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Q&A: What to Do About Unintentional Weight Loss

by Leslie Kernisan, MD MPH 115 Comments

Q: My 88-year-old father lives in his own home about 100 miles from us. He’s been living alone since my mother died five years ago. I thought he looked rather thin last time we saw him. I’m starting to feel worried about his nutrition. Should I be concerned? Would you recommend he start drinking a supplement such as Boost or Ensure?

A: This question comes up a lot for families. It is indeed very common for older adults to experience unintentional weight loss at some point in late life.

The brief answer is that yes, you should be concerned. But I wouldn’t recommend you jump to purchasing Boost or Ensure.

Now, in most cases, some nutritional supplementation is in order. But before focusing on this, you should first get help figuring out why your father is losing weight.

For doctors, unintended weight loss is a major red flag when it comes to the health of an older person.

So in geriatrics, we usually recommend that an older person — or their caregivers — monitor weight regularly. This enables us to spot weight loss sooner rather than later.

Once we’ve spotted unintentional weight loss, the next step is to figure out what might be causing it. And then we’re in a better position to recommend a treatment plan, which might well include a nutritional supplement.

In this post, I’ll go over each of these steps in more detail.

Why you should monitor for unintentional weight loss

[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles, Q&A Tagged With: weight loss

6 Causes of Paranoia in Aging & What to Do

by Leslie Kernisan, MD MPH 104 Comments

paranoid elderly motherQ: My mother is 80.  She is very active (despite breaking her hip 2 years ago), she still attends water therapy 3 times a week at the YMCA, she drives to the base (which is 20 miles away) and pays her bills on time.  She is a retired Psych nurse and has shown signs in the past of paranoia. 

Lately, she has “heard” voices of her grandchildren in her home and called my sister. She also has difficulty with getting the right words to say out and has her sleep pattern out of whack and will call people at odd times of the night.  With her independence comes the fact she won’t share any medical information because she thinks we are out to get her committed.  

How can I test her/question her to find out the level of decline she may be in to make sure she is safe? — K

A: Great question. As you may know, it’s fairly common for aging parents to develop problems like the ones you are describing. Understandably, these problems are frustrating and worrying for adult children.

You are absolutely right to be concerned about your mom’s safety. I do have some ideas for how you can get started assessing her, which I share below.

But first I want to explain the most common causes of this type of behavior in older adults. That’s because one of the things you must do is help your mother and the doctors figure out why she’s developed these behavior changes and other symptoms.

A fair number of people don’t get around to the medical evaluation because they assume that these crazy behaviors are either normal aging (definitely false) or dementia such as Alzheimer’s (true about 40% of the time).

Furthermore, it’s often hard to get a resistant older parent medically evaluated.

Still, it’s worth persisting in this, because many causes of paranoia or other odd behavior in older people can be treated.

Paranoid symptoms (e.g. believing that someone is out to get you, or is taking your stuff, or is in the house at night) falls into a category of mental symptoms that is technically called “psychosis.”

Symptoms of psychosis can include:

  • Delusions, which means believing things that aren’t true or real.
  • Hallucinations, which means seeing or hearing things that aren’t there.
  • Disorganized thoughts or speech, meaning saying or thinking things that seem illogical or bizarre to others.

Psychosis is uncommon in younger people but becomes much more common as people get older. That’s because any of these symptoms can emerge when people’s brains aren’t working properly for some reason.

A 2015 review article on “late-life psychosis” estimates that 23% of people will develop symptoms of psychosis in late life.

I like this review article because the authors organize the causes of late-life psychosis into six “Ds”:

  • Delirium (10 %).
    • This is a very common condition of “worse-than-usual” mental function, often brought on by the stress of severe illness, surgery, or hospitalization. See 10 Things to Know About Delirium for more.
  • Drugs, alcohol, and other toxins (11%)
    • Medication side-effects can cause delusions, hallucinations, or other forms of psychosis. Pay special attention to medications known to affect memory and thinking. Abuse of — or withdrawal from — alcohol or other substances can also cause psychosis symptoms.
  • Disease (10%)
    • Many physical health problems can interfere with brain function. These include electrolyte problems such as abnormal levels of sodium, potassium, calcium, or magnesium in the blood, low levels of vitamin B12 or folate, thyroid problems, severe liver or kidney dysfunction, infections, and neurological diseases. Brain damage from minor strokes can also cause psychosis symptoms.
    • Urinary tract infections can cause psychosis, but in my experience, they are almost never the cause of paranoia or other symptoms that have been going on for weeks, months, or longer. (A positive urine culture in an older person who has been having psychosis symptoms for a while probably reflects a colonized bladder.)
  • Depression (33%) and other “mood disorders,” including bipolar disease (5%)
    • About 15% of people with major depression may experience psychotic symptoms. Delusions of guilt or deserved punishment are especially common.
  • Dementia (40%), including Alzheimer’s disease, Lewy-Body dementia, and others
    • Delusions are extremely common in dementia, especially delusions of theft, spousal infidelity, abandonment, and persecution. Hallucinations (especially visual hallucinations) are also common, especially in Lewy-Body dementia. For more on how dementia is diagnosed, see How We Diagnose Dementia: The Practical Basics to Know.
  • Delusional disorder (2%) and schizophrenia-spectrum disorders (1%)
    • These two conditions have many symptoms that overlap with those of dementia, delirium, or other conditions affecting thinking. Doctors must exclude these more common conditions before diagnosing a person with schizophrenia or delusional disorder. Schizophrenia affects an estimated 0.1-0.5% of people over age 65. Many were diagnosed earlier in life but some people can develop the condition later in life. Delusional disorder affects an estimated 0.03% of older adults.

The authors of this review article also note that it’s common for older adults to have vision and hearing problems, both of which can trigger or worsen delusions and hallucinations.

So as you can see, when older adults experience delusions, hallucinations, and paranoid thoughts, there is almost always something more going on with their health. Figuring out what is beneath the “crazy” or “irrational” or “paranoid” behavior is key.

Hence I recommend you keep these six causes of paranoid symptoms in mind, as you try to find out more about how your mom has been doing.

How to check on “levels of decline” and safety

It’s great for you to be proactive and want to help check on your mother safety and situation. Ultimately you’ll need to work with professionals, but you can speed the process along by checking for common red flags, and bringing them to the attention of your mother’s doctor.

As a geriatrician, I generally try to assess an older person in the following five domains:

  • Ability to manage key life tasks
    • These include the ability to manage Activities of Daily Living (key tasks we usually learn as young children, such as walking, dressing, feeding ourselves, and toileting) and also Instrumental Activities of Daily Living (key tasks we learn as teenagers, such as managing finances, transportation, meal preparation, home maintenance, etc).
  • Safety red flags
    • This includes signs of financial vulnerability or exploitation, risky driving, leaving the stove on, wandering, or signs of elder abuse.
  • Physical health red flags
    • These include weight loss, declines in strength or physical abilities, falls, frequent ER visits, and complaints of pain.
  • Mood and brain health red flags
    • These include common signs of depression (especially sadness and/or loss of interest in activities), signs of loneliness or isolation, new or excessive worrying, as well as other signs of memory and thinking problems
  • Medication management red flags
    • These include signs of difficulty taking prescriptions as directed, checking on possible medication side-effects, and identifying medications that are on the Beer’s list of medications that older people should avoid or use with caution.

Because concerned family members often ask me about checking on an older parent, I created a guide with five checklists based on the five sections above.

You can print the guide and use the checklists to spot these red flags that often represent serious safety or health problems.

Now, no guide is going to enable you to diagnose your parent. And no guide can guarantee that you’ve identified and addresses the most important safety issues. You’ll need to work in person with professionals to do that.

But by being methodical in observing your mom and in documenting your observations, you will make it much easier for professionals to figure out why your mother has developed these behaviors you are concerned about.

Also, by identifying specific red flags or problem areas, you’ll be better equipped to work with your mom and other family members on addressing safety concerns. That’s because it’s much more effective to focus on issues that are specific and concrete (“I noticed that you seem to be having trouble with your grocery shopping”), rather than simply telling an aging parent that you are worried about their safety.

Tips on following up on safety issues and memory problems

Once you’ve identified safety issues and signs of underlying health problems, you’ll want to follow up. You’ll need health professionals to help evaluate and manage any underlying health problems, and you may find you need help from other types of experts as well.

If your older parent is paranoid and resisting your involvement, this often becomes a stuck spot for families.

How to get unstuck depends on the situation. Here are some ideas that often help:

  • Relay your concerns to your parent’s doctor. The doctor needs to know about the symptoms and problems. The doctor may also be able to persuade your older parent to accept some help, or even the presence of another family member during medical visits.
    • Patient privacy laws (e.g. HIPAA) do not prevent families from providing information to a person’s doctor over that person’s objections.
    • The doctor will probably not disclose health information to you but may do so under certain circumstances. That’s because when a patient is “incapacitated”, doctors are allowed to disclose relevant health information to family members, if they feel it’s in the best interest of the patient. For more on when health providers may disclose information to family members, see 10 Things to Know About HIPAA & Access to a Relative’s Health Information.
    • If you send your concerns in writing, they will probably be scanned into the medical record.
    • Also ask if any social work services are available through your parent’s health provider.
  • Contact organizations that support older adults and families, for assistance and for referrals. Some good ones to try include:
    • Your local Area Agency on Aging; find it using the locator here.
    • Family Caregiver Alliance. The navigator showing state-by-state services is especially nice.
    • Local non-profits serving seniors and families. Try using Google to find these.
  • Get help from a geriatric care manager (now known as aging life care professionals) or other “senior problems” expert. This usually requires paying out-of-pocket, but can enable more hands-on assistance than is usually available through social workers and non-profits.
    • The ideal person will be good at difficult conversations with older adults, will be able to help you communicate with doctors if necessary, and will know what local resources are available to address any safety or living issues you detect.
  • Get advice from other adult children who have faced similar situations. You can find caregiving forums and message boards online, where people share ideas on getting through these challenges.
    • There’s an active forum of people caring for older relatives at AgingCare.com.  You can find a lot of ideas and support there. However, most such forums have minimal moderation from professionals, so you should double-check on any medical, legal, or financial advice you get.
    • Daughterhood.org is a website and community for people helping older parents. Look to see if they have a local “Circle” near you.
  • Consider contacting Adult Protective Services if you think this might qualify as self-neglect. Self-neglect means an older person is living in a way that puts his or her health, safety, or well-being at risk. It’s not uncommon for older adults with memory or thinking problems to self-neglect.
    • This is considered a form of elder abuse and can be reported to Adult Protective Services (APS).
    • For a good overview of self-neglect and how APS can get involved, see here.
    • In most states, health providers and certain other professionals are “mandated reporters” for elder abuse and self-neglect, which means they are supposed to report any such suspected cases to APS.

When it comes to contacting the doctor and hiring an expert to help, it’s best if you can get your mom’s agreement before proceeding. (Or at least, not have her explicitly forbid you from doing these things). Here are some tips to help with your conversations:

  • Use “I” statements as much as possible. “I’ve noticed you’ve been calling people during the night. I’ve noticed you sometimes have difficulty with your words. I’m concerned and I’ve heard it’s important to have such symptoms evaluated by a doctor, because they can be due to treatable medical problems.”
  • Frame any suggestions you make as a way to help your mother achieve her goals. For most older adults, these include living at home for as long as possible, maintaining good brain function and physical function, and otherwise remaining as independent as possible.
  • Avoid relying on logic. Logic never works well when it comes to emotionally-charged subjects. And it especially doesn’t work if people are experiencing any difficulties with memory or thinking. So don’t expect your mom to be logical and don’t rely on logical arguments to convince her.

For more on approaching a parent who is resistant to help, I explain how to do this in my free online training for families:

Now, if you find it causes your mother intense anxiety or agitation to discuss your concerns and your suggestions for helping her, it may be reasonable to just proceed. After all, you do have reasons to believe that some kind of health issue is affecting her thinking.

So especially if you’ve identified any safety problems, it’s reasonable to move ahead despite her preference that you not intervene.

In closing, I’ll reiterate that this is a very tough situation to navigate, and it usually takes time and persistence for families to make headway. Do try to take care of yourself as you work through this. Connecting with others facing similar challenges is a great way to get support and practical ideas on what to do next.

Good luck!

This article was first published in 2016; it was reviewed & minor updates were made in August 2022.

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles, Managing relationships, Q&A Tagged With: memory, paranoia, resisting help

Q&A: How to Prevent, Detect, & Treat Dehydration in Aging Adults

by Leslie Kernisan, MD MPH 74 Comments

Q: How can we get my older mother to drink more water? She is susceptible to urinary tract infections and seems to be often dehydrated no matter what we do. We were also wondering if coffee and tea are okay, or should they be avoided to reduce dehydration?

A: Dehydration is indeed an important problem for older adults. It can be common even when it’s not hot outside.

Helping an older person increase her fluid intake, as you’re trying to do, is one of the best ways to reduce the risk of dehydration.

Now how to actually do this? Studies — and practical experience — suggest that the best approaches include: [Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles, Q&A Tagged With: dehydration, UTI

Q&A: What to do if your aging parent becomes rude & resistant

by Leslie Kernisan, MD MPH 105 Comments

Aging Parent with Adult ChildQ: My loving, Jewish mother is 92 and has turned into a rude, abusive foul-mouthed woman who I no longer recognize.

She’s in relatively good health and amazingly lives in the same house I grew up in. She has an aide during the day. She won’t leave the house,treats the aide poorly and last weekend cursed out my very patient spouse. We’ve been getting 5 calls a day such as ” I”m having a heart attack; no one will tell me whether recycling comes today”! 

I know she has early signs of dementia. Her cardiologist tells me not to take it to heart and this is not the same women who raised me.  She won’t go to the JCC adult programs, complains about being lonely at night, yet hangs up on me when I tell her we can get an aide at night or sell the home and let her live in a facility with women her age, etc. She threatens to call the Police if someone comes to her home at night. I have a POA but don’t want to rob her of her independence at 92. I try to tell her to speak nicely to the aides, myself, my spouse, but she says ” I don’t remember or I must have reacted to something someone did or said.”

I feel guilty as I’m not spending as much time with her as I would like, but it’s a matter of survival. Jewish guilt is thrown about with impunity and I can’t tell whether she’s being manipulative and obsessing over bullshit ( “oh my God the outside light may burn out tonight” ) or she really can’t control herself. Her aide  is a lovely human being but my mom orders her around like a slave.  Who is this woman? I’m torn, anguishing over what to do and am doing nothing but try to correct her inappropriate behavior and language. I wanted to take her to a geriatric psychiatrist but she refused to go. Medication to calm her down is dangerous per the MD as she could fall, etc. 

What should I do? I’m at my wits end. 

Dr. K’s answer:

Wow, difficult situation but unfortunately not uncommon.

You say your mother has early signs of dementia, and it is true that “personality changes” can be due to an underlying dementia, such as fronto-temporal dementia or Alzheimer’s, especially if a family notices other changes in memory or thinking abilities.

But it doesn’t sound like your mother’s been clinically evaluated for dementia, and you don’t say whether this has been brought up with her primary care doctor.

How to Get Memory & Thinking (or Personality Changes) Evaluated

[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles, Managing relationships, Q&A Tagged With: dementia, dementia diagnosis

Incompetence & Losing Capacity:
Answers to 8 FAQs

by Leslie Kernisan, MD MPH 122 Comments

Depositphotos_9669220_m-2015-brain-cogs-leaving-compressorHave 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:
[Read more…]

Filed Under: Aging health, Geriatrics For Caregivers Blog, Helping Older Parents Articles, Managing relationships, Q&A Tagged With: capacity, dementia, memory

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