When is it time to consider nursing home placement? (1. Signs) by Catherine D'Ambrosio, RN, PhD

Addressing questions regarding: When is it time to consider nursing home placement of your elder?

by Catherine D'Ambrosio, RN, PhD                dambrosi@uw.edu 

This blog specifically targets many of the questions and decisions family caregivers face when considering nursing home placement for their elder. 

Having (and taking) the time to plan and consider your options and preferences in advance is much easier, and far preferable to making nursing home placement decisions in emergent, often compromised situations. 

I’ve organized this blog in-line with questions most often asked by elders and their family caregivers who are considering relocation to a nursing care facility.  The three questions most commonly asked when families inquire about nursing home placement are:

      I.        What are some of the signs that it may be time to being exploring nursing home placement? 

    II.        How much do nursing homes cost and who pays for nursing home care?

A.   When? 

B.   For how long? 

C.   Under what circumstances?

D.   Does Medicare cover nursing home costs?

E.   How do I qualify for Medicaid?

F.    What about long-term care insurance?

   III.        We only have so much money, so how do we select the best nursing care facility?

 

This blog entry addresses the first question of:

      I.        What are some of the signs that it may be time to being exploring nursing home placement?

There are several situations when institutionalization (or nursing home placement) of an elder becomes increasingly non-negotiable.  These situations include, but are not limited to the following: 

A.   Often the elder is living alone –without a family caregiver.  There are conditions when the elder’s health and safety are jeopardized by their inability to care for themselves.  Some key indicators include (but of course are not limited to):

1.    You walk into the elder’s house and it smells like a latrine. 

2.    The refrigerator contains only moldy and rotting food.

3.    You see evidence of there having been a fire in the kitchen.

4.    You notice a pile of boxed meals that have been delivered (by Meals-on-Wheels for instance) over the past few weeks –that remain boxed-up, unopened and uneaten.

5.    You notice vermin, ant and roach infestation.

6.    You notice that your elder has not showered or groomed themselves in a long time and their body and breath are both odiferous.

7.    You notice the elder has been incontinent and is still wearing clothing caked in dried urine and feces.

8.    Your elder is unable to get out of bed, or out of their chair without assistance.

9.    You notice a marked change in your elder’s orientation (to time, place and person) or cognitive status.

10. If your elder is newly confused and disoriented, or more confused and disoriented than they usually are.

11. You notice your elder has lost weight.

12. You notice your elder exhibits signs of dehydration.

13. You notice your elder is either out of pills, or has not been taking their prescribed medications.

14. You notice other signs of self-neglect, including forgetting or refusing to eat or drink, or not having food or drink available in their house to consume.

An elder who is not eating or drinking should be taken to see their primary care provider, to an urgent care clinic, or to an emergency room where they can be evaluated and treated if necessary.

Each of these possibilities are not always in and of themselves sufficient to deem the elder incapable of staying in their house.  These indicators (and many more besides) are however indisputable signs that your elder will now need routine support –in order to remain in their own home.  Any change in their medical status should be evaluated by their primary health care provider.

Additionally, elders have human and civil rights that must be considered and respected.  If your elder is competent to make their own decisions, you will not be able to forcefully remove the elder from their home, no matter what you think.  You will have to consider the elder’s willingness to relocate to another family member's house, or an institution (Retirement Apartment, Assisted Living Facility, or Skilled Nursing Care Facility).

Often the elder is living with their spouse or other family members, or is routinely cared for by family members living in close proximity.  Under such circumstances, indictors that it may be time to consider changing the elder’s living arrangements (i.e., long-term or permanent nursing home placement) include: 

B.   The primary caregiver becomes ill, incapacitated, or dies and the surviving elder cannot safely care for him/herself and has no children (or family members) available, willing, or able to take care of them, and does not have sufficient financial resources to set-up, manage, and provide necessary private duty nursing care.

C.   The family caregiver is physically and emotionally exhausted and no longer has the will, the physical strength, or the emotional capacity necessary to continue providing the elder’s care. 

D.   The elder is endangering themselves, their family, and anyone else living in close proximity (i.e., the same apartment or condo building) by burning things in the kitchen.  When an elder is burning food and empty pots because they cannot cognitively manage cooking, it is imperative some changes be made immediately (such as disconnecting the gas or power to cooking appliances when the elder is alone or unsupervised). 

Sometimes cognitively impaired elders will put inappropriate things on the stove, in the oven, or even in the microwave.  I have consulted with families whose elders have put odd items including plastic house plants, bags of chips (bag included), unopened cans of soup, and bottles and cans of soda pop, and into the oven, the microwave, or simply placed the item on a burning stovetop.  None of them (fortunately) resulted in a house fire, but *did* result in some pretty spectacular messes and often substantial damage to the kitchen.

E.   The elder is wandering outside the home, getting lost, and sometimes endangering themselves and others.

F.    The elder is routinely incontinent and the family caregiver cannot cope with the intensive incontinence and toileting care needs of the elder.  Situations that increase the complexity of incontinence care for family caregivers include:

                      i.        an elder’s refusal to wear incontinence under garments (diapers).  This is often the case when the incontinence occurs sporadically between periods of continence maintenance. OR

                    ii.        inability to self-manage these incontinence undergarments (change and clean themselves after an incontinent episode). 

                   iii.        An elder becomes frustrated, angry and humiliated by their incontinence and begins lashing-out with violent or other abusive behavior towards others.

                   iv.        The house begins to smell terrible because of frequent incontinent episodes on carpeting and upholstered furniture.

 

G.   The elder is violent or abusive.  If and when the elder is violent, particularly when assaultive behavior is unprovoked or seemingly inexplicable, the primary family caregiver (who is often a frail elder themselves) is quite likely to be at great and immediate risk of being harmed.  It is important to seek-out both help and treatment for any assaultive or violent behavior. 

Many (but certainly not all) primary healthcare providers can assist you and your elder when confronting violent or assaultive behavior.  Finding an effective way to remedy the violent behavior can extend the time your elder may be able to remain in their current living situation.  There are medications that can calm or stabilize the mood, or ease the tremendous fear the elder maybe experiencing as their cognitive ability to process the world around them slips away from their grasp. 

Another person you may be able to turn to for assistance with a violent elder is a master’s prepared clinical nurse specialist, -providing you can access such persons in your community.  Sometimes an elder's confusion about what to do when experiencing the sensation of a full bladder or the urge to defecate can precipitate violent behavior.  A Gerontological clinical nurse specialist could most likely assist you with these types of problems and guide you and your elder regarding ways to both eliminate violent behavior and minimize the impact of incontinence on your lives. 

If you have been injured by an assault, you may have no choice but to seek care in an emergency room.  Sometimes it is appropriate to call 911 and obtain immediate emergency assistance from the police and EMTs –who will likely transport you to a local emergency room.  The police and EMTs will certainly address your immediate safety needs, but they are not likely to be of assistance with exploring your options and making plans that suit your needs and desires.

H.   The primary caregiver is abusing the elder, including situations when the family caregiver is:

1.    Assaulting or otherwise physically harming the elder.

2.    Physically restraining the elder. -for example tying the elder to their bed or to their chair. (Often the caregiver’s intentions are not malicious, but perceived as a pragmatic (albeit misguided) way to:

a.    keep the elder from wandering,

b.    prevent falling,

c.    keep the elder from inadvertently starting kitchen fires, and

d.    contain incontinence messes to a single location.) 

Unfortunately there are dreadful consequences to using restraints:

a.    Restraints are psychologically damaging.  It is demoralizing and humiliating to be tied-up or restrained. 

b.    Restraints impair mobility and increase an elder’s vulnerability to:

                                                                      i.        Losing their ability to get out of the chair and to walk

                                                                    ii.        Place the elder at great risk of incurring pressure ulcers (bed sores) because the elder cannot alter their position.

c.    Restraints place the elder in much greater danger of injuries from either falling or injuring themselves while trying to escape from or remove the restraints.

3.    Torturing the elder.  Torture is -in every case, the wrong thing to do.  Torture is a crime, but it happens.  It can be an insidious process.  When working with a cognitively impaired elder, what sometimes begins as a tit-for-tat, or frustrating attempts to control undesirable behavior can devolve into a form of torture –because you (as a cognitively intact caregiver) will nearly always have the upper hand with a cognitively impaired or physically frail elder. 

You (as the elder's caregiver) may feel (maybe you *are*?) controlled and oppressed by your elder’s needs.  Oppression is a tricky business that evokes dysfunction even from highly functional individuals.  People who are oppressed in-turn, tend to be the worst perpetrators of oppression.  Oppression easily twists and distorts reality and one’s perceptions of their options.

Torture is a bad thing.  If you are torturing your elder or you know or suspect your elder is being tortured or abused by another relative or caregiver, YOU MUST take immediate and proactive steps to protect the elder.  It is time to change the elder’s caregiving situation –without delay.  If you cannot do anything else, call the police and report what is happening or take your elder to an emergency room and tell the nurse or doctor what is happening.

a.    Starving the elder or depriving the elder of water.  This (deprivation of food and water) is sometimes done with the intention of stopping the incontinence.  I cannot argue with the effectiveness of such an approach (because the elder *will* stop peeing and pooping if you don’t allow them to get anything to eat or drink -they will also eventually die from this), but this is not a humane solution to the problem.  This is torture and a crime.  You MUST change this situation so your elder is living where they have regular (three times a day) access to meals, and constant access to water.

4.    Embezzling the elder’s money and using the money for purposes other than the care of the elder.

Embezzling money, particularly from a cognitively impaired elder is often prosecuted as elder abuse –in addition to theft.  Sometimes families in an effort to protect the family’s financial assets from being used to pay for the elder’s nursing care –will get their cognitively impaired elder to sign documents liquidating assets.  Medicaid officials are responsible to the US taxpayers to ensure the tax money designated to pay for the care of the poor and destitute does not get divested from a wealthy elder and spent on (for example):

·         financing the remodeling a daughter’s kitchen,

·         to put in a built-in swimming pool in the elder’s son’s back yard, or

·         a new tennis court for the elder’s nephew.

5.    Stealing the elder’s belongings. (either for their own personal accumulation or fencing the items –this includes selling-off the elder’s possessions not only at pawn shops, but also on on-line auction sites).