Joan Lunden sharing family photos with her mother.

According to the Family Caregiver Alliance, 43.5 million Americans are caring for an older adult.  Given that people are living longer than ever, most of these caregivers are baby boomers.  An average of 10,000 baby boomers are turning 65 every day.  This is the first generation of that might spend as much time caring for aging parents as they did for their children.  Read more in this excellent article from CNN Living: Caregiving the “New Normal”

• Hire good aides. Proper credentials, competence, experience, references and background checks are important. But just as importantly we seek aides who exhibit a friendly, willing attitude and understand the need for punctuality, initiative and a constant focus on client needs. To attract and retain good aides we treat them with respect and kindness and we try hard to meet their needs too. As a result we are rewarded with a steady stream of applicants from which to choose.
• Set high expectations for our office personnel. Our office employees know that we want every single caller to be treated with impeccable courtesy and responsiveness. They are expected to be productive and efficient. We also ask that they accept responsibility for challenging standards of performance.
• Make sure that owners take ownership. All callers know that they can reach the Bensons at any time for any reason. The owners are the public face of Ready Hands Home Care. We don’t employ marketing personnel or “community liaisons.” We don’t use an answering service or a delegated on-call staff.
• Assign each client his or her own primary aide. We want the same aide to work daily except for occasional relief. (Or, for round-the-clock care, the same two aides). We want a mutual bond of trust and good feeling to form between each client and his or her assigned aide. Many agencies will routinely assign aides to multiple clients each week. Ready Hands never does this.
• Strive to deliver on every promise. (And don’t promise what we can’t deliver well.) We know that generating happy clients through consistent high quality service is our best form of advertising—but that also requires knowing our limits. Prospective clients often present with unusual scheduling needs or other factors that we know will jeopardize our ability to the job well. In such cases, which arise virtually every week, we courteously decline and instead direct them to other home care providers in our area.
• Don’t cut corners with staffing and scheduling. Getting the right aide to each client every day is practically an art form. The aides’ abilities must be matched to clients’ needs. Commuting time, the presence of pets in the home, aides’ income needs and even personality considerations all must be taken into account. Those doing short-term relief assignments must be given careful advance preparation, often “orienting” to a client under the direction of the primary aide. We spend a lot of time trying to get staffing and scheduling right.

Jo-Ellen Benson accepting award from Ms. Seefeldt

Ready Hands Home Care is proud to announce that Jo-Ellen Benson, co-owner and Administrator of the company’s Manassas office, was recently presented with the Kathleen K. Seefeldt Community Service Award by the Dale City Civic Association.  The award is presented annually to a resident of the Dale City/Prince William County area who has made an outstanding contribution to the wellbeing of the community through participation in volunteer and charitable activities.

Ms. Seefeldt, in honor of whom the award is named, is a longstanding Prince William County resident and champion of community causes. She was elected to county Board of Supervisors in 1976 representing the Occoquan District, and from1992 to 2000 she served as its Chairman.

Benson has a many-year history of devoting her time and resources to causes that benefit the citizens of Prince William County.  She currently serves on the Board of Directors of Project Mend-A-House, a volunteer organization that assists senior, disabled and low-income residents to remain safely independent in their homes.  The organization’s volunteers perform home repairs, build accessibility modifications and provide adaptive aids to its clients.  Benson also serves as Capital Campaign Chair of the Arc of Greater Prince William and sits on the board of the Prince William County/Manassas Convention and Visitors Bureau.

Over the years, Ms. Benson has lent her time and resources to numerous other local organizations including (among others) the New Dominion Choraliers, the local chapter of the Boys and Girls Club of America, the Boy Scouts organization, ACTS and the Woodbridge Rotary Club.

As Administrator of Ready Hands’ Manassas location, Ms. Benson oversees the company’s provision of home-based care for community-dwelling seniors with functional limitations.  Ready Hands is a Virginia-licensed home care organization employing Certified Nurse Aides who provide personal care, household help and companionship for scores of area clients. The company is also financial supporter of various causes aimed at improving the quality of life for area residents.

Now often referred to as an “aging in place community”, the Beacon Hill Village model has spread to over 60 similar community organizations nationwide, with many more under development.  Although their offerings and resources vary, Villages share certain common features: they are grassroots organizations driven by neighborhood seniors who are determined to stay in their homes; they are primarily supported by and governed by resident members, who usually pay a regular membership fee; their central function is the coordination of access to affordable services, which can include anything from transportation to home repairs to social events to in-home personal care; they offer pre-screened providers who often discount their services to members; they depend heavily on neighborhood volunteers.

In Virginia, Maryland and Washington, D.C. there are now 12-14 open Villages and another 17 or so in the planning stages.  Mount Vernon at Home is one example.  It opened its doors in 2009 and now has about 180 dues-paying members.  According to its Executive Director, Barbara Sullivan, the organization now boasts 80 volunteers and has 250 preferred providers on its list.

Sullivan points out that starting and sustaining a Village requires hard work and careful strategic planning.  Since each community is different, planners must think early on about the specific needs of area seniors.  “Transportation was one of the biggest needs for our seniors.  If they don’t drive, they still must be able to do shopping and get to appointments,” said Sullivan.  Social connectivity and minor household repairs were other areas where the organization found it could provide value.  Mount Vernon at Home volunteers do myriad seemingly simple tasks that can be problematic for the elderly–everything from troubleshooting a computer to replacing a ceiling bulb.  “You’d be surprised at the requests we get from our members,” said Sullivan.

An ongoing concern for Villages is sustainable financing.  According to Sullivan, Mount Vernon at Home gets about 60% of its funding from membership dues.  The rest has to come from elsewhere, including charitable donations and federal, state and local grant monies.  Governments and private entities concerned with aging in place are taking notice.  The D.C. Office of Aging, for example, gave $15,000 to help launch the DuPont Circle Village in 2009.  The Village earlier received a $3,000 grant from the DuPont Circle Citizens Association.

Besides funding concerns, there are other challenges.  It is unclear how successful the Village model can be in low-income communities or sparsely populated rural areas.  In addition, neighborhood residents are not always receptive to the idea of paying hundreds of dollars in yearly dues.  Nevertheless, Mount Vernon at Home’s Sullivan is confident that neighborhood Villages are here to stay and will play an essential role in allowing seniors to remain safely in their home communities.

For Immediate Release: Wednesday, September 15, 2010

CONTACT: DC Press Office, 202-224-4159

WASHINGTON, D.C. – The White House has endorsed legislation by Senator John Kerry (D-Mass.) and Representative Jim McDermott (D-Wash.) to protect workers from losing benefits and protections as the result of a tax loophole.

The Fair Playing Field Act of 2010, which Kerry and McDermott introduced today, will close a tax loophole currently allowing businesses to misclassify workers as “independent contractors,” thereby creating an unfair environment for businesses that play by the rules and an unfair environment for workers. The bill is cosponsored in the Senate by Senators Kirsten Gillibrand (D-N.Y.), Patty Murray (D-Wash.), Sherrod Brown (D-Ohio), Al Franken (D-Minn.), Daniel Akaka (D-Hawaii), Chuck Schumer (D-N.Y.), and Patrick Leahy (D-Vt.)

“When employees are classified as independent contractors, whether by design or because the rules are unclear, they are denied access to critical benefits and protections, at significant cost to government at all levels,” said Vice President Joe Biden. “For these reasons, stopping worker misclassification is a priority for the President’s Middle Class Task Force, which I chair, and I applaud Senator Kerry and Congressman McDermott for introducing this bill. The legislation is timely, as misclassification is an increasing problem, one that puts employers who properly classify their workers at a disadvantage in the marketplace and costs the government billions of dollars in unpaid taxes. I urge the Congress to stand up for workers and create a level playing field for law-abiding businesses by supporting this bill.”

“This reform is pro-worker and pro-business,” said Sen. Kerry. “Today a tax loophole is being abused to deny workers basic protections and benefits. We shouldn’t reward those who game the system while hard-working Americans are denied their due protections and businesses that play fair are disadvantaged.”

“For too long, the misclassification of employees has put an unnecessary financial strain on American businesses and workers,” said Rep. McDermott. “Having a distinction between independent contractors and full-time employees is a good thing, but the current law is leading to significant abuse. Companies that misclassify workers have an unfair advantage over companies who play by the rules. Misclassification also leaves hard-working American families vulnerable to an uncertain economic future. This new bill makes important changes to the original by making sure there is a smooth transition to a clear obeying of the rules and it gives the IRS the tools it needs to even-handedly enforce those rules.%

via John Kerry – United States Senator for Massachusetts: Press Room.

It’s a troubling paradox. As medication breakthroughs offer new hope for treating disease, medication errors are harming more and more Americans. On the plus side, the treatment of virtually every major illness has been revolutionized in recent years by the advent of better agents. Take diabetes. Not so long ago the only drug treatment options were insulin and a handful of fairly primitive oral agents. Today physicians can choose from at least five different classes of pills and ten insulin formulations. At the same time, scientific studies clearly demonstrate that aggressive treatment greatly reduces diabetic complications. Thus diabetes today is often treated with combinations of two or more complementary drugs.

The same is true of many chronic disorders common in our society, especially among older adults. Hypertension (high blood pressure), coronary artery disease, arthritis, cancer, hyperlipidemia, depression and many other disorders are now routinely treated more vigorously and with more drugs than ever before. According to the Henry J. Kaiser Family Foundation, there were over 3.6 billion retail prescriptions written in 2009 in the U.S.  Seniors, who represent 13% of the population, account for 31% of these prescriptions. According to Georgetown University’s Center on an Aging Society, individuals between 65 and 79 years of age receive an average of 20 prescriptions each year.

But there’s a downside to all this: along with the proliferation of drug treatments there has also been an upsurge in so-called medication errors. One reflection of the problem is the high frequency of discrepancies between what patients are actually taking and what their doctors’ records indicate. An often-cited report published in the Archives of Internal Medicine in 2000 revealed such discrepancies in fully 76% of the patients studied. One big reason is poor communication between patients and health professionals.  Another is the woefully inadequate record-keeping in our fragmented health system.

Improper use of medications can cause harm as the result of dangerous side effects, drug interactions or inadequate treatment. Medication errors can be thought of as falling into three categories: overuse, underuse and misuse. Taking medications inappropriately (misuse) or excessively (overuse) can of course lead to preventable side effects. But underuse may be just as serious, because patients thereby lose the benefits that state-of-the art treatment can offer.

Medication errors take a staggering toll in terms of complications, preventable hospitalizations, inadequate treatment and even death. A 2006 report from the Institute of Medicine indicated that at least 1.5 million Americans are harmed every year due to medication errors, costing billions of dollars annually. 

  Medication errors can be prevented.  Here are a few suggestions:

1. Be an active participant in all treatment decisions. Make sure you understand why a given drug is being prescribed, how to take it safely, and what side effects are possible.
2. Keep careful track of any allergies or previous adverse effects from drugs.
3. Bring all medication bottles, prescription and non-prescription, to every visit with a health professional–even if you are not asked. Have someone go over your medications and check for any discrepancies with the medical record.
4. If you didn’t follow instructions for whatever reason, say so. Don’t leave your physician with the impression that you’re taking a medication if you’re not.
5. Don’t “self-prescribe” over-the-counter drugs for chronic conditions. The drugs approved for over-the-counter use in recent years are more powerful than ever. Besides causing potential serious side effects independently, they may interact adversely with prescriptions you are taking.
6. Use a pill dispenser if you have problems remembering to take your medications at the right time. There are many excellent designs available.
7. Ask your physician if a consultation with a pharmacist is covered by your health plan. Pharmacists have been playing a larger role in the health care team in recent years.
8. If a doctor advises you to change a medication that another doctor prescribed, satisfy yourself that they have communicated with one another about the change.
9. Keep an accurate and current list of all your medications readily available at all times. Include any medication allergies or intolerances. In an emergency, this simple practice can be life-saving.

The reason this issue can become such a point of contention across generations has to do in part with a difference in perspectives.  A son or daughter may notice a parent  exhibiting gait unsteadiness, missing medications or showing impaired ability to perform self-care or household tasks.  This naturally leads to concerns about safety and well-being.  Arranging for help in the home is an obvious solution that can allow a parent to live comfortably and safely.     

The parent’s perspective, of course, may be quite different.  His or her focus may be on privacy and independence.  To accept the need for an aide or companion may seem like surrendering one’s dignity and control.  Cost may also be a concern. Reconciling these different perspectives can be difficult if not impossible.  Here are some suggestions from our experience that may be of help to the children of elderly parents: 

Try to Avoid No-Win Arguments
We see lots of families locking horns over whether the parents are really slipping or not.  A typical discussion goes this way:         

“Mom, I’ve been noticing you haven’t been eating as well lately, and when I look in your refrigerator it seems like you have barely touched food that I bought for you days earlier.”

“I’m eating perfectly well, dear.  You know I’m not as active as I used to be, and I don’t need as much.  I’m certainly not going hungry.”

“But wouldn’t it be easier if we had someone come in and cook for you?”

“No, I don’t want that and I don’t need that.  I cook for myself just fine.”    

“Another thing, we’ve noticed that you aren’t as steady on your feet as you used to be.  We’re worried that you could fall.”

 ”I’m very careful. Don’t worry about me.”

“But you fell last month getting out of the tub.  It was lucky you didn’t hurt yourself.”

 ”That was just a fluke accident because the vanity light wasn’t working.  I’m really fine. I don’t need any help.”

 “John and I think you do, Mom.”

  ”Well, I don’t.”

These kinds of arguments usually don’t accomplish much.  They can lead to anger and can just harden resistance.  

Emphasize Your Needs, Not Theirs
A parent may be a little more accepting of help if you emphasize that it’s for your benefit.  Point out that you would feel more comfortable knowing someone was helping with the meals, laundry and household chores.  Pose it as a favor for you.  Explain that it would give you peace of mind as you attend to your own personal or job priorities.

Accept that Safety Doesn’t Trump Everything Else
One important lesson we’ve learned over the years is that compromise is almost always necessary on the issue of safety.  An elderly person with functional impairment and/or chronic illness is at increased risk of mishaps, injuries and adverse events.  To make safety the overriding issue seems like the compassionate, ethical thing to do.  But if it comes at the expense of dignity and quality of life, it may not be. 

Better to accommodate a parent’s values and preferences while practicing the art of the possible.  If your parent refuses your entreaties to get live-in care or move to assisted living, set up more limited home care visits and arrange for an emergency alert system.  If imbalance is a problem, make sure a medical evaluation is done, then learn about the many ways a home can be modified to protect against falls (e.g., installing grab bars and rails; using no-slip mats; assuring good lighting; removing trip hazards and clutter.)  If medication errors are a concern, make sure that a physician reviews all prescriptions to keep the regimens as simple as possible, then at least buy a medication dispenser (there are even a variety of electronic dispensers that will automatically dial a programmed telephone number if doses are skipped.) 

Don’t ignore the many possible ways in which technology can allow adult children to monitor the safety of aging parents.  Remote monitoring of vital signs like blood pressure, tracking movement throughout the home with motion detectors or cameras, confirming compliance with medications—all of these and more are possible nowadays. 

A great deal can be done to improve safety for an elderly person living alone.  But at the end of the day, no combination of strategies will eliminate all risk.  The challenge is to maximize safety while not ignoring important values like self-esteem, dignity and reasonable independence.

 Focus on Help with Household Tasks 
One way to persuade an elderly loved one to accept help is to present it as assistance with household chores, laundry and meals rather than personal care.  Many people of all ages use housekeepers, and this doesn’t entail the perceived stigma that a personal care aide may represent.  Once the “foot is in the door,” the elder can develop a relationship with the caregiver and then become less resistant to personal care. 

Enlist the Help of a Trusted Professional                          
Whereas an elderly individual may resist the pleas of concerned family members, the advice of a trusted personal physician, lawyer or clergyman may be more persuasive.  Meeting with such an individual is almost always a good idea.  But be careful about appearing as if you have enlisted the professional to press your point of view.  If the elder feels he or she is being “ganged up on,” this approach may backfire. 

Don’t Ignore Signs of Dementia 
Behaviors such as repeating the same story over and over, forgetting appointments, becoming lost in previously familiar surroundings or losing the ability to perform tasks that were once routine, are signs of dementia.  Too many people ascribe such behaviors to normal aging.           

When a parent has dementia, persuading him or her to accept help becomes much more complicated, because judgment may be seriously impaired.  How assertive should you be?  What are your filial and ethical obligations?  At what point do you insist upon taking control, and at what cost to your relationship?    

The first critical priority is to arrange a medical evaluation to assess the cause and extent of dementia and to initiate treatment, if possible.  Find out from the physician how much cognitive impairment exists, and what kinds of decision-making responsibilities you should be taking over for your parent.  Educate yourself about the problem by contacting the Alzheimer’s Association or the NIH’s Alzheimer’s Disease Education and Referral Center.

Age as a Predictor of Accident Risk
Among drivers overall, 16 to 19-year-olds have the highest accident risk, at 28.6 motor vehicle accidents per million vehicle miles traveled (MVA/MVMT).  For 40 to 45 year-olds, the rate drops to 3.7 MVA/MVMT, less than one seventh that of teens.  For the 80 to 85 age group, the figure is 15.1; for those over 85, it is 38.8.  But older drivers also log far fewer miles on average than younger drivers—just 2615 miles per year for those 80 to 84, as compared with 13,000 for the 40 to 44 year-old group.  

Statistics like these have led most experts to conclude that age alone is not reason enough to impose restrictions on someone’s driving, since accident rates among the elderly are less than rates tolerated by society among other age groups.  Mentally competent seniors typically limit their own driving to reduce their risk.  Common adaptations are to take shorter trips, use familiar routes, avoid night driving and rely more heavily on friends and relatives for transportation.

Alzheimer’s Disease Poses a Special Problem
Because Alzheimer’s diseases affects judgment, patients often do not recognize indications of increased driving risk and therefore may not voluntarily limit or discontinue their driving.  Overall, patients with Alzheimer’s disease continue to drive an average of 2.5 years after diagnosis.  When is it time to stop?

The American Academy of Neurology (AAN) published recommendations on this issue in 2000, based on an exhaustive review of scientific studies.  They found that for patients with mild Alzheimer’s (slight memory loss, impairment in problem solving and difficulty with time relationships), the accident rate was higher than age-matched controls but comparable to that of 16 to 19 year-olds.  For this group, the AAN recommended driving performance testing by a qualified examiner and re-evaluation every six months.  Patients with more advanced Alzheimer’s, according to the AAN, have a substantially higher risk of accidents and driving errors, such that cessation of driving should be strongly considered.

Clues to Impaired Driving
Statistics are fine, but for an individual driver with Alzheimer’s disease the practical question is, “Are their indications of impaired driving ability?”  Concerned family members need to create non-threatening opportunities to observe driving behavior, and make careful note of warning signs.   The Hartford Financial Services Group, Inc., the MIT Age Lab and Connecticut Community Care, Inc. have developed the following checklist:

• Incorrect signaling.
• Trouble navigating turns.
• Moving into a wrong lane.
• Confusion at exits.
• Parking inappropriately.
• Hitting curbs.
• Driving at inappropriate speeds.
• Delayed responses to unexpected situations.
• Not anticipating dangerous situations.
• Increased agitation or irritation when driving.
• Scrapes or dents on car, garage or mailbox.
• Getting lost in familiar places
• Near misses.
• Ticketed moving violations or warnings.
• Car accident.
• Confusing brake and gas pedals.
• Stopping in traffic for no apparent reason.

Approaching Driving Impairment in a Loved One with Alzheimer’s
If some of the warning signs on the foregoing checklist are present, family members and caregivers must address the problem driving.  Experience shows that no two cases are alike, and that there is no single best approach.  The following “road map” may help.  Employing several of these strategies together is usually most effective:

• Begin intervening early, when signs of impairment are not yet critical. 
• Try to make driving cessation a gradual transition.
• Understand the practical needs that driving meets for the patient, and provide alternatives to driving that meet these needs.
• Have others drive the patient to appointments, shopping, church or social functions.  Use taxi services or public transportation, if available, for patients with mild Alzheimer’s who are accustomed to such services.    
• Arrange for services to be provided in the home which would otherwise require driving.  Examples include home delivery of groceries and medications and the use of errand services.
• Enlist help.  No one family member should be forced to shoulder the entire load.  Consider involving a professional such as a geriatric care manager, social worker or elder law attorney.
• Talk to the patient’s physician, whose expertise can help guide the process and whose recommendations may carry greater weight with the patient.
• If necessary, take the keys or remove or disable the car.
• Don’t decide that you can safely control the risks by riding as a passenger when the patient drives. This may simply prolong a bad situation.

Reporting Impaired Drivers to State Motor Vehicle Departments
Most state laws call for investigating the driving performance of individuals reported to state motor vehicle departments as potentially unsafe drivers.  Virginia law, for example, states that if the Department of Motor Vehicles (DMV) has good reason to believe that a driver is unfit to operate a motor vehicle safely, it may require that the driver submit to an examination of his or her driving competency.  As part of its examination, the DMV may require a physician’s written assessment.  Upon written request, the DMV must provide its reasons for the examination.  However, the law stipulates that the DMV shall not reveal its reasons if its source is a relative or friend, or a treating physician.  After its examination, the DMV may take whatever action it deems necessary, including revocation of the driver’s license. 

What this means is that reporting to the DMV is an important option if a patient with Alzheimer’s will not otherwise accept appropriate restrictions.  There are pitfalls, however. Cognitive function in Alzheimer’s patients may fluctuate, so that an examination on a good day may miss risky driving behaviors, yet lead a patient to feel justified in continuing to drive.  In addition, despite the protection of anonymity, suspicion and resentment can result.  By addressing the problem early and using less drastic approaches, driving can be safely stopped without causing ill feelings.