Saturday, January 22, 2011

Is it time for a nursing home?

This has to be one of the most common questions I get from new patients in the office and something I discuss with every patient and family in the hospital. (the other being, do I have a memory problem).

While every case needs to be individualized, there's a fairly straight forward way of looking at a person's ability to function and the available options for living situations.

There are two broad things to look at: function and safety. The two overlap somewhat.

Looking at a person's function, I usually split it up into IADL's and ADL's. IADL's are instrumental activities of daily living and ADL's are activities of daily living. IADL's include: shopping, financial management, medical management, cooking, house keeping, laundry, driving/transportation, telephone use. ADL's include: bathing, dressing, feeding, grooming, ambulation, continence. For example someone does not need to be continent, but they need to be able to manage their own bowel/bladder habits to be considered independent. Someone does not need to be able to drive, but they need to be able to take a taxi by themselves.

Generally speaking, someone who has deficits in their IADL's will likely need some support from family members or hired help. This type of need is unskilled need (in a nursing sense). You can hire someone to meet these needs fairly easily: hire a house keeper, meals on wheels, laundry service, etc. Normally people with this type of need can stay at home and the necessary help can be hired. Family members can check in by phone or visit weekly. Another option is assisted living facilities (ALF). Currently this is the role that ALF's have. ALF's tend to be self pay and cost about $100-200/month.

Where things get more difficult for the patient is when there are deficits in ADL's. Some ADL's are more of a problem than others. Incontinence and being able to walk are very difficult. Not being able to walk usually means stairs are big barrier, so is bathing, and toileting. A person likely needs 24/7 help at this point. Incontinence, I find, is very tiring for the caregiver. At this point, care is skilled. A person needs to be careful how they help someone from a bed to a wheelchair so the person is not dropped or injured. Skin care requires some training for someone who is incontinent. At this stage, I always worry when there is one caregiver at home trying to handle things. Burnout is something I see almost every day. Fortunately there are a lot of options nowadays. First is intensive home services: hiring a home health aide 7-8 hours per day 7 days a week; LIFE/PACE program and nursing home. (PACE=Program for all inclusive care for the elderly). I have seen families handle this stage on their own successfully but the family has to be pretty committed and even then it is not without cost.

Hiring home aides for most people is prohibitively expensive and difficult. If someone is near poverty level, then Medicaid or the local Area Agency on Aging can sometimes pay for services. Sometimes family members get paid for services through waiver programs. The LIFE/PACE program is like an adult day care program on steroids. It involves signing over a person's medicare insurance to the specific LIFE/PACE program. It is open 5 days a week typically. Staff come to the house, help a person get ready, transport the person to the program. Once there, anything available in a Nursing home is available at LIFE/PACE including physicians, physical therapy, nutritionist, pharmacists, nursing, nurse aides etc. Finally the other option is nursing homes which can provide total care for long term needs.

In addition to function, the other big issues to deal with is safety/psychiatric issues. A person who wanders or has such severe psychiatric problems that even though they are capable of their ADL's and most of their IADL's, they're not safe to live alone. People who wander outside the house and get lost, or people who are physically/verbally aggressive/abusive to those around them almost always need placement.

One other way I think about it is also function based. If a person is safe (they have not gotten lost, no fires or water problems in their house) and their weight is stable, things may be okay or good enough. Not ideal, but not an emergency situation either.

In any case, I find starting with the ADL's/IADL's a good way to start looking at a situation and then customizing it from there.

2 comments:

Charlie Kimball said...

Before signing up for a nursing home, see what you can do to better accommodate the senior for living independently at home. Aging at home is clearly the preferred way to go for most seniors and families, for all the reasons we know (more comfortable, familiar, less expensive, and so on). However it is the responsibility of the senior and their family to make the environment safe for seniors and adapt to their new set of needs. The bathroom is a great place to start, and we provide these tips as a way to make simple, but effective modifications.

https://www.medicalcarealert.com/bathroom-safety-infographic-s/1853.htm Infographic provided by Medical Care Alert

Charlie Kimball said...

Before signing up for a nursing home, see what you can do to better accommodate the senior for living independently at home. Aging at home is clearly the preferred way to go for most seniors and families, for all the reasons we know (more comfortable, familiar, less expensive, and so on). However it is the responsibility of the senior and their family to make the environment safe for seniors and adapt to their new set of needs. The bathroom is a great place to start, and we provide these tips as a way to make simple, but effective modifications.

Bathroom Safety Tips Infographic provided by Medical Care Alert