You’re not alone in feeling stressed caring for your mom. Many adult children these days are struggling to make sure their parents are safe at home. There are supports out there. Please try the following:

1. Contact the Texas Health and Services Commission at http://www.hhsc.state.tx.us/Help/HealthCare/seniors.shtml Depending on your mom’s financial situation she may be eligible for Medicaid, which would provide some help in the home.
2. Contact the Texas Department of Aging and Disability Services at http://www.dads.state.tx.us/services/index.cfm Ask them to direct you to services and supports in your town or city. There may be social work services in the area that can help with planning. Please ask about their adult day care programs
3. If your mom is having difficulties walking, then try to have her assessed by a physical therapist. The physical therapist can recommend the proper grab bars, shower chairs, raised toilet seats and other assistive devices that will make your mom safer in the home. A hospital bed may be appropriate and in some cases they are covered under Medicare.
4. When you contact the Texas Department of Aging and Disability please ask about support groups for caregivers as this may be helpful to you in managing your mom’s care.
    

A back-up plan is very helpful so you are not stressed when you are ill and can go on vacation knowing everything is in place. Here are some things I would recommend:

1. If you are not the Power of Attorney for your mom, please make sure that you and your husband are named. An attorney in your area can help you with that. You may want to consider adding one of your cousins as a backup.
2. There are many grocery stores that have online ordering and delivery. Please check in your area.
3. If your mom will allow all of her bills to go to you directly, that may make it easier. You can still review with her in person what has been paid. Paying bills directly online also makes things easier if you are comfortable with online banking.
4. If you would like to know that you have a professional on call when you go away I would suggest contacting the National Association of Professional Geriatric Care Managers. You can call 520-881-8008 or go to the website http://www.caremanager.org/contact/ to find a professional in your area. A Geriatric Care Manager can act on your behalf if your mom has an emergency while you are away.
5. Please look at your state’s office on aging: http://www.michigan.gov/miseniors/0,4635,7-234-43295_43600-165937--,00.html. There may be additional support services.
    

In general, there are no hard and fast response time requirements for an asisted living facility. The definition of what constitutes asisted living versus a nursing home varies from state to state. However, upon admission, most assited living facilities require the resident to sign a contract assuring the facility that they will provide (either through the facility or independenly) for additional care that may be required in the future if the need for help increases after admission. It may be that your mother requires a higher level of care than the assisted living facility is able or prepared to provide at this point in time. If that is the case, shame on them for not discussing this with you and helping you to explore better options. If your mother likes where she is, you may consider hiring a personal care assistant to stay with her. If your father was, by any chance, a veteran, you should look into the Aid in Attendance program which can help with these expenses. Best of luck to you.  

Normally the individual should decide what time they wish to go to bed. Keeping good sleep hygiene (maintaing routines for sleep and wake times and turning off distracting lights or noise at bedtime) is very important to a dementia person's functioning and for good sleep habits. If the individual is attempting to go to bed very early and then is waking up in the middle of the night causing disruption to others, we would suggest increasing pleasurable activities to keep them up to a more suitable bed time. If the individual is tending to go to bed too late, avoiding naps in the day, eliminating TV or other distractors at normal bed times or if needed, giving medications to get their sleep/wake cycle under better control may be helpful.  

This is a very common problem. It really depends on how the contract defines a responsible party. We usually suggest either refusing to sign as responsible party and/or drafting an addendum which notes that the POA is responsible for making payment only out of and to the extent of the resident's own funds and does not agree to take any personal liability. 

Your parents should really see a certified elder law attorney because there are several things that your father can do now to protect assets. With regard to the home, it is protected as long as your father lives there, but could be subject to a lien from Medicaid eventually if he doesn't take steps now. Transferring the home into your name now is likely not the best option because there is a five year look back period for Medicaid. Therefore, your mother would not be eligible for Medicaid for at least five years if he did transfer it to you now.  

The Guardian has every right to sell the home because she has a fiduciary duty to use your step-mom's assets for her welfare. In fact, she probably has no choice but to sell the home because she must exhaust all of the assets before Medicaid would kick in and pay for care. Only the guardian can decide if property is removed and if it is, then if it has a value it should be sold for your step-mom's care. However, furniture and personal items of no significant value could be given to family members. Again the Will only applies to property that still belongs to the individual at the time they die. 

Aricept (donepezil) in a small proportion of patients can cause loose stools or bowels and weight loss. If no other cause is found, donepezil may be the cause. Adding fiber to the diet daily may be helpful. Rivastigmine (Exelon) patch in some individuals will produce less gastrointestinal issues since it is a patch and not a pill and circumvents the stomach. It can be given in place of donepezil. Adding nutritional supplements to his diet may also help with weight since he has a good appetite.  

If his appetite is low, consider supplementing his food intake with nutritional supplements such as Ensure, Boost, Health Shakes and others. They pack a lot of calories in a small amount of liquid. There are also medications that may help with appetite (mirtazapine, megestrol) that you can talk to his doctor about. If he is having trouble with chewing or swallowing, the only solution is to make his food softer to make it easier to swallow. If he is choking on liquids or food he should see his doctor. There are also products to thicken the consistency of liquids to make them not cause choking as much.  

 Alzheimer's patients often get to a point that they do not know how to look for or seek out food. They may lose language abilities that they can not express their desires that they are hungry. Depression should always be looked for. Crying spells, “wish I were dead” comments and apathy are all signs to watch out for.

Many demented patients have a tough transition when moved to another environment, especially when familiar people or things are not present anymore. Often over time (and that varies with the individual) they acclimate to their new home as they get accustomed to the staff, other residents and their environment. Depending on the stage of their disease and the degree of comprehension of their environment, that can take a long time in some cases. Some patients do better if the family visits often and others seem to do better if out of sight, out of mind. It depends on how he reacts to family to determine if that is more anxiety-producing than not. Anxiety and depression can be treated very well during the adjustment period and I would talk to his doctor for consideration of starting a medication to help.  

Older adults are engaged in a battle for control in all aspects of their lives. Most of these battles are over dilemmas that have no easy answer, like "where am I going to live?" In your mother-in-law's case, she has opted to give up control of her privacy to maintain control over where she lives. She needs on-site help to navigate the demands of being older and diminished health. But the on-site help comes with a price. This is the nature of dilemma solutions: messy and always, repeat always, in need of revision.

What her children and their spouses need to appreciate are the psychological developmental tasks of the last phase of life: control and legacy. This link gives you an overview of these critical tasks:  http://www.davidsolie.com/blog/the-final-mission-of-life/ Once they have a better understanding of your mother-in-law's "need" for control, they can revise their approach and offer her more choices, including the choice of more private space.

Best regards,

David Solie, MS, PA 

Evaluation is needed to find the cause of her false beliefs including memory screening and assessments. Please see the answer below for more details. 

What you are describing, false beliefs can be caused by many conditions. Certainly people with dementia (Alzheimer's disease, Lewy body dementia, Parkinsonian dementia and others) can have false beliefs due to their dementia. However, certain medications in some people may also cause false beliefs (steroids, anticholinergics, antihistamines, pain medications, amiodarone, mexiletine, antiarrhythmics, many antibiotics, sleeping pills, anticonvulsants, some antihypertensives, anti-Parkinson agents, and others) in some individuals. Toxins like alcohol can cause false beliefs. Lack of oxygen to the brain (hypoxia) from sleep apnea, COPD, poor heart function can cause false beliefs in some individuals. Significant liver or kidney disease can cause this. Low B12 or thyroid abnormalities can cause this in some people. In short, just because here are false beliefs does not mean the person has dementia. A careful and complete evaluation should be done to find the specific cause. There are medications that can reduce false beliefs (antipsychotics) that may be considered by their physician.  

That question can only be answered after she has had a swallow study. These tests are done by speech therapists to determine what consistency of foods are safe and what swallowing strategies are helpful in people who have trouble swallowing. In most cases actually thicker liquids are easier to swallow and often the recommendation is to thicken the liquids, but the only safe way to decide what is best for her is to have the swallow study done. You should ask her doctor to schedule on of these tests. 

Once you are appointed as Guardian for your sister, you should have the authority to move her. Some states require court approval for a move out of state and most states require court approval for selling the home. You should check with the Court where you were appointed Guaridan to confirm your obligations to secure approval and/or provide notice. If your sister is going to remain in Ohio, you will likely need to transfer the guardianship from Michigan to Ohio. This will require court proceedings in both states, but then will eliminate the need for continued dealings with the Michigan court. In general, an individual can receive Medicaid if they have spent down all of their liquid assets and their home is on the market because it is an unavailable asset until such time as it is sold. Merely being appointed as Guardian does not make one financially responsible for their ward from their own personal assets. You have a fiduciary duty to manage your sister's assets responsibly and pay for her care out of her own assets. You should be careful in signing contracts and admission agreements so that you do not take on any personal liability.

This is a common occurrence in the world of aging parents. It is in part the end product of the shrinking universe of aging. While your world is still expanding and filled with overt growth and accomplishments, their world is contracting and moving internally. This doesn't mean communicating with them is pleasant. It just means you are better served changing your questions about the experience. Instead of asking, "why are they so inconsiderate," you may want to ask "what are they wanting?" In a world of diminished status and purpose, I suspect they want to assert their presence however awkwardly when the opportunity arises. This also points out another dilemma of aging parents that impact adult children. Their parents may no longer be able or wiling to give them the nurturing they have in the past. This is a painful loss but part of the fallout of the process of getting ready to leave. The higher ground for this dilemma is what you suggest at the end of your question: let it be. It will be easier on both of you... 

The second Power of Attorney only “revokes” the prior power if says so explicitly. My practical advice to you is to provide a copy of the current Power of Attorney to every financial institution your husband deals with. This should put them on notice that they are only to acknowledge your Power of Attorney. It is important to remember that the distribution percentages within the will and the trust apply to different assets. The trust “trumps” the will with respect to any assets it owns. Were accounts actually transferred into the trust? It is unfortunately very common for trusts to be unfunded. The trust is then simply a wasted exercise. The house will pass automatically to the surviving joint owner unless the parties hold title as “tenants in common.” The will applies to all assets "not otherwise spoken for." This includes any asset without a beneficiary, not owned by a trust or not jointly owned with another person. I think it would be a good idea for you to sit down with an elder law attorney in your state to look at your Power of Attorney and Health Care Proxy to ensure that they are up to snuff.  

It sounds like something here has to give. The situation seems unhealthy for all involved. Without knowing more details, your siblings' behavior may stop just short of warranting an order of protection for you and/or your mother. You don't say whether or not your mother has actually made gifts to you of her assets. You mention that you have financial Power of Attorney, but you say that your mother is competent so presumably she could sign a check to you. It would not be uncommon for a parent who is living in her child's home to make contributions toward living expenses at the very least. The trick is to protect yourself from possible accusations that you are fleecing mom without her consent. Down the road, she may not be competent and the next complaints might not be dismissed. You may consider entering into a bona fide lease agreement whereby you are compensated for providing meals, transportation and accommodations. This will be difficult for your siblings to challenge. If all else fails, you will need to consider court intervention. Depending upon the jurisdiction, you can petition to become your mother's guardian or conservator. Your mother may be competent, but it seems clear that she needs help protecting herself from the harassment of your siblings. The initiation of this proceeding will force the court to interview everyone and decide what is in your mother's best interests. Hopefully your siblings will be read the riot act and you can settle the matter with clearly established guidelines and expectations for all involved. Lastly, I would install a “nanny” cam. Good luck! 

Your mother's primary residence is “exempt” for purposes of Medicaid eligibility. Medicaid will, however, likely place a lien on it and can recover against its value upon the death of your mother. The residence in your mother's name is not exempt for purposes of Medicaid estate recovery. However, if you have been living with your mother for the two years immediately preceding her nursing home stay, you may qualify as a caretaker child. As such, the transfer of the property to you will not disqualify your mother from receiving nursing home Medicaid. Lastly, the nursing home is entitled to your mother's monthly income with the exception of a $50 monthly personal needs allowance. If you cannot afford to remain in the home without your mother's income, I recommend that your mother transfer it to you and then you can sell it. 

I would be reluctant to tell you to go ahead and attempt the amendments on your own. This is especially true if the beneficiaries' shares will be altered. Whoever is “reduced” will likely look to challenge the instrument, which changed the original distribution pattern. You say that it was a document preparation company that created the trust. Please double check that the underlying assets were properly transferred into the trust. These document preparation companies have been sued repeatedly for failing to instruct people on transferring assets. An empty trust doesn't accomplish much. 

The usual goals of care would include safety and quality of life. Increasing pleasurable activities and using day care centers to increase brain stimulation may help quality of life. Look at all his medications to make sure they are not sedating him. Make sure that all caregivers get enough respite so that they can increase the amount of quality time with him. Consider a companion to get him out of the house.  

There is great variation of care provided in Assisted Living facilities. For some "memory care" is just having a locked unit where the dementia residents stay so that the Assisted Living facility can advertise they have a special place for dementia residents. The best places not only have secured units, but also have extensive training in the care of dementia residents. They have dementia specific activities based on the individual resident's level of functioning. They have more, rather than less, activities that are resident specific. They have environmental cues and stable nursing staff to help provide routine and stable environments for those with memory loss. They have training regarding behavioral modification techniques and ways to improve communication to those with dementia. They have training with ways to approach and care for those with fear, suspicions, anxiety, intrusiveness, and agitation other than always using chemical or physical restraints. They have expertise with their physician staff who know when and with what medication (behavioral stabilization and cognitive enhancers) using the appropriate dosing will lead to improved quality of life for a specific resident. They communicate routinely and often between each other and with their physicians to notice issues early and to take appropriate actions early. In looking for an assisted living facility you can ask about the topics I mentioned above. You can also ask how often they have to send a resident out to the hospital for behavioral or dementia issues or how often they give someone a 30 day notice to leave due to the resident's behavior or dementia issues. The best facilities rarely have to send the residents out or away as they have great staff and the training to appropriately care for the resident in place. Good luck on your search. 

Certainly types of chairs can cause irritation by the way they rub on your clothes, but would not cause a UTI. If the type of furniture makes you much more warm in your genital area than usual, you could get a yeast infection that might simulate a UTI. Although you can always switch chairs, you might ask your doctor to consider checking for a yeast infection if you think this is a possibility. Finally, feeling the need to urinate without much urine can be a sign of a UTI, which might be completely unrelated to the new chair, so you might need to check that possibility also. 

There are two issues here. One, older people can have a hard time using a standard shower or bath and you might need to put in a seat or handrails to help her. If this is not the issue, however, and she just refuses to ever bathe, and her sponge baths are not adequate, this is considered self-neglect (the blame is on her, not you) and is actually considered a reportable form of elder abuse. You should take her to a doctor and see if the doctor can talk her into bathing. If that does not work, talk to the doctor about getting social services involved. There can even be a referral to an agency called Adult Protective Services that will investigate why she does not bathe and offer suggestions. 

This is, unfortunately a common problem. It sounds like your mother's husband may be in denial about her cognitive and physical condition as well as his ability to adequately care for her. Conceptually, your medical POA (also called a Health Care Proxy) allows you to make medical decisions on her behalf. However, as a practical matter, if she or her husband are vocally objecting to your decisions, you may need legal intervention. As a first step, I would contact your mother's primary care physician. Your exisiting medical POA will allow the physician to speak with you about your mother's condition. Chances are that he or she will be in full agreement with your observations. You then need to speak with an elder law attorney about being appointed guardian or conservator (depending upon your state). Ideally, the mere initiation of this process will be the trigger to bring your mother's husband to the table and forge an appropriate care plan for your mother. 

If the shunt that was placed malfunctions or is clogged, it can cause acute hydrocephalus leading to severe headaches and lethargy leading to unresponsiveness. If there is an infection of the shunt in the brain, that can lead to sudden and severe cognitive impairments. A bleed in the brain related or not to the shunt (subdural hematoma, cerebral hemorrhage) can cause rapid deterioration. Degenerative dementias never progress in a matter of days. A CT head of his head or a shuntogram can help with diagnosis of the problem.  

I am sorry that you and your family have had to go through all of this turmoil. I am not sure of your question. Do both parents have dementia? Is it your mother or father that has all control? If your father continues to drive, is not using good judgment in his driving and is not safe, then disabling the car or removing it may be potential options. If your mother is overly controlling, you need to discuss with her that her husband's dementia syndrome will decline more slowly in the future by getting and staying on Alzheimer's medication if that is what his doctor is recommending. The longer the husband stays functional and able to take care of day-to-day activities, the less work it is for the wife. If it is the husband that is controlling, the family must try to do what they can to keep him safe. His doctor needs to bargain with him to just try the medication temporarily to see if he likes it or if it seems to have benefit. For a fair trial, make sure he gets up to the best dose. After a couple of months, the medication may be more routine and he will not complain about taking the medication or the doctor can suggest to keep on it a little while longer to see how it does.  

A Revocable Trust is often utilized to ensure that one’s assets pass at death without the need to probate a will. Probate is the process whereby a will is authenticated and its provisions are carried out under the supervision of the Surrogate’s Court. The probate process is normally straightforward but can be complicated by a variety of factors.

A Revocable Trust is sometimes recommended for those who are in a second marriage, who have a developmentally disabled child, or who wish to disinherit a child. This is because a Revocable Trust usually ends automatically upon a person’s death and the assets it contains pass to beneficiaries with no Court oversight and resultant delays. A Trust is a contract executed during life. This makes it different from a Will and makes it much less likely to be challenged at death.

A Revocable Trust alone, however, will not address all of one’s potential estate planning concerns. Contrary to the claims of unscrupulous promoters, a Revocable Trust will not protect assets in the event of a longterm illness. Nor will it protect assets from being subjected to estate tax upon death. Common sense dictates these limitations. To the extent that the Grantor of a Revocable Trust has complete access to all of its assets, how then can he turn around and claim that they are unavailable to pay the nursing home? Or that they should not be a part of his taxable estate at death. In estate planning, as in other areas of life, if it sounds too good to be true – it is!

Assets will not be immune from health care claims or estate taxes unless the owner actually parts with them.
Often an individual transfers a house or liquid assets to children in an attempt to shield them. A simple transfer of this type is almost always inadvisable. For example, if I were to gift my house to my children, I would lose my property tax exemptions. It would be subject to my children’s creditors – including spousal claims in the event of a divorce! Lastly, a simple transfer to children will likely result in capital gains taxes for them. This is because a gifted asset results in the donor’s purchase price being used as the “floor” to measure gain when the children later sell. Individuals who wish to protect assets for the future and commence the running of the so-called 5 year look-back period would be well advised to consider an Irrevocable Trust.

B. Yes, the term “Irrevocable: is a turn-off. However, if the trust is properly drafted, one need not surrender all control.
For example, the term Irrevocable does not mean that a house in it can’t be sold. It simply means that the Trustee of the trust is the one who signs the deed at the closing. And to play devil’s advocate, one must ask what would happen if the Trustee refuses to sign off on the sale? The Grantor of a properly drafted Irrevocable Trust would simply exercise his or her ability to replace the Trustee with another individual. Conversely, the Trustee can’t sell the house if the parents don’t want it to be sold-provided that the Trust contains this protection.

An Irrevocable Trust can also preserve the parent’s ability to alter their beneficiaries’ percentages or to add beneficiaries later. This is critically important in the event of a tragedy. If a parent (God forbid) loses a child, they should be able to freely assign that child’s share to grandchildren or, as the case may be, to remaining children.

If the trust states (and it should) that the parent is allowed to live in the house for life, then he or she will retain all applicable property tax exclusions. Moreover, when it passes out of the trust to the children upon the death of the parent, all of the built-in capital gains are erased.

So then, what exactly does the term Irrevocable mean? Simply that the parent acting alone cannot take back what he or she has transferred into the trust. For many of us, this should not be such a big deal – as long as the trust contains the above-referenced “parent protections.” The most important thing to keep in mind when assessing your planning options is that you should retain as much of your control as possible. Your documents can and should be customized to your individual needs and concerns.

 Medications can often cause hallucinations. Of the ones you listed, meloxicam might cause issues in some individuals, but it is not common. The other medications do not typically cause these issues. If any of these medications were started just before these behavioral symptoms started, then talk to her doctor about coming off that medication if possible. It is possible that she is having false beliefs or delusions and not specifically seeing or hearing things (hallucinations) that others do not see or hear. Seroquel is a medication specifically for these false beliefs. Perhaps she was started on it for that reason. The usual does range for Seroquel is 50 mg to 150 mg total dose daily in dementia individuals. Since there are many causes of these behaviors, including infections (urinary tract infection), metabolic disturbances, environmental considerations, among others, it is best to get her back in to her physician so they can make sure she does not have an infection and to check for other causes to treat.

If you have a Durable Power of Attorney (DPOA) for healthcare and your mother no longer had the capacity to make these decisions on her own and your father and siblings are all agreeable to place her, then there is no need for guardianship and you can make the arrangements to place her in a long-term care facility. If there is disagreement between family members, this becomes harder to do and then a guardianship may be the best option. To get a guardianship, you will need her physician to fill out paperwork obtained from the courts to provide information on her capacity. The courts then decide if a guardianship is appropriate and who the guardian will be. They may choose a non-family member. Another option is to contact Adult Protective Services to come into the home and evaluate the situation, particularly if you feel that her husband is not taking care of her properly. They can help as well in getting the process started for a guardianship if they feel that is needed.  

Assuming that your mother’s credit card accounts are in her name alone, any obligation on her death will become a liability of (i.e. payable by) her estate. Ordinarily, amounts owed by her estate in excess of estate assets will not transfer to heirs or beneficiaries. Keep in mind though that credit card debt will ordinarily have to be paid before the distribution of any monies or assets to beneficiaries and could potentially directly reduce any and all estate distributions. Therefore, although you and your sister would not be responsible for your mother’s credit card debt, the debt may be paid from estate assets you may have otherwise inherited. The same result is generally true for other debts and obligations. The answer could be different for your stepfather especially in a community property state. I’ve located several articles that provide a more detailed discussion of the issues, including the possible consequences for your stepfather, which you may find helpful:

What happens to credit card debt after death
http://www.creditcards.com/credit-card-news/credit-card-debt-death-1282.php

You won't inherit Mom's credit card debt
http://www.bankrate.com/brm/news/debt/Sep06_Moms_credit_card_debt_a1.asp

Can credit card debt be inherited?
http://today.msnbc.msn.com/id/30831970/ns/today-money/t/money-can-credit-card-debt-be-inherited/#.T01CgnldCSo
 

Although there is a strong possibility that your mother will be quite agitated with the move, you must look at the greater picture of “Is this going to improve the health of you father?” and, ultimately, “Will your mom be in a more stimulating and positive environment?” It is never an easy decision to make when you know that you are at a point of having to place a loved one in the care of others in a community environment. Safety is what I tell all prospects that you must first look at. Secondly, it is just as important to look at the health of the spouse or person who is providing the caregiving. Caregiver burnout is a growing concern in the healthcare community. Your mother may not need assistance with the basics such as toileting, grooming or dressing, but mentally and emotionally your father has to provide for your mom and that can be exhausting. Having agitated moments and yelling at your father for no apparent reason is a common issue and it takes not just skill but patience to deal with.

Your mom has energy from what I can see by the comment of pacing back and forth. Your father needs to be able to provide activities and stimulation for her so she can exhaust some of that energy without the use of medication to slow her down. You want her to be able to walk and explore life around her and thrive as much as she can because you are looking at a future that becomes a much smaller world for her. Having her in an environment that allows all that is what is in her best interest and also your father’s.

I have been in this field long enough and moved many residents into assisted living and have seen my share of residents become extremely agitated and upset at the beginning. But it works itself out. You have to keep in mind that she has dementia, so finding redirecting techniques and being very creative when explaining to her why she is in her “home” is why we are here – that’s our job. It can take a few weeks and even up to a couple months for someone to really adjust to their new environment depending on where they are within their disease. Here at Summer House, a memory support neighborhood at Anaheim’s Walnut Village retirement community, I have a nice blend of early-to-end-stage dementia/Alzheimer’s residents and they have all posed a different challenge when they first arrived. It is my responsibility to make sure that I provide as much comfort and education to the families as possible to help ease the transition. I would contact your local Alzheimer’s Association chapter or a skilled nursing facility nearby for referrals on assisted living communities that accept Medicaid. There are not as many around as private pay communities, but usually within a given county you can locate one.

If I can end by giving you one piece of advice: Look at the whole picture and not what is happening in the present. When looking into the future a bit, look to see if her quality of life would greatly improved if she were in a place where she is able to thrive and be among others she can relate to. Families have told me time and time again that it gives them such pleasure and peace to see their loved one be able to be all that they can while they still can.

 

In general, second opinions are worthwhile, if for some reason you do not feel confident in the first opinion (maybe the wrong type of physician, maybe not adequate training for the problem), or if the problem is severe, life-threatening or will be lifelong so that you really need the best answers. Many, if not most, insurances will pay for second opinions, but not third ones. With that in mind, I do usually tell people considering a second opinion, or coming to me for one, that there is no more than a 5 percent chance that the second opinion will give a different answer.

In this case, if the prospect of lifelong incontinence is worrisome enough that you are willing to undergo the time and effort for a second opinion, it would be worthwhile to you, realizing that there is a low chance of getting a different answer.
 

The first issue, which you seem to have answered in part, is whether your mother is able to competently handle her personal affairs—particularly, her finances. It seems from your question that her stage of Alzheimer's disease (AD) is not the reason for your concern. There could be other causes that a person may be found incompetent and a guardian appointed, however getting to such a finding would not be a pleasant journey and pursuing it would ordinarily be one of the last considerations. Not meaning to dissuade you from this avenue entirely, you and your brother should get medical and legal counseling on this if you feel it should be pursued. Whether or not any monies could be recovered is a corresponding legal question, which may have to be handled in court.

There may be valid reasons why your mother is giving her money away, but it seems that you have reason to doubt that as well as her financial capacity to do so. If you have not already, you may want to openly discuss your concerns with your mother. If you and your brother are not able to do this, you may be able to enlist the help of someone she trusts. In many circumstances, this is an appropriate manner of dealing with sensitive issues, assuming there is full disclosure and no breach of confidences. It’s entirely possible that your mother has what she thinks are valid reasons for what she is doing. It is also possible that she does not completely understand the consequences. For example, it may be that your mother has Medicaid planning in mind. If you are not familiar with this, there is an article titled Medicaid Planning, which you can access on the website ElderLawAnswers.com at http://www.elderlawanswers.com/elder_info/medicaid-planning.asp.

As a closing note, everyone should understand the reasons to have and how to best execute a Power of Attorney (PoA), which will best serve their needs—if and when needed. Whether or not your mother has given someone her PoA and whether or not she chooses to give one to you and or your brother is a very personal decision, which should be carefully considered.
 

You are so right to be concerned about your Mom. Lying on the couch is a surefire way to get weaker. I’m curious about the reason she won’t get up. Is she afraid of falling? Exercise will make her stronger, improve her balance and prevent falls. Is she depressed? Maybe some gentle counseling is in order.

Getting her motivated to move can be a challenge, but here are some things to consider. You might persuade her trusted doctor to talk to her. Check your local Y or senior center and see if they offer chair exercise classes. If you can get her to go to a group class, she might be more motivated because she’ll be missed by her friends if she doesn’t show up – and she miss them, too. I teach a senior Yoga class on Monday mornings, and my students were so upset about losing a class on holidays they asked me to reschedule for another day! They love practicing balance and getting strong together. I hope your Mom will, too!

Meantime, I recommend that you be sure you’re getting exercise yourself if you’re not already doing it. Sometimes what you do can be the most powerful motivator of all. Not only that, exercise will help you cope with the worry about your Mom. Good luck, and let me know what happens!
 

There are many potential reasons for her behaviors and so it will be hard to be very specific. In general if your daughter can bribe her with something she likes to eat or do, this may help. In other words increasing pleasurable activities usually helps. Perhaps you calling Barb just after she arrives home may ease the irritability. If none of that helps, you could talk to Barb's doctor about medications, like antidepressants that may help calm her a bit more.  

 Yes. In some individuals who have frequent urinary tract infections, physicians at times prescribe daily low toxicity antibiotics to help prevent them from occurring.

Many things may cause false beliefs or hallucinations in elderly people. An infection such as a urinary tract infection or pneumonia could cause this. New medications or overdose on medications is another common cause. Metabolic conditions or liver problems may cause these symptoms. If they are recurrent and especially if they are associated with fevers, confusion or other new symptoms, your grandmother should be seen by her physician.  

The only ideas I have for this problem are as follows: First, Advair is an inhaler that is know to have a bad taste and sometimes cause people to lose taste for other foods. If this is one of his inhalers, maybe there is an alternative. Otherwise, all of the inhalers need to be rinsed out of the mouth after the inhalation or they can affect the taste. If that is not being done, he could rinse after every inhaler use. I hope one of these will give you the answer.
 

Frequent falls are a difficult issue. Even in a nursing home, there is not staff there every minute all day long, which is usually what is needed to prevent falls. She needs to be on a falls prevention program. If they do not have an aggressive falls prevention program where she is, another facility might be best. She might need things like a belt restraint, a geri-chair, or similar strategies to prevent falls, but again she needs to be in a strong “falls prevention” program.
 

Behavioral issues are common in those with dementia. They are due to loss of brain cells and due to neurotransmitter changes in the brain related to the brain damage. Environmental or behavioral modification techniques can be helpful to reduce unwanted behaviors. However, they are often not enough and medication supplementation is often required to help even out the neurotransmitter impairments. Agitation, irritability, false beliefs and mood issues can often be relieved dramatically with appropriate pharmacotherapy. If your mother has fewer of these behaviors, it is much easier to care for her. Your father may also benefit from more respite. You could have your mother go to day care, have a paid caregiver come in or take her out or have family watch her while your dad gets some time to himself. Regular respite is invaluable and reduces burnout for caregivers. To evaluate how negatively she would respond to a nursing facility or assisted living facility, she could be taken there for a weekend or a trial period and see how she reacts. Many facilities have all levels of care in the same campus (independent living, assisted living and nursing home). A husband could be very close even if a wife has to move to the nursing facility when more care is required. Your local Alzheimer's Association chapter or Area Agency on Aging could give you a list of facilities that have those choices. My edited book, "Long-Term Management of Dementia" (Informa Publishers) has great information about all these management issues and much more (see the link next to my expert column at Parentgiving). 

Parkinson's disease usually starts with tremors/shaking on one side much more than the other. The shaking is worse when the hand is at rest and much less when the hand is moving such as when drinking from a cup. Other features are stiffness, lack of facial expression, slowness of movements and trouble with balance. When the shaking or tremors affect both sides of the body or head or jaw and are worse when trying to write or move, Parkinson's is less likely. Essential tremor, medication or toxin-induced tremors or familial tremors are more often the causes. Individuals with restless leg syndrome have a desire to move the legs or sometimes the arms and a feeling of not being comfortable. It often keeps them up at night. Medications for anxiety can also at times increase tremors as can other medications like those for asthma or breathing issues. My suggestion is to seek out a neurologist for a complete evaluation of potential causes and treatments.  

 Any activity that helps stimulate the brain is helpful for dementia patients…in moderation. Too much stimulation of anything can cause anxiety and confusion. A variety of stimulating activities at different times is better than only one activity. Music therapy can be very helpful to calm a person and stimulate certain parts of their brain. As with any activity, if the patient responds to it, it is worthwhile to continue. If their response is more anxiety or distress, then it is worthwhile to discontinue it.

Most Paget’s disease is essentially a skin-based form of breast cancer. Most people with Paget’s will also have a breast cancer in that breast, and treatment is primarily directed at the breast cancer. In the 15 percent of people who have Paget’s with no apparent underlying breast cancer, the usual treatment is removal of the skin containing the Paget’s, and radiation to that area to prevent metastases. That surgery is fairly mild and should have minimal complications. You have described this as ExtraMammary Paget’s. If that means it is not on the breast but rather elsewhere, that is exceedingly rare and I don’t think I could add anything to what the oncologist is saying. 

Caring for a person with dementia in the home can be rewarding, but can also be a challenge and stressful. It's important to have a support system for the caregiver to call upon when new or different services are needed. I would suggest you provide your mother with information about a local support group of caregivers through the Alzheimer's Association and literature about caring for a person with dementia. You might also do some research on home care agencies in your area if she wants to hire someone. At some point your grandmother might need constant supervision and 4 hours will not be enough. Talk to your mother about having a plan for this. It is important to understand how the disease progresses and what to be prepared for so that you are not solving problems while in a crisis. Watch for signs that your mother is stressed, and perhaps then you can introduce some of these supports and services to her to consider. 

About 70 percent of individuals with dementia, particularly with Alzheimer's disease, develop false beliefs. Only 3 percent develop hypersexuality with physical sexual aggressiveness. However, more commonly we see frequent verbal sexual comments. Typically, one can first try to use logic to dissuade the patient of their false belief or try to ignore the behaviors if they are not harmful. However, many times these techniques do not work due to the nature of the condition. When the behavior issues get to a point where they are causing significant problems for the patient or others, it is time to consider medications. Due to the potential seriousness of the accusations, use of an atypical antipsychotic (like quetiapine or ziprasidone or risperidone) to help reduce the false beliefs may be something his doctor may consider. There are also medications that may help with hypersexual behaviors, particularly antidepressants like selective serotonin reuptake inhibitors. Chapter 4 in my edited book, “Long-Term Management of Dementia” (Informa) goes into detail about dealing with problem behaviors if interested (see the link next to my expert column). It is also important that these concerns get documented by his primary care physician or dementia specialist. Evaluation and management of these problems by his physician, including a clear diagnosis of his dementia will help in case there are any legal issues that arise. If the behaviors are not treated, it may not matter where he lives as he may have the same accusations everywhere he goes. This is more typically the case than not. 

As it seems you are well aware, Medicare does not pay for nursing home care, which is generally expensive and can quickly drain one’s life savings. In order to avoid that, many people employ strategies that are commonly referred to as “Medicaid Planning.” Medicaid will pay for nursing home care for those with nominal income and limited assets. While Medicaid Planning is not appropriate for everyone and some do not consider it ethical, it may be a consideration for your parents.

Medicaid Planning can be complicated and usually requires the transfer of assets. For this reason and others, you should seek the services of a qualified attorney who practices in this area in your state. You may want to explore this further on your own before going to an attorney so that you can be somewhat knowledgeable about the issues. You should also discuss this with your parents to see if they are open to considering this. If you (including your parents) decide to continue, you should have an exploratory consultation with an attorney before committing. As with any professional services, it is important to understand the fee structure and find someone you will trust. You should make certain that your parents are appropriately advised and are in agreement before any asset transfers.

Following are links to two articles posted on the website ElderLawAnswers. Although I cannot vouch for their accuracy or completeness, they are both good primers on the issues:
Medicaid Planning: http://www.elderlawanswers.com/elder_info/medicaid-planning.asp
Is Medicaid planning ethical?: http://www.elderlawanswers.com/resources/article.asp?id=1175&Section=4&state=
 

One thing to discuss is the difference between a UTI, a urinary tract infection, and colonization of the urine, where there is always bacteria in the urine but it is not causing an infection. It is frequent in patients in a nursing home to have the colonization, and if that is the case it is more harmful to treat with antibiotics than to leave it alone. It is sometimes hard to tell if it is an infection or colonization. The urinalysis—looking at the urine under a microscope—can help because in an infection there are a lot of white blood cells because of inflammation from the infection, and in colonization there are not. The other way to tell is by symptoms. An acute change in mental function (including a glassy eyed look) can be one symptom of infection, but only if it is an acute change (if she has been like that for awhile, it would not likely be a symptom). Finally, if the doctor has taken a urine culture and has given her the right antibiotics based on the culture, and she has still not resolved the bacteria in her urine, it is likely a colonization. 

We turned to Laura Feeney AuD, doctor of audiology at The Ohio State University Hearing Professionals in Columbus, OH for her expertise:

The first step would be to visit your father’s audiologist to be sure that the hearing aids do not need any adjustment. If the hearing aids are set appropriately, then secondary assistive technology may be useful. One such assistive device is an FM system. The benefit of FM systems is that they improve the signal to noise ratio, elevating speech over background noise, and cut down on the distance between the speaker and the listener—the speech is directly sent to the hearing aids. FM systems consist of a receiver and a transmitter. The receiver would be attached to your father’s hearing aids, and the transmitter is a microphone that would pick up the speaker’s voice. The transmitter could be worn by one speaker, passed around to multiple speakers, or placed in the middle of a table. If the hearing aids are not FM compatible, there are FM systems that can be worn without hearing aids. Speak to your father’s Audiologist about the most appropriate options for him.

To learn more, go to hearing.osu.edu

This is a problem we see often in elderly patients. The first thing you should do is acknowledge to her that activities are more difficult with aging and ask if you can arrange for someone to help her with some of her activities, such as bathing. If she declines, the next step depends on your relationship with your mother. If it is very good, just be frank with her and tell her that her hygiene is poor and needs improvement. If your relationship is not good enough that you would expect her to accept news like this, you could ask her primary care physician to suggest the need for bathing more often. 

You can lose a lot of weight quickly if the weight is from water or fluid loss. Some patients are on diuretics that will cause them to urinate out excess fluids that may be building up in their legs or elsewhere. I would have her seen by her primary care doctor to look for reasons. 

I suppose it is possible they weighed her incorrectly. However, in general, patients with this low a weight who have dementia have a very hard time gaining weight. Also, a person can become dehydrated and lose a lot of weight if they are not drinking or eating much for two days. It is possible after her bladder infection is corrected, she will gain weight again. Continue supplements with or between meals and eat with her to help with weight gain. There are some medications that can also improve appetite (mirtazapine and megestrol), but they also may have significant side effects to watch for. 

Exelon at 9.5 mg/24hour patch is an effective dose for individuals with Alzheimer's disease. This medication is often combined with memantine titrated up to 10 mg twice a day. I have no experience with the use of cerebrolysin as it is not often used in the United States. More studies are needed for that agent in regards to how long it can remain effective for patients. Vitamin E 200 units daily can be helpful as an antioxidant in Alzheimer's disease patients. There have been encouraging signs from the monoclonal antibody "vaccine" against amyloid in human studies. More research is required to see how well it works. The same is true for the other passive and active approaches. If he is eligible and willing to participate in a clinical trial and there is a center close by doing these trials, I would be very supportive of getting involved. Altruistic patients with Alzheimer's disease wiling to participate in research will help to speed up the discovery of new therapies for them and others. 

There is no question that he would be best served by a physician who specializes in dementia. It would not matter if they are a neurologist or psychiatrist as long as they specialize in dementia. 

There are many potential reasons for dementia and most are treatable. His physician can assess for potential treatable causes and start appropriate treatment to help the condition. Some causes of dementia are treated by surgery like those with hydrocephalus. There are also some cases of Parkinson's disease where the symptoms can best be treated with deep brain stimulation or surgery. Potential candidates must be evaluated at specialized centers that offer these treatments. His neurologist would be able to let you know if he would be a potential candidate. 

Sorry to hear about the situation. It sounds like she may be suffering from a progressive degenerative condition. However, there may be treatable issues if she would allow an evaluation. This may not be possible until she gets so ill or gets an infection that she has to go to the hospital. She also sounds like she is a bit suspicious and maybe paranoid. Many times medications will help her behaviors enough that she would be more amenable to increased supervision, a shower, food, and an evaluation. Since no physician will prescribe without seeing her, it may be possible to get a visiting physician to come to her house when you are coming out to see her. They may assess the situation as dangerous to her and Adult Protective Services may have to come out. They may be able to get enough of a flavor of her behaviors that they may be willing to prescribe a medication. Some medications like risperidal come in liquid formulation and can be placed in something she drinks if she refuses to take any pills. You may have to visit daily to make sure she drinks her drink with the medication in it. This may help her suspiciousness and increase her willingness to allow more supervision and evaluations. Best of luck. 

Many times if there is a sudden change after surgery, it suggests that he is suffering from an acute confusional state. There may be many causes. The most common causes include medication effects, infection or strokes. Metabolic issues like impaired liver or kidney function can play a role. Not getting enough oxygen (short of breath) can be a cause. A scan of his head would rule out a stroke. Infection from the surgery or other causes (urinary tract infection) can lead to confusion. Often after surgery people are placed on pain medications and many of these can cause confusion. The faster he can get off these medications the better for his confusion. Anesthesia should wear off and would not cause long lasting impairment. Those individuals with underlying dementia would have less cognitive reserve and so will be much more sensitive to having medications, infections or other conditions cause a confusional state. They will recover most of the time completely, but it may just take a few weeks. Alzheimer's disease is a gradual progressive condition and there is no such thing as rapid onset Alzheimer's disease. If there is a sudden change in cognition there is always something else (maybe in combination with a mild dementia) as the main cause of the issues. 

There are many ways to help with sleep. First, try to make sure she does not nap in the day. Avoid alcohol and caffeine. Keep on a strict sleep schedule, go to bed and wake up the same times each day. As far as sleep aides, the least toxic for Alzheimer's disease is trazodone, maybe 50 to 150 mg nightly. Avoid all over the counter sleep aids as they can make her confusion worse. Other that can be tried include mirtazapine, zolpidem, gabapentin, and others. My book, Long-Term Management of Dementia (see information to the right of my column on Parentgiving) has other choices listed. 

Supplements are the first best choice. Ensure, health shakes, Carnation instant breakfast, Boost and others are all pretty good. Start with one can a day. However also make sure that someone eats with him as this will usually increase food intake. There are medications that can stimulate appetite like mirtazapine or megestrol. These can work very well in situations where there is severe appetite loss. However both can have side effects that are best avoided if supplements will work. 

Hospice care usually means end of life care to keep someone comfortable just prior to death. However, the amount of treatments given while in hospice care is usually left up to the doctor and family. Some families will treat infections, like pneumonia with antibiotics. Some families will not treat and just provide comfort care. Morphine is often given to help with pain issues and anxiety symptoms to make the patient comfortable. Ativan can be used for sedation or anxiety. Just prior to death, no food and limited water makes the patient more comfortable. Too much fluid may build up in their lungs giving a sense of drowning. Fairly soon the patient cannot drink anymore and death ensues quickly and comfortably. Often the patient may have made a Living Will that instructed family members that he would not wish to live if certain irreversible conditions became so unbearable that it made his life not worth living anymore. Exactly what medical issues or combination of medical issues occur that lead to that conclusion is very variable for different patients and different families. 

Anyone age 87 with progressive memory or thinking problems is very likely to have a degenerative condition like Alzheimer's disease. Her doctor should have run some lab tests and a scan of her brain to look for reasons for her memory loss. Dementia is a non-specific symptom, meaning someone is having trouble thinking and doing day to day activities. One cause of dementia is Alzheimer's disease, which is due to an abnormal accumulation of toxic proteins that accumulate in the brain and kill some of the brain cells, particularly in the memory areas. Dementia can also be caused by head trauma, having many strokes, low thyroid, vitamin deficiencies, kidney or liver problems or drugs, to mention a few other conditions. Many causes of dementia can be treated including Alzheimer's disease. I would ask her physicians what type of dementia they think she has. Then get more information about that condition. Visit the Alzheimer's Association for information and think about going to a support group meeting where you live. Inform the assisted living facility of the types of activities your mother would enjoy so that they can direct her to those types of activities. 

It is alright to reorient your mother to reality if it does not cause her significant grief and anxiety. If reminding her that her husband has died many years ago causes her much distress or disbelief, then it may be better to change the subject. You might agree that it would be nice to visit with him (her husband) and that it may be something to think about later. 

In regards to your mother-in-law, yes, significant kidney dysfunction can cause dementia. Toxins in the blood that the kidneys normally would remove may not be removed as well and so more get into the brain and effect its functioning. However, many conditions that affect the kidney (e.g. diabetes) can also affect the brain as well. If the dementia is only from the kidney dysfunction, it can be partially reversed by correcting the kidney problem or giving dialysis. If the brain dysfunction is due to several conditions then reversibility is less likely.

In regards to your aunt, given her long history of progressive decline, a degenerative brain condition is most likely. Those conditions, like Alzheimer's disease or dementia with Lewy bodies have a fairly predictable course. Patients lose more and more abilities to do day to day activities. The rate of decline is usually fairly stable and the speed that she has declined can help predict how fast she will continue to decline. Obviously UTIs, intercurrent illness, diet issues and other conditions can cause fluctuations in her bowels, incontinence, thinking and moods. Her physician can help with these intercurrent illness or conditions. Another excellent source of support and information about prognosis may be obtained at Alzheimer's disease support groups where families going through similar issues can share their experiences.
 

In general, trazodone is a very safe medication and often helpful for sleep issues. It is best taken every night to promote sleep. I use it often in dementia patients. It can be titrated to effect, usually helping with dosages from 50 to 100 mg nightly. In specifics for your father, it would be important to talk to his physician so that they can review his medical issues and other medications to make sure that he would not have problems taking trazodone. None of the conditions you mention that your father has would necessarily be contradictory to taking trazodone. It would most likely work fine, but his physician would have to review his case prior to prescribing it. 

First, you should ask: Is this new behavior or a longterm pattern? It would be important to have a medical or psychological cognitive evaluation to better understand what may be contributing to this behavior.

Regarding the various options you are facing:

If you opt to have your mother-in-law continue living with you, it would be best to engage a professional from your community who has experience with hoarding behaviors: geriatric care managers (which you can find by conducting a search using the national website: http://www.caremanager.org) psychologists, or psychiatrists. They will help you find a way to communicate with your mother-in-law, and determine how to best intervene, how to create a safer living environment using a risk reduction model, etc.

It doesn’t seem viable to have your mother-in-law move back home with her husband due to his care needs, unless she could manage in her home with an outside caregiver providing care to the husband, and keeping an eye on her hoarding behavior. Additionally engaging a geriatric care manager to oversee the care and work with professionals to try to keep a handle on the hoarding behavior would also be advisable.

Although moving to a facility doesn’t seem possible for financial reasons, if needed, you can research public benefits your mother-in-law might be eligible for. For example, VA benefits if her husband was in the military. These could help cover the cost of an alternative living arrangements.

There are also some “Do’s and Don’ts” to bear in mind as general guidelines:

Do’s:
• Be aware that there is no quick fix
• Establish a positive relationship
• Gain your mother-in-law’s trust
• Empathize – see her point of view
• Give her choices, thus helping her maintain a sense of control
• Help set goals and time frames for getting things done
• Respect her meaning and attachment to possessions

Don’ts:
• Don’t work with hoarders if you feel negatively about this behavior
• Don’t expect miracles overnight
• Don’t overwhelm or threaten
• Never remove belongings without person being present
• Don’t do a surprise or forced clean-up if at all possible


Below is some general information about hoarding behavior that you might find useful:

First from Randy Frost’s book, A Cognitive-Behavioral Model of Compulsive Hoarding

Definition/presentation:
1) The acquisition of, and failure to discard a large number of possessions that appear to be useless or of limited value.
2) The living spaces in the home are sufficiently cluttered so as to preclude activities for which those spaces were designed.
3) There is generally significant distress or impairment in functioning caused by hoarding.

Second, the diagnostic criteria of hoarding as a subset of Obsessive Compulsive Personality Disorder from Diagnostic and Statistic Manual of Mental Disorders IV:
• Accumulation of clutter
• Difficulty discarding/parting with objects
• Compulsive acquiring of free or purchased items
• Distress or interference
• Duration at least 6 months
• Not better accounted for by other conditions (OCD, major depression, dementia, psychosis, bipolar disorder)

Prevalence and Demographics:
• Prevalence in general population – 3-5%
• Underreported problem –only five percent of cases come to attention of authorities.
• Prevalence among patients with obsessive compulsive disorder is approximately 20-30 percent.
• Prevalence among patients with dementia is approximately 20 percent.
• Education – ranged widely
• Typical age of onset was during childhood or adolescence.
• Strong familial link – 80 percent of hoarders grew up in house with someone who had hoarded.

Co-Morbid Problems Associated With Hoarding
Hoarding is associated with several disorders including:
• Dementia
• OCD
• ADHD
• Depression
• Anxiety (PTSD, general)
• Schizophrenia /psychotic disorders
• Substance abuse
• Personality Disorders

Hoarding Stems From Four Types of Deficits
• Information-processing – decision making; categorization/organization; memory.
• Problems with emotional attachments to possessions – objects as extensions of oneself.
• Behavioral avoidance – excessive concern over mistakes.
• Erroneous or distorted beliefs about nature and importance of possessions.
• Perfectionism
• Need for control
• Responsibility
• Emotional comfort

Treatment Interventions
• Medications
• Psychotherapy
• Cognitive Behavioral Therapy
• Harm Reduction Model

Challenges To Treatment
• Very little data available regarding treatment outcomes with hoarders.
• Little evidence that antidepressants or other meds used to treat OCD are effective in treatment of hoarding.
• Hoarders have poor insight into nature of problem (denial).
• Motivation to change is limited and resistance to treatment is high.
• Treatment is frequently lengthy (one to two years)
• Limitations of Cognitive Behavioral Treatment Model

Hoarding In The Elderly Population
• Age-related illnesses are not primary cause of hoarding.
• Hoarding is a common symptom in dementia patients.
• Memory loss: inability to discriminate between relative importance of articles in home.
• Forty percent (40%) of hoarding complaints to local health departments involved elder service agencies.
• Self-neglect associated with hoarding.

Causes For Hoarding In The Elderly
• Compensation for loss
• Grief reaction – death or divorce
• Avoiding waste – Depression era
• Traumatic event – Holocaust
• Social isolation
• Finding security

Interventions With Hoarding In The Elderly
• Hoarding is a mental health and a public health issue
• Treatment involves:
· Mental and physical health assessment
· Risk reduction
· Treatment for identified symptoms
 

There are many potential causes of cognitive problems including medications, thyroid issues and vitamin B12 deficiencies that are completely reversible. Other causes including degenerative conditions like Parkinson's disease dementia or Alzheimer's disease are very treatable and those medications help to slow down the cognitive decline. Both family members need to be evaluated by their primary care doctor for causes of their impairments. Also family can ride with the mother-in-law to ensure she is still using good judgment with her driving. If there are questions regarding her driving skills, driver evaluation centers can be contacted for professional evaluations. 

You mention that she removes all her clothes after bedtime. Does that mean she originally goes to bed with them on? If that is the case, perhaps using a medication that promotes sleep like trazodone may help her sleep through the night and decrease the times she wakes to remove her clothes. Is any one living with her? If she has a bed alarm, or a baby monitor, the other person could be notified when she gets up and assist her to the toilet to prevent falls. Consider also the use of a commode at the bedside, which should reduce the time to reach the toilet and perhaps she will make it on time to the commode. Also be sure to enforce no fluids after dinner. Avoid caffeine or alcohol as these promote urination. Hopefully some combination of these ideas may be helpful to your situation. 

Hello Mike,
Your question is a very good one. Mobility isn't a one-size-fits-all solution, which is why there are so many different types of scooters and wheelchairs on the market. Similarly, BraunAbility wheelchair vans and wheelchair lifts are designed to meet the different heights, weights and personal preferences of our customers. With that said, there are some products that may fit your needs better than others. For example, if you're a taller individual who sits in a larger wheelchair, our XT (extra tall) conversion on the Toyota Sienna or Chrysler Town and Country may be a better fit for you. That's why we stress that you should visit your nearest BraunAbility dealer to have a mobility specialist on staff help you find the best fit for you as an individual. They'll ask the right questions, take the right measurements and let you try the vehicles out for yourself. If you're ready to start that process, you can find your nearest BraunAbility dealer at: http://www.braunability.com/dealer-network.cfm.

There is no personal financial responsibility for the guardian unless he/she is guilty of misconduct. The guardian uses the ward's funds to pay for the ward's expenses. I hope this helps. 

I am sure it is very disturbing to see your father like this. At the end stage we are focused most on quality of life for him. Certainly if part of his agitation is due to pain, that should be addressed. Also a review of any medications he is on that can increase confusion or agitation would be suggested. With the broken ribs, is he breathing well? Air hunger will cause agitation and confusion. Getting good sleep at night is always important. Trazodone may be of use if needed. The key, however, is to control his agitation and, do to that, one needs to figure out the cause (anxiety, air hunger, pain, fear, restless...). If his agitation is improved, then he has a better quality of life. Good luck.
 

When older adults give up their primary living environment, they feel out of control. Even if the new facilities and support staff are ideal, they cannot eliminate the psychological discomfort of being in a new space creates. For most elderly adults, their primary living environment represents the last area of control they have in a world of mounting losses. It sounds like your father is trying to assert some control as he comes to terms with his new living environment and you have become his primary focus.

While this is a natural response, it can be very taxing on the primary care coordinator (PCC) of the family. Unless you find a way to “rebalance” his expectations, you will exhaust yourself trying to ameliorate his discomfort. For his transition to be successful, you both need “breathing room.”

One-way to do this is to offer your father what I call “preferred choices.” Preferred choice is a way to say to aging parents “you matter” but that you are not at liberty to ignore or renege on the other responsibilities in your life. Even though your resources are limited, you will insure that your aging parents retain a priority status in how they are allocated.

The set up for this strategy is straightforward. Despite the day-to-day demands of trying to get everything done, you are giving him first choice whenever you can regarding his visits, appointments and outings. If you can only come for a single visit on a given day, what time would he prefer? If you only have time Monday and Thursday this week for his next doctor’s appointment, which day would he prefer? This sends a clear signal that he is of central importance in your life and is not being left out. But it also sends a signal that there will be times when you can’t drop everything and take care of his needs.

This is not say that your father will be the thrilled with the “preferred choice” system. But it will reset his expectations and give him clear choices as to when he gets your attention. Without these boundaries, he will not be motivated to seek out other sources of support and attention in his new environment. Like you, he needs a new structure to rebalance his over dependency on one person to meet his needs.
 

The transition between living spaces is always a dilemma. The loss of control, the need to let go, and the disorientation of the new surroundings are difficult enough without a surprise and unwanted change in competency (i.e. you need assisted living). In this case, the facility stuck with the physician’s recommendation, the family balked, and the move was “off.” But there were other options, albeit more time consuming and requiring more creativity, that could have helped both parties work their way towards an acceptable solution:

1. Map out and better understand the details of the health assessment. What were the specific ADL issues in the health assessment that led to the “needs assisted living” recommendation? Were they dramatic deficiencies or “entry level” limitations? How is the aging parent currently managing these issues in her living environment? The goal of this conversation is to help the family understand the scope and degree of the ADL concerns and, at the same time, help the facility understand the context and history of the older adult’s functionality.

2. Consider a PT enhancement program to improve overall functionality. Deconditioning is common in older adults and undermines all aspect of their functional ability. Have the older adult’s physician order a PT consult to assess movement, strength, and gait. Then have the PT professional map out a treatment plan that combines PT sessions with at home exercise program. This type of intervention returns control to the older adult (i.e. you have choices to improve your functional status) and can have a significant impact on ADL status and overall wellbeing.

3. Consider a “stealth” assisted living program. This option requires a committed engagement by local family members to supplement the independent living environment with hands-on support. While the main benefit is an initial placement in independent living (with a little help from family and friends), it also provides a softer approach for adding assisted living in the future.

4. Consider a trial period of independent living. Sometimes only a trial period will suffice. Opt for a 30-day trial period of independent living, track the details, and then assess the outcome. While this may be a short-lived trial, it provides the dignity of choice and the kindness to admit that none of us want to be seen as “in need of assistance” if we can safely avoid it.
 

Making the decision to place a loved one in a nursing facility is quite personal, emotional and difficult. It usually comes when care in the home becomes unmanageable physically, emotionally or financially. You must also take into consideration your own health and age and how long you think you can be the primary care provider. Ask yourself if 4 hours a day of help is enough, or if it's too much of a struggle the rest of the time for you alone. Do you have a support system to help when he needs more care in the future? What if he needs more "skilled" care from a nurse or care during the night for incontinence and to prevent skin breakdown? Are you able to get the rest you need? These are some reasons why people choose to enter a nursing facility. There is no easy answer, but follow your instincts and plan ahead for increasing care needs as his conditions progress. 

Thank you for the question! We've had customers ask about this from time to time, and I can tell you that we have a couple of lift models that have been successfully installed in motor homes before. As you can imagine, it depends on the vehicle. Your best bet would be to visit your nearest BraunAbility dealer. They'll have mobility experts on hand who can take the necessary measurements and let you know which option would fit your needs best. If you don't know who your nearest dealer is, you can find them at the dealer page on our website: http://www.braunability.com/find-a-dealer.cfm
 

These are valid concerns that need to be addressed with the specific facts. You should consult with a qualified attorney who can investigate the underlying facts. Any general answers may be misleading. You may want to start with the attorney who drew up the deed for your mother.

Most loss of vision after a stroke is due to damage of the nerve pathways between the eye and the brain. Recovery of the vision depends on how severe the damage is. Up to 2/3 of people with a stroke will recover some or all of the vision loss eventually, particularly in cases of less severe damage, but it can take from 1-6 months. There is no good evidence that any vision therapy helps this process. There are some eye and neurologic centers that offer Vision Restoration Therapies after a stroke, however, the results are usually mild at best. You could ask the neurologist involved if this is a reasonable option to pursue if the stroke was a while ago. If the stroke was very recent, time is the best therapy.
 

This is unfortunately a very difficult situation. There are many opinions about how to prevent falls from beds in hospitals and nursing homes, but not great conclusive evidence. The best way to prevent serious falls seems to be to have the bed very low to the ground and have a safety mat on the ground so if the person does fall out of bed there is little danger of serious injury. The issue with bedrails is that with bedrails up there are fewer falls out of bed, but the falls that do happen are more serious because they result from people climbing over the bedrail and falling from a greater height. Most specialists in falls suggest not using bedrails for that reason. Another safety feature sometimes used is a bed alarm that sounds when someone is climbing out of bed, but those have been shown to not help reduce falls because by the time a staff member responds to the alarm the person has usually gotten out of the bed (and fallen if it is a fall situation). People on Klonopin are at greater danger of falling.

The best solution would be to ask if there can be a low bed with a mat next to it. I do not know of any regulation preventing bedrail use, just the worries that are mentioned above. Places that use bedrails usually make sure to inform the family of the dangers associated with them, which includes not only the more severe falls when they do happen, but also people
getting tangled in the rail and injuring arms or legs by the tangling.
 

In Seattle, the first place I would suggest your mother be evaluated is at the Alzheimer's Disease Research Center at the University of Washington. They have expert neurologists who specialize in Alzheimer's and cognitive disorders. Dr. Murray Raskind is the Director of their center. Residents of other cities can get on the American Academy of Neurology website to "find a
neurologist in your area." That website is: http://patients.aan.com/go/home
 

The term dementia is a symptom and not a condition. Dementia just means that someone has trouble with thinking and functioning. It does not tell anyone what the cause of those symptoms are. Some causes of dementia are multiple strokes, head trauma, Alzheimer's disease, Parkinson's disease dementia, alcohol toxicity, medication toxicity, etc. Your mother's physician should have completed an evaluation to determine the cause of her dementia symptoms (her thinking and functioning problems). You can have a diagnosis of Parkinson's disease without dementia (just called Parkinson's disease) and you can have Parkinson's disease with dementia (called Parkinson's Disease Dementia). In some cases, those with dementia and Parkinsonian symptoms (stiffness, balance issues, tremors, slow movements) have a condition called dementia with Lewy bodies. It is possible to have Alzheimer's disease and Parkinson's disease, but that would be very rare and very unlucky.

In regards to the anorexia, there could be many causes. Some people with Alzheimer's disease, Parkinson's disease, Parkinson's disease dementia, dementia with Lewy bodies and other dementia producing conditions can be a cause of poor appetite and weight loss. Providing increased supervision during eating times, providing foods they like to eat, and providing nutritional supplements (Ensure, Health Shakes, Boost, Carnation Instant Breakfast, others) often help. Her doctor should look for other causes of appetite loss like the use of certain medications (cholinesterase inhibitors for example), gastrointestional conditions, renal or liver conditions, thyroid conditions, etc.
 

Unfortunately, broken femurs lead to significant disability that the patient may never recover from. This is especially true for those individuals with dementia who are unable to learn new procedures well. Watch for symptoms of depression as that condition can be treated with antidepressants. Sometimes appetite loss is a sign of depression. I would not go higher than 20 mg of Lexapro. If her compulsive habits are contributing to her appetite loss, sometimes fluvoxamine at higher doses may be helpful (most patients may need 200-300 mg daily in divided doses slowly titrated to effect). In regards to the anorexia, there could be many causes. In some people dementia conditions by themselves can be a cause of poor appetite and weight loss. Providing increased supervision during eating times, providing foods they like to eat, and providing nutritional supplements (Ensure, Health Shakes, Boost, Carnation Instant Breakfast, others) often help. I have found megestrol acetate (400-800 mg/day in two divided doses) may help with appetite. Her doctor should look for other causes of appetite loss like use of certain medications (cholinesterase inhibitors for example), gastrointestional conditions, renal or liver conditions, thyroid conditions, etc... The term dementia is a symptom and not a condition. Dementia just means that someone has trouble with thinking and functioning. It does not tell anyone what the cause of those symptoms are. Some causes of dementia are multiple strokes, head trauma, Alzheimer's disease, Parkinson's disease dementia, alcohol toxicity, medication toxicity, etc. Finally remember you can only do so much to help her and it seems like you are trying everything you can do. Sometimes the disease conditions take over and we are left with our loving support
 

“Just Medicare” is typically referred to as “Original Medicare.” Your HMO plan is a Medicare Advantage plan. Typically, what you’re buying with a Medicare Advantage HMO plan is:

• An HMO network of providers who are contracted to provide you with service
• Prescription drug coverage
• An annual limit of no more than $6,700 on the amount of money you’ll pay out of pocket.

Most Advantage HMO plans will have these three things, but they’re not provided by Original Medicare. Original Medicare is a terrific benefit, but it has gaps. Original Medicare (Parts A and B) have deductibles. And the Part A deductible is not tied to a calendar year like they are with traditional health insurance. Instead, it’s tied to a 90-day benefit period, with some exceptions. After the 90 days, the deductible typically resets.

The Part B benefit includes coinsurance after you meet your deductible, which means Medicare pays a percentage of each bill and you pay the rest (typically between 20 and 45 percent, depending on the service) after applicable premiums and deductibles. Your Advantage plan may also have deductibles and coinsurance, but Original Medicare does not limit how much you’ll pay out of your own pocket for covered medical services each year. And, again, Original Medicare does not cover the cost of most prescription drugs. Many people who participate in Medicare without an Advantage plan elect to fill the gaps with Medicare Supplement and a Part D prescription drug plan.

If you’re trying to save money on your monthly premiums, you can go online to see prices and benefits for competing Medicare Advantage plans that may be an option for you. Each year there is an annual enrollment period when you can switch from one plan to another. This year the annual enrollment period runs from October 15 through December 7. If you do decide to go with original Medicare, you will need to enroll in a stand-alone Medicare Part D plan to be sure you have prescription drug coverage and don’t face penalties for going without. You can pick your Part D plan during the same annual enrollment period.

You may also try to get coverage through a Medicare Supplement, but most Medicare Supplement plans will require you to pass a health screen if you are not within your first six months of Medicare eligibility. So, there is a chance you will not have access to that alternative.

Details about Medicare Advantage Plans for 2012 will soon be available. Medicare reports that on average Medicare Advantage premiums will be four percent lower for 2012. That is good news, but it is still important to see what your plan will charge in premiums next year. Also, review your copayments if you require medical care, your out of pocket spending limits and your prescription drug benefit.
 

Medicare might pay for the bed rails. The doctor’s order is necessary and the equipment must be purchased from a Medicare certified supplier. You can check with Medicare in advance of the purchase by calling 1-800-MEDICARE. If you have a Medicare Advantage plan you should check with that plan to make sure you follow its requirements.  

You’re right. The donut hole resets each year. Annual enrollment for the 2012 plan year runs from October 15 through December 7, 2011, so we are approaching the right time for you to go online and check to see if there will be any changes in your mother’s existing plan as well as the whether the coverage provided by other plans better fit her situation. I would highly recommend that you use a Medicare Part D prescription drug plan comparison tool, such as the one we offer at PlanPrescriber.com or the one that is available at Medicare.gov. Here’s why: If your mother hits the donut hole in 2012 she can get a 50 percent discount on brand-name drugs and a 14 percent discount on generic drugs if the drugs she’s taking are covered by her plan.

She can only access those discounts if the drugs she takes are covered by the plan she’s enrolled in. And, if the plan she selects does not include her drugs on the plan’s formulary, she could wind up paying full price for those drugs.
 

Waiting for an emergency to make a move is never the best way to make it happen, but sometimes is the only way. My advice is to be prepared by visiting facilities and even trying to arrange for a visit for lunch with one or both of your parents. Start the process of paperwork if you can and talk to the doctor about what you are trying to accomplish since they will also need to fill out admission paperwork. Depending on the finances, sometimes one half of a couple chooses to enter assisted living even if the other is too resistant. If the home environment really becomes unsafe and unhealthy, you might need the assistance of a social worker from elderly protective services or a social worker from your town department of social services. You can also try to explain to your parents that they have a choice...to accept some help in the home or to move to a place where there is staff available. The choice could be taken away from them if they don't work with you in this process.
 

If your mother has not already been evaluated for her memory loss, she needs to be seen right away. There are many causes of memory impairment that are reversible. Some examples include certain prescription medications, some over-the-counter drugs, sleep apnea, low thyroid, vitamin deficiencies, and many others. Even if she is found to have a degenerative dementia like Alzheimer’s disease, the earlier she starts on treatments, the slower the decline of her memory and functional abilities. This allows her to be a functional caregiver for her husband for a longer period of time. It may also be a good idea to get an in-home assessment to identify potential safety issues in the house and to suggest possible home modifications to make caring easier. In addition, providing more supervision and increased respite opportunities will help to prevent early burnout.
 

There may be limited options. It would be most important to know how severe the neck fracture was and how unstable his cervical spine is because of the fracture. If there is substantial risk to cervical spine stability and he does not wear his collar, then it may be worth the risk to have surgery to stabilize the neck. Other options may include placing a more secure neck
brace that is harder to remove. If his fracture is not that unstable, it may be better to go without any collar than have him constantly tug at his neck, trying to take a collar off. Another option: Placing mittens on his hands may reduce his ability to loosen or remove his collar.
 

That's a very good question. There are over 4.3 million wheelchair users in the United States, and that doesn't even include people that use scooters! Our vehicles are typically used by individuals with a variety of disabilities or those with a mobile challenge that requires a wheelchair/scooter in order to move around. Within the wheelchair user community, you will find this includes veterans, seniors, adults and even children. Any of these folks are candidates for a converted vehicle and I'll explain why.

Getting from point A to point B is a crucial part of a person's life, no matter if they require mobility assistance or not. When that ability is taken away, it can drastically change a person's quality of life. This person could be a child who requires a wheelchair, an ailing parent or even the adult driver him/herself. A wheelchair accessible vehicle grants these individuals a level of freedom and independence to get around.

Our job is to provide them with a vehicle that will assist in their mobility and help them get to a job or a doctor's appointment. Just think of a newly married couple or a veteran returning from war with a new way of life to adjust to. Braun's goal is to develop a vehicle that is going make it just a little bit easier on someone who needs to get somewhere, and we're constantly looking for ways to make these options more safe, more reliable, and more customized to what they really need.

 

A toileting schedule can be very useful to prevent incontinence and urgency issues. However, I typically do not have them toilet every 2 hours while they are sleeping. This would be especially true if it appears that waking him is disrupting his sleep cycles and making him irritated. Unfortunately, I am not aware of any studies that have looked at this. 

There are several things to consider that may be helpful. During the day, increasing daytime activities and reducing the chance for naps may help him fall asleep more easily at night. Also avoiding liquids before bed reduces the waking at night for toileting. Medications, pain issues and mood states may all lead to sleep disturbances that should be considered. To help with sleep issues, trazodone, an antidepressant, helpful to promote sleep, can be given at night. This may help to reduce sleeplessness without any hangover effect the next day. Zolpidem may be another choice to try to help with sleep issues if trazodone is not useful.

If he has significant false beliefs or suspiciousness or paranoia, then an anti-psychotic medication may be the correct choice to give. Perhaps lowering the dose or giving it in the late afternoon may help with the evening behaviors and not cause next day side effects.
 

You are not over-reacting. Choosing an in-home caregiver is not a decision to be taken lightly, and you hired this person because you trusted that they would provide the care you felt was necessary for your mother. As a home health aide, it is critical that they work toward providing the highest quality of care your mother expects and deserves.

Every client and caregiver relationship is unique; however, the bottom line is that the home health aide must provide the set of services that were initially agreed upon being hired. If your mother’s mental/physical state has changed since the plan was implemented, the care plan may need to be adjusted to fit her current lifestyle.

If the home health aide is employed by an agency, call the agency to discuss potential solutions, including reevaluating the care plan or introducing a new caregiver if the current health aide is unable or unwilling to provide the services your mother requires.

If your home health aide is an independent contractor, sit down with them to review the services that were agreed upon in the contract. If necessary, adjust the care plan or consider hiring a new home health aide to better serve your mother.

A compatible client/caregiver match is critical to ensuring the best quality care is being delivered. As one’s needs change, so may the home health aide and/or care plan, so it’s important to check in regularly and remain flexible as your mother’s needs change.
 

If you are a caregiver for your parents and you’re trying to enroll them in a Medicare Part D plan when they’re not with you, make sure you have your parent(s) give you power of attorney so that you’re authorized to make that decision. When you sign your parents up, the insurance company will ask you for a copy of the power of attorney when you sign the paperwork. However, if you don’t have power of attorney, don’t let that stop you from helping your parent(s) enroll. You can work with an agent to pick the right plan, and then have your parent follow-up with the agent to confirm their decision.

If your mother is just looking to you for a second opinion on her choices, she can ask her agent to add you to a conference call when she is reviewing options with the agent. The agent should be able to make plan materials available to you by e-mail.
 

This is a great question as it is an important reminder to everyone enrolling in Medicare plans this year. Medicare’s Annual Enrollment Period (AEP) for Prescription Drug and Medicare Advantage plans did change this year. The new Annual Enrollment Period takes place between October 15 and December 7, 2011. It starts a full month earlier than last year and ends three weeks earlier as well (previously, AEP ran from November 15 – December 31).

What’s good about the date change is that it pushes the enrollment process up ahead of the holiday season, where most people probably don’t want to be pouring through insurance information. The bad news is that not everybody may be keeping track of these new dates. Every year we get phone calls on January 1st from people who forgot to call in December and want to try and make a late change to their coverage. And, unfortunately, we have to tell them that they’re too late. I’m fully anticipating the number of these calls to increase in 2011.

That being said, I do think that in the long run the date change is a good thing. In the past, Medicare’s Annual Enrollment Period encompassed Thanksgiving, Chanukah and Christmas, and ended on New Year’s Eve. These are major US holidays when people tend to travel, visit family and generally just have an awful lot going on. By moving the event up three weeks, my hope is that more people will make their changes early so that they can get it over with and enjoy the holiday season.
 

There are two important considerations in your question. First, in addition to diabetics, women and older people may have silent heart attacks. Heart attacks are much more common in people with risk factors for heart disease, which include hypertension, high cholesterol, diabetes, smoking, obesity, lack of exercise and family history of heart problems, but people with little to none of these risk factors can have heart attacks also.

The second, and possibly more important consideration, is that the EKG may have been interpreted incorrectly. Most EKGs these days have an automated interpretation by a computer, and those are often incorrect. I have seen this computer interpretation often diagnose a prior heart attack, that on more expert review of the EKG is not suggested. I would ask the doctor if a cardiologist overread (meaning also reviewed the EKG) it and if the cardiologist also thinks an old heart attack or two old ones are suggested. It might also be helpful for a doctor to look at an old EKG of yours, if one is available, to see if there are changes from before. A lack of new findings on the EKG, particularly if any available prior EKG was from a while ago, also makes a heart attack less likely.
 

One of the best techniques is to get your mother on a toileting schedule. That is, have her sit down on the toilet every 2 to 3 hours whether she has to go or not. This will reduce the urgency and her not getting to the toilet on time in many cases. At times, patients may not like to be told what to do. They may also not like to be told to go to the toilet every 2-3 hours when they do not feel the need. Often suggesting that you are also going to use the toilet but do they want to go first, may ease their notion that they are being picked upon or bossed around. Giving them other excuses to go use the toilet may be helpful such as suggesting that they should go to the bathroom before they go out, etc. Also try to avoid prescription medications to control urinary leakage or incontinence as they often reduce the effectiveness of medications that are helpful for memory such as Aricept, Exelon or galantamine.
 

Parkinson's disease treatment will vary depending on the stage of the disease and the patient's other medical conditions. Unfortunately I cannot be more specific. Most medications for Parkinson's disease and for diabetes do not contradict each other. 

It would be hard to be specific with any recommendations for medications, not knowing her condition and medical issues. However, consider anxiety or mood as a contributor to pain when turning. Use of an antidepressant (SSRI) or divalproex sodium may be considered. Also, if it has not already been addressed, the type of bed or chair that she lies in may make a big difference in her pain issues when she is turned. Specialty beds and chairs should be discussed with her therapists.
 

There are two issues to discuss for your problem. In terms of the wandering, it is believed that people who have abnormal mental function often wander because they are looking for something, but due to their trouble thinking they are not sure what it is. Medications do not help this, and in fact in facilities that specialize in dementia the wandering is often encouraged because stopping or preventing it can be frustrating to people with dementia.

The bigger issue for her may be to figure out why she has had the decline in her mental state. She may have developed dementia, which is a term for mental deterioration that has several causes, the most common of which is Alzheimer’s disease. However, there are often correctable causes for mental status deterioration such as side effects from medications, other new medical conditions, abnormalities in blood tests such as low sodium and psychiatric issues such as depression. She should be evaluated for the cause of the decline in mental function. If it is correctable, the wandering may stop.
 

In order for a person to be eligible for hospice care their medical doctor has assessed that given that person's diagnosis, with the expectation that the disease will run it's anticipated course, that the patient's prognosis is 6 months or less. However many people may receive hospice care well beyond that six month time frame. To continue to be eligible for hospice care the patient continues to exhibit signs/symptoms of overall declining health and disease progression - for example, increasing fatigue; pain issues; weight loss; functional decline. If a patient's health is improving then they may be discharged from hospice services - sometimes referred to as "graduating" from hospice. A patient can always resume hospice services again in the future should their health decline. Hospice care is intended to provide services to the patient through the dying process and expected death.