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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.

Falls are the single biggest cause of fatal injuries in people 65 and older, so keeping elders safe in a home where they may have lived for decades is one of a family’s biggest challenges.  The familiarity of the surroundings and the history of safety can work against both the recognition in adult children of growing dangers and can build resistance on the part of the elder to any change in a familiar and comforting environment.

There is good/bad news here:  fortunately, many factors that contribute to fall risk are under a family’s control; unfortunately, fall risks are sometimes especially difficult to eliminate, because it can require change that generates resistance in the elder to the very actions needed to improve safety.  When we visit families, one of our first activities is a review of the home to inspect for these risks; we typically find that a person who recently moved to a condo or other new arrangement has many fewer accumulated hazards than someone who has lived decades in a home and intends to stay.

Many sources are available to help families take action to reduce fall risks. AARP, Mayo Clinic, and the Center for Disease Control, for example, all contain articles on the topic.  For those tackling the task at home along, here are some tips culled from our experience.

Physical Health

Regular exercise is probably the single biggest factor that helps reduce falls. If the elder will participate in a class like Tai Chi, which focuses on strength and balance, that is best.  But simply walking 20-30 minutes daily at a moderate pace is an enormous help.  Studies consistently show that people who remain active walkers later in life fall less often than more sedentary counterparts.

Review meds, and when possible, reduce them.  Write down every prescription and non-prescription drug or supplement, including anti-depressants and sleep aids, and take them for review by the senior’s physician.   Request a review for side effects and interactions that may increase fall risk.

Limit access to alcohol.  Even in safe doses, alcohol makes everyone a bit less steady, and alcohol abuse among elders, who are often lonely and isolated, is surprisingly common.

Check the elder’s health.   Poor vision, inner ear problems, urinary tract infections, and other health conditions may be the harbingers of increased fall risk.

Environment

Turn your attention to the environment.  Start with the elder himself or herself - be sure the elder wears proper shoes. Flip flops, sandals, and bedroom slippers, even in the home, can cause a stumble or fall.  Properly fitting and sturdy shoes are the keys the stable walking.

Next, examine each of the home’s component parts. Consider these questions:

Floors

Is there a clear path through every room?  If you have to walk around furniture, or if there are low items like coffee tables or foot stools, these will increase fall risk. Even if items have been present for decades, try to move them; they represent a risk now that they did not in years past.  If necessary, consider saying that they need repair or that they are dangerous for a grandchild. Avoid arguments over whether the elder is likely to fall; most likely, the response will be “I’ve lived here 50 years and haven’t fallen, so I want nothing to change.”  Your goal is not to get elders to agree that their skills are declining; it is rather to remove the risks, so always try to do it in a way that leaves the person’s dignity intact.

In particular, remove small throw rugs – these are among the most significant hazards. (“We took it for cleaning” or “It was ripped and is being repaired” are handy excuses if needed.) If the rug is so well-loved that it cannot be removed without undue stress, use double-sided tape on a non-stick backing to keep it securely in place.

If there are small objects on the floor, remove them.  These include pet toys or pet food dishes, laundry baskets, footstools, shoes, magazines and newspapers, etc.  Especially in the bedroom, where people often rise at night in the dark and are disoriented and sleepy, these present significant fall risks.

Get wires and extension cords out of the way.  If necessary, have an electrician install a new outlet.  Tape or staple cords out of the way.

Examine stairs and hallways.  Be sure they are well-lit – often older homes do not have bright lighting for stairways.  Be sure the light can be turned on/off from both the top and bottom of the stairs. If not, call to have a new switch installed.  Is there loose or torn carpet? Remove it or replace it.  Even better: attach non-slip rubber treads to the stairs.  Check for sturdy hand-rails on both sides of each stair.

These changes of course will not prevent all falls, but they can go a long way to eliminating the risk of unnecessary injuries.

Our next column will address fall risks in bathrooms and bedrooms separately, because they are so important.