Caring for Elderly Parents What Matters Most

The Caring Generation® – Episode 137 May 11, 2022. Learn the 4Ms of caring for elderly parents what matters most. Caregiving expert, Pamela D Wilson relates the framework of an age-friendly health system to actions that family caregivers and aging adults can take today to manage health care decisions and make good choices about daily life.

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Family caregivers ask what is most important when caring for aging parents. What matters most can range from care in the home to medical, financial, and legal aspects.

In response to a request by a caregiver, I  recently created a video called the Top 5 Daily Responsibilities of Caregivers that offered a shortlist of tasks to consider. This week’s program about Caring for Elderly Parents What Matters Most takes this idea to the next level because it combines activities That the healthcare system is focusing on—that are also important for aging adults and their caregivers.

The 4M framework that I share [insert the link to the document] calls attention to managing healthcare decisions and making good choices about daily life. I first learned about this initiative that the John A Hartford Foundation supports in a research article in the Journal of the American Geriatrics Society by Sarah Leser and others. I’ll include a link to the article in this transcript if you want to learn more.

The 4M Framework of Age-Friendly Health Systems

Thinking of caring for elderly parents, what matters most, the 4M framework will be combined with my 20+ years of experience to add additional insights and practical information that you can use. There is also a term you’ll hear called “age-friendly living” that is another one of those medical-speak terms you listen to me refer to that the healthcare system uses that sound like a foreign language to consumers and patients.

Age-friendly translates to Involvement in the healthcare system—hospitals, doctors, nurses—plus vaccinations, preventative medicine, health screenings, home care, palliative care, hospice, and aspects of living in the community. To these, I add financial and legal considerations.

Money relates to financial planning and saving for retirement and healthcare expenses later in life. Then legal and estate planning—for example, appointing agents under a medical and financial power of attorney, creating a living will, a will, and a trust.

While the healthcare system recommends estate planning, they call it ACP or advance care planning, which relates to making health care decisions. Healthcare providers stop at the patient. This means little or no discussion of family caregiving issues that should be addressed in legal planning documents but often are not.

It is essential for patients and their family caregivers to categorize information not directly related to medical care by placing it in the proper context and realizing the value of consulting experts or advisors in these areas. Advisors and experts can be a massive help in all areas of life.

Seeking advice from multiple specialists can be beneficial when making important caregiving decisions, as it allows for a broader perspective. Keep in mind that there are many considerations when caring for aging parents that will affect other decisions you may have to make in the future.

Caring for Elderly Parents What Matters Most

Healthcare information—understood by providers—rarely translates to information that makes sense to consumers or patients who are not information seekers. This is why health systems struggle when attempting to implement age-friendly programs in primary care and other medical practices. Add to this the need for translation research confirming that older patients require a different level of care and attention.

This podcast, video, and transcript seek to bridge the knowledge gap to connect healthcare systems and providers with caregivers and care receivers. So let’s look at the 4Ms in the simplest terms.

1 What Matters Most

The first on the list of 4Ms for elderly parents, what matters most is discussing what matters most. This broad topic means that elderly parents and caregivers must become interested in and involved in health diagnosis.

Discussing health knowledge, expectations, goals, and the desired level of care advances the 4M framework one step forward. However, complications arise when adult children and spouses become attached to the outcomes of actions. An outcome is another health speak term that means results.

Overly Attached Caregivers Can Complicate Care

How do you know if you are overly attached to the results of caring for elderly parents? Here are a few signs.

• Do you disagree with loved ones about what you think they should do or about activities in their daily life?
• Are your elderly parents refusing care or your recommendations?
• Are you pressuring loved ones to do things against their wishes because these things are more important to you than to them?

Why Caring Conversations Fail

If you are attached to outcomes, you might notice this type of interaction:

• You might be too pushy, insensitive, or controlling, wanting everything your way.
• You might not be asking, listening, or considering what your elderly parent or a spouse wants.
• Or you may have good intentions and vital information to share. But you aren’t going about sharing or presenting the information in a way that makes sense to them.

As a result, aging parents or spouses may seem stubborn and difficult. They may not understand why they should pay attention to you.

Let them know that above all, you care and want the best for them. Maintaining positive caregiving relationships can be a challenge when caring for elderly parents and balancing what matters most.

Caring for Elderly Parents What Matters Most: Heart to Heart Conversations

In caring for elderly parents, what matters most is initiating conversations about topics that may be uncomfortable to discuss. What do you know about a parent’s or spouse’s current health conditions and how these will progress? If you don’t know, now is the time to investigate and learn.

Do you know what effort a loved one is willing to make to contribute to their own health? For example, if an elderly parent was diagnosed with cancer, would mom or dad want to go through chemotherapy or radiation?

Now, obviously, you would want to speak with medical providers about the possible results of chemotherapy or radiation. Will treatment stop cancer from progressing? What will a parent’s daily life look like? Will they feel sick or feel better?

I know some people who would say, ‘ Yes, I want to live,’ and others who would say, ‘ No. ‘ If it’s my time, then it’s my time. I don’t want extensive treatment.

Is Extensive Treatment a Care Goal?

What do you think? Do you or your loved ones want feeding tubes and breathing machines? Do you want to be treated in the intensive care unit at the hospital if this becomes necessary?

How much medical care do you or the person you care for want? Or maybe being comfortable and avoiding pain and extensive treatment is more of a priority?

These are essential thoughts to consider, prompting an effort to learn about home care, palliative care, and hospice care. You may not be familiar with these topics today if your elderly parent’s health is stable.

However, when caring for elderly parents, what matters most is the first of the 4Ms. Understand that having these conversations may be emotionally uncomfortable when talking about the realities of care from today to the death of a loved one.

2 Mobility

Let’s talk about number two of the 4M framework of an age-friendly health system, which is mobility. You might hear this and think mobility. Why is that important?

Being in good physical condition affects everything a body does. How you get out of bed in the morning, your ability to shower, get dressed, get in and out of a car and drive to work, play with your children or grandchildren, take your dog for a walk, go golfing, hiking, skiing, and more.

Little consideration is given to how vital physical fitness or strength is until an injury happens that negatively impacts daily abilities. Here are some simple examples. What happens when you spend an entire day working in the yard, washing windows, or getting down on hands and knees to scrub floors?

What do you notice? Are there sore muscles the next day? Soreness results from the non-use of body parts or being generally physically inactive.

When caring for elderly parents, what matters most is having conversations about remaining physically able and independent. Most parents want to continue to live in their homes, but don’t relate physical weakness to a greater likelihood of falling and having to move out of the family home.

Effects of Lower Levels of Physical Activity

With age, for most people, less time is devoted daily to physical activity that works the heart and muscles. How do you know?

Let me share a few terms that you might have heard. Know that my intention is not to make fun of people who are out of shape but to share phrases that caregivers and others share with me for those soft or squishy spots that weren’t there before.

With age, you might notice one or more of these: bat wings, muffin tops, cankles, double chins, saddlebags, love handles, moobs, spare tires, or pooches. If you notice any of these, there are plenty of videos on YouTube about how to get back in shape.

Mobility Impacts Living Independently

Why is regular physical activity important? To answer this, watch your aging parents or grandparents and ask these questions.

• Do they walk evenly and briskly, or slowly and unbalanced?
• Is it difficult for aging parents, grandparents, or spouses to stand up from a chair? Do they have the arm strength to push up from the arms of a chair?
• Is it physically challenging to get out of bed or in and out of a car?
• Can loved ones stand for an extended time in the kitchen to make a meal or walk a block or two without becoming exhausted or out of breath?
• Do you have trouble with any of these tasks?

Mobility concerns can result in hip fractures and permanent moves to live in a nursing home. In addition, sitting too much can result in pressure sores, poor circulation, or blood clots that result in a physically or mentally debilitating stroke.

Make Physical Activity a Routine

Remaining physically active and strong is the best way to choose how you want to live past 65, 75, 85, or 95. On the other hand, the less physically active you become, the more likely you will have increasing health problems and need more care from other people.

The word exercise is a turn-off for many people. If so, then call exercise “moving around.”. When caring for elderly parents, number two for what matters most is daily physical activity.

If parents balk, help them find a walking buddy or someone to golf, hike, play tennis, or accompany them to do other activities. Socializing is a positive factor for good health.

Instead of watching television all day, talking with others sharpens the aging mind. On the other hand, being alone or feeling isolated is a negative factor for health that can lead to depression.

The 4M framework is a valuable consideration for family caregivers. When caregivers are attentive to the 4Ms, they will be ahead of the age-friendly curve with the potential to have more control over their daily lives and health.

The Meaning of Age-Friendly Outside of the Health System

Outside of the healthcare system, ‘age-friendly’ means many things. For example, an age-friendly neighborhood has certain features that support the well-being of older adults. Here is a list of domains of livability according to AARP’s Network of Age-Friendly States:

• Outdoor spaces and buildings for recreation
• Transportation services for the elderly who are no longer able to drive
• Housing options for different income levels, including homes or communities that have been designed or modified for aging in place
• Opportunities for socialization through community events or community centers.

Additionally, some older adults want to continue working after formally retiring in paid or volunteer positions that provide them with personal meaning and connections to people of all ages. Opportunities for non-tech-savvy individuals to learn technology are a benefit of age-friendly communities.

As you can see, there can be a long list of things for caring for aging parents, what matters most that fall outside of the health system providers. These are conversations to initiate with your loved ones well before health concerns become significant.

And while you are having these conversations, think about answers to all of these questions for yourself. Sometimes it’s not easy to know what we want until we examine and investigate options.

Establish Preferences for Health and Aging Decisions

The goals of the first two of the 4MS, what matters most, and mobility are to establish preferences for where aging parents want to live, if they will need caregivers, and the extent of medical care desired.  Negotiating aspects of health is a significant part of caregiving relationships because adult children, elderly parents, and spouses disagree.

While caregivers may have good intentions, it’s easy to go too far in being overly helpful or sacrificing parts of their own lives to care for elderly parents or a spouse. Setting clear boundaries before caregiving hours start to increase in number is so

When caregivers have difficulty initiating these conversations, there are various options. If a parent is over age 65 and on Medicare, investigate setting an appointment with their physician for an Advance Care Planning and Annual Wellness Visit if this has not been scheduled. Then attend the doctor’s appointment with your parent and begin the discussion.

Caregiving What Matters Most? The 4Ms

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Medicare has benefits to to support family caregiving discussions. 

Medicare Advance Care Planning (ACP) and Annual Wellness Visits (AWV)

The qualifier to schedule an ACP or AWV medical appointment for adults with Medicare is enrollment in Medicare B for 12 months.

What is Advance Care Planning?

Let’s talk about the advance care plan meeting first, and what this means, specifically to caring for elderly parents, what matters most. An advance care plan is a face-to-face meeting with a physician or, in some cases, a physician assistant, nurse practitioner, or certified clinical nurse specialist.  The discussion centers around what are called advance directives.

I relate this to estate planning with an attorney, as these discussions involve legal documents that pertain to future medical care if you, an aging parent, spouse, or someone else you care for, is unable to make decisions. At an advance care planning meeting, you will be asked who you want to make medical decisions on your behalf if you are unable to do so.

Terms you may not be familiar with may be used. For example, a living will, a health care proxy, or health care power of attorney. In a living will document, you specify the types of intensive care you wish to receive if you are in a life-threatening situation.

So, as I mentioned before, the use of feeding tubes, breathing machines, and other mechanical or invasive treatments that keep the body alive is considered an extensive measure. Unfortunately, individuals with these interventions often experience a significantly reduced quality of life. Their health may not be expected to improve.

Linking Health Care Power of Attorney to Financial Power of Attorney

A health care power of attorney or proxy is the person you trust, plus a backup person who will make medical decisions for you if or when you are unable. In my opinion, advance care planning is not complete without discussing the financial aspects beyond the realm of healthcare professionals.

Here’s why talking about money is essential. What happens if or when you outlive your savings or don’t have enough income to pay for the care you need?

Delaying these discussions can increase stress levels in your family. Discussing care needs puts you in control. You can help aging loved ones apply for Medicaid and other public benefit programs if money will not be sufficient to pay for care costs in the long run.

How to Avoid Family Care Disagreements

Additionally, the agents you appoint for medical and financial decision-making should agree on the care desired by aging parents. For example, let’s say that the agent appointed by mom or dad under a medical power of attorney is not following documented wishes or the agent under a financial power of attorney disagrees about paying bills for care costs.

What happens when one agent withholds agreement? Disagreements between agents are precisely the reason to have an attorney draft your documents instead of using forms provided by a hospital or healthcare system or forms you download from the internet.

Planning for the Unexpected

The goal of caring for aging parents what matters most is planning for the unexpected to avoid potential negative or stressful events that you can prevent with a little bit of foresight. To prevent disagreements between the agents you appoint for medical or financial power of attorney—if they are not the same person—nominate a person, a “protector” to settle disputes.

Being proactive makes it less likely that your agents will disagree. Then, if a disagreement happens, the protector breaks the stalemate.

Additional provisions in legal documents for health, financial, and a will include establishing alternate or backup agents and the power to remove an agent who may become cognitively impaired and be unable to act reasonably or responsibly. One or all of these situations commonly occur.

Healthcare system providers, such as doctors, nurses, and other medical staff, while well-intentioned, often lack the legal expertise to draft documents, so they cannot provide you with accurate advice. Additionally, medical providers and the legal system view the term “incapacity” differently in relation to memory loss and decision-making.

What Happens at an Annual Wellness Visit?

Next, in Medicare programs for caring for elderly parents, what matters most is the Annual Wellness Visit, which may be scheduled in conjunction with an Advance Care Planning session. The wellness visit offers an opportunity to review a parent’s medical and family history.

The annual wellness visit is an excellent opportunity for family caregivers to attend and learn about all of the medical concerns of a parent or spouse.

• During the appointment, the doctor should discuss risk factors associated with the diagnosis and potential treatment options.
• In addition to an in-depth discussion of health conditions, any specialists you see and current prescriptions will be reviewed.
• Basic measurements, including height, weight, and blood pressure, are taken, in addition to lab work, if not done recently.
• The doctor may review preventative health screenings and vaccinations to make recommendations.
• A cognitive assessment is conducted to identify signs of memory loss and to screen for fall risk, depression, or other relevant conditions.

As you can see, these Medicare benefits are valuable and something that adult children caring for an aging parent can request. If, for some reason, your primary care doctor is not aware of the benefit, refer them to the Medicare website.

3 Mentation

So let’s turn to the third item on the list for the 4Ms framework of an age-friendly health system. This one is called mentation, which may not mean much if you are a patient.

I think the healthcare system was trying to find another word that started with M, and mentation happened to fit. What does mentation mean?

Mentation means the process or result of mental activity. More specifically, it means a review of cognitive or mental health.

First, looking for a diagnosis like memory loss related to dementia, Alzheimer’s, a brain injury, or some other condition, then depression, and delirium. Most people know what depression mean,s but may not recognize the signs.

Signs of Depression or Delirium

Thinking of an elderly parent or an aging spouse, are you noticing changes in energy level, interests, participation in social activities, a change in appetite, more or less sleep, an inability to concentrate, lowered self-esteem, or any mention of suicide?

From a mood perspective, a person may experience increased anxiety, feel hopeless or helpless, cry, or desire to spend a significant amount of time alone. One or all of these are reasons to see a doctor and ask for a depression screen.

Delirium is a medical condition that can lead to taking a loved one to the emergency room. In addition, delirium can relate to mental health, memory loss, or general health concerns.

You might notice that a loved one sees things that aren’t there. For example, mom or dad may be hallucinating or be more restless, agitated, or combative. They may be more confused, have slurred speech, or have difficulty speaking in a manner you understand.

If you see these signs, call 911. Delirium can happen from not eating or drinking enough, an infection that comes on rapidly like a urinary tract infection or pneumonia, imbalances in electrolytes, high or low blood sugar, or other reasons.

Receiving fast treatment is critical to resolving delirium or a sudden change in health. Some infectious situations can turn into sepsis, a life-threatening health condition.

4 Medication

The last of the 4Ms framework of an age-friendly health system is medication. Medication use in persons over age 65 should be monitored very closely for several reasons: changes in the body that affect how drugs are metabolized or processed.

Additionally, all medications can have side effects that you may not realize are side effects unless discussed with a doctor or a pharmacist. Here’s the gray area with medical care.

While doctors are medical experts, patients and caregivers must ask questions. Doctors are not mind-readers.

Aging parents who are not active participants in their care benefit from having a caregiver who can help get expected care. In addition, based on more than 20 years of experience and research about the 4M framework of age-friendly health systems, older adults need extra care and attention from the healthcare system.

If you are still seeing the same primary care physician you’ve seen for 40 years, it may be time to change to a geriatrician or an internal medicine specialist to get the care you need. Aging is a medical specialty, so more healthcare systems are participating in age-friendly programs.

When aging adults, their caregivers, and healthcare providers come together for these meaningful discussions about the 4M framework, better care and decision-making are possible.

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