“Since Dad died two years ago, Mom has done amazingly well,” Elizabeth told me. “Her house isn’t as clean as it used to be, but it’s still pretty neat. I can’t really explain why I worry about her being alone.” As I questioned Elizabeth about her eighty-year-old mother’s housekeeping, she interrupted me and said, “Stella, to answer you, I’d have to snoop around like a detective whenever I visit Mom.”
“That’s not a bad analogy,” I replied. “In a sense, we do need to become detectives to help our parents continue to live safely. There may be faint warnings of physical or cognitive disabilities to come. These ‘red flags’ alert you when a parent begins to need more care. It might mean extra help around the house, more medical attention, or a review of medications.”
“To tell the truth,” continued Elizabeth, “I’m not sure she’s keeping track of her finances, and I’m worried about what she’s eating.”
“Nobody knows your mother as well as you do,” I said. “If you think there might be problems, there probably are. The sooner you identify red flags, the sooner you can begin to shape a plan for the future before a serious event occurs.”
Assessing lifestyle changes is a highly personal journey for you and your parents, and there are no hard-and-fast rules. Although you may be uncomfortable entering your parents’ home knowing you are there to check up on them, it may be a valuable service. To help assess how well your parents are doing, I have compiled a list of ten common red flags, starting with personal care.
I. Personal Care
Chris and Lili. Chris came to see me about his ninety-two-year-old mother, Lili, who lived alone in Beverly Hills. A physician, Chris felt he had covered all of Lili’s needs by carefully putting many support systems in place for her. To him, Lili seemed alert. She had always been a social, elegant woman who dressed beautifully and loved parties. She seemed to be doing fine on her own.
During a visit to his mother, however, he noticed that she now wore the same housedress every time he saw her. He also noticed a musty odor in the house. It dawned on him that Lili probably had not been bathing. “I think she was pouring on the perfume whenever I came to visit,” he told me later. Since the odor was a subtle change in his mother’s behavior, he did not consider it important. By the time Lili joined us, her personal hygiene needed immediate intervention. The mere mention of a bath made her nervous and fearful.
Bathing can be a frightening experience for the elderly. It takes considerable coordination and organization, and your parent may not be up to the task. Simply adjusting the hot and cold water controls in the shower can get confusing. It may also be difficult for older people to maintain their balance as they step in and out of the bathtub. In Lili’s case, she didn’t want to bathe because she was afraid of falling. In grabbing the sliding bathtub door to steady herself, she could have lost her footing and fractured her hip—a common accident among the elderly.
As small changes take place, you can lose a lot of valuable time before noticing a parent’s true condition. If your mother has always worn attractive shoes that matched her outfits, but is now wearing old slippers, this is a significant change. On the other hand, switching from comfortable old tennis shoes to comfortable old slippers might not be significant.
II. Housekeeping
Stewart and Amy. Stewart had been watching over his eighty-eight-year-old mother, Amy, for the past two years. “I never really worried about her,” Stewart said. “I took her grocery shopping, and she did the rest. Last week when I opened her refrigerator, there was more food than usual, and it didn’t smell good. Seeing the look on my face, Mom urged me out the door, saying, ‘Let’s go. I’ll tidy that up when I get back.’ The following week when I checked the refrigerator situation, what I found scared me. The foul odor had intensified. Food needed to be thrown out, and the refrigerator needed a good scrubbing. Heck, the entire kitchen needed attention. That was the moment it hit me—Mom needed help.”
It is difficult to accept that your parent is no longer able to care for himself. As one man shared with me, “Stella, my father is a retired superior court judge. Stepping into his life to help or intervene is hard to imagine.” Is your parent aware he needs help, or is he unaware? Either way, a comprehensive medical evaluation will determine if the cause is physical or cognitive. Could depression be a factor? A family physician with experience in caring for the elderly can provide helpful insights.
III. Meals and Appetite
“Following my dad’s death,” said Vincent, “my mother stopped preparing dinner, something she had done every night at six o’clock for fifty-two years. Now it looks like she’s losing weight. When I asked her about her diet, she said, ‘If there’s no one to enjoy the meal with, it’s not worth cooking.’”
The need for assistance in buying and preparing food may begin very subtly. Meals are a social time for most of us. If your parent is living alone and has lost a spouse or good friend, his appetite may diminish. Perhaps your parent can’t see clearly enough to read cooking instructions, or maybe arthritis prevents her from handling pots and pans and silverware. Dental problems can make eating difficult or painful. In addition, certain medications affect appetite while others cause the mouth to be uncomfortably dry.
IV. Memory
“Mom started calling me every night to let me know she was going to bed,” said Roy of his eighty-seven-year-old parent. “Five minutes later, she would call again, and repeat the same loving message. By the fourth call, I felt like unplugging the phone.”
If your parent calls frequently asking trivial questions about dinner or the weather, this may indicate a need for attention or a lack of stimulation. But watch for a pattern of repetition; if she calls four or five times a day with the same question, test the waters by saying, “Mom, have you already called me today about this?” This gentle question will not offend or frighten your parent, but will help you assess her situation. When she honestly cannot remember she has already called, you will know this is a behavior change that needs to be addressed.
It doesn’t matter how good-natured you are, when that same phone call with the same question keeps coming over and over, there will be a day when you lose patience. Try to remember that your parent is responding to thoughts that are perfectly logical to her and that she will have no idea why you are upset. To her it’s a brand-new call. If you do lose your temper, remember that every other adult caregiver has done this, and probably more than once. You may feel the impulse to call your parent back to apologize. However, if your parent has no recollection of your anger, an apology might only confuse her. If her memory lapses continue, contact her physician and request a cognitive assessment. (For more about cognitive assessments, see Chapter 7: “My Mother Doesn’t Have Alzheimer’s, But…”)
V. Communication
Nathalie and Her Mom. Nathalie, a petite, elegant woman in her late sixties, leaned over the desk as she described her mother to me. “My mother is extraordinarily intelligent,” she asserted. “She taught at the college level for twenty years and speaks three languages, so I can’t understand what the problem is. I tried to teach her how to put a cassette in a tape recorder. I said to her, ‘Mom! Stick the tape in the slot and put the lid down! Is that so hard?’ My brother Jack has given up on her. He told me, ‘Nathalie, don’t argue with her. You know what the doctor said about her memory.’ And I said, ‘I will not patronize my mother. I’m not going to talk down to her.’ But I just can’t get her to use that tape recorder. Every time I try to help her, she gets more upset and confused. Sometimes she can’t remember a word, or she says the wrong word. I tell her, ‘Mom, I cannot understand you; you have to say it again.’ I won’t let her give in to this!”
“Nathalie,” I said gently, “You mom’s memory isn’t what it used to be. Think of her mind as a tall building with all the lights on. A light goes out on the top floor, and another light goes out on the fifth floor, and so on. Eventually, the whole building will go dark. Nathalie, your mother can’t keep up with you anymore.”
She looked at me and began to cry softly. “I’m losing her, aren’t I?” she said.
As adult children, we do not want to accept that our parents cannot follow directions, or that they get easily confused and anxious. It scares us for our own sake as well as for theirs. Diminished communication is a warning sign that your parent is beginning to lose cognitive abilities. If you frequently find yourself exasperated at your parent’s inability to follow a conversation, it is time for an assessment by a physician well versed in cognitive disorders.
VI. Mobility
If you have noticed your parent’s movements are more slow, stiff, and unsteady, it may be time for an assessment by his physician; in fact, an evaluation by a physical therapist might be in order. Ben told me, “I knew Dad was having problems when he grabbed his walker to pull himself out of the car and both he and the walker toppled backward.” Fortunately, since an elder’s physical decline is often due to inactivity, mobility is one area that can be improved through exercise. Exercise is also known to reduce arthritis pain, improve sleeping habits, and increase mobility and energy levels. Consult your parent’s physician for an appropriate and safe exercise program.
VII. Depression: Losing Interest in Life
Of course, altered behavior can have physical causes. Your mother may not be able to read small print anymore. Your father may have stopped watching TV because he can’t hear. Your mother may not knit because of arthritis. Or all of the above could be caused by depression.
Bret and Karen. At eighty-seven, Bret lived alone after his wife died. His daughter Karen said her father had always been a very social man, and it saddened her to see him withdrawing. Whereas he used to count the days until his grandchildren’s visits, now he showed little interest in seeing them. He began to lose weight. His depression deepened. When Karen took him to UCLA Neuropsychiatric Institute, he was admitted for clinical depression. After he was discharged, Bret joined us in assisted living. It took him about a week to join our activities and really interact with the group. We found that he loves to dance, and he has become quite the romantic hero with the ladies. Given the title Official Greeter, Bret goes out of his way to help new residents with their first few days of relocation. Residents who have led highly social lives frequently benefit from the stimulation they receive in community living.
People over sixty-five cope with an increasing number of losses—death of loved ones, financial problems, feelings of powerlessness, physical disabilities, chronic pain, social isolation, and diminished memory. Any one of these can cause depression; cumulatively, they can be devastating.
A silent predator, depression not only damages quality of life, but also takes a toll on physical health. Symptoms may include insomnia, fatigue, loss of appetite, and changes in daily activities. But depression should not be considered a normal part of aging; it is treatable and needs to be evaluated just as you would a medical illness.
VIII. Medication
My Mom and I. At age eighty-two, my mother prided herself on being able not only to recite all thirteen of her medications, but also to tell you the purpose of each drug. Each Sunday for the past several weeks, I had stopped by to see Mom in the early afternoon. Typically, I would find her ritually preparing her medications for the coming week. Thirteen bottles of medication would be neatly lined up in a row as she diligently poured each medication into her seven-day organizer. This particular afternoon, I heard my mother mutter to herself, “What have I done now?” Peeking into the dining room, I saw Mom staring at the medication bottles, looking very puzzled. “Mom,” I said, “let me lend you a hand today, so we can sit and visit. I’ll take the container, and you hand me the pills.” Looking down, I found two of the same pills in Monday’s slot and none in Tuesday’s or Wednesday’s. How long had there been a problem? It was my first red flag that my mother had entered a stage in her life where she needed guidance and support.
Due to the large number of pills elderly people take every day, medications are a serious area of concern. If your parent is taking ten different drugs a day, which is not uncommon, and if the medication schedule varies for each pill, keeping track can become a real headache. If you have not already done so, make a list of your parent’s current medications. Tactfully checking your parent’s medication bottles, look at the dates when they were filled, and figure how many pills should still be in the bottles. Keep in mind that our parents may see three to four different specialists, each of whom prescribes medications within his own specialty. Often, medications contraindicate one another as various physicians fail to look at the whole medical regime.
Georgia. Georgia, eighty-seven, lived alone. Following an acute episode of irregular heartbeat, she was given blood thinner medication for stroke prevention as well as prednisone for severe bronchitis. Three weeks later, her doctor prescribed a baby aspirin, which was meant to replace the blood thinner. Instead, Georgia took both the aspirin and the blood thinner. All three medications she was taking could cause bleeding. During her last visit to the doctor, Georgia’s lab work showed she was anemic. As a result, she was placed on a daily dose of iron, which in turn caused a constipation problem. No one thought to look at the whole picture. On the day of her admission to assisted living, we asked the doctor for lab work to assess Georgia’s blood levels. Our lab reported a hemoglobin level so abnormal that Georgia required immediate hospitalization and two units of blood. Not surprisingly, each of the three medications Georgia had been taking had been ordered by a different specialist. With her medications reevaluated, she returned to assisted living, taking only baby aspirin.
According to the California Pharmacists Association, as many as one hundred thousand Americans die from adverse drug reactions every year. Millions more are injured. Ideally, all your parent’s medications should be filled at one pharmacy. Ask a trusted pharmacist to review your parent’s current medications. Be sure to include all over-the-counter drugs she is currently taking, since they can interact with prescription drugs. The pharmacist will let you know if there are any contraindications you should address with the doctor.
IX. Finances
Suzette and Her Dad. “My dad is an eighty-four-year-old retired psychologist who worked in counseling for thirty-two years,” began Suzette, an attractive redhead in her sixties. “In retirement, he made ends meet with Social Security and some investments he had made. Dad’s entertainment was going out to dinner on Tuesdays, Thursdays, and Saturdays with friends. About a year ago, I noticed he was eating at home on Tuesdays and Thursdays. The following week, I invited Dad to join my husband and me for dinner. Driving home after we dropped him off, my husband remarked to me, ‘Did you see all the thank-yous from different charities on your dad’s desk? There had to be at least ten.’ Stella, I had to bring this up with Dad, but I wasn’t sure how to go about it.”
“Gathering financial information is tricky,” I told Suzette. “Since finances are a private area, you may appear to be prying with the simplest question, and your dad may feel threatened or uncomfortable.”
“That’s for sure!” Suzette exclaimed. “My questions about his financial statements did not go over well. But the thank-you notes were still on the dining room table and there was over seven hundred dollars in donations. Also, his checkbook hadn’t been balanced in eight months. To make a long story short, Dad finally did go over his finances with me. Not only was he skipping dinners, but he was also cutting some of his medications because he couldn’t afford them! I’m not sure Dad even remembered giving to all those organizations. After I took over his finances, he could afford all his medications and his beloved dinners again.”
Because personal finance is as closely tied to your parent’s sense of independence as driving is, financial issues are among the most difficult to discuss. Don’t be surprised if your parent is uncomfortable sharing his financial status, but try to have a discussion before there is a need for intervention, so if a problem arises, you can effectively step in.
How do you begin the conversation? You could try a version of the following: “Dad, I’m worried I won’t be able to help you with your banking if you ever have a medical emergency. When Marcy’s father had a stroke, she had no idea of his financial situation, and now he is unable to tell her. Since she can’t access his accounts, Marcy is struggling to pay all his household and medical bills.” Or, you could say, “Mom, I’m starting a retirement plan that I hope will cover my living expenses. How did you plan your retirement? Is it working?”
If your parent is alert and does not feel comfortable divulging financial information to you or anyone else in the family, suggest he speak with a trusted attorney or financial planner.
X. Driving
William, Gert, and Matthew. William, eighty-six, visited his wife, Gert, twice a day at the nursing home. Matthew, their only child, had a growing concern about his dad’s driving ability. When Gert still lived at home, William had allowed a driver to take them to Gert’s dialysis treatments. But now that Gert was in a nursing home, he stated adamantly, “I don’t need a driver!”
Their son lobbied to have a caregiver drive his father twice a day for visits. “He has no business driving,” said Matthew. “He doesn’t always look both ways, and he switches lanes without signaling.”
Two weeks later Matthew called me, anxious and frightened. “Stella, I just got a call. Dad’s been in an accident. He’s in the emergency room. I’m on my way there now.” William had hit an eighteen-year-old girl who suffered a fractured wrist and lacerations over one eye, requiring stitches. William himself had fractured four ribs and his pelvis. Close to tears, Matthew admitted to me, “I knew I should have taken those keys away, but Dad put up such a fuss, it was easier to let the situation slide. Now I feel responsible for Dad and that poor girl.”
Many families have to wait for unexplained dents or minor accidents before broaching the subject of surrendering car keys. Remember: Loss of driving privileges equals loss of independence in our society, especially for men. If you are the bearer of the bad news, don’t be surprised if resentment descends on you full force. If your parent is mentally alert and able to make his own decisions, there will be a limit to the intervention you can offer. Having said that, if his driving is placing him and others in clear and imminent danger, you must act. Find a person to whom your parent will listen. It may be a grandchild who says, “Papa, I’m worried about your driving,” or it might be your family physician. Chances are, your parent will value the doctor’s recommendation more than yours.
The Time to Start Is Now
Does your father have problems with his personal hygiene because he doesn’t notice, because he doesn’t care, or because it’s too hard to keep up? Could his condition be a combination of all three? As his caregiver, you must make it your job to figure it out. If personal hygiene is not the first red flag, it may be banking activities and complicated financial problems that need your attention. Perhaps housekeeping has become an issue, or your mother has lost the ability to communicate how she spent her day. Start observing your parent now. Pay attention to the red flags, and create a plan. If your parent can be involved in the planning, it not only allows him to retain his role as decision maker for the remainder of his life as you carry out his financial, medical, and end-of-life wishes, but it also simplifies your role as caregiver.
CHECKLIST:
Red Flags to Watch For