Summertime vacations always bring an increase in calls from concerned adult children with some flavor of this question: “During vacation, we noticed Dad is slowing down. We think he might need help at home, but we aren’t sure. How can we tell?” The decision is not always clear; here are some signs that home care is needed.
The easiest decisions follow events that show clear and present danger: traffic accidents or dangerous driving, falls, or home safety hazards caused by inability to mange the home (stove left on, unaddressed plumbing problems, roof leaks, etc.). If this is happening, then it is time to step in, even if “nothing bad happened yet.”
Rationalizing – “It could have happened to anybody; could have happened when I was 40.” – is often deployed by someone resisting care, but the point is that you don’t want to wait until something bad happens; the near-miss is a gift and an opportunity. It shows, with little to no cost, a need for change. Take the gift, and do what is needed. Even if there is resistance, be persistent.
(The caveat: all competent adults have a right to self-determination; this is not an excuse to force a parent to live the way you’d prefer. Yes, fender-benders happen to younger drivers, too. If you are unsure of where you are in the spectrum, keep reading.)
Even clearer signs include early or moderate dementia, incontinence or poor hygiene, and poor medication management. These are not debatable: if this is present, your loved one is unsafe living alone and needs help.
The more difficult decisions arise when warning signs are present but not determinative and you are the closest family member responsible for safety. The best approach, if at all possible, is to open an honest discussion with the person. You can keep it hypothetical if that helps – “Uncle Albert, while you’re still healthy, I wanted to talk about what to do in case something happens. What do you think we should do if your driving skills fall off, or if it gets too hard to manage the house?” Often times, people do not know how to ask for care and a discussion of hypotheticals may allow preferences to emerge that would otherwise have remained unstated.
As you consider whether the time has come to step in, focus first on physical skills: how well does the person drive? Can your loved on walk and get up a flight of stairs easily? Is it still a reasonably simple task to get proper daily nutrition daily, take meds, manage the home, and maintain personal hygiene? The next consideration is how the elder would handle an urgent or emergency situation: what would happen if Dad were alone and cut himself with a kitchen knife, or there were a gas leak, or he fell? Do not focus on what is optimal or what you prefer; he is entitled to handle these his own way, provided he can keep himself safe. If you are concerned about these matters, however, this is a sign that it might be time to start the discussion about extra help.
And on that topic, be sensitive to how you raise the issue and your attitude. Remember that most adults would love to have a personal assistant, but nobody wants a baby-sitter. If your unstated attitude is, “You are clearly too old to be living alone, and you cannot manage your own affairs,” you are much less likely to have a productive conversation than if you convey, “We love you and want your golden years to be as easy as possible. Let’s get you an assistant so someone else handle the chores.” And if the assistant can be a family member or friend, that’s often more palatable, especially at first.
If you are still uncertain whether it is time for more help, or if your initial discussions meet resistance, it may be best to get a neutral third party to help advise your loved one. If the relationship with the primary care physician is good, ask for an appointment that you can both attend to discuss your concerns. A professional geriatric care manager (check with the National Association of Professional Geriatric Care Managers at http://www.caremanager.org) who specializes in creating care strategies can also be a great aid. We find that those whose backgrounds are in social work or counseling are best in these situations. Many GCMs are nurses, but you want someone whose training makes her a good mediator and facilitator of family discussions in addition to conducting the actual assessment of the elder.
Finally, do all you can to involve other family members in the discussion. The more collaborative the decision-making is, the greater the chance for success and for cooperation from everyone.