Incompetence & Losing Capacity:
Answers to 8 FAQs

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Have you ever been concerned about an older relative who seems to be making bad decisions?

Perhaps your elderly father insists he has no difficulties driving, even though he’s gotten into some fender benders and you find yourself a bit uncomfortable when you ride in the car with him.

Or you’ve worried about your aging aunt giving an alarming amount of money to people who call her on the phone.

Or maybe it’s your older spouse, who has started refusing to take his medication, claiming that it’s poisoned because the neighbor is out to get him.

These situations are certainly concerning, and they often prompt families to ask me if they should be worried about an older adult becoming “incompetent.”

In response, I usually answer that we need to do at least two things:

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How to Help Doctors Notice What’s Wrong: The story of the missed pelvic fracture

by Leslie Kernisan, MD MPH

Once upon a time, the ER missed a pelvic fracture in one of my older patients.

Actually, this kind of thing has happened more than once, and perhaps it’s happened to your family too.

As much as we’d like to believe that our older loved ones will get the right care when they are sick or injured, the truth is that our healthcare system is imperfect, and it’s fairly common for serious problems to be missed.

Unless, of course, a proactive family caregiver knows to help the doctor focus on what’s newly wrong.

Here is a true story about why geriatricians pay attention to “changes in function” and why it’s essential that you help doctors spot any changes in function or ability.

The case: unable to walk after a fall

My patient with Alzheimer’s dementia, 85-year-old Mr. C., sat down short of his easy chair at home and fell. Within minutes, his daughter found him on the floor. She helped him to the chair, and they watched some TV. But half an hour later, he was unable to get up again and walk. She took him to the emergency room for evaluation.

“I’m fine. Nothing hurts,” Mr. C. told the busy ER staff more than once. “I just want to go home.” X-rays of his hips and pelvis revealed nothing, and so — after an exam that probably lasted only a minute or two — he was discharged.

Back home, however, he still couldn’t walk. He still insisted nothing hurt. “I’m a tough old bird,” he told his daughter. Later that night, though, she noticed that he grimaced every time he rolled over in bed. She knew something was wrong. But what?

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Depression in Aging:
Diagnosis & Treatment When the Golden Years are Blue

by Nicole Didyk, MD

Most of us can relate to feeling sad or blue, sometimes for days at a time. It may be in response to a major life event like losing a job, a break-up, or as part of grief. These sad feelings can lead us to feel less interested in enjoyable activities, make us lose our appetite or disrupt sleep.

Although research shows that people often become happier as they age, sad feelings are also very natural and can be associated with some of the typical transitions and changes of aging. But clinical depression, from a medical point of view, is something different, and should not be considered a normal part of getting older.

In this article, I’ll explain the most important things to know about late-life depression, including:

What’s different about depression in later life?
What are the symptoms of depression and how is clinical depression diagnosed (especially in an older person who may also have medical illnesses that can mimic depression symptoms)?
What does testing for depression look like?
What treatments are recommended for older adults with clinical depression?
What you can do if you’re worried that someone is depressed, and how to help someone with depression.

In an upcoming article, I’ll also cover the special considerations and challenges when it comes to diagnosing and treating depression in those living with dementia, which is a common scenario in my practice as a geriatrician.

Depression in Later Life

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How to Prevent Falls: 4 Proven Approaches To Ask Your Doctor About

by Leslie Kernisan, MD MPH

Worried about falls in an older parent or relative? If so, do you know if their doctor has considered the most useful fall prevention approaches?

Fall risk can be reduced, but it generally takes some thought and effort. That’s in part because most older adults have multiple factors making them vulnerable to falls.

In a related article on this site, I’ve explained that best fall prevention plans involve identifying an older person’s particular risks — especially risks related to health conditions — and trying to counter those.

Get Your Free Fall Prevention Resource Guide! A handy short PDF to help you quickly find the key online resources mentioned in this article. Click here to download.

So for instance, if an older person has diabetes and is having frequent moments of low blood sugar (also known as hypoglycemia), then to reduce falls, addressing the hypoglycemia is as important, if not more, as starting an exercise program.

In other words, I always recommend that aging adults and families learn to tailor their fall prevention plans. You want to focus on what are the most important modifiable risk factors for that individual person.

That said, over the years I’ve noticed that there are four approaches that I find myself using over and over again, in almost all my patients who have had repeated falls.

These four approaches are used often by geriatricians, but much less often by busy primary care doctors. Unless, that is, a proactive family asks about them.

My Four Most-Used Fall Prevention Approaches

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How You Can Help Someone Stop Ativan

by Leslie Kernisan, MD MPH

Have you heard of Ativan (generic name lorazepam), and of the risks of benzodiazepines drugs in older adults? Is an older person you care for taking prescription medication for sleep, anxiety, or “nerves”?

Would you like an easy, practical tool to help someone stop a drug whose risks often outweigh the benefits?

If so, I have good news: a wonderful patient education tool has been created by a well-respected expert in geriatrics, Dr. Cara Tannenbaum. Best of all, a randomized trial has proved that this tool works.

As in, 62% older adults who received this tool — a brochure with a quiz followed by key information — discussed stopping the medication with a doctor or pharmacist, and 27% were successful in discontinuing their benzodiazepine. The brochure includes a handy illustrated guide on slowly and safely weaning a person off these habit-forming drugs.

This is big news because although experts widely agree that long-term benzodiazepine use should be avoided in older adults, getting doctors and patients to work together to stop has been tough. It is, after all, generally easier to start a tranquilizer than to stop it!

But through a patient education brochure, Dr. Tannenbaum’s team was able to make this tricky process much more doable for older adults, their families, and their doctors.

Why it’s important to try to stop lorazepam & other benzodiazepines

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10 Things to Know About HIPAA & Access to a Relative’s Health Information

by Leslie Kernisan, MD MPH

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Have you ever had questions about what might be going on with an older loved one’s health? But then you find that your older relative is unable — or unwilling — to let you in on the health details?

Or maybe you’ve wanted to talk to your parent’s doctor, but worried that doing so might be a HIPAA violation?

Such issues come up often for the family caregivers of aging adults. Common situations include:

An older parent who starts to act in ways that are strange or worrisome, such as becoming paranoid or delusional.
An older adult who seems to be physically or mentally declining, but seems reluctant to discuss the situation
A hospitalization or emergency room visit
A hospitalized older person becoming confused (this would be delirium) and becoming no longer able to explain to family what the doctors have said

In these situations, family caregivers often find themselves grappling with issues related to the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule.

Why all the grappling?

Well, although most people — and all clinicians — have heard of HIPAA, its rules and requirements are often misunderstood. So for instance, families may assume that it’s a HIPAA violation to report a relative’s worrisome behavior to the doctor, because their relative hasn’t given them permission to do so.

Even worse: doctors and other clinicians sometimes refuse to disclose any information to families, and will incorrectly claim that it’s a HIPAA violation to do so. This can create extra confusion and stress for families, or can even sometimes put an older person at risk for harm.

If you’ve been concerned about an aging parent’s health, or are otherwise helping someone with their health concerns, then it can be very helpful to understand HIPAA better. HIPAA regulations will also govern your access to medical records and other important health information.

In fact, the American Bar Association includes “Know your rights of access to health information” among its Ten Legal Tips for Caregivers.

The detailed ins and outs of HIPAA can indeed be hard to fully understand. But, it’s not too hard to learn some practical basics, especially since the US Department of Health and Human Services (HHS) provides a Summary of the Privacy Rule here, and maintains a truly useful set of online FAQs about HIPAA here.

In this article, I’ll explain five useful key basics to help you understand HIPAA better, especially when it comes to getting information and medical records as a family caregiver.

I’ll also address five questions I’ve often heard family caregivers ask about HIPAA.

At the end, I’ll share some of my favorite online HIPAA resources, as well as some final tips to keep in mind.

5 Key Basics About HIPAA

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How to Manage Sleep Problems in Dementia

by Leslie Kernisan, MD MPH

Sleep problems are common in Alzheimer’s and other dementias. They also commonly drive family caregivers crazy, because when your spouse or parent with Alzheimer’s doesn’t sleep well, this often means that you don’t sleep well.

To make matters even worse, not getting enough sleep can worsen the thinking or behavior of someone with dementia. Of course, this is true for those of us who don’t have Alzheimer’s as well: we all become more prone to irritation and emotional instability when we’re tired. Studies have also shown that even younger healthy people perform worse on cognitive tests when they are sleep-deprived.

Hence getting enough sleep is important, for people diagnosed with dementia, and for their hard-working caregivers. Now, sleep problems do often take a little effort to evaluate and improve. But as I explain below, research has found that it is often possible to improve sleep problems in dementia.

The key is to know what common causes to look for, and then come prepared to provide useful information to the doctor. In this article, I’ll cover:

Common causes of sleep problems in Alzheimer’s and other dementias,
How sleep issues should be evaluated
Proven approaches that help improve sleep in dementia
What to know about commonly tried medications for this problem

Common Causes of Sleep Changes and Problems in People with Dementia

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5 Things to Know about Aging Parents & Financial Decline

by Leslie Kernisan, MD MPH

You probably already know that many older adults develop problems managing finances as they age.

Now how would you answer the questions below:

Has your aging parent planned for a decline in financial abilities?
Are you prepared to detect signs of a financial decline?
Do you know what to do if you do notice problems with finances?

Many people, even the ones who are caring and well-informed, will often answer “no” to these questions.

But this post will equip you to start answering yes. And I want you to be able to answer yes, because declines in the ability to manage finances are very common among older adults, and often causes serious health and life problems.

The trouble, of course, is that financial decline is uncomfortable for older adults and their families to think about. Managing money, after all, is one of the ways we maintain autonomy and control over our lives.

So nobody likes to confront the fact that our ability to manage money will — in all likelihood — someday decline. (Research suggests that even aging adults who don’t develop dementia often experience declines in financial ability.) And families are understandably squeamish about monitoring an older relative’s financial abilities.

Fortunately, a little education and guidance can make it much easier to be more proactive about this tough topic.

In this post, I’ll cover

Five warning signs of financial decline
Five important things to know about aging & finances
How to protect aging parents from financial problems
What to do if your aging parent is having trouble managing their finances

I’ll also cover some ways that geriatricians and other healthcare providers can help, both to reduce declines in financial ability and to properly evaluate them when they occur.

5 Warning Signs of Financial Decline

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6 Steps to Take When Aging Parents Need Help – Even if They’re Resisting

by Leslie Kernisan, MD MPH

Have you noticed worrisome changes in your aging parent?

Maybe they’ve been mostly okay but now you’re seeing problems with memory, such as forgetfulness or asking the same questions repeatedly. Or maybe you’ve noticed trouble with driving, keeping up the house, managing stairs, or paying bills.

Some aging parents simply begin to seem more withdrawn. Others start leveling accusations at others, claiming someone took or moved something, or acting paranoid.

For many adult children, these changes lead to mounting questions. What’s wrong? What’s happening? Is it safe for Mom to keep driving? Should Dad live alone much longer?

I think of this as the “uh-oh” stage. It’s a transition no one looks forward to, and most haven’t prepared for: the time when you might have to start helping your aging parent.

And for many, it comes with an added challenge: Most aging parents don’t welcome much help from their adult children. They may see it as interference, or an invasion of privacy.

Some parents might even refuse to accept that they’re having difficulties, despite issues that feel glaringly obvious—and concerning—to you.

By the time you’re noticing changes and have safety concerns, it’s quite possible that you’re right: that your parent does need help of some kind. So how should you best get involved, especially if your attempts to do so have gone poorly in the past?

Well, it’s certainly not easy. These situations are complicated from a medical and eldercare perspective, plus they tend to bring up difficult emotions for older parents and adult children alike.

But I do believe that it’s crucial for families to get involved. It’s not likely to be easy. But it can be easier, if you’re able to learn the better ways to do so—and also what to stop doing.

[Read more…]

COVID Vaccination for Aging Adults:
What to Know & Do

by Leslie Kernisan, MD MPH

COVID is an important issue for older adults: they are more likely to be severely affected by COVID, and they represent most COVID deaths.

Luckily, COVID vaccines are effective and significantly reduce the risk of hospitalization and death in older adults. In particular, I want to offer science-based information to help with common questions, such as “Which COVID vaccine is better for seniors?” or “Which COVID vaccine for a 90-year-old?”

This page covers my older science-based updates on COVID vaccines.

For my latest update, see here: Covid & Aging Adults: Current Vaccines & Updates

[Read more…]

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The case: unable to walk after a fall

Depression in Later Life

My Four Most-Used Fall Prevention Approaches

Why it’s important to try to stop lorazepam & other benzodiazepines

5 Key Basics About HIPAA

Common Causes of Sleep Changes and Problems in People with Dementia

5 Warning Signs of Financial Decline

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