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=
 

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. 

If she has not had a medical evaluation for her memory issues, this would be suggested. Many conditions causing memory loss are reversible or treatable. Checking for thyroid issues, vitamin deficiencies and metabolic problems should be performed. Looking at her medication list to eliminate those medications, where possible, that can cause cognitive issues and confusion could also help. If a degenerative disorder is thought likely, starting anti-dementia medications will be very helpful. Behavioral modification techniques can be used to help reduce her anxiousness about wanting to go home in the evenings. It is always nice to be "home" especially as evening is coming. For many people trying to redirect her to the reality that she really is home does not often work. So, empathize with her concerns. Tell her that it is getting late and that she should stay here for the night and you will have her home first thing in the morning. Tell her not to worry and that you will be with her until she gets home. If she has other symptoms of false beliefs, paranoia or suspiciousness, talk to her doctor about possible medication use (antipsychotics) that may be considered. If she has other symptoms of anxiety, angst, or fretfulness, talk to her doctor about possible medication use (anti-depressants) that may be considered.
 

The clause you are referring to typically pertains to financial assets. There should be no problem moving dad's personal effects into your house. 

It sounds like you are saying that your husband is having hallucinations and false beliefs. These types of symptoms in dementia patients are common and are usually very treatable. If the symptoms are mild or infrequent, changing the subject or empathizing with the patient may be all that is needed. If the hallucinations and false beliefs are persistent and causing a lot of distress, then use of low dose antipsychotic medications can be very useful. His physician can prescribe such medications if needed. Locked units are to protect patients so that they will not wander away. I am not sure if he has these issues. If he is safe where he is currently living or after behavioral treatments, then there may be no reason that he would have to go to a locked unit at this time. 

Unless the POA is being used to transfer real estate it does not have to be recorded or registered anywhere. To find out if your sister has POA, ask your mother. If she is unable or willing to tell you, then ask your sister. If she won't tell you, then you could commence a guardianship if mom's affairs are not being handled properly. In this proceeding you could seek to revoke the POA. The nursing home admission agreement must be reviewed to determine who has the power to sign mom out. Typically for health care decisions you would need an advance medical directive. I hope this helps. 

Chris, the Medicaid rules are very state specific. I suggest you speak with a certified elder law attorney in Ohio where your mom resides. Generally speaking, if someone is in a nursing home and doesn't intend to return home, then their former residence is considered an available resource with respect to Medicaid eligibility. 

The only way to address running out of Medicare days is to file an appeal with Medicare. The social worker at the nursing home should provide you with this option in writing, and inform you about the process of how to proceed. I would ask the therapist who made this comment to explain why he/she thinks your mother is not in pain and to give you examples to back up this assertion. Sometimes, patients are observed by staff doing certain things that do not produce pain, while they cannot do the same things in therapy without pain. This can lead to this type of comment.

If you feel this therapist is negatively biased in working with your mother, I would request another therapist work with her or ask for the therapy supervisor to do an assessment.
 

One thing that can cause this is termed fecal impaction, which means that there is severe constipation and the only stool that can get out must be loose stool that leaks around the area of the constipation, often several times a day. The only way to find out if this is the cause is for someone to do a rectal exam and feel for a mass of hard stool. If this is not found, then his medicines, particularly the Omeprazole and maybe the Sulcrafate, could be the cause.

He needs an extensive neurologic examination. With normal scans the likely causes focus on nerve damage, with multilple possibilities such as Guillian-Barre syndrome, which do not show up on lab testing or scans. Sometimes a neurologist will do an EMG test that can also help diagnose the cause.
 

There are many reasons why she might be tired all the time and dizzy, so it's best to have a full medical work-up through her primary care doctor or perhaps a geriatrician, if you have one in your area. A review of her medications, blood work, nutrition, mood, and social activities should be reviewed and discussed. 

Critical to this developing situation is, does the daughter (or someone) have Mom's Power of Attorney (POA) for both healthcare and finances? As many forms of dementia are degenerative in nature, someone must secure the POA now, before Mom's confusion progresses to a point beyond which a POA can be obtained. The person creating a power of attorney, also known as the "grantor," can only do so when he/she has the requisite mental capacity to do so.

One of the most distressing aspects of dementia is the fluid movement of remembering/not remembering persons, thoughts and actions. This cycle is frustrating for both the older adult and the family. Without knowing the current status of Mom's cognitive health, I would recommend 1) A family member obtain Mom's POA at the earliest opportunity and 2) Have a family member speak directly with Mom's physician to acquire a greater understanding of her physical and cognitive capacities at this time. The result of this discussion will tell everyone a great deal more.

While the move to senior living is the catalyst for this question, other areas of concern are part of the whole picture here. The answer, ultimately, may be a move to a congregate living community, but the family must learn Mom's ability to even make this life-changing decision.
 

FMLA applies to all public agencies, all public and private elementary and secondary schools and companies with 50 or more employees. These employers must provide an eligible employee with up to 12 weeks of unpaid leave each year for, including to care for an immediate family member (spouse, child, or parent) with a serious health condition. Employees are eligible for leave if they have worked for their employer at least 12 months, at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles.

One notable requirement: For FMLA leave purposes, “parent” is defined broadly as a biological, adoptive, step or foster parent or an individual who stood in loco parentis to an employee when the employee was a child. An employee’s parents-in-law are NOT included in the definition of “parent” for purposes of FMLA leave. More information on FMLA is available on the US Department of Labor website at: http://www.dol.gov/whd/regs/compliance/whdfs28.htm
 

If parents have legal capacity and would grant POA and health care directives that would be better. It doesn't sound like your stepmom would do that since she thinks things are going fine. You need to go to court to seek permission from a judge to make decisions for your stepmom and dad. This process can take several weeks and is very complex.  

David, first off, I am sorry that you have been suffering with urinary incontinence. If you have not done so, I would suggest that you be evaluated by a urologist since we have very, very good treatments available for incontinence. It is a very rare patient we cannot help. Second, I doubt that the urinary tract infection was caused by not wearing diapers for a few days. I do not think simply foregoing the protective garment was associated at all with the infection. The fact that you had a severe urinary infection is another reason you should be evaluated by a urologist. I hope this is helpful. Again, don't suffer needlessly with urinary incontinence; a urologist can probably help.
 

It seems that there may be a legal question about your stepfather’s competency at the time that he borrowed. This concern should be answered by an attorney knowledgeable about state statutes governing lending in your father’s situation. You could alternatively check with the office of your state attorney general. They should be able to assist you. You may also ask them what recourse they suggest in having the power of attorney recognized by the lender. Putting that issue aside, if you only need information on the loan balance, your sister may have better luck getting this information from the lender with your stepfather’s participation. If he is able, it may be as simple as handing the phone to your stepfather to confirm her authority during her phone call to the lender. Your sister may also try writing to the lender. She should include a copy of the power of attorney. Of course the loan documentation and account statements would also provide this information.

Hopefully you have some respite as it appears your mother requires much supervision and care. In regards to the dementia component, you are probably doing what you can with the Exelon patch. The dementia will continue to progress unfortunately. There may be some help for her behavioral issues. You mention paranoia and false beliefs. Some Parkinson medications may cause these symptoms (Sinemet, Requip, Parlodel, Amantadine, others). Perhaps her physician can taper down on some of these medications if she is on any and this may help. At times adding a vey low dose of an antipsychotic like quetiapine may be in order to help with those symptoms. The motor symptoms may be difficult to treat except for close supervision and aid when she ambulates. If she is fainting due to low blood pressure with standing there may be some medications that can help that. Sometimes frequent urination may be an obsessive-compulsive behavior and not related to bladder issues or UTIs. At times high doses of antidepressant medications (SSRIs) like fluvoxamine may be useful to reduce the repetitive behaviors. If the behaviors are worse at night and she is up constantly, trazodone may be useful to help with nighttime sleep promotion. Talk to her physician about all these issues. 

Long-distance caregiving can be a challenge. You will likely need to go in person to make any changes in this situation, or enlist a local geriatric care manager to help facilitate some change. The things I would look into are Adult Day Care or a Senior Center to increase socialization and stimulation. Some places provide transportation, lunch and skilled nursing if medications need to be given. Isolation and withdrawal from activities can often be a symptom of depression in the elderly, so you should have him evaluated for this by his primary care doctor.
 

There are many causes of weight loss and this should be addressed by her family physician. However if she has a good appetite, trying nutritional supplements such as Ensure, Boost or Health Shakes or similar products 1 to 2 cans daily may help to keep her weight up. Carnation Instant Breakfast, ice cream and other more calorie-laden foods may also work. In many of those with dementia at the end stages, weight loss is an issue. However, this is not typical in earlier stages. In more severe cases, there are appetite enhancers (medications like mirtazapine or megesterol) that may help reduce weight loss. These can be discussed with her doctor to see if they are appropriate for her. If your mother does have dementia, make sure she has an evaluation to find out the cause so that she gets started on treatments that may be available. Treatments usually work better if started earlier and not put off for months or years. 

Every community is much different in their availability of support groups. The first place I would contact would be the local Alzheimer's Association. They may know of such a support group or help you start one. Other organizations that may help include the Alzheimer's Foundation of America, Children of Aging Parents (http://www.caps4caregivers.org), National Family Caregivers Association (http://www.thefamilycaregiver.org) and ParentGiving. Some of these organizations have chat rooms and message boards that can be utilized as well. 

Most of the time those with Parkinson's disease will have more problems (like tremors or slow movements) on one side of their body more than the other. Usually they may get symptoms on both sides, but almost always one side is worse than the other. Medication adjustments may help these new symptoms. Stem cell research is ongoing but not available outside of research. Deep brain stimulation (DBS) has been approved for some Parkinson's cases and can be done in some centers. This is usually reserved for those patients that are refractory to medications. 

Taking medications in pudding, applesauce or yogurt does help in patients with swallowing problems. Most medications can also be safely crushed and place in food or drink if they are not coated or not special extended release formulations. It would help to know when she is refusing to let you feed her the pudding with the medication—whether it is the sight of the medication or just the food or that at the moment she is not interested in eating and wants to be left alone. If it is the sight of the medication, crushing the medication to hide it in the food may be helpful. If she is just not interested in eating at that time, try changing the timing of the medication administration to when she is hungry. Also try to front-load her medications all in the morning if possible—you need to talk to her physician about any medication timing changes—when she is more in the mood to take her medications. Also check with her doctor to see if any more of her medications can be switched to liquid formulation as sometimes they will accept something to drink more than something to eat. It sounds like the use of Seroquel at night is helpful for her behaviors. You may talk to her doctor to see if an additional dose one hour before she normally develops her "attitude" in the afternoon may be advised. Ativan typically is to be avoided in most dementia patients because if given too often it will cause confusion and sleepiness and is addictive with withdrawal symptoms. Antipsychotics, like Seroquel, may be a better choice to help with certain unwanted behaviors. It is far better to avoid physical restraining if at all possible for many reasons (i.e. safety, psychological). I have written extensively on behavior management in dementia in my book, Long-Term Management of Dementia (Informa Healthcare Publishers). Best of luck to you and your mother. 

If they like to do the activities or like the socialization, then as often as they can afford it or are able to. Encourage any of the activities that they enjoy (it doesn't matter what the activity is); otherwise they will not continue to do them. Even if they do not participate, they will get good brain stimulation just watching others. 

It appears your father does not recall your conversations due to memory issues. He also seems to have poor insight. I assume he needs an assisted living facility as he is having trouble with performing day-to-day activities. It sounds like he is concerned and anxious about when he will return "home." Most likely he will continue with these concerns. Sometimes it helps to not tell patients with dementia or Alzheimer's disease that something is permanent (as indeed it usually is not). I would say that "temporarily he is staying in this new place." Perhaps you can mention that temporarily he is there since his wife has been ill (health problems and depression). Sometimes making a permanent note and placing it in a place where he can see it will remind him that he is at the new place for now as his wife has had health problems. Generally over time, as people get more accustomed to the new place, they will ask less and less. They will usually have less anxiety about being away from their spouse. If the anxiety does not get better, sometimes an antidepressant (such as sertraline or citalopram) will help. 

Based on your information, it is safe to say that the short-term memory loss is most likely due to the use of multiple medications, known as polypharmacy. I am not sure the reason why a pacemaker was implanted, but that alone would not be a cause for increased memory loss. If she did not sustain a traumatic brain injury from the fall then the use of multiple medications—especially 16—can without a doubt have an effect such as memory loss/confusion. There are certain classes of drugs, such as beta-blockers, psychotropic and hypertensive medications, that have confusion listed as one of their more common side effects. As we age, our body's ability to metabolize a single medication becomes slower. The obvious side effect you would see is confusion and/or just a sense of “not feeling” balanced. Your sister is in a high-risk category for experiencing multiple side effects due to the increased amount of medications she is taking. Another factor is that you listed her nutritional intake as poor. It is very important for her to stay hydrated and maintain an adequate amount of calories.

I would recommend taking all of her medications to her cardiologist and primary physician, and neurologist if there is one, so they each have a clear picture of what she is taking. If this has already happened, what needs to be looked at is what medications are life sustaining and possibly stop the others. This can allow for a clearer picture if it is in fact the use of multiple medications causing the memory loss. Keep in mind that it is not just prescription medications that have side effects of memory loss, but many over-the-counter medications as well. 

 

If we are fortunate enough to have parents who live into their 80s and beyond, we will likely confront injury, frailty and even loneliness that can affect our parent's overall wellness. A 2007 AARP survey, however, found that nearly 70 percent of adult children have not talked to their parents about issues related to aging. Some adult children avoid this most intimate of conversations because we believe our parents do not want to consider the future. Others believe they already know what their parents want. In both cases, the opposite is likely true. These are difficult conversations to have with our aging parents, and even harder to start. Some tips:

The best strategy is to begin the conversation with our siblings before a crisis. When approaching an older parent about making a transition of any kind, all siblings and family members must have a single voice and philosophy. One rogue adult child or sibling who is encouraging the status quo can make a new transition nearly impossible.

Gather a list of your own questions and ask your siblings to bring their concerns to the table. We, as adult children, should consider our approach to introducing topics, as much as the topics themselves. Often siblings will collaborate and decide what we believe is best and present it to our parent(s). Raising issues as shared conversation or as seeking advice is less confrontational (and more productive) than presenting parents with a ready-made plan. We must let our parents know the conversation is about them and their wishes for the future. Respect is a key ingredient for a successful outcome. Adult children can best start the conversation by simply listening to our parent(s).

Family discussions should honor the experience and feelings of everyone involved to achieve a successful outcome for the entire family. From the older adult’s perspective, the desired results generally involve feeling secure, maintaining personal freedom, having peace of mind, making their own choices and having family and friends nearby.

Consider the possible reasons for your parents’ reluctance to talk about a change. Are they trying to be difficult or is it something else? When someone is “being difficult,” they are often responding from a place of fear: fear of change and fear of the unknown. What if I move and I don’t like it? What if I don’t fit in? What if I can’t afford it?

Each adult child also must be honest with their parents (and siblings) about the depth and breadth of help we can provide. We, as the adult children, need to acknowledge our own limitations and then be prepared to make arrangements for the tasks remaining. Honesty is critical. This particular part of the conversation will often be the most productive in achieving focus and direction. It also offers our parents (and siblings) some insight into our own family obligations, career challenges, etc., which may preclude us from helping extensively. Once everyone understands the scope of the unmet needs, a lifestyle change is often the obvious choice – for both the older adult(s) and the rest of the family.

Lastly, we need to realize there is no such thing as “a” conversation about aging. Caring for an aging parent is generally not a sprint; it’s a marathon. Even after the smallest crisis, we are all living with a new uncertainty. The future will not be resolved in one afternoon. The good news about having these difficult conversations is that we may find we are truly connecting with our parents at the best possible time.

Yes, diabetes affects our kidneys as well. There are also other reasons kidneys may be affected, but diabetes for many years is right at the top. I would encourage you to seek out a nephrologist (a doctor who specializes in kidney problems). There are some medications that may be prescribed and in some cases a lower protein diet is recommended. In either case, a specialist is the one to make a diagnosis of exactly what the kidney issue is related to and how best to approach medications and/or diet. Wishing you the best.  

There is no relationship between most forms of dementia and kidney stones or urinary tract infections. However, if the kidney function is very poor, it does not filter out toxins in the blood and they can build up, leading to uremia and a dementia condition. These ailments are not an indication of widening effects of dementia. That is, dementia does not cause these types of conditions. Prognosis would be impossible for me to speculate with so little information regarding your relative's case. 

Typically people that inherit Alzheimer's disease from their parents will get the disease at about the same decade in life as their parents did. However, since you have been worrying about this, it might be useful to talk to your primary care physician. They can test your thinking and memory to see if there are problems and also get a good baseline to compare to future years ahead. One simple screening test they can consider using is called SAGE (Self-Administered Georcognitive Examination). This self-administered test is best taken at your doctor's office so that they can score the test and interpret the results. Your primary care physician can download SAGE from the web (sagetest.osu.edu) and give it for you to take. 

Unfortunately I do not have any additional suggestions for the neuropathy. You are on the maximal dose of those medications and those are the recommended treatments for diabetic neuropathy. Getting your diabetes under control also can help but your A1C is at recommended levels. 

There are several issues here to address for you. First, yes the Ativan can be causing all of your Dad’s symptoms. Your father is on a very high dose even for a young person, and particularly for someone of his age. There are other possibilities of what could be causing his symptoms, however, and he should see someone with knowledge in this area as suggested below. Unfortunately, also, Ativan is very addicting and has severe withdrawal effects. He really should get off it, but that requires a very slow withdrawal over several weeks at least. The preferable drugs for depression with anxiety component for an older person are celexa (citalopram) or Zoloft (sertraline). As for what doctor could help him, the options are a geriatrics specialist preferably or if not available a neurologist, general internist, or even a psychiatrist. 

Moving to a nursing home is a difficult transition for the older adult and family members. The responsibility of helping a loved one adapt to any community living environment is shared between the family and the new residence. A few tips to assist in this later life transition:

• Both the family and the nursing home can encourage the older adult to make a new friend (or two). Survey the scene and help identify individuals whom he or she might engage in conversation.
• The nursing home can also connect potential friends during the congregate dining time. Routine is part of the landscape in nursing home life, and sharing this routine with a companion makes it a more positive experience. (Close friendships are often formed in the senior living setting, due to the sheer number of shared experiences.)
• Personalizing the room almost immediately helps it become “home.” The nursing home should encourage the older adult and family members to bring a few, well-chosen mementos—photos, a stuffed animal, a favorite afghan, for example. Carving out one’s own space is critical to overall quality of life, and the nursing home experience is not any different.
• The nursing home should also encourage an extra helping of family visitation during the early days of the nursing home transition. Older adults truly fear “being left” in a nursing home, and frequent visits from family members will dispel this anxiety from the outset.
• Once the initial transition period is over, family members should establish regular visiting days and hours. It provides the older adult with an exciting event they can anticipate, and it helps create a more positive interaction when the appointed time arrives.
• The older adult should also observe constructive interactions between the staff and their family members, as it offers the peace of a “caring connection.”
• Everyone—both family members and nursing home staff—need to be responsive to the new resident’s concerns or questions. Listen well and allow the new resident to be heard.
   

 Many patients with dementia develop behavioral problems, which are very treatable. These behaviors are a direct result of the damage in the brain from the dementia condition. In addition, infections like urinary tract infections, anticholinergic or other mind altering medications, and other medical conditions will exacerbate these behaviors or cause new behaviors. Treating any underlying infections, reducing specific medications or resolving medical issues may help reduce problematic behaviors. These behaviors are also treated by judicious use of psychotropic medications meant to adjust neurotransmitters (chemicals) in the brain that become imbalanced due to the dementia condition. In your grandmother's case, she is displaying a lot of suspiciousness, false beliefs and agitation. Trying to use logic or trying to re-orient to reality will usually not work very well. Medications are often necessary to help with these types of behaviors. Atypical antipsychotics may be advised for similar behaviors. Please talk to her dementia physician or primary care physician about the possible use of psychotropic medications to help with her significant behavioral problems. I have written extensively on behavior management in dementia in my book, Long-Term Management of Dementia (Informa Healthcare Publishers). Best of luck to you, your mother and your grandmother.

To find a doctor knowledgable in your condition, there are several places you can contact. First ask your primary care physician who they might recommend. Call the Alzheimer's Association in your area; they often know which doctors in your region are specialists in FTD and Alzheimer's. Call your regional medical center; they can refer you to their Neurology (or Psychiatry) Department who will know who in their department is
knowledgeable for your condition. 

To get your answer, we turned to my colleague, John Buckles, President of Caring Transitions:
Helping a parent transition to a new home is often overwhelming for the whole family. Below are some steps to help you plan, organize and reduce some of the stress.
1. Set Goals: Establishing goals helps people manage their time and achieve desired milestones. Start from the move-in date and work backward to allow enough time for multiple tasks. The key is to determine what exactly you want to accomplish, when it has to be done. And who is going to do it. Develop a timeline based on your unique situation.
2. Create a Space Plan: Don’t overlook the cost of keeping things. Many Americans invest thousands of dollars to keep possessions they never use again. Take the time to consider what will fit in your new place. Then decide if you are likely to use the rest of the “stuff” you have, or if it is going to take up space in the basement or sit in a storage unit “just in case.” If you are unlikely to use and enjoy certain personal belongings, someone else may. There are a great number of local charities that will benefit from your donations.
3. “Eclectic” Decorating: Your well-worn, but comfortable furniture helps make a new house feel like home. Be sure to keep your favorite pieces, but don’t hesitate to add new items where the old ones just don’t fit. Often an oversized dining table can be replaced with a more practical drop leaf table for two or four. Your new place doesn’t have to look like a magazine cover—it just has to reflect your personal style.
4. Optimizing Value: As you downsize for a home transition, it is important to recognize the value of your possessions, whether financial value or sentimental value. Experts can help you optimize the value you of items you have been holding onto. A qualified professional can assist with shipments to relatives, online auction or pricing, merchandising and advertising an estate sale.
5. Know your Limitations: Don’t underestimate the time and physical demands of downsizing—packing, arranging donations, hiring movers or realtors and making arrangements for the items you decide not to take. What may be viewed as a simple task can quickly become a huge project or undertaking. Don’t hesitate to ask family, friends, the senior community or professional resources for help and advice.
6. Ask for Help: Family, senior living communities and qualified professionals can all offer help and advice as you.

Choosing Professional Resources:
When seeking a mover, organizer, realtor or estate sale specialist, consider the following:
• Obtain more than one bid from professionals so you can compare the cost and value of services, but understand the lowest price option is typically not the best service option.
• Online referral services can be helpful, but many online resources will let anyone advertise on their websites. Review referral websites to understand if the providers listed have to meet certain standards such as licensing and security background screening.
• Research each company’s licensing, training, credentials, insurance and reputation. The Better Business Bureau is still a great resource, as is your local Chamber of Commerce or State Mover’s Association. Always ask your service providers for references.
• Beware of companies that ask for cash deposits upfront or do not have written service agreements.
• Local referrals from friends, family and trusted members of the community are still typically the best way to find a reliable service provider.
 

This is a great question. I’m sure you’re already aware that most Continuing Care Retirement Communities (CCRCs) not only offer life-care contracts, but also “modified” and “fee for service” contracts. For the benefit of everyone reading this, residents, in exchange for a one-time initial entrance fee and monthly service fee, are guaranteed a lifetime of housing, supportive and health care services for the rest of their lives. The entrance and monthly service fees vary depending on the type of contract a person executes with the CCRC. There are primarily three types of CCRC contracts: an extensive or “life-care” contract, a modified contract with a specified or limited amount of health care and a fee for service or “rental” contract that makes residents responsible for all costs of additional health care services as needed. Because of the life-care concept and its provisions, people who want to live in a CCRC must meet certain physical and financial requirements. Prospective residents must be able to function independently at the time of their admission and demonstrate the financial resources to meet the CCRC’s initial and monthly fee requirements. A CCRC, for the most part, is an option that requires a significant upfront financial investment, which many Americans cannot afford to pay.

Now let me expound upon what I’ve been hearing and seeing recently in the industry. With 78 million baby boomers beginning to retire this year, many senior housing and care companies are recognizing the overwhelming need for more affordable senior housing options. What I’m seeing is a focused shift toward developing more affordable independent living units complete with supportive services and senior-friendly design features that allow its residents to remain independent and age in place for a longer period of time.

Affordable housing with supportive services is a key component to our nation’s long-term care continuum. The US Department of Housing and Urban Development (HUD) Section 202 Supportive Housing for the Elderly Program funds affordable housing for low-income seniors and enables seniors to “age in place” with the help of supportive, community-based services. Today there are over 300,000 Section 202 units throughout the United States and an estimated ten seniors that are waiting for each Section 202 unit that becomes available. The other problem is many of the existing affordable housing units were built in the late 1960s and early 1970s. These accommodations were originally designed for seniors in their 60s and early 70s. Today these units are occupied by older, frailer seniors who are oftentimes well into their 80s and even 90s. These living units lack many of the state-of-the-art senior-friendly design features that make these accommodations safer and more comfortable for an aging adult. What you need to look for are features that help our seniors maintain their independence for a longer period of time and providing them a better quality of life. Some of these senior-friendly design features to look for include overall building designs that are completely stair-free, wider doorways and hallways for better accessibility, location of countertops, cabinets and shelving to lower heights for easier accessibility, drawers instead of kitchen cabinets to hold pots and pans for easier access, lever handles on doors, cabinets and faucets instead of knobs for ease of use and shower stalls with molded pull down seats instead of tubs to help prevent frequency of falls.

For an expanded version of this response, please go to the feature, www.parentgiving.com/elder-care/older-population-growing-need-more-senior-housing/

Alzheimer's disease often does not cause gait or balance problems until late in the disease. Balance or walking problems may occur earlier if apraxia (difficulty in sequencing movements to result in a smooth gait) exists. I would talk to her physician to ask if there may be other causes for her walking issues. 

There are many medications that might be useful for depression and anxiety associated with Alzheimer's disease. However, do not confuse apathy (no interest in doing things) with depression (sad, crying, feeling low). Not wanting to go out of the house or not wanted to perform tasks may represent more apathy symptoms than depression. Apathy is not helped much by antidepressants. It can be helped by Aricept. If she does have apathy, you may wish to maximize her Aricept. If she is not taking 23 mg every morning, that would be a consideration by her physician. If she has significant depression or anxiety, one could increase her Lexapro (maximum dose 20 mg daily) or switch to another antidepressant (sertraline) to see if a better response can be obtained. I have written extensively on behavior management in dementia in my book, "Long-Term Management of Dementia" (Informa healthcare publishers). 

It would be difficult to say that there is a number one cause. The most common causes would be related to medications, dehydration, poor heart function or due to aging of the nervous system. The most common medications to cause this are blood pressure or heart medications, with pain, anxiety, depression and prostrate medications also capable of this. Dehydration causing low blood pressure is most commonly from diarrhea, vomiting, or being too sick to take in fluids. Systolic heart failure, if severe, can cause the heart muscle to pump poorly and lower blood pressure. Finally, up to 20 percent of elderly people will have orthostatic hypotension (low blood pressure only when sitting or standing) due to a change in autonomic nervous system function with aging. While sepsis frequently causes low blood pressure, it is fortunately uncommon. Merely having a diet low in salt can cause low blood pressure, but this is also rare.

While in the hospital, an outside care manager can be very helpful in being an advocate for the patient, and also communicating with the staff, getting information, participate in discharge planning and helping you cope with a stressful situation. The patient, or the patient’s legal representative, must consent to having an outside person receive information from the hospital staff, and often must sign a release of information form, per the HIPPA protocols, which protect patient information and privacy. There are also hospital case managers who will help with discharge planning, and it is important for an outside care manger to communicate with this person on your behalf.

It is never too late to take steps to protect your assets. While it is certainly advantageous to plan ahead, there may very well be worthwhile options for you to pursue. You should consult with a certified elder law attorney in your state. 

Some individuals can have dental procedures that may allow for fixed bridges or the like. Discussion with her dentist is recommended regarding those options. Dentures are often misplaced or hidden by dementia patients. If in an institutional setting, engraving of dentures may help to identify whose dentures belong to whom. Also be sure to look for missing dentures in any device that holds water. We have found dentures in toilet tanks commonly. Also it may be most important to determine if the patient wants to wear the dentures. If she has no interest in the dentures and views them as some foreign object, than I would avoid using them at all. Individuals are still able to eat softer diets without needing teeth. If the family is concerned by appearance, than they may put the dentures in only when she has company. 

Forgetting names of relatives and their relationship is common with Alzheimer's disease patients. Confusing daughters with sisters is common as they live more in the past where his daughter was much younger and his sister was not yet passed. He may not be able to learn that this person is really his daughter and not someone else. If their relationship is pleasant, then it may not be so important to always get him back to reality which he would have a hard time believing. If he is suspicious of this daughter and wants her to leave or makes it unpleasant for him or her to be together, then treatment with medications to reduce his suspiciousness may be warranted. This may also help other significant false beliefs or suspiciousness. If medications are considered, low dose of quetiapine, ziparsidone or others may be considered by his physician.
 

Palliative care is comfort care provided to enhance a person's quality of life by treating their pain and symptoms associated with their illness. Based upon what you have described your mother would benefit from the services palliative care can provide. Your mother seems to be suffering physically and emotionally. Her physical pain caused by her chronic, debilitating illnesses needs to be assessed and managed. Untreated pain is contributing to your mother's diminished quality of life. Palliative care nurses are specialists in pain management. With successful pain management your mother's mobility, overall mood and outlook may improve. As we know, life threatening or life altering illnesses do not just affect us physically, but also emotionally and spiritually. Many of the patients I work with who have similar circumstances as your mother also express their wish to die. They may be depressed regarding the multiple losses they face—loss of their health, their independence, mobility, day-to-day activities as well as loss of a spouse, family members, and friends. Although it may be difficult for you, you can support your mother by allowing her to talk about her feelings of "being put to rest" - validating these feelings with understanding that many people her age living with chronic illness also feel that way. Utilize this time as an opportunity to leave nothing unsaid—time for expressions of love, forgiveness and gratitude. It is also important to have discussions with your mother about her wishes- the medical treatments she would want and not want; whether or not she wants to go to the hospital; where she would like to die; funeral planning. These discussions can be difficult but are necessary to ensure that your mother's wishes will be met. A palliative care social worker can provide both you and your mother with supportive services including emotional support, education, and the resources you need to cope with your mother's illnesses.

Patients with Alzheimer's disease can develop many behavior symptoms including irritability, anxiousness, depression and false beliefs. These can be part of the disease. However, if there is some other active medical condition (urinary tract infection, pneumonia, drugs or drug interactions, significant heart, liver, or kidney disease, etc) going on, then there are often more sudden changers in behavior. The false belief of not recognizing family members as family members is called Capgras delusions. These false beliefs are best treated with atypical antipsychotic medications (like quetiapine and ziprasidone). If there are other concurrent medical issues, then those of course should also be treated. Increasing Prozac may possibly be contributing and since that was a recent medication change, I would consider lowering her dose back to 20 mg daily if agreeable by her doctor.