Early one morning, a bit later in our POPcycle, I got another significant POP phone call. This time it was from a concerned employee at my parents’ assisted-living facility (ALF). Mom had taken a bad fall. She tripped while making the bed I’d erroneously believed was being made for my parents by the staff. Lillian had turned away the first set of medics, refusing their help or to go with them to the hospital. Clearly, a “disciplinarian” POParent was needed on-site. I reassured the staff member that I would come as soon as I could drive there and take care of things. “Please call her another ambulance. I’ll be right over and make sure she gets to the hospital.”
By the time I arrived, the paramedics had already returned. One was in the bathroom where Mom apparently had “landed” after her fall. Now she was in much pain and “acting out,” as therapists say of teenagers. I overheard the brawny professional warning her: “Look lady, I don’t care if you are ninety years old, if you don’t stop fighting me and let me do my job, I will call the police.” He came out to the living room where Dad, the head of the facility, and I all sat demurely. “Is she always this difficult?” he asked. Three heads nodded simultaneously.
As it turned out, my osteoporotic mother had taken a serious fall and damaged her hip. The hip is the body’s second-largest bone and is central to all lower-body movement. Within minutes, Lillian was transported to the hospital. The details and sequencing of events in the ER are a blur for me. The combination of stress, super-bright lighting, an endless list of unknowns, and just plain fear generated a feeling of timeless spaciness in my head.
Hence the next thing I recall was coming back to “consciousness” and watching Mom being wheeled away on a gurney, apparently headed for major surgery. I jumped up and started running after them—no one had spoken with me nor gotten my signature on her consent forms. The confused-looking nurse told me: “Lillian said it was fine and told us she had no family.” Uh-oh.
Mom’s postsurgical experience evolved into a far bigger nightmare than earlier that morning. Never a shrinking violet, my mother had seemingly morphed into the patient from hell. In the days following the procedure, Mom’s surgeon actually refused to visit her in the hospital, claiming he wouldn’t attend a patient who was spitting at and biting him and the hospital staff.
Subsequent to those episodes, my mother mysteriously began refusing both food and water. As a result, she couldn’t take her medications and, should it continue, would soon become malnourished. Her decision put the hospital in a legally compromised situation. Since they lacked the legal authority to force her to ingest anything and feared for their liability, the hospital personnel spent hours and hours trying to place Mom in a psychiatric ward, even in a rehabilitation facility—anywhere to get her off their wards.
As that long Saturday afternoon dragged on and no one could locate a single facility in Ventura County willing to accept Lillian Wolf, things began to get desperate. Mom’s health was being compromised by her actions and attitudes and it would only get worse with more time.
With the clock ticking away and frustration increasing from all quarters, only one viable option remained. I had to leave the hospital to go get and bring in the Big Guns—Dad. I raced back to the ALF and briefed Dad about our situation in the car as we drove back to the hospital. As he approached his wife, Dad put on his grimmest, most authoritative face and announced that, until she took food, water, and her meds, he would neither talk with nor listen to Mom. That put an immediate end to her boycott. I knew it—Jack still had the power with his wife!
In the long run however, Mom never did really recover from the fall. She never learned to walk on her own again, despite valiant efforts by the long-suffering physical therapists. Even I tried to work with them by holding out my open arms to her, quite literally, during her physical therapy (PT) sessions. Her fear of falling again, the cognitive limitations that made it too hard to learn “new things” or follow directions, her physical weakness, and whatever unknowns all conspired together.
With her life confined to chairs and beds, not surprisingly, my formerly weight-conscious Mom gained pounds easily, became less mentally alert, and grew more depressed. Unable to follow through with the demands of PT, Medicare soon cut off that option, and Mom’s once graceful body became forever limp. Several people would be needed thereafter to lift and transfer her.
Clearly Mom’s returning to the ALF would not be possible. From a financial point of view, we couldn’t afford the monthly expense of two full-time caregivers on top of paying for ALF for both of them. Nor was the ALF viable from the point of view of the level of care she was beginning to require, which was readily provided in a skilled nursing facility (SNF).
Jack’s physical, cognitive, and emotional needs didn’t require the same level of care that Mom’s did. He chose to stay at the AL, where he was comfortable, and he began to create a life there by himself. Although his world had become smaller in a way, Dad seemed to thrive, reading his books—sometimes over and again—watching his TV shows, and sharing himself with only a few. I saw that he craved the peace and quiet he’d not had living with Mom, for a long time—perhaps since their beginning together.
Frankly, he seemed somewhat relieved. Dad enjoyed the role of being called in to rescue Mom, comfort her, and visit with her. Without having to share space with anyone, Jack took the opportunity to create his “man cave” of books, television, and occasionally some music.
My Mom’s life would thereafter be spent alone, too, but differently than Dad’s. After her fall, like so many older people, Mom lacked what she needed to regain most of her previous life. My parents’ married life together, as they’d known it for over sixty years was over, and I witnessed her life becoming even more limited and frail. It was very sad.
One of the most challenging jobs as a POParent is to get proficient at managing the unexpected, whatever its source. What caused my family’s POPlans to be dismantled won’t be the same things that disrupt your POPlans. Your family will need to use its available resources to address your parents’ unplanned-for happenings and the further consequences of those events, and then to craft its own unique, workable solutions. Nonetheless a common theme emerges for all POParents: how can you plan for the unexpected when you’re doing POP?
The term “snafu” is attributed to the American military from the Second World War. The initial letters stand for “systems normal, all fouled up.” If you’re doing POP, snafus are probably an everyday occurrence. Your ability to remain flexible and resilient, to not crumble when things don’t go as expected is—and will remain—one of your most important qualifications for doing this job satisfyingly. Like all POParents you’ll do a better job when you’re willing—and able—to face what’s ahead with candor and objectivity rather than fantasy and wishful thinking.
Even if you can’t predict exactly when or why snafu’s will occur, you can: predict they will; have some fall-back POPlans, and work on how to regain your equilibrium as quickly as possible after they descend. You also can get better at managing your emotions and yourself when these unexpected events do occur. Finally, you can learn to get better at resetting your family’s POPcycle back on a useful course as quickly as possible when your POPlans get interrupted.
Tragically your aging parents may have been let down by one (or more) of the many institutions originally set up to protect them—Medicare, Social Security, insurers, their ALF, and so on. In some cases you may find yourself facing three “Goliaths.” Each of these behemoths may be staffed with lots of experienced people who have time to get things done, whereas you, “David” here, may be extremely limited in terms of your experience, time, and energy.
You may also be frustrated by fussy parents who may be confused by these various entities, want something special, or don’t want to go where you’ve found them the “perfect” place. It’s insulting and disappointing that the profit motive has so often trumped private institutional caring and how often governmental agencies have disappointed the elderly and disabled. You may find yourself seeking solutions to complex situations where it feels like you’re navigating a course between the proverbial rock and a hard place—one institution, say Medicare, on one side and another institution, your parents’ physician perhaps, on the other.
You and your siblings may be scratching your heads, figuring out how to keep your own paying jobs, health, and marriages while also performing your POP miracles. Hopefully, you won’t need to get your dad a timely admission to an appropriate placement (one corporation and its rules) before the hospital (a second giant institution) sends him home, having been pressured financially by Medicare (a third institution) to release the patient quickly. In any case, you will likely encounter your own challenges with “rocks” and “hard places.”
POParents can’t expect these often overburdened institutions to always be advocates for your parents. You’ll have to discover what you need to know about these organizations and how they work (or don’t work). Doing so will be imperative for helping your aging loved ones through this part of their life. You will need to recognize that this arena is one of shifting sands legislatively and administratively.
As a result, you can rarely learn all you need to know in advance of needing to know it. You must jump in and immerse yourself whenever a POP problem needs solving, which is considerably easier now than it was in years past because of the internet, social networking, and POP’s home website, as we’ll talk more about in this book’s final chapter.
It is useful for POParents to be conversant with the most common ways the seniors in your charge may become weakened or even die unexpectedly. You’ll want to be conversant with the diseases your parents may be particularly vulnerable to, but you need not become familiar with every geriatric disorder nor obsess that your parents will come down with one or more of them just because they’re advanced in age.
To pay proper POP attention to a disease or disorder, you’ll need to be aware of its most common symptoms. So, for example, if your parents have had pneumonias and you hear them coughing persistently for days, you’ll want to take them to the doctor. Pneumonia is one of the leading causes of death among seniors and the leading cause of morbidity and mortality among those seniors who live in long-term care (LTC) facilities.
Over the course of our POPcycle, my parents came down with pneumonia so frequently that I lost count. During their California years, pneumonia was the cause of every hospitalization for both my parents, except for the consequences of their taking falls. I had hoped to be able to better protect Mom and Dad from the ravages of pneumonia in balmy Southern California, but that didn’t prove to be the case. Pneumonia also is the primary reason that residential facilities, like ALFs and board and cares (B&Cs) transfer their residents to more acute locations, like SNFs and hospitals. Other symptoms of pneumonia include fever; fatigue; loss of appetite; discomfort in the chest, lungs, or upper abdomen; discolored sputum (green or bloody phlegm); and disorientation. Take your parents to competent professionals for diagnosis and treatment, especially if their coughs or runny nose appear to be chronic.
Physicians often rely on reported clinical changes (physical, functional, or mental) in an older patient’s status to signal that something may be wrong, since pneumonia can be difficult to diagnose and X-rays are not always helpful. But because your elderly parents often lack good memories, they aren’t always useful as their own medical historians. They may lose track of how long they’ve had their symptoms. Your aging parents may also wish to avoid yet another trip to the doctor for “just a cough.” When asked about their cough or runny nose, your parents might say: “I don’t like to complain, honey.” Therefore it will become even more your POP responsibility to pay attention to symptoms that persist.
There are two distinct types of pneumonia: community-
acquired and aspiration pneumonia. Community-acquired pneumonia is airborne and easily
communicable, thus presenting major challenges both during cold winters and in senior
facilities, where the large number of people present may support quick contagion.
Seniors often arrive at facilities with their immune systems and swallowing functions
already compromised due to age and preexisting medical conditions (such as a stroke,
congestive heart failure, or other disorders).
There are some steps you can take to prevent the spread of community-acquired pneumonia, influenza, and colds. You can remind your parents to wash their hands frequently with sanitizers or other substances that stop the spread of bacteria. You can easily and economically sanitize handles on their shopping carts at the market and on their light switches, door handles, and window handles at home. You can ascertain if your parents’ phones and any community computers they touch are sanitized. Similarly, if your parents use keyboards in public places like the library, you can recommend ways to clean them thoroughly beforehand. You and your parents can avoid using public telephones, especially in emergency rooms. You might also urge your parents to forgo reading magazines in doctors’ offices, where many sick people may have fingered them. Instead, bring along your own periodicals, tablet, iPad, and the like to amuse your folks, show them your photos, and play games with them while you wait.
The second type is aspiration pneumonia. It develops from a combination of factors that may include fairly common things such as impaired swallowing, fluids draining into their lungs, and inhaling bacteria from the back of their throat, mouth, or nose into the lungs. Preventing your parents from getting aspiration pneumonia is possible, but it will require your parents to change some of their habitual ways. That is not easy and it’s far from foolproof. You can begin by altering your parents’ diet so it consists primarily of softer foods that are easier to swallow. You can also give them a thickener to add into their liquids and perhaps you (or an occupational therapist) can teach your parents new swallowing maneuvers.
The treatment for pneumonia is generally straightforward, typically lasts ten to fourteen days, and doesn’t depend on how the disease was contracted. Initially, antibiotics are administered to kill the bacteria. With this illness, as with others, you will want to check that your parents are receiving the correct geriatric dosages of medications. A senior’s body often requires or can handle only smaller amounts of prescription drugs. Breathing treatments and expectorants are also frequently introduced to open up their airways, loosen phlegm, and cough out the mucus that accompanies pneumonia. Some of the most serious hazards are caused when your parents lie flat in bed all day, because fluids tend to settle into their lungs.
Seniors with pneumonia in just one part of their lungs have a good chance of full
recovery. The presence of pneumonia in several parts of the lungs is more severe and
makes recovery more difficult. With advancing age, the lung tissue becomes less elastic,
decreasing the lung’s ability to expand and contract. Even osteoporosis, another common
geriatric disorder, with its resulting
deformity and curvature of the spine can affect breathing by impairing lung expansion.
Your POP responsibility includes helping your parents avoid all predictable health risks, just as your parents did for you when you were young. You’ll need to research and weigh the advantages and disadvantages of having your parents receive pneumococcal and influenza vaccines. Many geriatric professionals believe that because seniors’ bodies are more vulnerable than other adults, everyone over sixty-five should be inoculated against such diseases. Others hold differing views. If you’ve hired professionals you trust and they think a course of treatment is best for your parents, you’ll want to follow much of their advice. If you find you are consistently not aligned with your parents’ physicians’ point of view or you aren’t taking their advice, find other doctors with whom you can work in better accord.
One health hazard for your senior parents that may surprise you is being admitted as a patient to a hospital. Hospitals concentrate lots of people with serious health problems into small spaces. Many POParents attempt to keep their parents out of the hospital unless it’s absolutely necessary. When I’d visit one sick parent in the hospital, I’d keep the other parent at home, rather than expose my healthy parent to a lot of sick patients.
Some of their hospitalizations caused my parents unforeseen complications. I was told that my Mom had contracted a case of Methicillin-resistant Staphylococcus aureus (MRSA) during one such hospitalization. MRSA is a bacterium that can be fatal. Sometimes it is called the “superbug” because it is resistant to many commonly used antibiotics. It weakens the immune system of those already vulnerable physically and it’s rampant in some hospitals. When I would visit Mom in the hospital after she got MRSA, I had to wear a mask, a gown, and other protective clothing. Later on, when I would need to place my mother again in other SNFs, some refused to admit her because she carried the contagious disorder.
Generally speaking, parents who reside in LTC facilities have higher levels of functional disability and underlying medical illness than their peers who live out in the community. I was unaware of that fact when I placed my parents in such residences. I also didn’t consider that some contagious diseases would spread more easily in these facilities. However, as I like to tell my patients, we must make all decisions with “inadequate information,” and nonetheless, we must decide. Looking back, I still wouldn’t have changed my POP choices, since they seemed wise when I made them, and I felt that I had done the best I could when I made those choices.
Some estimate that, in the near future, as many as 40 percent of Americans will spend some time living in a LTC facility. Given our baby boomer demographics, it’s foreseeable that the number of frail older adults living in these facilities (including ALFs, SNFs, and B&Cs) will increase dramatically over the next thirty years. Some POP families may find community-based options preferable to LTC facilities. But as responsible POParents, it’s important that you not overreact to every potential danger or jump to hasty and unwarranted generalizations. Whether or not the results turn out as you expected, as good POParents, you must decide things sanely and thoughtfully, considering all the elements available to you at the time.