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5 Steps to Successfully Managing Elder Care:

“Lather, rinse, repeat.”

by Dr. David Stephen & JoAnna Ribordy

If you are faced with the challenge of making elder care decisions, the following five-step model may be useful in achieving your goal of being a successful caregiving manager. The steps are deceptively simple: assess needs, plan solutions, implement plans, monitor changes, and evaluate results.

Step One: Assess the needs of your elderly loved one and your family. This first step sounds simple-but may be one of the hardest since we are reversing caregiving roles with an elder. This role reversal is often emotionally difficult for adult children, who may deny that the aging relative needs assistance. Face the question directly and honestly. It is important to include the elder in this assessment. They may feel anger, fear or shame when faced with admitting they have difficulties coping with Activities of Daily Living (ADL). Aging, and the concurrent decline in ability, can happen gradually or, if a health crisis occurs, suddenly. Allow all stakeholders the freedom of hope and optimism, but be realistic. Patience, persistence, tact and empathy are the keys to successful assessment. Seek help from case assessment professionals, if you feel you need help with this first, crucial step.

Step Two: Plan ways to meet those needs – and do not forget to plan ways to meet your own personal needs. Often a spouse, an adult child, or friend may try to fill the role of primary caregiving. Volunteering to become the primary caregiver is a noble gesture, but part of the assessment in step one is to realize the consequences of “going it alone.” “Caregiver burnout” is common and can result in feelings of resentment, frustration, and guilt. Allow yourself to accept your own need for help. Perhaps a more practical role is to be the primary manager of caregiving. There are many resources for finding assistance with ADL, from senior day care centers, to volunteer home visitors, to professional part time and full time caregivers. Create a network of people who can help you help your loved one. Be smart: ask for help in planning – and keep asking until you are satisfied that you have identified all the resources you and your elder need.

Step Three: Implement the plans. The first stage of successfully managing elder care is assessing needs and making plans. The second stage is action. In implementing the plans, make changes gradually so that all stakeholders can adapt and adjust. If appropriate, consider implementing the plans on a continuum – as needs for ADL assistance increase so can the amount of caregiving. Respect the desire of the elder to remain at home as long as possible. If so, some changes will probably have to be made in the home: bathroom grab rails, improved lighting and night lights, reduced hot water temperature, etc. Again, ask for help – it is available.

Step Four: Monitor the caregiving. If you think of yourself as the manager of caregiving rather than the primary caregiver, you may be more objective. Maintain close communication with the network of caregivers you are utilizing. Be especially alert to subtle changes – changes in appetite, weight, alertness, balance, mobility, sleeping, mental acuity, social interaction, etc. Listen to others and tell them how much you appreciate their assistance, whether they are paid caregivers, volunteers, or family members. And don’t forget to listen to the care recipient – even a person with dementia (such as Alzheimer’s disease) can participate and deserves to have his or her emotional responses validated.

Step Five: Evaluate reactions and results. This step is really a small bridge back to the first step. You probably recognize that assessment is just another name for evaluation. Although this list goes from one to five, it is really a cycle. Confronting the aging loved one and family in the initial assessment (step one) is the most demanding. By the time you get to step five, the process will likely be much smoother.

I am reminded that managing elder care is a cycle every time I read the back of the shampoo bottle- “Lather, Rinse, Repeat.” Being a successful manager of caregiving requires you to 1) constantly assess needs, 2) make plans and identify available resources, 3) actively manage people and mobilize resources, 4) monitor changes and communicate with others, and 5) evaluate results in order to re-assess needs and make new, more appropriate plans.

The Costs of Being a Family Caregiver – an Overview of Recent Research

David W. Stephen, Ph.D.

If you work and also spend time caring for a family member, what is the cost to both you and your employer in dollars, in time, in productivity, in career advancement, and in physical and emotional effort? As a business management professor, I was recently asked to provide some facts and figures about the impact of family caregiving on the workforce and on the lives of caregivers.

I hear first-hand stories almost everyday from people who say, “I haven’t had a vacation for two years, since Mom moved into our home so we could care for her... I quit my regular job and now work out of my home so I can care for my father, who lives nearby... My friend works full time, has two kids, and is going over to her parents’ house every day to help out... that schedule is killing her, she needs help!”

The stories are often heartbreaking. The research statistics are sobering. Here is a summary of recent research on caring for elderly loved ones.

Eighty percent of home care for seniors is provided by family members. In 1997, a major survey revealed that nearly one of out every four households in the U.S. is providing care to someone aged fifty or over. This number will increase in the near future. Life expectancy for both men and women will extend by seven years by the year 2050, which means that there will be an increasing demand for family members to care for more elders for more years. In the Denver metro area, we currently have over 300,000 seniors over the age of sixty.

Q: Who is caring for these elders?

A: Imagine a 46 year old daughter with a full time job who lives about an hour away from her elderly mother, who needs care. This middle aged woman will be her mother’s caregiver for about 4 ½ years before the situation changes. Here’s the breakdown:

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75% of caregivers are female.

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The person most likely to be providing care is a daughter (26.6%). The next most likely caregivers are other female relatives (17.5%), a son (14.7%), wife (13.4%), husband (10%).

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The average age of a family caregiver is 46.

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Nearly 7 million Americans are long-distance caregivers (travel more than one hour to provide care).

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Caregivers spend an average of 4.5 years providing care.

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64.2% of caregivers are employed and 51.8% work full-time.

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The amount of time spent on caregiving varies greatly, ranging from 9 to 56 hours per week.

Q: How much does caregiving cost in terms of lost productivity in the workplace?

A: Many adult children are taking time off from work to care for elderly relatives. Aggregate costs of caregiving in lost productivity to U. S. business is $11.4 million per year.

Q: What are the major effects on employees who also double as caregivers?

A: The three most dramatic effects are difficult to quantify in terms of dollars, but any employer should be alarmed to learn that many employees are deserting job duties to fulfill caregiving obligations. The major job effects are:

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Turnover: 10% quit or take early retirement to care for family members.

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Absenteeism: 11% take a leave of absence; many more take time off during the day and that absence interrupts the workday.

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Talent drain: 7.3% go from full-time to part-time, take a less demanding job, or decline promotions and business trips; many have to shift their attention and resources from work to manage non-family caregivers.

Q: From the employee’s perspective, can you put a dollar value on the efforts of a family caregiver?

A: Combined, the result is a whopping loss of $659,139 over the lifetime of a family caregiver. Informal (or non-paid) caregivers are estimated to lose :

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an average of $25,494 in Social Security benefits,

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an average of $67,202 in pension benefits, and

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an average of $566,433 in accumulated wage wealth.

Q: What are these caregivers doing? What kind of care do most elderly family members need?

A: Personal care. The most intense care needs are not medical, but the need for assistance with "activities of daily living” (ADLs). The five classic “functional” ADLs that seniors usually need help with are:

assistance with eating (or mealtime companionship and encouragement to eat healthfully);

help with mobility (transfers, walking or moving about with a walker or wheel chair, sitting down and rising, avoiding falls);

aid with sleeping (getting to bed and getting up, changing position in bed, sleeping through the night);

personal grooming and dressing help;

toileting assistance.

Of course life demands more activities than just those listed above. There are a group of activities called “instrumental” ADLs that are essential if a senior is to live alone. These activities include:

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financial management;

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transportation;

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help with medications;

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shopping;

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preparing meals.

Caregivers spend their time helping seniors accomplish both functional and instrumental ADL tasks, the kind of activities we usually take for granted.

Q: Is it just familial obligations that make a person be a family caregiver?

A: There are lots of rewards. People do it for different reasons, but love is the most powerful motivator for caregiving. One survey showed that:

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96% are caregivers because it makes them feel loved

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90% say it makes them feel appreciated

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84% are proud of being a caregiver

Q: Is there a downside?

A: Definitely. On the less positive side the same survey recorded that

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53% of caregivers feel worried

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37% feel frustrated

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28% feel sad or depressed, and

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22% admit to feeling overwhelmed with the responsibility and effort. Working caregivers are more prone to depression, headaches, weight changes, and frequent anxiety.

Conclusions:

Clearly, these facts and figures show that there are real, quantifiable costs associated with the care of elderly loved-ones by family members. The research incidcates that there is an underground economy of unpaid caregiving. But since there is no such thing as a free lunch, someone must be paying the costs for these services. This summary of recent research indicates that the costs are born by caregivers other family members, employers, and therefore by extension, by consumers and society in general.

Emotional Caregiving - The Other Half of Elder Care

Mary Lou Stephen, R.N. (Ret.) & David Stephen, Ph.D.

Attending to physical needs is often straightforward since physical needs are right there in plain view – making the bed, planning, preparing and serving meals, washing, drying, folding and putting away clothes, keeping things neat and clean. But emotional needs are subtle and more difficult to discern. An African proverb says, “Every door has its own key.” Here are three keys to emotional caregiving. If an elder seems to be “crotchety,” it may be directly related to unfilled emotional needs. If emotional needs are not met, the symptoms may include complaining, hostility, and an attitude that “nothing is right.” These behaviors may irritate or alienate the caregiver, which makes it even harder for the caregiver to attend to the other half of elder care, emotional caregiving. Less attention results in more emotional need, and this can lead to serious depression. To avoid this downward spiral, there are three basic needs to fill.

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the need for inclusion

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the need for control

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the need for affection.

Inclusion is the need to establish personal relationships and to interact with others. This is a basic human social need. Every person needs prestige and status – a social identity that signals to others that, “I am a distinct individual who deserves attention.” Inclusion requires that a caregiver show enough interest to discover an elder’s personal characteristics, likes and dislikes, opinions and ideas. One way to establish this social identity is to encourage the person to reminisce. This “memory mining” can be cathartic and cleansing. It can help the senior recall the social status he or she achieved in the past and can help the caregiver and care recipient establish a genuine appreciation for one another. Control is the need to maintain the personal power to make decisions and to influence one’s own physical and social environment. Control makes us feel competent and responsible for our own future. When an elder feels that personal control has been wrested away, he or she may give up all feelings of being self responsible. This can result in feelings of worthlessness, anxiety, and diminished trust in everyone. Negative behaviors might include rebelliousness, hostility and a domineering attitude in an attempt to regain a sense of control.

Affection is the third key to emotional well being. Family members and close friends most often meet this need. However, when these people are not present, the need must be satisfied by others. Establishing a personal friendship is the beginning of affection – a give and take relationship and sharing mutual interests. Communication is what turns this key. Establishing an emotionally close relationship requires that the caregiver actively listen to the elder’s anxieties, wishes, concerns and feelings. Active listening gives feedback to the speaker, acknowledging that the speaker’s messages are worthy of attention. This validation is the basis for developing trust, friendship and affection. Determining deep emotional needs requires close attention and subtle skills. But in the simplest terms, filling emotional needs is something we each have an innate capacity to do since we all share the same basic needs. Emotional caregiving satisfies the needs of both the caregiver and the care recipient and brings satisfaction to all involved. The old admonition to treat others in the same manner you wish to be treated is also the Golden Rule of emotional caregiving.

In-Home Assistance – a Practical Guide

by Dr. David Stephen & JoAnna Ribordy

Most elders living at home would prefer to stay there as long as possible. In-home assistance with Activities of Daily Living (ADL) may be a resource to prolong the security, independence and dignity of living at home, but not alone.

One of the fastest growing segments of the eldercare industry, ADL caregivers are often live-in service providers. Frequently, it is not the big health issues that make elder life frustrating, it’s the little things such as neglected housework, difficulty in dressing or personal grooming, problems with in-home mobility and transportation, forgetting medications, abbreviated meal preparation, and declining social interaction due to isolation.

Assistance with ADL is not a new concept; relatives and friends have helped elderly loved ones since time began. But as our senior population skyrockets, ADL caregivers can fill the gaps when friends or relatives are at work, need time off, or cannot provide around-the-clock assistance.

Often, it’s not easy for the senior – or the family – to accept the need for an ADL caregiver. When my elderly aunts (age 83 and 88, one with Parkinson’s, the other with macular degeneration) reached the need for 24-hour ADL care, both they and their adult children suffered a period of being “in denial.” When we finally placed a live-in caregiver with them, adjustment was rocky during the first month. Although 80% of all elders at home would prefer to retain their in-home independence, accepting a new pair of helping hands in the house is frequently difficult. They may not acknowledge a need for help, and family members may feel guilty that they aren’t able to single-handedly care for their loved one.

Here are some tips to help you and your family prepare for this step:

Determine the level of care you need. This is the key to finding the right person with the right skills. A non-medical ADL caregiver does not need to have all the health care skills required by the client. A visiting nurse, physical or occupational therapist, or a senior center may be able to round-out the health care and social needs. Assessment by a qualified professional can help you identify needs and resources.

Establish a budget. Face it, health care is expensive. One way to defray expense is to trade room and board costs in exchange for lower service fees. Although this arrangement requires some environmental adjustments (private room, bed, empty closet, etc.) many homes can accommodate another person and the grocery budget is usually only slightly affected.

Establish roles. A live-in ADL caregiver is a boarded employee, not a family member or house guest. Even though compassion, patience and sincere affection are qualities required of ADL caregivers, you will want to establish house rules, task schedules, privacy protocol, and other expectations. Put this in writing, for everyone’s clear understanding.

Weather the storm. There will likely be a settling-in, getting-to-know-you adjustment period. Confront problems directly but gently, especially during the first month or two. Unconscious hostility may be overcome by patience, sympathetic communication and counseling. It may help to have an agency involved to assist with mediating problems and to continually monitor the situation.

Pay fairly. Don’t forget that every caregiver – family, friend, volunteer, or professional – needs time off. Budget for a respite caregiver to relieve your primary ADL caregiver and plan on paying time-and-a-half for work on holidays.

Play fair. An ADL caregiver’s primary focus is maintaining the client, not the property. It’s not fair to ask them to do heavy housework, cook or clean for others in the home, do yard work, etc. Even though the typical caregiver will say, “Oh, I don’t mind...” remember the roles you established and stick to them. “Caregiver burnout” is often the result of feeling overwhelmed by too many tasks, too much responsibility, and too little time off. Burnout results in reduced quality of care.

Beware. When I first began hiring ADL caregivers for my family, I literally asked myself, “Would I trust this person in my own mother’s home?” If you do not have the resources or experience to do a criminal background, driving record and credit check along with employment verification and multiple personal interviews, consider using an agency that does.

Finally, be relieved and realistic. The goal of ADL assistance is to improve the daily life of the client, resulting in improved quality of life. An ADL caregiver relieves family and friends from the burdens of worry and stress. But be realistic about the inevitabilities of aging, a process that ADL assistance improves, but cannot reverse. Continue to be proactive, involved, and in close communication with your ADL caregiver to monitor changes that will occur.

Seniors desire to retain the dignity and independence of living at home. Balancing that wish with growing needs for personal care is often difficult. In-home care – and the assistance with daily activities that it provides – is a viable alternative to moving to assisted living or the home of a relative and is an additional resource for concerned family members.

Home Care: Assisted Living Delivered to Your Door

David Stephen, Ph.D.

When my elderly aunts became dependent on family members for assistance with daily living, I assumed the role of family care manager. I soon found I was in over my head. I took nurse’s aide training, learned how to recruit caregivers, do criminal background checks, conduct phone screening and personal interviews, find substitute caregivers, and overcome family objections and denial. I had to learn to deal with the complexities of rehabilitation facilities, discharge teams, case managers and social workers, visitng physical therapists, and an array of assitive technologies. The intervention of a nurse helped us discover that certain medications caused traumatic psychotic reations and that other medications were improperly prescribed.

By the time I had gone though my year-long learning curve, I decided to use my experience to offer a home care service to others. Here is an overview of what I have learned from classes, books, other professionals, and personal experience.

THE EVOLUTION OF HOME CARE

Caring for an elder at home is not a new concept, by any means. But as the modern eldercare paradigm evolves, getting professional assistance with activities of daily living (ADL) in the home is becoming a more popular option. Today, one of the fastest growing segments of eldercare is in-home ADL assistance, or home-care agencies, simply because most seniors prefer to stay at home as long as possible.

Home care is at the beginning of the continuum of eldercare, a way to have assisted living delivered to the home. Most people seek home care when consistent, but not acute care, is necessary or advisable. Think back to the early nineties. Then, the concept of a bricks-and-mortar assisted living facility was not widely accepted as a viable option. Over the years, though, assisted living communities have become a well established alternative. Today, in-home professional care is becomming an increasingly attractive option.

TYPES OF HOME CAREGIVERS

The level of care and the skills required by the home caregiver vary widely, depending on the needs of the care recipient. In general, every person needs to be able to perform certian ADLs (Activities of Daily Living), which include bathing, dressing, toileting, mobility, and eating. The list is often extended to include “instrumental” ADL such as meal preparation, shopping, money management, housekeeping, transportation, communication, etc. Home caregivers are trained to assist with these ADLs, but obviously some tasks require more skills and training than others.

Homemakers & Companions provide help with housekeeping, meal preparation, shopping, errands and medication reminders but may not have the skills to provide hands-on personal care. Ironically, in Colorado, a Certified Nurse Aide, who is trained to help with hands-on care such as transfers, bathing, mobility exercises, etc. are fobidden to to handle prescription drugs unless they are “med certified.” However, a non-certified care giver does not risk losing professional certifcation by setting out medications. Make sure any caregiver you use is formally trained or thoroughly instructed if you are going to ask them to perform “skilled care” which could potentially harm a senior, such as dispensing medecine, helping with walking, transfering from bed to walker or chair, getting in and out of the tub or shower, managing wounds or sores, adjusting oxygen or IVs, etc.

Home Health Aides (HHAs) are also known as Personal Care Providers, Personal Care Aides and Certified Nurse Aides (CNAs). All are trained to help with basic ADLs. Most of these caregivers have CPR and first aid training. In Colorado, CNA’s are trained to lift, transfer and reposition patients, in addition to monitoring vital signs and performing other supervised nursing duties. Such people may have a higher skill level than homemakers and companions, depending on their experience and training.

Registered Nurses (RNs) & Licensed Practical Nurses (LPNs) have a much higher level of skill and may administer medication, draw blood, make assessments, devise care plans, and supervise aides. A nurse may work for short peroiods of time in concert with a daily caregiver to provide for acute needs, such as managing wounds, feeding tubes, IVs, oxygen, etc.

Physical Therapists (PTs) & Occupational Therapists (OTs) are state licensed or certified to help an elder increase, improve or adapt to higher levels of physical, mental and social functioning. Such professionals can help seniors learn to use assitive technology (such as a reading machine, electirc wheelchair, or prosthetic) as well as reccommend environmental changes in the home (such as hand rails, lighting, kitchen and bath modifications).

Dieticians, Speech Pathologists, and other specially trained professionals may also be valuable consultants. The senior’s doctor may reccommend therapy, exercise programs, special diets and other treatments that require such specialists to help maintain or enhance vitality, decrease the risk of falls, and generally insure that staying at home is a safe option.

HOW MUCH CARE?

The number of hours you need an in-home caregiver varies with your needs and resources. One “bargain” in home care is a live-in caregiver. You provide room and board for a live-in caregiver in return for lower caregiving costs. For example, my elderly aunt with Parkinson’s disease requires 24 hour attention because she is at risk of falling when she moves about the house. The cost of a live-in caregiver outweighs the risk of serious injury, so we have opted for live-in care. This arrangment is generally more economical than paying hourly or shift rates and can provide greater consistency in caregiving. For live-in caregivers, the general rule of thumb is that a client should not be left unattended for more than two hours at a time.

Many agencies have a minimum number of hours for service, usually a two to four hour session. This is a sensible solution for those who need limited assistance. Sometimes, a caregiver can prepare several days’ worth of meals and help keep up with weekly laundry and housework by working a few hours, several days a week. Since most home caregivers also help with housework, meal prearation and errands, it may make sense to increase caregiver hours and cancel your housecleanning service, home delivered meals, taxi service, and other kinds of support since a single caregiver can often perform all these tasks.

WHERE TO FIND A HOME CAREGIVER

If you decide to directly hire a caregiver, you assume the responsibilites of becoming an employer. You will likely be responsible for income tax withholding, Unemployment and Workers’ Compensation Insurance, Social Security contributions, and a host of workplace regulations. In addition, you should do criminal background investigations, check references, conduct interviews, find substitue caregivers, monitor the quality of the service, etc. Reputable agencies usually cost more than directly hiring a caregiver yourself, but they also have the resources and experience to manage all these essential screening, placement, payroll and managment tasks.

Special consideration must be given to those who live at a distance from the care recipient and for working adult children who attempt to balance family and personal obligations with caring for an elder. In these cases, friends and local chruch and senior groups may offer some support. However, as care needs increase (as they tend to do), you may tap-out the volunteer resources and seek professional home care.

Minimum, Necessary and Sufficient Care

by David W. Stephen, Ph.D.

When caring for elders, how do we decide what care is right? What guidelines can we follow to be confident that we are providing just enough care to meet thier needs, and not so much care that we take away the independece that they could retain?

My best friend, Marc Ringel, is a family doctor who practices in the small town of Brush, Colorado. Last month, we took a men-only vacation together with his two college-age boys, a three day raft and camping trip that gave us a lot of hammock time.

“When I started out as a physician, I wanted to cure everybody. Now that I’ve aged and many of my patients have entered their golden years, I am much more concerned with helping them – and myself - maintain the health they do have and cope with the problems I’ve given up trying to cure,” Marc said as we sat in the shade at the cove by our camp on the open river. It was the kind of place where trees seem to act out whatever has happened to them, the kind of place where you might expect to see trouble just walking away.*

We talked about elder care and aging with grace, about the loss of independence that comes with getting old and having to rely on others, about how hospitals and nursing homes and medical staff can rob an elder of dignity by taking away their choices about where they live, when they eat and bathe, what they do for entertainment, whom they converse with, and what kind of medical and personal care they receive.

Together, we pooled an interesting mix of professional experience and formal training that included philosophy, theology, business, medicine and medical ethics, education, motivational psychology, sociology, and Fine Arts. By the end of our trip, we had cobbled together some guidelines about eldercare, gleaned from all these disciplines, from our own experience, and from our own personal consciences.

We made this proclamation: Eldercare decisions should be based on allowing the elder to retain independence, dignity and security. Further, we determined that three words could help determine how to accomplish these ideals. The words are minimum, necessary and sufficient.

These three words, minimum, necessary and sufficient, represent a concept of the Montessori school of education. That concept applies to how much positive reinforcement – praise – a student should receive for doing something right. The last two words, necessary and sufficient, are pretty much self explanatory, but it takes a little understanding of motivational psychology to understand why the minimum amount of reinforcement is best. Reinforcing a behavior that is already in place is actually DE-motivating.

Here’s a story to illustrate why this can occur. A writer lived in an apartment building and his study had windows that opened onto the alley below. Every afternoon at four, a group of three boys would stop in the alley on the way home from school and make a terrible racket beating trash cans with sticks. This disturbed the writer at a time when his creative juices were flowing at their daily peak, so one day he called down to the boys and asked them to come around to the front of the building. He invited them into his apartment and showed them how his windows were directly above the place where they performed their daily tattoos loudly on the trash cans.

“I always look forward to your noise,” he told the boys. “Thanks. It gives me a welcome break and helps me take my mind off my work for a while. Here’s five bucks for each of you. If you promise to come by again tomorrow and do the same act, I’ll give you money again tomorrow.”

The boys thought the guy was nuts, but next day they came and performed enthusiastically, making even more noise than usual. Then they reported to the writer’s door to collect. “Good job, men!” praised the writer. “It was the noisiest and best yet,” and he gave them each a dollar. “Be sure to come back again tomorrow,” he said. Somewhat puzzled, the boys left, grumbling. The next day, same thing, but this time he gave them each only a quarter. “You’re a freak,” the boys proclaimed, “and a cheap freak, to boot. You think we’re going to do that for just a quarter? Get outta here...” ...and they never returned.

This shows that providing more reward than what is necessary and sufficient can backfire. So, let’s apply these three words to the goal of preserving and promoting independence, dignity, and security.

MINIMUM – Sometimes, less is more. Allow the elder to do as much as he or she can do, and provide only the minimum amount of assistance. Strive to be patient, tactful and compassionate as you encourage the client to be independent. For example, it may take an hour to help an elder get dressed, if you allow him or her to do most of the tasks independently. You could be more “efficient” and dress the senior yourself in a few minutes, but time is less important than independence. There are many ways to serve an elder’s needs and not rob them of independence. When you provide the minimum amount of care, you promote independence. Our first goal is to help the elder retain independence.

NECESSARY – Always honor the elder’s wishes. Use good judgment to determine what kind of care is necessary. Too often, elders are robbed of their dignity when someone else decides what is “necessary” or “right” for them. The senior may need your help to perform activities of daily living, but that does not mean that they want you to make decisions for them. For example, the senior may not want to exercise, or eat, or cooperate in following his or her care plan. But if the elder makes most of the choices in crafting his or her individual care plan, and if the elder’s goals are clear, then the elder will be more cooperative and it will be easier for you to determine what is necessary. Always offer the senior a choice. Self determination – allowing the elder to make choices – is the key to living with dignity. When you let the elder decide what is necessary, you promote dignity. Our second goal is to help the elder retain dignity.

SUFFICIENT – You are obligated to provide sufficient care to keep the elder safe and secure. First, do nothing that might harm the senior; second, remedy any unsafe condition as much as you can and as soon as you can; third, report any accident, incident or safety issue to someone who can help. But the elder should not only be in a safe environment, the elder should also feel safe and secure. The senior needs to feel that he or she can depend on you for support. Emotional security is as important as physical safety. When the elder knows that you reliably and willingly provide sufficient care, you promote emotional and physical security. Our third goal is to help the elder retain security.

To paraphrase 1 Corinthians:13, “Abide these three: independence, dignity, and security... and do so by providing the minimum, necessary and sufficient loving care.”

Resistance to Accepting Care: Dealing with Elder-care Needs

JoAnna Ribordy & David Stephen, PhD

Problem:

Mom has been living independently at home for the last 15 years. Now, at age 84, to remain living safely at home, Mom needs assistance, otherwise she will end up in a hospital due to an accident or in a senior facility to preserve her own safety and health. Home care would be an attractive option but Mom is resistant to admitting the need for outside help, let alone allowing a stranger into the home. Here are some hints to overcome objections to accepting assistance.

First, let’s analyze the reasons for resistance. For many seniors, accepting assistance is perceived as a loss of independence and an admission of weakness or failure. The most common emotional response is to deny the need for help. When you approach them, examine the underlying reasons for their reactions. Are they ashamed to have others see them in a state of diminished capacity? Are they worried that you are going to abandon them, or that you don’t want to be involved anymore? Many are afraid of the unknown, especially afraid to have a stranger in the house. For a woman it is hard to relinquish the control of housework, hard to have someone new in your kitchen, not doing things your way. For a man it can be a loss of status to have to accept help when he was probably was the breadwinner, decision maker, and respected head of his household.

Strategic Planning

We like to tell people that the three strategies for overcoming objections are, “Pick the battles you can win, make changes in small steps, and be an active manager.” Deal with emotional concerns first, then address the practical issues. You are not likely to have a productive and rational conversation until you’ve calmed the emotional waters. Think your discussion through in advance and practice with a friend or family member.

It is essential to keep an elder’s self respect in tact as much as possible. Don’t insist on a “total care plan” if initiating care in small steps is more palatable. Discuss the pros and cons of having outside help, and how it will benefit everyone. We all need to feel we control our own destiny, so involve your loved one as much as possible in the decision making process.

Express your needs

Communicate using “I” messages instead of “you” messages. Ask them to help you resolve your fears, not admit their deficits. For example, if you notice that the housework is not being done, or the lawn needs tending, instead of saying, “You have really let the place go. What a mess!” try saying, “I worry that you are working too hard to keep up on the yard work and housekeeping. To relieve my concerns, I’d like to have someone come in once or twice a week to help out, otherwise I’ll feel like I’m not doing as much as I should.”

Baby Steps

Some hands-on care is intimate in nature and can be perceived as an invasion of privacy. It will take time for an elder to feel comfortable with someone helping them bathe. Imagine how you would feel having a stranger undress you, see you naked, and then wash your body. If your loved-one doesn’t want the caregiver to bathe them on the first few visits, give them time to get comfortable. Be sympathetic and understanding, but remain firm in your belief that they do need this assistance, for your peace of mind and for their welfare. Above all, be patient and persistent.

Take baby steps and make small changes. A senior has the right to direct the caregiver and determine how much help they receive. Reassure them that you are willing to be involved in training the caregiver to respect their privacy needs and that experienced caregivers are trained to be respectful and tactful. As trust grows, so will receptiveness.

Managing Caregivers

Put on your manager’s hat and help manage the caregiving process. Once you have a caregiver in place, supervise the situation yourself. Drop in unannounced when the caregiver is working, and see how things are going. Check that their work is being done properly, that they are pleasant and respectful, and that your loved one feels comfortable.

To build trust, its helpful to have service from the same caregiver consistently. A fear of strangers in the home can foster fears of theft. Reassure the elder that a reputable home care agency carefully screens a caregiver with a comprehensive criminal background check and personal interviews. You have the right to insist on close supervision and oversight by the agency’s managers. Elders have the right to “have it done the way I want it done” and should clearly communicate expectations and instructions to the caregiver. This gives the caregiver valuable feedback and gives the senior a feeling of control. Allow everyone to feel the status of being a care manager.

Verify Complaints

Sometimes problems don’t stay fixed. You may have to re-discuss and re-establish your mutual goals (keeping Mom or Dad at home as long as possible). If they are resentful about receiving care, they may try to complain so much that you will realize the error of your ways, and stop trying to get help for them. Some seniors will try to make the caregiver’s job so unpleasant that they’ll quit. Keep in contact with the caregiver and the agency to maintain clear communication. This way you can tell if any complaints are valid, or if they are trying to be difficult and sabotage the process. Remind them of your concerns about the consequences of refusing assistance.

Your Choice

There are more choices for elder care today than twenty years ago. Explore your choices now, rather than wait until a crisis arises that may limit your options.”Aging in Place” is the new catch-phrase for remaining at home as long as possible by utilizing personal care services and assistive technology. In home care is an option that allows Mom or Dad to stay at home and have assisted living delivered, on their terms and yours.