Assessments, adjustments can help older adults remain at home

Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Today I'll be speaking with Upstate's chief of geriatric medicine about caring for aging parents. Dr. Sharon Brangman is also a distinguished service professor of geriatric medicine. Welcome back to The Informed Patient, Dr. Brangman.

Sharon Brangman, MD: Thanks, Amber. Thanks for having me again.

Host Amber Smith: Now, when do you think adult children need to start turning the tables and thinking about caring for their parents?

Sharon Brangman, MD: Well, it's a very individual thing, and actually the holiday season is a time when we often get the most calls. And that's because that's when families come into town, and they may get a totally different impression as to what's going on compared to what they got while they were talking on the telephone or faceTiming with their parents. They can see up close and personal what's actually going on in the home. And so many adult children, especially if they don't live in the area, call us during the holidays wanting to get things organized.

And so the first thing they often notice is that the house is not really being kept up well, and maybe their parent is just having more and more trouble with repairs and managing the mail, keeping the refrigerator stocked, getting rid of clutter and those sorts of things. And that is often the first sign that something may be amiss. Sometimes they will notice the car has a lot of unexplained dents on it or things that look like little fender benders, and usually the parent will minimize it and try to say that the son or the daughter is making a big deal about nothing, or something like that. But those are usually the early telltale signs.

And then when they're spending more time with their parents, they may notice that the day just doesn't go in an organized way. There may be long periods of sleeping or not getting dressed and ready for the day, or difficulty organizing meals. I had one family, for example, who came for Thanksgiving, and usually the mother would prepare this enormous meal for everyone. And when they got there, things were in disarray. The food was not prepared. And when you think about making a big meal like for Thanksgiving, that involves many, many little decisions in order to get the food on the table and cooked and ready to go at the right time. And some people, as we get older, start to have trouble keeping track of all those little details.

So there can be any number of little hints, and adult children start to recognize this when they spend time with their parents.

Host Amber Smith: So the things that you've described -- keeping up the house or whatever, not keeping up the house -- does that necessarily correlate with a health condition or something physically deteriorating in the person?

Sharon Brangman, MD: Well, not necessarily, but it could be that the parent has too many things to keep track of, and it may be time to simplify their routine or downsize, or get help taking care of some of the details in life. It doesn't always correlate with an illness, but sometimes it can be the first signs of a memory problem, or someone who's just becoming what we call physically frail. That is someone who may not have that robust vitality that they used to have, maybe to mow the lawn or to clear the driveway of snow. And they may not have dementia or any specific medical problem, but just physically it's harder to keep up their previous routines.

Host Amber Smith: Is this the point where an adult child needs to look at their parents home in terms of safety like they would before bringing a baby home from the hospital, where they just want to make sure everything is safe for the person to exist there?

Sharon Brangman, MD: Yes. That is something that is important to do. But the challenge is, often the parents don't see the same problems or have the same level of concern. So this is often a challenging discussion. There are very few older adults who have that same level of alarm, for example, that an adult child might have. They also are not comfortable with that role reversal with a child, telling them what should be done.

You know, we spend our whole lives looking for autonomy and independence and doing things the way we want, and it's inevitable at some point that we are all going to need some help when we get older. There are very few people that have the insight to recognize when they need that help. And so that's a bit of a challenge for adult children, and for parents. And it can be a source of friction if it isn't approached properly.

Host Amber Smith: How does an adult child determine if their parent or parents can remain in their home, or if they need to move?

Sharon Brangman, MD: Well, again, if there is signs of that house not being kept up, and it may just be too much, too much house. You know, after children are gone and there's no need for three or four bedrooms and a lawn to mow and a driveway to shovel and a house that needs painting or some sort of repairs. You know, a house constantly needs repairs, and that can just become overwhelming.

So it's time to have a frank conversation. And it's usually not settled in one discussion. And it has to be approached with respect and consideration. Now, if the parent does not have dementia or any kind of cognitive impairment, they really have the ability and the right to live the way they want to live. So we cannot impose what we think is appropriate, even though it may be safer and it may make sense. You can't make someone do anything. And you know it, it just doesn't work that way.

So this can be a challenge for adult children, particularly those who do not live near their parents. So, you know, we have a very mobile society, and many of us do not live close to our parents or where we grew up. Or our parents may still live in our hometown, and we adult children have moved elsewhere. So the ability to kind of reach back across the miles can be very challenging. Now, there are a lot of resources for people who recognize a problem and want to seek help, but it can take a while for some parents to have that level of insight to get there.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith, and I'm talking with Dr. Sharon Brangman. She's the chief of geriatrics at Upstate, and we're talking about caring for aging parents.

For families facing this issue of caring for aging parents, A D L, or activities of daily living, may be a new term. Can you walk us through what those are and why they matter?

Sharon Brangman, MD: There are two categories of activities of daily living. One of them is instrumental activities of daily living, and these are things we do to kind of interact with the world around us and to keep our lives moving and organized. So those are things like grocery shopping, keeping appointments, paying bills and banking, keeping track of medications, driving from one place to another, keeping the house organized and, say, scheduling repairmen and that sort of thing. Instrumental activities of daily living are usually the first things to go when either there's a memory problem or there's physical limitations, maybe due to illness or frailty. And those are activities that can usually be purchased by another person to do. So you can get someone to come and mow the lawn and shovel. You can get someone usually to come into the house to help keep it neat and do grocery shopping and maybe even cook some meals. Usually, activities such as setting up medications and keeping track of appointments can be coordinated with adult children, or you can hire a companion to assist with that. So those are things that are done to help assist someone to get through the day.

Host Amber Smith: So somebody might be able to stay in their own home if they can set up some support systems like that?

Sharon Brangman, MD: Exactly. And we usually advocate for people staying in their own home. You know, people sometimes think that because we're in geriatrics, we are just here to sign people up for nursing homes, and that is not true. We want people to live in the most independent setting, they can, with the highest quality of life. So the first option is to see if you can get help to come into your home. And not all adults like that. They don't want someone in their home. Or they can't afford it. It can be very expensive. And now, with our pandemic, it can be hard to find those people to do that work because there's a huge labor shortage. But that is the first step, is to get someone to help with some of those tasks.

There are people who can help you drive. There are car services. There are ways to help set up medications and reminders for that. There are ways to get meals into the home and cleaning services so that you can get some help for those things that we all need to kind of get through the day and stay organized.

The next set of activities of daily living are the basic ones, and those are the things we all absolutely have to do. And those are things like maintaining our hygiene, taking a shower, walking, feeding ourselves, getting dressed, getting to the toilet in time, knowing what to do after you're on the toilet. Those are the basics. And when people start to have trouble with the basics, they need a different kind of help.

Now that can still be done in your own home, but it usually requires more time because those are things that you need, essentially, hour by hour during the day. So depending on how and what kind of help you need, you may need someone for several hours a day or you could need someone for 24 hours a day. And that's what we help families figure out is what the needs are and how much time is needed to meet those needs.

And when somebody starts to need 24-hour-a-day care, that is very expensive. And Medicare does not cover that. Many people get unpleasantly surprised when they start to need home care because they assume it's covered by Medicare. But Medicare pays for hospital care, and it pays for our office visits to your doctor, and depending on what other plans you have, it may pay for your medications. But it does not pay for that hands-on care. Hands-on care is paid out of your own pocket, or if you do not have the funds, you can apply for Medicaid.

Host Amber Smith: I was going to ask how do families afford it if they need 24-hour care for their family member? A lot of families end up becoming caregivers themselves, right?

Sharon Brangman, MD: It's very expensive, and many families struggle. There are some programs where if you are a family caregiver, you can be paid to do that through special programs. But many people just need several hours a day, and even that can be cost prohibitive, and it all comes out of your own pocket. Some people have long-term care insurance plans, and those can kick in and cover some of that expense as well.

Host Amber Smith: Well, we've talked a little about nursing homes, but kind of in between living at home and nursing home, there's some other options. Can you talk about the difference between independent living and assisted living?

Sharon Brangman, MD: Independent living is when you have your own apartment, and you come and go as you please, and you often have a car and drive and make your own meals. It can be in your own home or it can be in a senior complex or a regular apartment building.

Assisted living is really like a real estate agreement where you rent a room and you also get certain services with that room. It is not a medical model because you keep your own doctor, and assisted living does not have nurses in the facility to help with any medical issues. So you are essentially renting a room, and you're getting a meal plan. Some people just get one meal a day, so they may just get dinner, and they make breakfast and lunch in their apartment. Some people get all three meals in their meal plan. And you can add other services, but then you pay for those. So you can pay for a nurse to come and check your blood pressure, for example. But if you were to fall and get hurt, you would have to go to the emergency room because there's no nurses or doctors in those assisted living facilities to provide medical care. It's really a room agreement and a meal plan. They are not nursing homes at all.

Nursing homes, on the other hand, are actually medical models where you get medical care in a residential setting, and you'll have nurses on hand. A nurse practitioner is often there, and a doctor will come in on a regular basis. And if you have a medical problem that can be treated at the facility, that can happen. Serious medical problems, you're sent to the hospital. But you can get medical care in a residential setting in a nursing home, and it's totally different from assisted living. And most people in nursing homes have dementia. They usually have some level of cognitive impairment that keeps them from taking care of themselves. That's the number one reason why someone goes to a nursing home is because they have dementia and they can no longer take care of themselves.

Host Amber Smith: What is the typical age of someone in a nursing home?

Sharon Brangman, MD: It can vary. I would say the average age is probably in the upper 70s or 80s. There are some younger people with chronic problems who might be there, but the majority of people, I would say, are in their 80s.

Host Amber Smith: At what point would you advise people to seek care from a doctor who specializes in geriatrics?

Sharon Brangman, MD: Well, typically, the age of geriatrics is 65 and above, and that was a number that was arbitrarily set a couple of generations ago when people who were 65 had usually done very hard physical jobs and had a lot of injuries and illnesses. But now with the advent of a lot of public health and different jobs and a different kind of medical care, we can postpone that aging process a little bit. And some of those chronic diseases now are happening later on in life so that the majority of patients that a geriatrician sees tend to be people in their 80s and beyond. And these are people who have multiple chronic illnesses. They may have some trouble getting through the day. They may have some memory problems.

Geriatricians are experts in managing the complex long list of medical problems and medicines that a person may have, and then helping the patient and families figure out the best way to get that care, whether it's in your home or in another setting. And as I said earlier, we really like to have people stay in their own home. We really like people to be at the highest quality of life that they can have in the best setting for them. So we can help families make that determination.

Host Amber Smith: Would a geriatrician take the place of a primary care provider, or are they more of a specialty consult doctor?

Sharon Brangman, MD: Depending on where you live, geriatricians can be your primary doctor or they can be your specialist. In Syracuse, at Upstate, we are specialists. We work with the primary care doctor, and we help the primary care doctor optimize their care. And then we help the family make decisions about care for that loved one if they need care at home or at a higher level of care.

But we also do other things. You know, older adults accumulate a lot of medications as they get older, and sometimes those medications can cause side effects that can make somebody look sicker or have more medical problems than we anticipated. So we can help work on the long list of medications to make sure they all make sense and they're not interacting with each other. We look at someone's physical function to see what we can do to help support them so that they can maintain as much independence as possible. And, of course we help people who have memory problems to help them also optimize their function for as long as possible.

Host Amber Smith: If someone's interested in a geriatric assessment because they're concerned about cognitive decline, what would be the difference between coming to a geriatrician for that assessment versus a neurologist for that assessment?

Sharon Brangman, MD: A neurologist can help with a specific diagnosis that is going on, that might be affecting their thinking ability or their brain power. A geriatrician takes a different perspective. A neurologist is certainly one of our partners in care, but we work on the principle of a comprehensive geriatric assessment. So we look at the whole person. We look at their past medical history. We look at their current medical problems. We look at their cognitive status, their mood, their medications, and their functional status. And then we help them come up with a comprehensive plan for moving forward. So we don't just make a diagnosis. We actually make a diagnosis and then help them set up a care plan.

And in our office we have a team of social workers who can help families identify resources in the area. And we have a team of nurses who are experts in taking care of older people and can help families walk through some of the issues that might come up where you just need to talk to someone and ask a question. So our practice is really geared toward specifically helping people with chronic illnesses and the aging process where they all kind of come together. Because aging itself is not a disease. It's a natural process that we are all going through. We want to make sure that you're not looking at aging as a disease, but you're actually looking at the diseases you may have and see how they are impacting your aging process.

Host Amber Smith: Now your patient is the senior, but do you involve the caregiver at the appointments, and are they sort of your patient too?

Sharon Brangman, MD: So yeah, we definitely involve our caregivers because they are an important part of the team. They are really doing the heavy work, and we're just helping them because they have to provide care often 24 hours a day, every day of the week. So most of our patients come in with a caregiver. A caregiver could be a partner or a spouse, or it could be an adult child, or it could be some other relative, like a grandchild. And sometimes it's even a friend or a neighbor. But we have to make sure that the caregivers are equipped and rested and not stressed out because if they are, then we lose two people.

Host Amber Smith: Let's talk about who are the caregivers to these aging parents. What percent are women?

Sharon Brangman, MD: I do have sons who have stepped up, but it is mostly women with their own families and working, and they are overdone. It's usually the oldest daughter. I usually ask them, "are you the oldest?" And 90% of them say yes. That's my unofficial survey. The oldest daughter is usually the one. And if there are multiple children and they're all cooperating, they often take a different role. Like one will be in charge of making medical appointments, one will be charge of the finances.

Host Amber Smith: What age are these women, mostly?

Sharon Brangman, MD: So these are women usually in their 50s, depending on when their parents had them, but usually 40s, 50s. And it's interesting because some of my patients who are in their 90s, their children are geriatric in their sixties, so we really could have a family practice in a way. But I would say the majority of them are in their 50s. They're still working. They have children. They may have grandchildren. And I have more than one who has a spouse with medical problems, so they're taking care of a spouse as well as parents. And they can be very stressed.

Host Amber Smith: Have you seen families that make it work somehow?

Sharon Brangman, MD: Oh, yeah. Families can make it work, but you have to be an educated consumer. You have to know what the resources are, what the options are, and you can't be too afraid to ask for help. There's no shame in asking for help, and I think a lot of women in particular are used to kind of just making it happen on their own, but you do have to reach out and ask for help.

Host Amber Smith: And you said you are seeing more men that are finding the role of caregiver?

Sharon Brangman, MD: I can think of many men who really step up and take care of their parents, their mothers, coordinate care. So you can't think that men aren't able to do caregiving at all.

Host Amber Smith: Do you ever encounter caregivers who expect that the senior parent is going to recover and get back to the way things were before?

Sharon Brangman, MD: So we have all sorts of expectations that patients and caregivers have, and we try to help them understand what makes sense. We help them understand what are realistic expectations. We don't write anyone off, but we help people deal with the reality of a situation so that we can optimize their care and give them the highest quality of life possible.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Sharon Brangman. She's the chief of geriatrics at Upstate, and we're talking about caring for aging parents.

What advice do you have for adult children who suddenly find themselves in this new role trying to care for their aging parents? Can they do it alone?

Sharon Brangman, MD: So yeah, you can do it alone, but that makes it harder. And there's lots of support, and we live in a part of the state where there are lots of resources. So it makes sense to reach out and use those resources. And there's no point in trying to reinvent the wheel because there's a lot of things that are already in place that you just may not know about and you should take advantage of.

Caregivers often feel like this is the first time this has ever happened to anyone, but in reality, this is a very common situation and we have probably seen most of the scenarios out there and can provide support.

Host Amber Smith: So maybe they would want to set up an assessment with a geriatrics practice. What about a geriatrics care manager? What is that, and do they need one of those?

Sharon Brangman, MD: Geriatrics care managers are excellent. They know the resources and they can help an adult child or other caregiver figure out the basics of a care plan and rolling them out. There's a national association of geriatric care managers, so that if you have a parent who lives in Texas, for example, you can reach out to a geriatric care manager in that city in Texas.

There's some in Syracuse that we work with who are excellent, and they can help with some of that day-to-day decision making and problem solving. Caregivers, especially if they're out of town, appreciate that because they just can't be there.

Host Amber Smith: What about lawyers and financial planners? Is it time to line those up as well?

Sharon Brangman, MD: That's another piece that can be important, and setting up a power of attorney if you have a loved one who may need help with finances. A healthcare proxy is important, and that's when you as the caregiver can step in and make medical decisions for your loved one when they are no longer able to do so. Understanding the financing of home care and nursing home care is very important, so having discussions with any financial planners or lawyers is important. And a lot of the laws and rules change frequently, so you really need to be up to date with what's going on.

Host Amber Smith: One of the issues that inevitably arises is when to stop driving. How does an adult child know when it's time?

Sharon Brangman, MD: Oh, this is probably one of the toughest things that we deal with in our office. If you can remember when you were 16, and you got your driver's license, and you drove away and that wonderful feeling of independence. Or even now, if you need to go somewhere, you can just go without having to ask or wait. But there is a time when driving is no longer safe.

And, it is a very, very hard discussion because you have to be able to substitute those services that would be accessed with driving and most older adults tell me, "I've been driving for 60 years, and I'm fine." So we have to have a plan, and we have to discuss it frequently and sometimes it requires having a repeat road test or repeat written exam to make sure someone is still able to follow the rules of the road. There are some driving schools that can do an assessment. And there are some organizations that will do a driving update to refresh someone so that they're safe behind the wheel.

But when they start to have a lot of physical illnesses where they may not have the strength to step on the brake hard or to turn their neck to look to see if there's a car in the other lane, or if they have memory problems and they don't remember how to drive or how to follow the rules of the road, that's when we have to have these hard discussions.

Host Amber Smith: We've talked mostly about adult children looking out for their aging parents, but what about people who have no children? Do you have suggestions for how they can plan for their caregiving needs as they age?

Sharon Brangman, MD: So that is a different category of older adults with no children, and it's a growing entity because there are so many people now who are not having children. And I try to tell them, well, you know, there are some people with children who aren't helping them either. So it doesn't mean that just because you have kids, you have a built-in network of caregivers.

But what you have to do is you have to plan. You cannot avoid the discussion, and if you are living alone and you're by yourself, you have to plan and you have to set up your network. And you have to make sure that you have a health care proxy and somebody who you trust to help with your finances. And you have to have someone who knows what your wishes are and what you value in life, what matters most to you, so that they can help you make those decisions. And then you have to work on setting up that support network. And that takes some time.

Host Amber Smith: It sounds like it. Well, Dr. Brangman, I really appreciate you explaining this to us. Thank you.

Sharon Brangman, MD: Sure. You're welcome.

Host Amber Smith: My guest has been Dr. Sharon Brangman. She's a distinguished service professor of geriatrics medicine and the department chief of geriatrics at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.