The Ultimate Role Reversal: Taking care of one’s aging parents
Dr. Alicia Arbaje has made a career of helping older adults manage their health so they can continue to live full lives, travel, and even work well into their seventh and eighth decades. As a geriatric medicine physician at Johns Hopkins Medicine, she is a specialist in the unique issues associated with older adults, including managing chronic disease, nutrition, cognitive and memory issues, maintaining balance, and the side effects of overlapping medications. “People are living longer with more burden of disease, so they need more help managing their health to live fully,” she says. Even so, older adults can use this time to learn new skills, leave a legacy, and live independently if they receive the proper support, and Dr. Arbaje stresses that their children should play an active role in providing the right environment.
Of course, helping older parents live well as they age can bring challenges. She cites her own father, who was on multiple medications for managing his blood pressure; primary side effects included fatigue and an extremely dry mouth, which made it difficult for him to speak for several hours after taking his pills. “My father is very active at 80, and he needs to talk to people and schedule meetings. For a few hours every day, he sounded like he was drunk,” says Dr. Arbaje. So she worked with his geriatric medicine specialist to see which of his medications could be streamlined or reduced. “We mentioned to his doctor that we were willing to put up with slightly higher blood pressure as a trade-off. That would not have happened if we had just looked at blood pressure alone, but when considering his life goals, there is an enormous upside for him to not have this side effect that affected his quality of life.”
Because reducing medication is something most doctors are not trained to do, getting an aging parent to a board-certified geriatrician—available at many teaching hospitals—is a good first step in taking control of health issues associated with aging. These doctors take a team-based approach, meaning the patient is not required to visit multiple specialists who might prescribe different medications and give varied recommendations. This prevents the patient from having to see a different doctor three out of five days a week; instead, a single team may consist of a geriatric medicine physician, a nurse practitioner, a social worker, and other specialists who provide coordinated care. “Make sure the care is focused on [the patient’s] goals,” advises Dr. Arbaje. “Medication is just one way to care for chronic conditions, and there are many other approaches that do not involve medication.” In her father’s case, doctors helped him improve his diet and exercise regimen, two factors that not only helped mitigate the reduction in his blood pressure medication but also keep him mobile and independent.
Enhanced fitness and nutrition can also decrease the effects of many chronic illnesses such as heart disease, high blood pressure, and diabetes. And since nobody wants every parent-child conversation to revolve around health issues—potentially creating a dynamic that turns the adult child into a constantly nagging parent—a geriatric specialist or dietitian can make recommendations about exercise and diet so they do not have to come from the family. When considering mobility issues, children of older adults often focus too much on safety, when a better and more holistic approach would be to focus on their life goals. “Mobility is part of staying independent,” she says. “That does not mean patients do not have a disability, but that they are able to cope with disability.” An adult child could consult a physical therapist or personal trainer to improve a parent’s mobility, or hire a driver to take a parent to regular exercise classes where there is also interaction with others.
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Aging in Place
Families can also modify the home itself to make it more accessible, and a good place to start is to consult a remodeling contractor who is a specialist in the issues of aging. The National Association of Home Builders (NAHB) Remodelers council has a Certified Aging-in-Place Specialist designation so prospective clients know which builders and remodelers have the expertise to make modifications that are useful and attractive. “We talk a lot about universal design, which allows you to put [a solution] in place without giving the home an institutional look,” says Paul Sullivan, immediate past chairman of the NAHB. “There are grab bars that are beautiful, for example, and we can install them so that they look like towel bars.”
Minor changes may include substituting faucet handles and door handles for levers and installing toilet seats that are 19 inches tall in place of the industry standard of 17 inches or lower. “A lot of people are asking for these kinds of things when they renovate a bathroom, even if they are in their 50s and early 60s. They just want to be prepared,” says Sullivan, who also builds a lot of first-floor master bedrooms and adds specialized pull-down shelving for kitchens to accommodate those who use walkers or wheelchairs. Shower thresholds can be a tripping hazard, and Sullivan renovates bathrooms so that the room’s entire floor slopes toward the drain in the shower and eliminates the need for an enclosure. “That is partly for aging in place, but it is also what people want right now,” he says. Lighting and window coverings can be controlled via remote, assisting those who may struggle to operate lamps and window shades. He can even install a panic button on the same remote control so a person can get immediate help in an emergency.
Most major home renovations address getting up and down stairs, and some people do not wish to use a bulky chair lift. For one client, Sullivan installed an elevator that opened to the garage, to the kitchen on the first floor, and to the master bedroom on the third floor. “Now they can live in this house for as long as they want, even if one of them is confined to a wheelchair,” he explains. The elevator door is disguised by a second door on each floor, so it is not obvious. And the interior of the elevator matches the drywall, flooring, and crown molding in the house, so it looks and feels as though one is entering a small room.
Once a home has been appropriately modified, Dr. Arbaje believes family members should focus on ensuring that older adults have enough stimulation in their lives. “Make sure they have access to activities they enjoy,” she says. This could include hiring an artist to come into the home and give lessons in singing, painting, or photography. It may mean providing a driver to take the individual out to social events, lectures, or golf outings. Many upscale retirement communities give residents access to five-star dining, visiting lecturers, university-level classes, and facilities that include golfing, top-of-the-line exercise classes, and creative workshops. These opportunities can be offered in the home, as well. “The idea is to have a conversation about what they want their lives to look like right now,” says Dr. Arbaje. “Ask them, ‘What do you want to spend your days doing? What kind of legacy do you want to leave?’ So often we impose our ideas on them, telling them what we want for them. I am guilty of this myself. But they aren’t our children; they are still our parents.”
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Care and Companionship
Children of aging adults would also be wise to consider what may happen when a parent will need more constant help in the future, like hiring a caregiver who can assist with daily living tasks and errands and offer companionship. If a plan is not made for this before it happens, the outcomes can be difficult to manage. By the time Michael Ament realized that his mother Dolores wasn’t eating regularly or taking her medications, he knew he had to get help quickly. Ament lives in Florida and his mother in New York, but at age 81 her osteoporosis was getting worse and she was in a lot of pain. He began to worry that she would fall. When she did fall and was hospitalized, Ament first engaged a home aide service recommended by the hospital staff, but his mother kept sending the aides home and insisting that she did not need any help. “Older adults have a tendency not to share information because they are afraid that someone is going to tell them they cannot live at home anymore,” says Bridget Gallagher, a senior vice president at New York’s Jewish Home Lifecare, a nonprofit geriatric health system that provides support services for older adults and their families. “Once they do fall, they tend to restrict their activity, and they are at even greater risk of falling when they become inactive,” she adds.
Ament knew that his mother’s difficulty moving around meant she could not readily go to town to get groceries or visit friends. And older adults who become isolated are at risk of becoming depressed and even dehydrated, which can exacerbate their medical difficulties. In desperation, Ament called Synergy HomeCare of Westchester, a specialized service in New York that provides nonmedical home care via home health aides and companion aides. (Synergy has more than 140 franchise locations across the U.S.) J. Heinlein, the president and owner of Synergy HomeCare of Westchester, visited Dolores Ament at her apartment. “I always try to do the home assessment,” he says. “It gives me a feel for a client’s cognitive state and how he or she engages with the environment, which helps me determine the type of aide to use and the skill set required, and how safe the client is maneuvering around the home.” He also learns more about a client’s personality, helping him to better match client and aide.
Heinlein stresses that anyone who hires a home health service should question how the aides are trained and vetted. Ask what kind of background checks have been done and how much supervision aides get while on the job. Heinlein himself spends time calling the family and visiting the homes of clients to ensure both client and aide are enjoying their time together. When he sent Tamesha Coleman to Dolores Ament for one visit per week, they hit it off; soon the family asked Synergy to have Coleman visit Dolores daily. Coleman cooked for her, verified that she took her medications, got her to appointments and errands, and even went to the hospital to visit Dolores when her cancer suddenly returned. “She was my mother’s guardian angel,” says Michael Ament of Coleman. “To have someone like that, it takes the weight off of you.”
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How an adult child frames the idea of bringing someone into the house matters, and it may help to create a list of tasks with which the aging parent can get help. “We are finding that sometimes the best place to start is to expand the role of a housekeeper, a person the parent knows and trusts. And if you do not need someone to help with toileting or bathing, we can work with her and expand her skill set,” says Patricia Mulvey, director of the Solutions at Home program at Jewish Home Lifecare. That might include checking medications, or preparing meals, and making sure the caregiver is also available to accompany the individual to the hospital if needed. “You need to have an advocate for your parent in an emergency situation,” Mulvey explains. “Even if you walk in because you have a high fever, it takes a while to get noticed. You must have someone pushing the system to get attention, even if you have money and connections with doctors.”
Those with an elder who needs more short-term or ongoing medical attention might employ a home health aide or visiting nurse who can help a parent transition back to living at home after a hospital stay when there is a need for someone to change bandages and assist with bathing and visits to the bathroom. “You can hire a nurse for one hour of wound care or dressing change or just to check on blood sugar level; other clients require constant care from a multidisciplinary team in the days following surgery,” says Cris Toscano of Bayada Home Health Care, an agency that has offices in 21 states. Ongoing care is ideal for someone who needs regular assistance to remain safe and independent at home.
In addition to nurses, the multidisciplinary team of specialists available at agencies such as these often includes medical social workers, physical and occupational therapists, speech pathologists, nonmedical aides, and home companions. In some cases like Michael Ament’s, the client is an adult child who lives far away and may ask the agency to provide other services, too. “One client told me he had found a car service to take his mom to the doctor and asked if we could hire the service, coordinate with the driver, and add the cost to his bill. It was no problem,” says Toscano, who adds that potential home health care clients should ask questions about accreditation and how employees are screened and trained. Bayada, for example, has been accredited for excellence by the Community Health Accreditation Partner.
Many times people think about engaging these services during a health-care crisis; that means when the phone rings at Synergy HomeCare, Heinlein knows the person on the other end may be in tears or suffering from family caregiver burnout. “There’s an emotional element to this. Something has triggered the call, whether it is a fall or perhaps a stay in the hospital. Our goal is to be a resource for people even if they will not be using our services,” says Heinlein, who speaks of wanting to help people feel valued as they age. Many who work with the elderly have this same drive to help. “We do everything a daughter would do,” says Jewish Home Life-
care’s Mulvey. “We are like a daughter you can rent.”