Helping Older Parents Articles

Wondering whether you should worry? Having trouble getting parents to accept help? Overwhelmed by challenges and concerns?

This part of the site is especially for you! It includes our hand-picked articles, tips, & resources for people helping older parents.

Coronavirus Info: What to Expect Regarding Hospitalization (3.27.20)

by Leslie Kernisan, MD MPH

Like many of you, I’ve been following the recent coronavirus developments closely.

In March, I devoted my twice-monthly Helping Older Parents members calls to this topic.

Here is a video commentary I recorded on 3.27.20. Although the statistics about COVID numbers in the US quickly fell out of date, I am leaving this video available as the information on what to expect regarding hospitalization should be relevant for quite a while. This video covers:

What I’d recently learned about the clinical course of COVID
If you think you (or your older relative) might be sick with coronavirus
What to know about hospitalization for this, and how a “surge” situation might affect that
Options for care at home, including palliative care
My recommendations on planning ahead and then hoping for the best.

Also, in the video, I forgot to mention that one of my favorite clinical sources is currently making its coronavirus topic free to the public: Uptodate.com: Coronavirus disease 2019 (COVID-19).

The video is below, or get the audio-only through the podcast here.
(For those who have asked about transcripts: I wish I could but right now we are too short on funding; transcripts cost $1.25/minute to produce plus more time to format and finalize.)

Please stay as safe as you can, and take care!

Related resources:

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How to Make Hospitalization Better & Safer in Aging

by Leslie Kernisan, MD MPH

Dr. Stephanie Rogers UCSF Inpatient Geriatrics

As you may know, hospitalization is actually somewhat risky for older adults.

This is sometimes surprising to older adults and families. After all, hospitals are supposed to be places where people who are ill or injured can get the medical supervision and services that they need, to recover and be restored to health.

Well, it’s certainly true that hospitalization is often the only way for a person to obtain more substantial care from nurses and doctors. (There actually is an alternative called Hospital at Home, but it’s not widely available.)

If you’ve broken a hip, or have developed really significant shortness of breath from pneumonia, or otherwise are too unwell to be safely treated in the outpatient setting, hospitalization is often necessary. And since aging increases one’s vulnerability to a variety of health problems, older adults get hospitalized at higher rates than younger people do.

The problem, however, is that although hospitalization is intended to help patients, we’ve also realized that it tends to stress the body and mind in many ways. This is hard on every patient, but especially affects older adults. For instance:

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13 Recommended Resources for National Family Caregivers Month

by Leslie Kernisan, MD MPH

This month — November — is National Family Caregivers Month.

If you’ve been in any way assisting another adult with managing health concerns or life tasks, you qualify as one of the estimated 40 million family caregivers in the US.

Such help often starts out with small things, such as helping an older relative get to appointments or assisting with grocery shopping.

But it’s also fairly common for families to end up providing quite a lot of care. A 2015 report found that on average, family caregivers provided 24.4 hours of assistance per week, and 23% of caregivers were clocking 41 hours or more.

Many people find themselves eventually struggling with the caregiving. Most of us haven’t prepared or been trained to do this, and many people are unsure of where to get information, help, or support.

So in this article, I’ll share some of my favorite resources to make family caregiving a little easier.

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End of Life Planning Made Easy Through PREPARE

by Team BHWA

Living wills. Advance directives. Powers of attorney for healthcare. Making your wishes known.

Many older adults have never gotten around to addressing these issues, and of those who have, many are overdue for a review.

After all, this is not something where you should “set-it-and-forget-it.” Especially not if you completed the paperwork with a lawyer years ago, and have experienced changes in your health since then.

But if you wanted to get started addressing this, you may have run into a few common hitches. The forms are often in legalese and hard to understand. And people often are sure just how to go about “making their wishes known.”

Fortunately, geriatrician Rebecca Sudore, MD, noticed this problem early in her career, and decided to do something about it.

Over the past 15 years, she developed and tested California’s first easy-to-read advance directive, then designed PREPARE, an easy online video program created to help older adults address advance care planning.

In a recent podcast episode, she and Dr. Kernisan discussed PREPARE, advance care planning, and how to make it easier for older adults to address what matters most to them when it comes to end-of-life planning.

This article will share some highlights and key points from their conversation, including:

The easy-to-read advance directives (and where you can get one)
Why advance care planning needs to include more than completing forms
How the PREPARE program helps older adults talk about what matters most
How to use PREPARE resources to help yourself or your loved ones talk about what matters and complete your planning

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7 Steps to Managing Difficult Dementia Behaviors
(Safely & Without Medications)

by Paula Spencer Scott

(This article is by my colleague Paula Spencer Scott, author of the book Surviving Alzheimer’s: Practical Tips and Soul-Saving Wisdom for Caregivers. I invited her to share an article on this topic, since many in our community are coping with dementia behaviors. — L. Kernisan)

The odd behaviors of Alzheimer’s and other dementias can be so frustrating and stressful for families.

I’m talking about the kinds of behaviors that try patience, fray relationships, and drive us in desperate search of help:

“First she thinks the caregiver is stealing her sunglasses and now she accused me of having an affair.”

“When I tried to help Dad wash up, he hit me.”

“My husband follows me so closely I can’t stand it. But if I go in another room he’ll wander out of the house.”

“Mom started unbuttoning her shirt in the middle of the restaurant!”

“Just when I’m completely exhausted at the end of the day, he seems to get revved up. He keeps peeking out the windows, convinced that someone is trying to break in. Now he won’t sleep.”

A common approach to difficult behaviors is to go right to medicating them with tranquilizers, sedatives, or antipsychotics. But that’s risky and often not what’s best.

In fact, experts recommend trying behavior management first, and for good reasons: It tends to be more effective in the long run than “chemical restraints,” has no dangerous side effects, and leads to a better care relationship. But people often don’t know how to do this.

I’ve learned how.

I’ve lived through five close family members’ experiences with Alzheimer’s and other forms of dementia. Lots of trial and error, and insights from dozens of top dementia experts (whose brains I’ve been lucky to pick as a journalist and dementia educator), got me through regular scenes with…

My father-in-law, who needed a walker to move yet spent hour after hour for several days straight hauling all his clothes and toiletries from his room to our driveway, insisting that his (imaginary) new wife was about to pick him up
My dad, a formerly sharp dresser who wore the same shirt and pants every day no matter how dirty
My grandmother, who insisted on going “home,” when she was home
And other relatives, in dozens of similar scenes.

In this article, I want to share what I wish someone had explained to me early on: the “Why-This, Try-This” approach to dealing with difficult behaviors.

This is a mental framework that can help you get unstuck from unproductive responses that get you nowhere or make things worse.

It can bring calm -– to both of you — whether the issue is verbal or physical aggression, agitation, confusion, wandering, disinhibition, delusions, hallucinations, or a restless or repetitive behavior (like pacing, shadowing, rummaging). It also works well with milder irritants like repetitive questions and indecision.

Then, I’ll boil down the Why-This, Try-This concept to a 7-step process you can use every time. These “7 R”s give you a basic platform for responding to any frustrating behavior:

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Why the Flu is Often Missed in Older Adults
(& What to Do About This)

by Leslie Kernisan, MD MPH

elderly flu symptoms You’ve likely already heard the news: the flu is pretty bad this year, with the Centers for Disease Control (CDC) confirming a higher than usual level of illnesses, hospitalizations, and even deaths.

You also probably know that older adults (and certain other groups of people) have a higher risk of falling very ill from the flu, and have the highest death rates from flu.

But what many people don’t know is this: influenza is easily — and often — missed in older adults.

What do I mean by missed? I mean:

Older adults (or their family members) may not realize an older person has the flu, because many older people don’t develop “typical” influenza symptoms.
Health professionals often fail to test older people for influenza, even when they are sick enough to be hospitalized. This phenomenon was confirmed in a recently published study.

This is a very serious issue, especially when the flu virus is causing a lot of severe illness, as it is now.

The main problem is this: delayed — or entirely missed — recognition of influenza means that older adults often don’t get treated early — or at all — with anti-influenza drugs such as oseltamivir (brand name Tamiflu).

Particularly for those older adults who have chronic illnesses (especially those affecting the heart or lungs) or are frail, you don’t want to miss that chance to take anti-influenza drugs. They can’t guarantee an older person will avoid a hospitalization or death from influenza, but they do improve one’s chances.

And anti-influenza drugs are most likely to work when they are given within 48 hours of a person falling ill from influenza, with earlier being better.

So when flu activity is widespread, families need to be prepared to recognize potential flu.

And, you should be prepared for the possibility that the health providers might not think to test for influenza, unless you ask about it.

This article will help you learn to do these things. Here’s what I’ll cover:

What are the usual symptoms of “influenza-like illness”
Common symptoms of influenza in older adults
Why older adults may not show typical influenza symptoms
What we know about older adults & influenza testing
What the CDC currently recommends, regarding influenza diagnosis and treatment
What to do, if an older person falls ill during influenza season

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New High Blood Pressure Guidelines Again:
What the Cardiology Hypertension Guidelines Mean for Older Adults

by Leslie Kernisan, MD MPH

And once again, high blood pressure is making headlines in the news: the American Heart Association and the American College of Cardiology (AHA/ACC) have just released new guidelines about hypertension.

Since this development is likely to cause confusion and concern for many, I’m writing this post to help you understand the debate and what this might mean for you and your family.

By the way, if you’ve read any of my other blood pressure articles on this site, let me reassure you: I am not changing my clinical practice or what I recommend to others, based on the new AHA/ACC guidelines.

The core principles of better blood pressure management for older adults remain the same:

Take care in how you and your doctors measure blood pressure (more on that here),
Start by aiming to get blood pressure less than 150/90 mm Hg, as recommended by these expert guidelines issued in 2017 and in 2014,
And then learn more about what are the likely benefits versus risks of aiming for more intensive BP control.

Perhaps the most important thing to understand is this: treatment of high blood pressure in older adults offers “diminishing returns” as we treat BP to get lower and lower.

Scientific evidence indicates that the greatest health benefit, when it comes to reducing the risk of strokes and heart attacks, is in getting systolic blood pressure from high (i.e. 160-180) down to moderate (140-150).

From there, the famous SPRINT study, published in 2015, did show a further reduction in cardiovascular risk, when participants were treated to a lower systolic BP, such as a target of 120.

However, this was in a carefully selected group of participants, it required taking three blood pressure medications on average, and the reduction in risk was small. As I note in my article explaining SPRINT Senior, in participants aged 75 or older, pushing to that lower goal was associated with an estimated 1-in-27 chance of avoiding a cardiovascular event. (The benefit was even smaller in adults aged 50-75.)

SPRINT did not include people who have certain common conditions, including diabetes, heart failure, past stroke, or dementia. Hence it’s not clear that the (small) benefits of intensive blood pressure control would apply to those older adults who would not have qualified for the SPRINT trial.

I will come back to the SPRINT study later in the article, since it undoubtedly influenced the recent AHA/ACC guidelines. But first, a little on why the new guidelines are notable.

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How Exercise Helps Aging Adults:
Key benefits (and disappointments) from a landmark study

by Leslie Kernisan, MD MPH

Have you ever wondered whether it’s worth your while to encourage an older person to start exercising?

In 2014, the top-notch journal JAMA published the results of a fantastic research project: a study in which 1635 sedentary older adults (aged 70-89) were assigned to get either a structured exercise program, or a program of “successful aging” health education. The researchers called it the Lifestyle Interventions and Independence for Elders (LIFE) study. (You can read the full study here.)

During the LIFE study, the two groups were followed for a little over 2.5 years. And by the end of the study, guess which group of volunteers was more likely to still walk a quarter of a mile (without a walker)?

That’s right. When it came to avoiding “major mobility disability” — which the researchers defined as becoming unable to walk 400 meters or more — a structured exercise program was better than a program of healthy aging education.

Specifically, the researchers found that 30% of the exercisers experienced a period of major disability, compared to 35.5% of the seniors enrolled in the healthy aging education program.

This is a very encouraging finding! That said, it’s also a bit sobering to realize that even with exercise, almost 1 in 3 older adults experienced a period of limited mobility, of which half lasted 6 months or more.

In this post, I’ll share some more details on this study, because the results provide a wonderful wealth of information that can be helpful to older adults, family caregivers, and even geriatricians such as myself.

Want to know how often the exercisers experienced “adverse events”? (Hint: often!) Wondering just what the structured exercise program involved? (Hint: more than walking!)

Let’s dig into the details! At the end of this post, I’ll share my list of key take-home points for older adults and family caregivers.

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Q&A: Hospice in Dementia, Medications, & What to Do If You’re Concerned

by Leslie Kernisan, MD MPH

Q: Dear Dr. K,

With all the news about opioids and benzodiazepines, and their risk of death, I would love to hear your take on the use of these drugs in hospice.

We’ve had two family experiences now (my Mom and my Aunt) who were given these drugs right away when they went on hospice…without hospice trying anything else first that would be less dangerous. My Mom was up and about walking one day at her memory care facility, even laughing. The next day, when hospice put her on morphine and Ativan, she was in a coma. She died 13 days later without ever regaining consciousness. When I protested and asked why she wasn’t waking up, the hospice nurse said, “It’s not the drugs, it’s the disease.” (Mom had dementia.) The nurses wouldn’t let us give her fluids (“you don’t want your mother to aspirate, do you?”) or feed her (“you don’t want your mother to choke, do you?”).

With my Aunt, she had also been in the memory care facility and got to the point of needing a two-person assist. Her power of attorney (POA) was given the choice of moving my Aunt into a nursing home or bringing in hospice. Hospice immediately gave her morphine and Ativan, then backed off the Ativan and gave her morphine every two hours until she died 3 days later.

Now the third sister, also with dementia, has been in hospice for two months and counting. She is lucid most days, eating/drinking, comfortable—all without the opioid/benzo drug combo, because of our experience.

How can family members identify a hospice that doesn’t use this troubling combination of drugs from the start, without first trying something less dangerous, to make a patient “comfortable”?

A: Thanks for sending in this question. I’m very sorry to hear that your experiences with hospice have left you concerned.

It is indeed extremely common for hospice to use morphine and lorazepam (brand name Ativan) to treat end-of-life symptoms. That’s because many people on hospice are suffering from troubling symptoms that these medications can relieve, such as pain, shortness of breath, anxiety, and agitation.

Still, these medications are not always necessary. They are supposed to be prescribed and used as required to relieve the dying person’s symptoms, not by default. So the situation you describe with your mother and your aunt does sound potentially concerning. At a bare minimum, the hospice personnel should have done a better job of discussing their proposed care plan with your family.

Now let me be clear: I cannot say if the way they prescribed morphine and lorazepam was inappropriate or not, because it’s impossible for me to know the specifics of your mother and aunt’s medical situation.

Still, we can certainly review some basics about hospice care for people with Alzheimer’s and related dementias, as well as recommended best practices, when it comes to using opioids and benzodiazepine sedatives.

Here’s what I’ll cover:

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Our Podcasts & How to Listen

by Leslie Kernisan, MD MPH

I’m very happy to announce that the new Helping Older Parents Podcast is now live and available for you to listen, alongside the existing Better Health While Aging Podcast!

You can find all the new Helping Older Parents Podcast episodes here, and over 100 existing Better Health While Aging Podcast episodes here.

Leslie Kernisan Podcast Cover With Subtitle 320px

And now, let me answer some of the questions people have already asked me about the shows and about listening to podcasts.

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