staff envision your parent as someone other than a frail or stubborn resident. Assemble a scrapbook. For parents that can physically handle this task, it’s a great way to organize memories and start a new hobby – one that can be shared by the whole family. Include photos, ticket stubs, fabrics from, say, a wedding dress, newspaper clippings, recipes, and other homespun memorabilia. For parents that are unable to create a scrapbook, adult children can put it together, and keep it handy as a conversation starter. If you’re making a scrapbook for parents with advanced Alzheimer’s disease or dementia, keep the book short and simple. Allow your parents to reap the physical benefits. Recollecting good memories, and dropping old burdens, has a positive physiological effect on older adults. Research shows that sparking these memories causes blood pressure and heart rates to drop, essentially producing a calming effect. (Pet therapy produces the same effect.) Document the past for the future. There’s something in life cycle review for everyone involved, especially future generations. Photos and scrapbooks are often considered family treasures, but new generations of archivist are using audio and video tapes as well. Use new technology it to capture a little bit of your family’s past, just make sure you hang on to the right playback equipment or your memories could be lost – remember the fate of eight-track players?

A sibling’s guide to caring for aging parents

BY BONNIE LAWRENCE

Caring for an aging parent alone is complicated. When your brothers and sisters are also involved, and when care, medical and financial decisions must be arrived at together as a team, caregiving can become even more complex. Your siblings can be enormously helpful and your best support. But in many families, they can also be a source of stress. No two families are ever alike.

In this column, we’ll talk about how to identify the family dynamics that can impact shared caregiving, ways your siblings can help, how to increase your chances of getting that help, and how to deal with emotions that arise.

A visit home. Often, around this time of year, adult children returning home for a visit realize for the first time that their parents are far more frail than they expected. Although Mom or Dad always report they are “just fine” when you make those weekly phone calls, during a visit, you realize that this is not the case. Your parents suddenly seem much older, and you see the memory lapses, or shortness of breath, wavering balance, multiple prescription containers, or other signals of waning health.

Reactions differ among your siblings. Perhaps your sister, who lives two hours away, is angry that her mother is not the source of emotional support she used to be and doesn’t want to accept what she sees; your brother, who lives across the country and only gets home once a year, is stunned by changes he didn’t expect.

You and your siblings talk in whispers about what should to be done to ensure Mom’s safety and care. There is no money for assisted living, even if your mother would agree to it. Someone needs to step up, to see what can be done, to make decisions, to find some help, or even to live with your Mom to keep her as safe and healthy as possible. And it’s determined, often by default, that one person — perhaps the one who lives the closest, or doesn’t have kids, or is the oldest — will take on the role of primary caregiver.

Why sibling tensions can surface as parents need care

People are living longer — but not necessarily in good health. Their adult children may be caring for them for years or even a decade or more. Siblings or step-siblings are coping with a major emotional passage that stirs up childhood feelings and conflicts. But it’s made more challenging when there’s no model for working together as a team to handle the practical, emotional and financial issues that go with caring for someone who is no longer able to be independent. Some families are able to work out differences; many others struggle.

Consciously or unconsciously, needs arise for love, approval, or being seen as important or competent as a sibling. The disagreements now are over care for your parent: who does or doesn’t do it; how much; who’s in charge. At the same time, your parent is very aware — and most likely not happy — that he or she has become so dependent on you.

To help your family navigate through this situation, we offer this advice:

1. Think about, and talk about, family history and dynamics, and how they might affect caregiving. When we get together with our families, many of us tend to slip into our old roles. Maybe one person was the “responsible” one, one was the “social” one, one was the “helpless” one. But do those roles define you today? And more importantly, can you take a fresh look at who your siblings are now in the context of how these roles and assumptions can affect care for your parents?

2. Consider that care for a parent is a shared responsibility. A key concern is who will be the primary care provider(s) and what support other family members can provide. Since this is a role that can progress to more than a full-time job, this is an important decision. Rather than letting assumptions become default decisions (e.g., Barbara is oldest so she will be in charge, or Max needs a place to stay, so he’ll take care of mom), really consider who is most able, willing, skilled, and emotionally prepared to fill this role. Then consider what other family members can contribute in time or money.

3. To help reach the goal of effective shared decision-making, hold a family meeting. Family meetings are a way for siblings, parents and other concerned relatives or friends to try to clarify the situation, work out conflicts and set up a care plan that, ideally, all can agree upon. If the meeting is likely to be contentious, or if you want an experienced, objective voice to guide it, involve a facilitator such as a social worker, counselor, geriatric care manager or trusted outside party who will ensure that all participants have a chance to be heard. You may need more than one meeting. And although emotions might run high, it’s possible to conduct a productive meeting by following a few guidelines:

• Set an agenda for the meeting and keep to it.
• Focus on the here and now. Try not to bring up past or unrelated issues.
• Share your feelings with siblings instead of making accusations.
• Listen and respect the opinions of all participants. Give everyone time to speak.
• Share all information. If possible, get a professional assessment of your parent’s condition from a doctor, social worker or geriatric care manager and send the report to all participants before the meeting.
• As time goes by, use email, online care-sharing tools, conference calling and/or in-person family meetings to help keep everyone abreast of care issues and information.4. Understand and respect that your brothers and sisters might have different ideas about the care your parent needs. It’s hard to accept that your parent now need your help. Unless there’s a sudden crisis like a stroke, adjusting to this new reality takes time. Some adult children have to work through their denial that anything serious is wrong. Others might feel reluctant to get involved, fearing they are “meddling” in their parent’s life.

  Yet, to the primary caregiver, the person who is present day-to-day, it’s clear that his or her parent is less and less able to handle everyday needs. They see that Mom requires assistance with grocery shopping and cooking, that transportation and bill paying are problems, or advancing memory loss or fading eyesight or painful joints keep her from normal activities. Her needs are evident and most likely will become more intense.

  Working through differences: communication plays a critical role.

• If you’ve held family meetings, everyone concerned should have a clear idea of the medical status of your parent. Focus on the facts.
• REALLY listen to what your siblings have to say. Be willing to compromise and to try new solutions, as long as no one’s safety is jeopardized.
• For the doubters, it may be helpful for them to spend a weekend or even a day as a sole caregiver, to get a first-hand view of the issues.
• Be straightforward about financial issues. Finances are a key component in long-term caregiving, affecting where your parent lives, whether paid outside help is available, whether placement in a facility is a suitable or desirable option, or whether home care is manageable with family support. Overseeing bill-paying and dealing with Medicare and other health care bills is a job in itself, and can be delegated as such.
• Let your siblings know that their help is needed and wanted (if, in fact, it is — see below). Be direct and specific about what tasks you need help with. Even if they live far away, siblings can help with finances, can provide virtual companionship to your parent with frequent phone calls and Skype, or can provide occasional respite or substitute care.
• Keep communication lines open.

Tips for gaining the support of your siblings

• Accept your siblings for who they are. Not everyone thinks, feels or acts the same way, especially when a situation is this emotionally charged. Try to keep your own expectations and expressions of “should” in check, and instead, strive to accept and work with your siblings’ personalities and abilities.
• Be aware of how you ask for help. If you’re angry and frustrated when you’re talking with your siblings, it will come through in your voice. Their reaction will be defensiveness or anger. Likewise, making siblings feel guilty may lead to resentment and tension that will not be productive in solving the problems at hand.
• Figure out what you really expect from your siblings. Do you think they should provide more hands-on care? Help with errands? Visits? A day or week of respite? Financial support? Help with decision-making? Analyze whether you’re able to give up control to allow a sibling to help you, or if you’re unconsciously communicating that you don’t trust the care that someone else provides.Some caregivers really don’t want help, or can’t rely on help from siblings who are undependable or unavailable. If you’re in this situation, admit it to yourself, accept that you’re on your own, and work to make the care as efficient as possible while still attending to your own health and well-being. If other relatives or friends are willing, ask for help from them or from religious communities your parent might have been involved in. Check for resources in your community. When people offer to help, say yes.
• If what you really want is recognition and appreciation from your siblings for all that you do, you can ask for that. (You also need to express your own gratitude when you do get some help.)
• Seek advice from someone outside the family. A mediator, social worker or geriatric care manager may help get past long-standing emotional roadblocks, family competition, controlling behavior, denial, or other issues interfering with successful resolutions.

Conflicts over legal, financial and inheritance issues.

With Durable Powers of Attorney or an Advance Health Care Directive, your parents can designate who will be in charge if they become incapacitated. Sometimes this creates tension among the adult children. If at all possible, this should be discussed at a family meeting and clarified for everyone concerned. An advance directive will outline the types of care that your parent desires at end of life. With this information in writing, a difficult situation is made a little more tolerable.

Some families compensate the primary caregiver for their work, particularly if he or she has cut back on employment to care for their parent. How much the compensation is and who pays it can be covered in a Personal Care Agreement, which is a written contract. This can be reviewed periodically to ensure it reflects any changes in care.

If an inheritance is in question, or if someone feels they should get a larger portion of an inheritance because of their caregiving duties or other reasons, this is another source of potential conflict. Be aware that your parent’s will is his or hers to direct as they like, and is not necessarily representative of who was the “good” son or daughter or who did more or less for their parents.

Sharing care among siblings is a reality that millions of Americans manage on a daily basis. By taking steps to foster positive communication and support one another as much as possible, the challenging role of providing care for elderly parents can be a fulfilling, rewarding experience, which ultimately can bring siblings closer together.