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July 2006
In this Edition:
Transitions, Changes and Losses
Summer is a time of change. Many of the changes are the wonderful milestones that we look
forward to in life. Graduations, marriages, long leisurely summer vacations…these are the
joyous pictures of spring and summer. Even happy occasions have their challenges: our beautiful
daughter is now someone's wife (how can that be?); our only son dares to move 2000 miles away
to start his career! Change can be hard even when it is the very thing for which we have waited
and carefully planned.
However, there are also changes and transitions that challenge us to cope with the very meaning
of life. The loss of a parent or friend, the move to a residential care community, the loss of
function caused by physical or mental health concerns can all lead to undiagnosed grief reactions
and depression in older adults.
Depression is one of the least well diagnosed illnesses in the older population, that is often
triggered by transitions, changes and losses. This is true for many reasons including:
- Ageist attitudes (what do you expect at 86?)
- More isolation (due to the loss of family and friends, and sometimes the ability to drive)
- Loss of role and status in society and the family
- Loss of function that may be caused by physical limitations
- History of undiagnosed depression
So, how can we help our elders to cope with the buffeting they take in later life caused by
both natural changes and society's lack of readiness to meet their needs? Families play a
huge role in the health and wellbeing of our elders. Even long distance families can play
a significant role in helping to mitigate the challenges of transitions and losses for our
loved ones.
What do older adults need to help them through the grief process that accompanies all losses
and changes? Here are some helpful hints that families can use to create a customized
plan to combat the losses that accumulate in later life:
Create a sense of belonging.
- Even when family is far away, staying connected is important. Attempts to share the daily
lives of families (the good and the difficult) can keep the elder connected;
- Share pictures of family events;
- Ask the elder to share stories and history of similar events from the past;
- Family heirlooms that are passed along should come with a story to create a sense of history
and connection between the past and the future;
- Help the elder to create an ethical will in which they describe the things in life that have
been important to them and that they want future generations to understand;
- Preserve family recipes or traditions with the help of the elder;
- Work on a family tree with the elder's input; or
- Create your own new traditions that will help the elder to feel connected and part of the
current family and the future
Give them back some power in the family.
- Listen to what they have to say about their lives and their personal history. You may have
heard it before, but this time really listen to the lessons and not just the facts;
- Ask them for their ideas and input, even when you are going to make your own decisions.
Let them know that their wisdom is meaningful, even when you disagree;
- Include them in decision making about their own lives. Even if someone no longer has the
ability to make decisions on their own, there should be a process of discussing the future, so
that changes feel more like a natural progression than a shock;
- Include them in discussions with healthcare professionals. One of the things that doctors
tend to do is to speak about the person as if they were not in the room. Write down your
questions together before you go to the appointment. Write down the answers that you get, so
you can discuss it later. Check with the elder to determine if they understand what the
physician is saying and to see if they have other questions;
- Don't make changes to their home environment without including them in decisions about
changes. Home is our most intimate environment and changes without our permission are not only
an invasion of privacy, but a challenge to our dignity and self determination;
- Recommend ideas for safe and healthy living, but respect the limits and the risks that the
elder may wish to take. Often times, elders can cope with greater risks than their family members
can. We need to respect that in all adults.
Treat them like adults.
- Give them the respect and the freedom to make choices about where and how they live.
Again, even when there is some dementia and impaired decision making ability, there needs to be
a process of "desensitizing" the elder to the impending changes.
- Help them to make good choices about their lives, relationships and health care by involving
them in discussions about options and consequences.
- Give them the responsibility for the outcomes of their decisions;
- Allow them the dignity of privacy and intimacy even when you don't respect their choices;
- Encourage discussion of negative or difficult feelings, without needing to provide answers
or a "fix" for their problems. Sometimes venting and creative expression can do more to help with
coping than all of the "fixes" in the world;
- Learn just to be there with them as a fellow traveler without imposing requirements or
expectations for specific performance.
These are perhaps difficult ideas to implement. They take time. They take thought. They take a new way
of thinking about and relating to our elders. However, the cost of buying into the ageist attitudes
that allow our elders to flounder in their losses is even greater. Relating to elders often does take
more time than we think it "should." So we need to change our mind set and prepare ourselves that each
activity may take twice as long as it takes. If we approach relating to our elders with a more open
and patient mind set, we are likely to find that it is a better time for everyone.
When you cannot do these things on your own, a healthcare professional, such as a care manager can help
you to implement some of these ideas. By respecting the accumulated experience and wisdom of our elders,
we place them in a role that helps them to play the role of true elders in teaching, inspiring and leading
us. We can help them to bridge the past and the future and enrich our own lives, while enriching theirs.
Happy transitions, changes and a healthy, peaceful summer to all!
Surviving Losses
George was a 95 year old, single man when he was facing the loss of his two closest relatives and
friends. He didn't think he could survive these overwhelming transitions, but with the help of his
care manager he continues to thrive despite his grief.
In the past 2 1/2 years, George lost his brother-in-law and then his sister. They were a very close
family that traveled, socialized and finally settled as a trio in Florida. Apart from his sister
and brother-in-law, George who had never married had few friends.
The brother-in-law was the first to die and George became depressed because he and his sister,
who had dementia and functional limitations, depended totally on him. The brother took care of his ailing
wife, he cooked, shopped and paid all the bills for the three of them. The brother also had a great
sense of humor, which helped everyone to cope with their stressful caregiving responsibilities.
Although there was an aide to help with the physical care of his sister, George felt incapable of
supervising her care and this increased his anxiety.
George's depression wouldn't allow him to eat and he couldn't stop crying. He was totally overwhelmed
by his grief and anxiety. Even the aide couldn't get him to eat.
Fortunately they had an attorney, who was also their Trustee who contacted Rona Bartelstone Care
Management & Home Healthcare for support in caring for George and his sister. During the initial
home-visit it was determined that George needed counseling and an antidepressant. It was further
recommended that his sister have 24 hour home care to assure her physical safety and wellbeing. This
was started immediately, and quickly gave George a little relief because he did not feel so alone in
his new caregiving responsibilities.
With weekly emotional support from Sandy Goldberg, the care manager, George began to eat better and
his depression was helped by the medication. The care manager also provided support and guidance to
the aide in caring for his sister, which further helped George to be reassured that she was getting
the best possible care.
Unfortunately, the sister's dementia worsened and she was beginning to have some behavioral problems.
As a result of this she fell and fractured her hip and shoulder. She was considered too frail for
surgery and after six months in a rehabilitation facility, she also passed away.
With this second crisis, the care manager provided additional support to George to help him through
this new acute phase of his grief. The care manager worked with the physician and a psychiatric nurse
who was adjusting his antidepressant medication. An appetite enhancer was also added because he was
again experiencing difficulty getting enough nutrition.
With the support of his medical healthcare team, the care manager and the aide, who continued to work
with George, he was able to cope with the loss of his sister without becoming ill. He knew he was being
well cared for and had a sense of stability with all of the care and emotional support that was being
provided. This time, instead of becoming immobilized, George was able to participate in making the
funeral arrangements for his sister and helped to discard the belongings of his sister and brother-in-law.
George still has home healthcare from his trusted aide. He is functioning better and more independently now,
including taking responsibility for his own medical appointments. He continues to find the support of the
care management relationship as a stabilizing influence in his life. He and Sandy Goldberg have a great
rapport and this provides George with a feeling of having a surrogate family, which he desperately needs
for his mental health.
George is a perfect example of the power of the care management relationship in times of loss and transition.
This relationship has enabled him to remain as independent as possible, to reside in the community and to
cope with his losses.
Transitioning from Illness to Health and to a New Home
In February, 2006, Linda Gaibel, LCSW, CMC, did a consultation for two sons who were
concerned about their 92 year old father, Mr. Brown, who was recently hospitalized
for congestive heart failure and a bladder infection. While he was in the hospital
for a week, his 87 year old wife seemed to be showing signs of dementia by acting
very confused. Through Rona Bartelstone Care Management & Home Healthcare, the
son who was in Orlando, FL arranged for a full-time home health care aide to be
with his mother and also requested a geriatric care manager to help with planning
for the future and supervision of care for both parents. The other son and his wife
also live in Florida, closer to the parents, but they were overwhelmed by the current
crisis. The sons along with Mr. & Mrs. Brown were planning to move to a retirement
community in North Carolina in May, and wanted the care manager to evaluate the parents
to help determine if the couple would be able to manage the move and adjust to the
new environment.
Linda Gaibel, the Care Manager, began seeing Mr. & Mrs. Brown on a weekly basis for
evaluation and supportive counseling soon after Mr. Brown returned home from the hospital.
Mr. Brown was frail and needed physical therapy to fully recover. Mr. Brown was very
involved in his health care, he was mentally alert and was always reading about his
various medical conditions, which included diabetes.
The home health aide provided by Rona Bartelstone Care Management and Home Healthcare was
a good match for this couple and they were very grateful for her help. They also related
well to the Care Manager and used the weekly meetings to talk about their anxieties
concerning moving from their home in Florida where they had lived the past 20 years
and making a move to the retirement home in N. Carolina. Their home is near the ocean in
South Florida and had sustained hurricane damage during the storms of the previous summer.
This, along with the fact that one son and his wife would be moving from Florida to a new
home very near the retirement home in North Carolina was part of the motivation for their
relocation.
In the first few meetings with the Care Manager, Mr. Brown did all the talking. It soon
became apparent that Mrs. Brown had a serious hearing problem. With the help and guidance
of the Care Manager her daughter-in-law took Mrs. Brown to an audiologist and after a
period of adjustment to the hearing aides, she also became more verbal during the meetings
with the Care Manager. Mrs. Brown had been wrongly diagnosed with dementia and it was the
Care Manager who helped the family to realize that it was very a serious hearing impairment
and not a cognitive decline that caused Mrs. Brown's initial confusion. Imagine the sense of
relief that the entire family experienced, knowing that Mrs. Brown's situation had a
relatively simple solution and was not the beginning of a long degenerative decline!
Both Mr. & Mrs. Brown were very committed to one another and expressed concern for each
other in supportive ways. They were both hopeful about making a new beginning in North
Carolina, and were able to air their anxieties in a helpful way with the Care Manager, so
that it did not negatively impact their relationship or their expectations.
Mr. Brown developed some insight to realize that that he would sometimes become irritable with
his wife when he was not feeling well. With this insight he was able to be more aware of his
behavior and try to become more considerate toward his wife when he was feeling stressed. This
insight also helped his wife to realize that this was not a personal attack and it enabled her
to cope better when he wasn't feeling well.
The sons requested the Care Manager work with the admissions person at the retirement community
in North Carolina to assess the level of care that the Brown's should move into at the new residence.
It was mutually determined that the assisted living section would most closely meet their joint needs.
Mr. Brown recovered sufficiently to make the move with his wife and son in May, 2006. Both he and his
wife were grateful to the Care Manager for her support during this transitional time. They were happy
about making the move to North Carolina and looked forward to living in a new, social setting. The
Care Manager was able to help them realize that they could draw on their strengths as social, outgoing
people to facilitate their beneficial adjustment to the structured activities at the retirement home.
Since the Browns seemed to be quite limited when they were first met by Linda Gaibel the Care Manager,
this relationship felt especially successful because they went from seemingly very frail back to health
and to a new beginning in a wonderful new environment.
Staying Involved after Placement: Tips to Ease the Transition
Placing a loved one into a care facility is often a very difficult and traumatic
experience for a caregiver. It can cause a sense of loss, sadness, emptiness or
even a sense of failure. Far from being a failure, a placement is often the
healthiest way for someone to continue caring for their loved one, while also
assuring their own health.
Since we have been talking about transitions, here are some helpful tips for
smoothing the initial move into a new facility. Going through a process of
educating the elder and the facility will help everyone to make a better
adjustment, when it is deemed time for this type of transition.
- Help the staff to know more about your loved one by providing them with
a brief life history and some pictures, prior to the move. That way, staff
can express an interest in the new resident as a whole person with a full
life.
- Alert the staff to food preferences, allergies, and medication sensitivities
and be sure this is put on the resident's permanent clinical record.
- If you know that there are times of the day or activities that are more
difficult for your loved one, tell the staff about the lessons that you have
learned for coping with these specific situations.
- Tell the caregivers about the routine, personality and history of your
loved one. For example, if someone is meticulous about his/her appearance, ask
the staff to take an extra second to put on the right shade of lipstick or to
match the sweater to the rest of the outfit. A resident who was a truck driver
was only happy when he had a fistful of car keys. Of course, he couldn't go
anywhere, but this small detail made him feel whole.
- Provide the staff with the things you learned about what calms and comforts
the resident. One resident had a teddy bear that was her symbol of comfort,
and without it she cried incessantly. A former dancer was always comforted by
show music.
- Create a ritual to say goodbye to the old home and to welcome to the new
home. If religion is important hang a cross or a mezuzah or some other important
spiritual symbol. Buy a housewarming gift. Hang pictures.
- Move during the week when there is more staff on duty to help with the details
and to provide emotional support.
- Make a point of introducing the new resident to the staff, other residents and
the environment. You may need to do this several times.
- Once the resident is settled, the family needs to be able to leave, so that the
resident can begin to make the adjustment.
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