When Do Your Parents Need Help?

C. Grannan

      Mom can’t get along all by herself in that great big house much longer. Or can she? And how will I know?

       It's the worry shared by a generation, an entire middle-age demographic layer watching nervously as their aging parents' ability to live independently declines. If those older adults neglect to make decisions and plans for their own futures, it's the grown offspring who must take on the responsibility.
       Trying to assess an older relative's ability to function is painful and difficult. "It's hard for all of us to accept that our parents are no longer in charge," acknowledges Ann Von Essen, a consultant on aging issues in Woodside, Calif. "The adult child is often in denial. They just know they don't want to be the caretaker."
       "There are no 'six easy steps' to feel great about taking care of your aging parents," cautions Harriet Lerner, an author and psychologist at the Menninger Clinic in Topeka, Kan. whose most recent book, "The Mother Dance: How Children Change Your Life" describes coming to terms with her aging parents' increasing needs. "It's a profoundly difficult emotional issue."
       Even professionals in the aging field have trouble facing their own parents' situation, agrees Dorothy Howe, a senior program specialist with the American Retired Persons. "We find that in our offices, when it's your own situation, you don't always deal with it any better than anyone else."
       Adult children need to initiate communication, begin exploring options, and do their best to "proceed with calm and clarity," as Lerner puts it. This is the time to tune into aspects of aging parents' lives that we normally regard as their own business. That's not easy for anyone, and it's harder when the parent lives far from the child.
       Sometimes only a crisis makes the situation clear. "I've seen cases, especially when the children are far away, where the older person gets sick and is hospitalized. That's when it suddenly becomes clear that they can't live alone," says Dr. Cathy Alessi, a staff geriatrician at the Sepulveda Veterans Administration Geriatric Research, Education and Clinical Center in Los Angeles.
       Specialists in the gerontology field gauge abilities with a list of "activities of daily living," or ADLs. In the six basic ADLs, loss of function is unmistakable: continence, feeding, getting in and out of bed, getting to the bathroom, bathing and dressing.
       It's the eight ADLs known in the field as "intermediate" or "instrumental" that may need to be monitored more closely: using the telephone, shopping, preparing food, keeping house, doing laundry, using transportation (whether driving or other transit), taking medications and managing finances. These are vital abilities for maintaining independence, but it's not necessarily time for the nursing home when aging parents begin to lose them as home health care is also an option.
       "A lot of older people with impairments in these areas can remain relatively independent in the community if they can get the right kind of help," Dr. Alessi points out.
       The adult child needs to find a middle ground between patronizing prying and full retreat from the older adult's situation. Such an inoffensive act as opening the refrigerator can provide clues to how someone is functioning. Specialists suggest areas to keep an eye on, and some ways to spot problems.
       Poor nutrition poses a common hazard to the elderly, especially those who live alone. "If the refrigerator doesn't have food in it, that's a bad sign," says Von Essen. "Older people who are in trouble also forget to finish their meals." It's not always poverty — the apocryphal image of an old person living on cat food — that causes nutritional problems. One older woman with a Mercedes in her garage was hospitalized after living for weeks entirely on Pepperidge Farm cookies and tea. "That's really not rare, even among the wealthy," she adds.
       In the case of a patient of Dr. Alessi's, eating habits were the signal that she was no longer competent to live by herself. "This woman had mild dementia. She was buying all her meals from a small convenience store nearby, and losing weight." At that point, her family realized it was time to make a change.
       For adult children living near their parents, it's not hard to keep an eye on the condition of the house and personal grooming habits. It's also wise to be aware of bruises and other signs of trauma, possible clues that the parent has fallen. A common problem in the elderly, falls are both cause and symptom of an inability to function independently. They can signal general weakness, balance problems or other medical troubles, as well as possible overmedication.
       Not that every older person will cheerfully tell the family about an embarrassing or frightening fall. Indications that a person is at risk for falls include difficulty walking and inability to get up from a chair without pushing off.
       It’s not unusual for older people to try to hide problems, points out Von Essen, who does regular assessments of the residents of a San Francisco Bay Area retirement community. “If they aren’t telling you things, if they withdraw and insist they’re doing fine, that’s an alarm signal,” she says. "Though they may also withdraw and not want to see people because of hearing problems. It's difficult to socialize when you can't hear the conversation." Becoming reclusive and showing signs of paranoia can also be signals of depression, a common and devastating — but often treatable — affliction among the elderly.
       Sometimes it's money issues that bring out paranoia symptoms. "Some people accuse family members and other people around them of stealing," Von Essen says. "That could be a way of covering up for areas of uncertainty, covering up that they can't balance their checkbook.
       "Then you see the opposite situation — people giving money away," she adds. The predator taking advantage of a confused older person is most often a caretaker, a political cause or a purported church official. ("What seems to happen is a church member getting the money for themselves," Von Essen notes.) Occasionally an older person gives money to every junk-mail solicitation that lands in the mailbox. Others fall for scams and get on "sucker lists," which put them in the sights of other swindlers. Phony sweepstakes are a common ploy. Any talk about sweepstakes or prizes should raise an immediate alarm.
       Visiting adult children can keep an eye out for overdue bills lying around or fishy-looking mail being saved, both signs that the senior needs help. "Once the problem is in the open and there's cooperation between the adult child and the older parent, you can just keep a small amount of money in their checking account," Von Essen suggests.
       Unusual behavior can also signal loss of memory. Forgetting where you put your car keys is not a problem. Forgetting what the car keys are for is a problem."
       But less drastic memory loss can still be serious, as in the classic hazard: forgetting to turn the stove off. One woman in her 60s who spent years dealing with elderly parents suggests casually checking the kitchen cabinets for blackened pots.
       Medical illness can mimic symptoms of decline, as can overmedication. Von Essen recalls assessing one woman whose withdrawn behavior turned out to be a sign that she was taking overdoses of a sleeping pill. "When I rang the doorbell, she peeked around the door in a very tentative way, almost hiding, and I found that she couldn't walk without holding onto the wall. I asked if I could look at her medications."
       A prescribed sleeping pill piqued Von Essen's interest. The woman was apparently taking an extra pill when she woke during the night. Von Essen has since worked with the woman's physician to make sure she takes medications as prescribed.
       In one cautionary horror story, a California man appeared to be in terminal decline three years ago, until his grown daughter asked his doctors what all his pills were for. Eugene Daly was dazed, immobile, in diapers and not eating when his daughter, Adair Lara, insisted that his medications be stopped. A week later, an enraged Daly got out of his wheelchair and stalked out the door in an attempt to escape from a nursing home. Now 77, he's back in the Marin County, Calif., apartment that Lara and her siblings had begun clearing out.
       Lara, a writer at the San Francisco Chronicle who described the episode in her newspaper column, says her father had "started to slow down like a train" after his doctor prescribed a tranquilizer. Unaware of the drug, Lara took him to the San Francisco Veterans Administration hospital, where he was put on a powerful antidepressant. He fell rapidly into decline, and Lara blames the VA.
       "They said he was senile," Lara says. "When I asked how it could happen so suddenly, they showed me a brain scan." It was after he was transferred to a nursing home that Lara questioned her father's prescriptions. When the drugs wore off, Lara says, "He awoke in a fury." Against medical advice, Daly's children moved him back to his apartment. "He's living fine on his own," Lara says, "even though he has a form of senility and he's confused sometimes. " A VA spokesman said he couldn't comment on an individual patient's case.
       Whether the error is the patient's or the health-care provider's, overmedication is frequently mentioned as a hazard of aging. Some experts suggest routine "brown-bag" consultations: Put all medications in a bag and take them to the doctor for evaluation.
       When the parent insists everything is OK in the face of all evidence, that's a red flag, Von Essen warns. "If they're falling and forgetting where their car is and making accusations about their money and taking two sleeping pills instead of one and they deny that there's a problem, that's an inappropriate response and it's time to take action," she says.
       But whatever is done next needs to be done with respect for the parent as a decision-maker and as a human being, Dr. Alessi cautions. "In general, I find older people are extremely wise," she says. "They're the survivors. They've thought about death and what to do.
       "Your parent is still an independent person, "she emphasizes. "Even a person with early or moderate dementia still has needs and wants and opinions, and they need to be respected."

                          
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