usa today collegiate case study: elderly care

C o l l e g i a t e

Case

S t u d y

THE NATION’S NEWSPAPER

Juggling work, care for agingparentBy Stephanie Armour

................................................................................6-7

When is it time to put thebrakes on elderly?By Robert Davis................................................................................8-9

Caregivers struggle withdenial, disintegrationBy Kathleen Fackelmann

................................................................................4-5

www.usatodaycollege.com

It has been projected that by the year 2020, nursing homes will needapproximately 25,000 nurses with advanced preparation in gerontology. Giventhe current nursing shortage, the baby boomer population is now at risk, andphysicians who provide nursing home care are threatened with anoverwhelming burden. This case study explores how aging parents and theirchildren cope with ailments and the growing cost of health care.

Elderly Care

Seniors head south toMexican nursing homesLow costs, climate luring elderly across the border

Your aging parents and youBy Mindy Fetterman

.............................................................................. 10-12

Case Study Expert:Karen S. Dunn, Ph.D.Associate Professor, Oakland University

.............................................................................. 16

By Chris HawleyUSA TODAY

AJIJIC, Mexico — After Jean Douglasturned 70, she realized she couldn'ttake care of herself anymore. Her kneeswere giving out, and winters inBandon, Ore., were getting harder tobear alone.

Douglas was shocked by the high costand impersonal care at assisted-livingfacilities near her home. After search-ing the Internet for other options, shejoined a small but steadily growingnumber of Americans who are movingacross the border to nursing homes inMexico, where the sun is bright andthe living is cheap.

For $1,300 a month — a quarter ofwhat an average nursing home costs inOregon – Douglas gets a studio apart-ment, three meals a day, laundry andcleaning service, and 24-hour carefrom an attentive staff, many of whomspeak English. She wakes up everymorning next to a glimmering moun-tain lake, and the average annual hightemperature is a toasty 79 degrees.

"It is paradise," says Douglas, 74. "Ifyou need help living or coping, this isthe place to be. I don't know that thereis such a thing back (in the USA), andcertainly not for this amount ofmoney."

As millions of baby boomers reachretirement age and U.S. health carecosts soar, Mexican nursing homemanagers expect more American sen-iors to head south in coming years.Mexico's proximity to the USA, lowlabor costs and warm climate make itattractive, although residents cautionthat quality of care varies greatly in anindustry that is just getting off theground here.

An estimated 40,000 to 80,000American retirees already live inMexico, many of them in enclaves suchas San Miguel de Allende or theChapala area, says David Warner, aUniversity of Texas public affairs pro-fessor who has studied the phenome-non. There are no reliable data on howmany are living in nursing homes, butat least five such facilities are on LakeChapala.

Are options for careof the aging better?How are the care options foraging available to you nowcompared with what wasavailable for your parents?

By Jae Yang and and Bob Laird, USA TODAY

Source: Fi-nancialFreedomSeniorFundingsurvey of1,063 se-niors 62 to75 yearsold. Marginof error ±3percentagepoints.

USA TODAY Snapshots®

Not sure21%

Worse 11%Better55%

Same13%

Additional resources:.............................................................................. 14-15

© Copyright 2008 USA TODAY, a division of Gannett Co., Inc. All rights reserved.

"You can barely afford to live in theUnited States anymore," said HarryKislevitz, 78, of New York City. Astroke victim, he moved to a convales-cent home on the lake's shore twoyears ago and credits the staff withhelping him recover his speech andability to walk.

"Here you see the birds, you smell theair, and it's delicious," Kislevitz said."You feel like living."

Many expatriates are Americans orEuropeans who retired here years agoand are now becoming more frail.Others are not quite ready for a nurs-ing home but are exploring optionssuch as in-home health care services,which can provide Mexican nurses at afraction of U.S. prices.

"As long as the economies of theUnited States and Europe continue tobe strong, we're going to see peoplecoming here to Latin America to passtheir final days," said Oscar Cano, man-ager of Apoyo a los MiguelensesAncianos, a group that runs a nursinghome in San Miguel de Allende.

Cozy cottage, meals, health care

Retirement homes are relatively newin Mexico, where the aging usually livewith family. There is little governmentregulation. Some places have suddenlygone bankrupt, forcing American resi-dents to move. Some Mexican homeshave rough edges, such as peelingpaint or frayed sofas, that would turnoff many Americans.

"I don't think they're for everyone,"said Thomas Kessler, whose mothersuffers from manic depression andlives at a home in Ajijic. "But basically,they've kept our family finances fromfalling off a cliff."Residents such as Richard Slater saythey are happy in Mexico. Slater cameto Lake Chapala four years ago andnow lives in his own cottage at theCasa de Ancianos, surrounded by pur-ple bougainvillea and pomegranatetrees.

He has plenty of room for his two dogsand has a little patio that he shareswith three other American residents.He gets 24-hour nursing care and threemeals a day, cooked in a homeykitchen and

served in a sun-washed dining room.His cottage has a living room, bed-room, kitchenette, bathroom and awalk-in closet.

For this Slater pays $550 a month, lessthan one-tenth of the going rate backhome in Las Vegas. For another $140 ayear, he gets full medical coveragefrom the Mexican government, includ-ing all his medicine and insulin for dia-betes.

"This would all cost me a fortune inthe United States," said Slater, a 65-year-old retired headwaiter.On a recent afternoon, lunch at theCasa de Ancianos consisted of veg-etable soup, beet salad, Spanish rice,

baked dogfish stuffed with peppers,garlic bread and a choice of four cakesand two Jell-O salads. Slater's neighbor doesn't likeMexican food, so a nursing homeemployee cooks whatever she wantson a stove beside her bed.

Like many retirees, Slater has satellitetelevision, so he doesn't miss anyAmerican news or programs. When hewants to see a movie or go shoppingdowntown, the taxi ride is only $2-$3.Guadalajara, a culturally rich city of 4million people, is just 30 miles away.

For medical care, Slater relies on theMexican Social Security Institute, orIMSS, which runs clinics and hospitalsnationwide and allows foreigners toenroll in its program even if they neverworked in Mexico or paid taxes to sup-port the system. He recently had gall-bladder surgery in an IMSS hospital inGuadalajara, and he paid nothing.

Many of the nursing home employeesspeak English, and so does Slater's doc-tor.

The Casa de Ancianos began taking inforeigners in 2000 as part of an effortto raise extra money, director MarleneDunham said. It built the cottagesespecially for the Americans and usesthe income received from them to sub-sidize the costs of the 20 Mexican resi-dents at the home.The program was so successful that thenursing home has plans for 12 morecottages, a swimming pool, a Jacuzziand a gazebo with picnic area. Thenursing home now advertises on theInternet and through pamphlets dis-tributed in town. Some U.S. companieshave also begun investing in assisted-living facilities in Mexico, said LarryMinnix, president of the AmericanAssociation of Homes and Services forthe Aging, which represents 5,800nursing homes and related services.

However, Minnix cautioned that laxgovernment regulation poses dangersat smaller homes.

Cost of careNursing homes and in-home healthservices are relatively new in Mexico,where most seniors live with a familymember. In L ake Chapala, a privateroom in a nursing home costs $18-$50 per day compared with anaverage of $206 in the USA. How thecountries compare:

Note: Mexican costs are from a survey of facilitiesin five cities.Sources: MetLife Mature Market Institute;Mexico’s National Institute of Statistics,Geography and Information Processing; U.S.Centers for Disease Control and Prevention;USA TODAY research

By Frank Pompa, USA TODAY

Number of for-profit nursinghomes:

USA

Mexico 288

Cost of a home health care aide:

U.S.averageMexico

$19

$9

(per hour)

Cost of a homemaker-companion:

U.S.averageMexico

$17

$2-$5

(per hour)

9,900

AS SEEN IN USA TODAY’S NEWS SECTION AUGUST 16, 2007, 1A

Reprinted with permission. All rights reserved.

"It's the same danger you have of goingacross the border looking for cheapmedications," Minnix said. "If you don'tknow what you're getting, and you'renot getting it from people you trust,then you've got an accident waiting to happen."

'Nice place, but it's lonesome'

Since many nursing homes are run outof private homes, regulation by statehealth departments is often spotty.Managers such as Beverly Ward ofCasa Nostra and Maura Funes of ElParaiso, both in Ajijic, said thatMexican officials inspect them onlyonce a year, unlike U.S. inspectors, whomay visit a home several times a year.

The U.S. Embassy said it had no recordof complaints against Mexican nursinghomes, but some residents in the LakeChapala area reported bad experiencesat now-defunct homes.

The first home that Jean Douglas livedin after she moved from Oregon wasstaffed by "gossips and thieves," shesaid. It went out of business.

Irene Chiara of Los Angeles also livedin a home that was shut down byJalisco state authorities.

"It was filthy, and the food was verybad. It was all made in themicrowave," she said.

Some Mexican managers also underes-timate the costs and difficulty of run-ning a retirement home. Two hotelsturned into assisted-living facilities,The Spa in San Miguel de Allende andThe Melville in the Pacific Coast city ofMazatlan, recently abandoned thebusiness, their managers said.

"It was very expensive to run it," saidLuis Teran, manager of The Melville.Some managers said they were espe-cially selective when admitting foreignresidents, to make sure they'll be ableto pay. Medicare, Medicaid, theDepartment of Veterans Affairs andmost U.S. insurance companies will not

cover care or medicine as long aspatients are outside the USA.

Some American residents said they haddoubts about the quality of Mexicanmedical facilities and would go back tothe USA if they became seriously ill.Jim May, 74, a resident of the Casa deAncianos, said he recently decided tomove to Texas to be closer to VeteransAffairs hospitals.

The language barrier can be daunting,and Mexican food can be very differ-ent, some residents said.

Some residents said they miss homeand find it hard to make friends withMexican residents. "It's a very niceplace, but it's lonesome," said PollyCoull, 99, of Seminole, Fla., a residentat Alicia's Convalescent Nursing Homein Ajijic.

Mexican entrepreneurs are doing theirbest to prepare for a tide of Americans.

In the Baja Peninsula town ofEnsenada, the Residencia Lourdesopened in 2003, offering care forpatients with Alzheimer's disease andsenile dementia. The towns aroundLake Chapala have at least five smallretirement homes. Most of themopened in the last five years and housefrom one to 25 foreigners.The largest, Alicia's ConvalescentNursing Home, consists of four reno-vated homes, one of them specializingin stroke victims and another forAlzheimer's patients. Prices range from$1,000 to $1,500 a month and includeeverything except medicine and adultdiapers. The rooms are outfitted inMexican style, with murals, hand-carved beds, arched ceilings lined withbrick and individual patios.

In other American enclaves, in-homenursing services have sprung up toserve the retirees. In Rosarito, justsouth of the U.S. border, INCARE pro-vides nursing aides to retirees startingat $8.33 an hour, less than half the costof the same service in nearby San Diego.

Developers look to Mexico

Developers of "independent living"facilities for seniors are also beginningto look to Mexico. A Spanish-U.S. ven-ture is building Sensara Vallarta, a 250-unit condominium complex aimed atAmericans age 50 and older in thePacific Coast resort of Puerto Vallarta.And in the northern city of Monterrey,El Legado is marketing itself as a"home resort" for seniors.

Academics and government officialsare beginning to take notice. In March,the University of Texas at Austin held aforum for developers, hospital officials,insurance companies and policymakersto discuss health care for retirees inMexico.

"With the right facilities in place,Mexico could give (American retirees)a better quality of life at a better pricethan they could find in the UnitedStates," says Flavio Olivieri, a memberof Tijuana's Economic DevelopmentCouncil, which is seeking funding fromMexico's federal government to buildmore retirement homes. "We thinkthis could be a very good business asthese baby boomers reach retirementage," he says.

Hawley is the Latin America correspondent forThe Arizona Republic and USA TODAY.

NMiles

0 500

PacificOcean

Mexico Gulf ofMexico

Guatemala

Texas

Ajijic

USA TODAYSource: ESRI

MexicoCity

San Miguelde Allende

Chapala

Rosarito

AS SEEN IN USA TODAY’S NEWS SECTION AUGUST 16, 2007, 1A


By Kathleen FackelmannUSA TODAY

Barbara Center has raised four children, but now, at 59,she's helping care for her mother, who has Alzheimer's.

She's also dealing with two elderly aunts in nearby insti-tutions. Both have Alzheimer's, and one is in the finalstage of the disease.

"Sometimes it is really hard," says the Springdale, Ark.,resident. She says she has seen her 86-year-old mother,Vera Romine, become more confused and difficult.

Center is one of 10 million Americans who struggle withthe task of caring for a relative with Alzheimer's or someother form of dementia, according to the Chicago-basedAlzheimer's Association.

Family caregivers help out with household chores andperform all kinds of services, including personal care.One in four caregivers have the equivalent of a full-timeunpaid job: They're spending at least 40 hours a weekproviding services to a loved one, the association says.

Caregivers who don't get any relief can develop anxietyand depression and are prone to getting sick themselves,says Jan Busby-Whitehead, a spokeswoman for theAmerican Geriatrics Society

Alzheimer's often forces caregivers to step in and makedecisions for a relative who's showing signs of impair-ment, says Larry Wright, director of the SchmiedingCenter for Senior Health and Education in Springdale.

About two years ago, after her mother ran a red lightand got into a minor fender-bender, Center had to takeaway the car keys.

Her mother disagreed with the decision. "She got veryangry," says Center, adding that her mother still insistsshe is a safe driver.

Kathryn Betts Adams, a researcher at Case WesternReserve University in Cleveland, says people withAlzheimer's and their family members will try to stickwith familiar routines. Even as the confusion gets worse,they'll deny that a problem exists.

Center found that out the hard way.

She already had been providing care for her aunt withAlzheimer's when Romine, who had already been show-ing signs of confusion, was diagnosed about a year ago.Center thought she knew how to handle the situation.

"I just went full force into helping her," she says. But shesoon found that her efforts sparked arguments with hermother, who didn't or wouldn't acknowledge the dis-ease or the impairment in her thinking ability or memory.

Romine insisted she was fine, and Center's father agreed,so Center had to back off — even though she was leftwith constant worry.

"It's so frustrating, because they don't allow me to helpthe way I should," she says.

She has tried to hire caregivers to help out, but her par-ents have rejected each one for different reasons. So thefamily muddles along.

Center, who works part time as a clerk in a CrackerBarrel store, does the grocery shopping for her parents.She buys lots of frozen dinners that her father can easilypop in the microwave.

Center says her mother still wants to cook, even thoughshe has started at least one fire. To avoid an argument,she tells her mother that the stove is broken: "There'sjust no reasoning with her."

Alzheimer's destroys the brain regions that governthinking ability, judgment, and even emotion andbehavior. People who have the disease can lash out inanger, and that makes the job much harder, Wright says.

Caregivers struggle with denial,disintegrationWatching a loved one sink into Alzheimer's can be harrowing

AS SEEN IN USA TODAY’S LIFE SECTION JUNE 28, 2007, 10D


Adams says many families resist getting help until a cri-sis occurs.

Center says her mother, who has balance problems, stilltakes a bath by herself. She worries that Romine will slipand fall, but she can't get her parents to agree to anyassistance with the routine.

"It's going to take an accident of some kind before myfather ever agrees to get help," she says.

The stress and worry has driven Center to seek out somesolace, which she gets by going to a support group forpeople who care for relatives with Alzheimer's. She saysjust talking to others who are going through the samething can help. Her children — she has three growndaughters who live nearby — also help out from time totime.

People with Alzheimer's can live for 10 years with ongo-ing destruction of brain tissue, Wright says. The disease

starts off with mild memory loss and other subtle prob-lems. But then they have more and more trouble form-ing even routine tasks. In the end, people with advanceddisease are completely helpless and mute. They usuallydie of an infection or some other complication.Center has seen this dreadful progression up close: Oneof her aunts is bedridden and doesn't recognize her. Shehas stopped eating.

For now, Center's mother still lives at home but hasbecome increasingly difficult. She puts household itemsin odd places. She lashes out and is sometimes paranoid.She repeats things over and over and sometimes can'tremember past events — even the good times.

"I see the deterioration and it scares me," Center says. "Idon't know what we'll have to go through in the future.”

AS SEEN IN USA TODAY’S LIFE SECTION JUNE 28, 2007, 10D

Yes 73% No 27%

Yes 52%No 48%

No 55%Yes 37%

Noopinion

8%

USA TODAY/ABC News/Gallup PollnWho’s caring for elderly parents

Source: USA TODAY/ABC News/Gallup poll of 689 baby boomers.Margin of er ror for full sample is ±4 percentage points; margin for subgroups(such as boomers with a living parent) from 5 to 7 percentage points.

By Robert W. Ahrens, USA TODAY

USA TODAY/ABC News and Gallup polled baby boomers about caring for elderly parents. Here’s what we found:Do you have any parents, step-parents, adoptive parents orparents-in-law who are currently alive?

Assisted-living or long-term care facility

Liv ing with you in your home

Liv ing with a relative in their home

None of these

12%

8%

73%

8%

If you have a living parent, where dothey live?

Financial help

Personal care

Both financial and personal care

Not providing ongoing care

Are you providingany assistance?

59%

7%

30%

4%

Of those who said yes, if you are not currently providingassistance, do you expect to have to take care of a parentin the future?

21%27%28%

23%

How concer ned are you about beingable to provide care in the future?

Very concernedSomewhat concerned

Not too concernedNot concerned at all

No opinion

Have you talked to yourparents about how tohandle their health careafter they can no longercare for themselves?

If you have talked to your p arents abouthow to handle their care in the future,how did the discussion go?

Ver y easilySomewhat easily

Somewhat difficultVery difficult

No opinion

32%28%28%

10%2%

1%


AS SEEN IN USA TODAY’S MONEY SECTION JUNE 26, 2007, 3D

Juggling work, care for aging parentSome companies help their workersBy Stephanie ArmourU S A TODAY

Sheree Anderson of Sioux Falls, S.D., calls her mother,Virginia Harvey, her best friend. She considers it a laborof love to care for her in her home now that her mom is87 and prefers not to live on her own.

But for Anderson, the need to balance her workdemands with her role as a caregiver poses a persistentchallenge. When she goes on business trips, she has hersister drive several hours to stay with Virginia. She alsostructures her work hours around the need to runerrands for her mother or take her to the doctor.

"From time to time, it causes stress," says Anderson, 51,a self-employed educational and military consultant."It's hard to have to always be there to cook the mealsand give her medicine. I'm tied to a routine, and I try towork in-between."

For both employees and the self-employed, shoulderingthe burden of caring for an elderly parent while alsomeeting job demands can be a Herculean task. Thenation includes an estimated 34 million unpaid care-givers for adults, typically older relatives, according to astudy released this week by AARP. Nearly 60% of malecaregivers work full time, as do 41% of female care-givers, according to the National Alliance for Caregivingand AARP.

But as the ranks of employed caregivers swell, a smallbut growing number of employers are beginning toestablish novel programs to provide help and schedulingflexibility. Twenty-six percent of companies offer anelder care referral service, which helps employees con-nect with service providers or other services, accordingto a 2006 survey by the Society for Human ResourceManagement of small, midsize and large companies.Five percent provide emergency elder care help (such ascontracting with a firm that has nurses or otherproviders who can help care for an elderly relative), and3% subsidize the cost of elder care.

Programs for federal employees vary by agency, butsome provide telecommuting, caregiver fairs and lunch-and-learn events on elder caregiving issues.Still, attention to the issue isn't meeting employeeneeds, says Randall Abbott, a consultant at WatsonWyatt Worldwide, a benefits consulting firm.

"Employers are doing incrementally more but not asmuch as you'd expect, given the changing demographics," Abbott says. "I continue to be amazedthere is not more attention paid to this. (The caregiving)population is huge, and it's an enormous drain on pro-ductivity."

Employees who lack access to programs or flexible workschedules typically must use vacation time or sick daysor limit their caregiving to weekends, notes CaliWilliams Yost, author of Work+Life: Finding the FitThat's Right For You.

They can take unpaid time off to care for an aging parentunder the federal Family and Medical Leave Act. Thattime off can be taken in segments, such as a few hoursto take a parent to the doctor."There are also times where employees have no choice(but to quit)," to move closer to their elderly relative,Yost says.

But some employers are taking action:

uIBM offers an online course that covers caregiving.One-on-one counseling is offered via phone to helpemployees find caregivers and nursing homes, on-siteclasses for employee caregivers, webcasts, online lec-tures and moderated chats. A 2004 internal surveyfound that 36% of IBM employees are affected by eldercare issues, up from 9% in 1986.

"These programs are important because it's a retentionissue, but it's also to motivate talent," says Maria Ferris,IBM's director of global workforce diversity. "To thedegree employees are worried about an elderly parent,they're not productive."


uErnst & Young provides consultations to help employ-ees learn about available resources, from assisted livingto nursing homes. The service also addresses the emo-tional and psychological aspects of being both a caregiv-er and an employee.

The accounting giant also provides backup emergencyadult care services, whereby a service provider will visitan employee's or relative's home to help provide care.Employees are allowed 12 days each year for eachdependent, and the cost is subsidized.

There are also seminars on elder care issues and, insome locations, caregiver discussion groups in whichemployees can share experiences. In addition, the com-pany offers some flexible-scheduling options to helpwith work and elder care demands.

uXerox provides elder care consultations and referralsthat help employees find caregiving services. The con-sultants help with such issues as finding transportationfor elderly parents, meal services and Medicare. Xeroxalso has a program to help deal with the pressures ofjuggling work and family duties.

Demand for such services is growing. Bright Horizons, acompany that offers a network of in-home providers,says it's seen a rise in employers interested in backupemergency elder care programs. The company, whichlaunched the service less than a year ago, has had about75 major employers sign up.

"They're trying to help employees," says Dave Lissy ofBright Horizons, based in Watertown, Mass. "(The serv-ice) builds loyalty to the employer and helps employeesbe more productive at work."

But for many employees, especially those also caring forchildren, the need to help an elderly parent can imposean emotional strain for which referral services are hard-ly enough, says Richard Chaifetz, CEO of ComPsych, anemployee-assistance provider.

"The psychological drain can be enormous," Chaifetzsays. "It results in more absenteeism, distraction andlost productivity for employers. We're seeing this growdramatically."

For some employees with aging parents, employer serv-ices have been a relief and an invaluable help. RosemaryRay, 42, of Cary, N.C., had been coping with her mother,

who had Alzheimer's and died in December at age 86.Her father, 93, lives in Texas.

Ray was able to use an internal website that her compa-ny provided to learn more about the issue and to speakwith a specialist about how best to handle problems,such as her mother's forgetfulness

"I was able to read about it and talk to someone," saysRay, an IBM business analyst. "I could see I am not theonly one dealing with this. Peace of mind helped a lot. Itmade me feel better talking to a professional in thisfield.”

Tips for balancing care, workEmployees with aging parents or other relativesoften find they must negotiate with their employ-ers to take time off to care for family while alsoremaining productive on the job.

It's a tricky balancing act. Some advice:

uFind out if your employer must follow the fed-eral Family and Medical Leave Act. If so (forexample, if your company has 50 or moreemployees), you're entitled to up to 12 weeks ofunpaid time off annually to care for a parent witha serious health condition. Generally, that timecan be taken in increments.

uFind out if flexible arrangements are possible.These might include formal programs as well asinformal agreements. "The more you can makethe workplace fit your needs, the better," saysElinor Ginzler, co-author of Caring for YourParents: The Complete AARP Guide.

uFlexibility is especially vital for employees whoare long-distance care-givers. Employeesshould find out if theycan work remotely (forexample, they may beable to work from thehome of the relativethey're caring for).

Some helpful web sites:

www.aarp.org

www.caregiving.org

www.caregiver.org


AS SEEN IN USA TODAY’S MONEY SECTION JUNE 26, 2007, 3D

AS SEEN IN USA TODAY’S LIFE SECTION MAY 2, 2007, 7D


When is it time to put the brakes on elderly?Heed the early signs to avert disasterBy Robert DavisUSA TODAY

As they age, drivers tend to take their cars on shortertrips. But even so, health problems often catch up withthem.

Reflexes, flexibility, visual acuity, memory and the abili-ty to focus all decline with age. Because no two peopleage exactly the same way, one 80-year-old can be morefit to drive than another 70-year-old.

Doctors and advocacy organizations who specialize intreating the elderly say medical professionals, familymembers and friends must do more to watch for earlywarning signs of medical problems that affect safe driv-ing.

uAlzheimer's disease, a disorder that causes memoryloss, can cause slower reaction times, problems judgingspace and distance, and a diminished ability to planahead. It also can increase the risk of getting lost, beingconfused by divided highways and one-way streets, andbeing in an accident.

uDiabetes, a blood sugar disorder, can damage thenerves in hands, eyes and feet. This can slow reactiontime and limit vision. If blood sugar levels dip too low, adriver may feel dizzy or shaky and become confused oreven lose consciousness. Diabetics should check theirblood sugar levels before getting behind the wheel.*Parkinson's disease, a neurological condition that caus-es rigidity, slowed movement and tremors, may affectthe ability to turn the steering wheel and make quickmovements.

uStroke, which is caused by an interruption in bloodflow to the brain, damages brain tissue and may causebalance problems, diminished vision and a loss of mus-cle control.

"All of the sensory input you take in constantly as youdrive is really amazing," says Laurel Coleman, a geriatri-cian from Augusta, Maine, who serves on the board ofthe Alzheimer's Association. "You do so many thingsautomatically that you do not consciously think about.Where can the process go wrong? In so many ways."

The way in which a person responds to small problemscan be an indication of how they will act behind thewheel of a car.

"I get concerned when somebody doesn't problem-solvevery well," Coleman says. "When they tend to do thesame thing in response to a problem, I get concernedbecause driving requires you be very adaptive.

"You will see things happen that you have not seenbefore. Somebody will pull in front of you. There will bea detour. There will be something different. That iswhere it gets very challenging."

As a result, the signature crash for elderly drivers occurswhen their paths cross with others who are followingtraffic rules. They turn in front of oncoming cars thatthey never see, studies have found. They miss red lightsor stop signs.

And they crash while making routine trips.

For instance, weekends are risky times for teenagers tobe on the road. But according to data from the Center forthe Study & Improvement of Regulation at CarnegieMellon University in Pittsburgh, the mile-for-mile fatali-ty rate is about three times higher for drivers 85 andolder on weekdays.

"People should not have to get into car accidents or getpulled over by state police for health care providers orfamilies to take notice," Coleman says. "We should haveheightened awareness and that is all of us, not just med-ical professionals but your neighbors and your family."

Coleman has to push some patients hard. She has writ-ten letters asking the Department of Motor Vehicles toretest patients who then lost their license.

"Sometimes patients will never speak to me again," shesays. "But driving is a privilege and it's not a right. Idon't want to be cavalier about it, because the potentialrisks and consequences are so great."



Before you get behind the wheelSafety experts say that senior citizens can take steps to ensure that they are competent drivers. "It's part of theresponsibility of the individual to be aware of their own driving behaviors and do everything they can to be safeon the road," says Elinor Ginzler, AARP's director of livable communities. Precautions that experts recommend,according to USA TODAY research, include:

uDrive under less stressful conditions — during the day, in good weather, on less busy roads and in familiarareas.

uAvoid distractions such as adjusting the radio, eating or talking on a cellphone.

uPlan your route. That allows you to concentrate on driving, not navigating.

uUpdate your driving skills in a refresher course for older drivers.

uHave your vision and hearing tested regularly. Ask your doctor how frequently you should schedule examinations.

uPerform stretching exercises to improve strength and flexibility of the neck and shoulders.

uWalk to stay fit and keep the lower extremities flexible and strong.

Consider stopping the carExperts suggest you retire the keys if you:

uAre inattentive, make erratic moves, react too slowly, get anx-ious at busy intersections, feel unsure of what to do or areafraid to drive.

uHave trouble with gas or brake pedals.

uHave received several traffic tickets or warnings from police inthe past year or two.

uMove too slowly on the highway.

uFail to come to a full stop at stop signs.

uCan't see when backing or changing lanes.

uHave frequent close calls or near accidents or if you sometimesdent or scrape the car.

uMiss traffic signals or are uncertain of what they mean, or ifyou get lost.

uGet honked at by other drivers.

uUpset your passengers, or if people refuse to ride with you.


MindReaction time slows, confusion grows,quick decisions become more difficult anddistractions have greater impact.

The neck stiffens, motionbecomes painful, glancing overone shoulder to look for trafficbecomes difficult. Arthr itis canmake it hard to grip the steeringwheel .

Neck

Joints stiffen, foot and knewmovement b ecomes difficultand p ainful, gas pedal getspushed instead of brake.

Knees, ankles, feet

Cataract s cloud thelens of the eye, causingblurred or hazy vision.The dr iver becomesmore sensitive to lightand glare; nightdriving can be difficult.

Glaucoma raisespressure inside theeyeball, reducingperipheral vision andmaking it moredifficult to see apedestrian or vehiclecoming from the side.

Macul ardegenera tion causesloss of the centralportion of vision,making it moredifficult to see othercars or pedestrianscoming toward you.

Aging causes several vision problemsthat can interfere with dr iving:

Eyes

Prescription drugs thatmay cause drowsinessor slow reaction time:

MedicationsOpioids

MorphineOxycodonevv

Benzodiazepin esAtivanValium

vv

AntidepressantsPaxilElavilvv

Hypnoti csAmbienLunes travv

AntipsychoticsRisperdalMellaril

vv

AntihistaminesBenadrylClar inexvv

Glaucoma agentsXalatanTrusoptvv

Muscle relaxa ntsFlexarilSkelaxinvv

Source: AARP, American Academy of Family Physicians, National Institute on Drug Abuse, Mayo Clinic, Medco Health Solutions, USA TODAY r esearch By Frank Pompa and Alexandria Newman, USA TODAY

How aging affects the ability to drive

Effects simulated byFrank Pompa, USA TODAY

By Frank Pompa and Alexandria Newman, USA TODAY

Source: AARP, American Academy of Family Physicians, National Institute on Drug Abuse, Mayo Clinic, Medco Health Solutions, USA TODAY research


AS SEEN IN USA TODAY’S NEWS SECTION JUNE 25, 2007, 4A

Reprinted with permission. All rights reserved. Page 10

Your aging parents and youBy Mindy FettermanUSA TODAY

MOM is quitting her bridge club because "they think I'mstealing from them." A week later, she mentions an oldboyfriend from the war who's coming to take her to din-ner. * You think, OK, it could be true. Then the police callfrom her house. "Your mom thinks there's someone hid-ing under her bed." * Now you know. The forgetfulness,the fantasies, are dementia, Alzheimer's, something likethat. Your sister suspects the worst. * This isn't just thestory of one petite brunette with terrific legs who wascalled "Shorty" by her husband, granddaughters anddaughters, including me. * This is the story of millions ofAmericans caring for elderly parents and maneuveringin the murky worlds of medicine, law, hospitals, nursinghomes, guilt, fear and family ties. A USA TODAY/ABCNews/Gallup Poll of baby boomers finds that 41% whohave a living parent are providing care for them — eitherfinancial help, personal care or both — and 8% ofboomers say their parents have moved in with them. Ofthose who are not caring for an aging parent, 37% saythey expect to do so in the future. About half say they'reconcerned about being able to provide such care.

It's estimated that 34 million Americans serve as unpaidcaregivers for other adults, usually elderly relatives, andthat they spend an average 21 hours a week helping out,according to a study being released today by AARP.Millions more grown children are calling regularly, fly-ing into town every few weeks or months or just stop-ping by to take Mom or Dad to the doctor.

Among boomers who are helping their parents, 89% saythe responsibility is only a "minor sacrifice" or "no sacri-fice at all," according to the USA TODAY poll. But as theirelderly parents get older, some boomers are beginningto worry they won't be able to care for them in thefuture.

AARP estimates that the economic impact of this "free"care was about $350 billion in 2006. That's more thanthe U.S. government spent on Medicare in 2005. Itexceeded the size of the federal budget deficit in 2006.

AARP estimates that unpaid caregivers who contributefinancially spend an average of $2,400 a year on care.Those who put in more than 40 hours a week spendmuch more: an average of $3,888 of their own moneyeach year, AARP says. But when a parent actually movesinto the children's home, the total cost isn't really added

up. Families pay and pay and pay, emotionally andfinancially.

The typical unpaid caregiver is a 46-year-old womanwho works outside the home while taking care of a rela-tive, according to AARP. That burden forces her to cutthe hours she works at her regular job by about 41%,causing her salary and benefits to fall sharply.

The National Alliance for Caregiving (NAC) estimatesthat $659,000 per person is lost in pensions, SocialSecurity benefits and wages as adult children — mainlywomen – take time off from work to care for their par-ents.

The physical toll can be severe, too. Caregivers reporthaving one or more chronic conditions, such as highblood pressure, at nearly twice the rate of all Americans.Of those who say their health has worsened because ofcaregiving, 91% report depression.

Caring for elderly parents also can threaten the emo-tional health of caregivers and their families. Being the"parent of your parent" can unlock your family's hiddendysfunctions — "You were always Mom's favorite!" —and reopen old sibling rivalries and conflicts: "You'retrying to kill our father!

If you never really got along with your parents or yoursiblings, it can be even more stressful. Elder care canexhaust and sometimes demoralize the caregiver who'son the front line. And it can frighten and confuse elderlyparents.

"My dad was never a gentle soul when we were growingup; he was a military guy," says Nia Wilson, a lawyerwith the state of Pennsylvania. "His kids were additionaltroops he had to keep in check."

Now she spends most weekends driving about fivehours from Harrisburg, Pa., to Washington, D.C., whereher 84-year-old mother is caring for her 90-year-oldfather, who has Alzheimer's. Her two brothers live near-by but don't help much, Wilson says.

"They think they help, but not as much as I would like,"she says with a sigh.

In most families, women — daughters or daughters-in-law, aunts or nieces — typically assume the burden ofcare, according to the NAC. Wilson says her parents

First you get phone calls that seem kind of strange


want to stay in their home, even though they probablybelong in an assisted-living facility, she thinks.

"We keep raising the idea with Mom," Wilson says. "Butshe says, 'Don't worry about me. I'm OK.'"

Starting to take over

After a second midnight call from the police, the ser-geant tells my sister: "You all need to do somethingabout your mom." But what?

A plane trip back home to Louisville, and we face her:"Shorty, you have to see the doctor. We've made anappointment. Let's go."

She smiles and nods.

The next thing we know, the skittish 75-year-oldwoman has sneaked out of the front door and scam-pered across the street to a neighbor's house. We findher hiding — literally hiding from her daughters —behind a tree in Mr. Trinkle's backyard.

She's frightened by what she senses is happening to her.On some level, she realizes she's losing her ability tothink and reason. But right now, she's afraid of whatmight happen to her. She's afraid she'll be taken fromher home and placed in a nursing home.

So she runs. What now?

A friend suggests calling in a man. "Women of that erawill do what a man tells them," she says.

I call my ex-husband, a man Shorty has known since hewas 8 years old. "Put on a suit and tie and bring theMercedes over," I tell him. "Shorty will go to the doctorwith you."

He does. He talks her out from behind the tree and intothe front seat of the big car. "Can I go, too, Mom?" I ask,tentatively.

Shorty talks only to John: "Tell her she can come, butshe has to sit in the back seat."

Starting to take over for your parents can be one of themost distressing experiences of a lifetime. "It's so muchmore difficult, because they are our parents; we are thechildren," says Julie Lucero of Vacaville, Calif.

For the past two years, Lucero's 79-year-old father,Edward, has been living in her home with her three chil-dren.

"Right now," she says, "we're fighting about his driving.Not out of malice, but because I know it's better foreveryone if he doesn't drive anymore. Heaven forbid ifhe injures himself or someone else."

Her father, who has had some fender benders and mis-takenly parked in the wrong driveway, disagrees. "Theycan take away my driver's license, but I'm still driving,"he declares.

After Shorty had been driving fairly cluelessly for twoyears or so, we hid her keys. Her dementia had pro-gressed to the point that she didn't remember that shecouldn't find the keys. She had been a widow for 25years; driving was vital to her.

A battle over keys can be the first struggle between eld-erly parent and child. "It's my responsibility now,"Lucero says. "I have to decide."

Obtaining legal rights

One trip to a gerontologist with Shorty confirms whatwe suspected.

"Your mother is very charming," the young doctor says."She even flirted with me. But she really doesn't knowwhat's going on." She couldn't tell time or count change.She didn't know who the president was. She didn'tknow what day it was.

The doctor prescribes an anti-psychotic drug to helpwith the voices in her head. He checks her into a psychi-atric ward for four days, primarily to give my sister andme time to figure out what to do.

"She can't live alone," he says. "She needs 24-hour care."

So we begin the trek across town to assisted-living facil-ities and nursing homes. Both of us are single workingwomen, so taking Shorty into either home isn't anoption.

Some facilities we see are elegant replicas of colonialhomes with oriental rugs and cherry wood furniture.Lovely, but we realize she likely needs more medicalcare than those retirement homes could provide. (Wesuspect they were decorated more to please the adultchildren than the residents.)

Other facilities are starker, more medicinal. In one, aman was screaming. Shaken, we go home.We try in-home care. But Shorty keeps firing people. Wetry her former house maid of 30 years, a woman whowas 78 herself. She stays about five days, until Shortythrows her clothes out an upstairs window, yelling, "Getyour — out of here!"



We try an apartment at an assisted-living condo. Shortycalls a taxi three days later and has herself taken home.She lives at home alone for another year, with my sisterstopping by each day after work to check on her. Verystressful.

Finally, we have her committed. We get a lawyer, takeher to court and have her declared incompetent.

We sit across from a jury and testify against our ownmother. My sister is named her guardian. We check herinto a nursing home with an Alzheimer's wing. Thatmeans the doors are locked.

"You're doing the right thing," the lawyer says.

Maybe, but we feel terrible.

Ray Payton knows the feeling.

She had to go to court to have her grandmother declaredincompetent. Now she must file forms with the courtevery six months to prove she's not wasting or stealingher grandmother's money.

"I'm the legal guardian of my grandmother, who hasdementia," says Payton, 35, whose parents are deceased."I thought, 'How could me, a grandchild, take her tocourt so I could pay her bills?'

"I felt like I was being a bad granddaughter."

Straining a family

Every rivalry you had with your brothers and sisters,every argument you had with your parents, every effortyou ever made to become independent can be put to thetest once your parents become old and sick.

You find yourself arguing with your siblings, arguingwith your spouse, arguing with your parents, arguingwith yourself

"The No. 1 thing you'll fight about is money," says DavidHorgan, a producer of TV commercials from Ludlow,Mass. His 69-year-old mother-in-law moved in with himand his wife, Julie, and three kids about three years ago.

"We fight about Grandma a lot. My wife will say: 'Whatdo you want me to do? It's my mother!' And it goesback and forth, and then it escalates. As a good daughter,she always feels guilty, and I always come out the badguy."

They've spent thousands of dollars on a new air-condi-tioning system for their home because of his mother-in-law's lung problems. He loves and admires her but feelscrowded in his own home.

"The toughest thing is that she is a beautiful woman, thekindest and nicest person," he says. "She'd do anythingfor you. But as soon as you live on top of each other, it'shard."

Lucero has nine half-siblings. Her father, who divorcedher mother when Lucero was young, lived with one sonfor two years. He has only Social Security and some vet-eran's benefits, about $600 a month. No savings. Hecan't afford a nursing home or an assisted-living facility.

She wishes his other children would help more. "It wasmy choice to take him on, but now that he lives withme, they say, 'Oh, Julie's got it covered.'"

In my mom's case, one daughter lives near Shorty, theother — me — lives hundreds of miles away. So the near-est sister gets the burden of visiting every week, oftentwice. She's saddled with the emergency runs to thehospital and trips to the doctor's office.

The faraway sister spends thousands of dollars on planetickets and rental cars and buys most of her mother'sclothes and necessities. She spends money to keep upher mother's house, so we can sell it. She spends moneybecause she's not there to help, and she feels guiltyabout everything.

Shorty's money starts draining away, faster and faster.Nursing home care is $60,000 a year. After a few years,her savings are nearly gone. So we sell the house andmost of her stuff. We divide the valuable and sentimen-tal things. I ship home my new antiques.

We realize we've done exactly what Shorty feared thatday she ran across the street and hid behind the tree:We've sold her belongings, taken her rights and put herin a nursing home.

In our minds, we know we did the right thing. But wefeel terrible.

Epilogue: Evelyn Fetterman died in February at age 84.She had been living in assisted living or a nursing homefor 10 years. Her daughters are sad and tired. They misstheir mom the way she used to be. They're relieved thatit's all over. And for that, they feel terrible.



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1. Most often, the role of taking care of older adults is viewed negatively because of ageist stereotypes. The majorreasons for this are a lack of knowledge regarding what are normal age-related changes and consequences of illnessor disease. For example, most people think that if they live long enough, they will become senile. This is a myth. Evenamong those who live to be 80 or older, only 20-25 percent will develop Alzheimer's disease or some other incurableform of brain disease. "Senility" is a meaningless term which should be discarded. Therefore it is essential to knowwhat is normal and what is not. Discuss what you believe are normal age-related changes and what are consequencesof illness or disease.

2. Mistreatment and neglect of elders still prevail even though our government has attempted to intervene throughstricter laws and regulations. Much of this can be attributed to caregiver burden and stress. Discuss othergovernmental strategies that can help decrease or eliminate caregiver burden and stress.

3. Many older adults have begun to look outside of our country for cheaper housing and caregiving. Given ourglobal economy, discuss what impact this may have on our economy. What are the pros and cons? Discusshow other countries may view these changes and the American culture.

4. The ability to drive is highly valued resource in this country and has been linked to independence, autonomy,and quality of life. Therefore, losing one’s driving privileges is inconceivable, especially for older adults. By2030, 70 million people (20%) of the population will be 65 years and older. Older adults however, are atincreased crash risk per mile driven and are predicted to cause 40% of all fatal crashes by 2025. Discuss whyolder adults are at a higher risk for fatal car crashes. Discuss strategies that can be implemented to promoteolder drivers’ safety and mobility.

1. Many assisted-living and long-term care facilities have adopted principles and practices highlighted in the “EdenAlternative.” The major goal of the Eden Alternative was to eliminate helplessness, hopelessness and boredom thatplagued nursing home residents by creating richer human habitats. Dull institutional environments would betransformed into home-like habitats with the inclusion of animals and plants that the residents could care for. Inaddition, children would be brought in to provide companionship, recreation and play for the residents. Thisalternative model however, has not successfully eliminated the three plagues as was intended. Families and staff,rather than the residents, have benefited from this. What do you think are the reasons for this failure? Whatimplementation strategies can be done to improve the outcomes of this alternative model? Develop a new model thatyou feel would be more successful based on your reasons for failure and your implementation strategies.

2. Technological advances in many fields can be used to improve elder care in America. Specifically, informatics,healthcare, stem-cell research, and genetics have been highlighted. Discuss how these fields can improve elder care inAmerica.

3. Most people believe that older adults with Alzheimer’s disease are institutionalized. This is a myth. The majority arecared for in the home by spouses, daughters, or daughter-in-laws. Discuss strategies that can be implemented toimprove elder care of these older adults and decrease caregiver burden and depression.

4. Environmental modifications are necessary to ensure safety for older adults. Discuss what types of environmentalmodifications are needed for older adults in the home and in the community.

Discussion Questions:

Future Implications:

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As the growth of our older adult population continues to expand with the baby boomer cohort nearing retirement age, theneed for cost-effective and innovative leadership in eldercare programs will concurrently expand and grow. American lifeexpectancy has increased dramatically since the early 1900s from 49 years of age to 79 years for women and 74 years formen. New Census Bureau projections for the United States (US) estimated that by the year 2030, the over-65 age groupwould double to approximately 70 million, with the fastest growth rate to occur in the over-85 frail elderly age group (e.g.,9 million).

Frail elders are a medically vulnerable population, often experiencing problematic accessibility to health care and costlymedical services that require case management of medical, nursing, rehabilitative, mental health, social and environmentalassessments and interventions. Current health care reform and the restructuring of the health care system that focus oncost-containment of health care expenditures have posed additional challenges to this aging population.

It has been projected that by the year 2020, nursing homes will need approximately 25,000 nurses with advancedpreparation in gerontology. Given the current nursing shortage, the baby boomer population is now at risk, and physicianswho provide nursing home care are threatened with an overwhelming burden. Interdisciplinary geriatric health care teamsthat adopt primary care-prevention models, and demand particular attention to cost-containment of health careexpenditures, have been found to be extremely successful in the care of older adults. These geriatric teams consist ofphysicians, gerontological advanced practice nurses (GANP) and social workers.

The GANP has been recognized as a vital member of this core team by delivering primary care within a holistic frameworkthat addresses cultural diversity, family functioning, and the bio-psycho-social, and spiritual dimensions of aging adults.The role of the GANP is diverse, ranging from independent to collaborative practices in multiple practice sites (e.g. acutecare, long-term care, physician offices, rehabilitation centers, and home care settings). As reported in the researchliterature, GANPs provide cost-effective care, decrease hospitalization rates, improve the image of the health care facility,increase residents’ satisfaction with care, and educate ancillary staff. Therefore, GANPs are recognized leaders in elder caremanagement and will be instrumental in the development of cost-effective and innovative elder healthcare models.

uElderWeb: Cost of Eldercarewww.elderweb.com/home/node/891

uUS official site for Medicare/Medicaid Benefitswww.medicare.gov

uA Practical Guide to Caring for Caregiverswww.aafp.org/afp/20001215/2613.html

uOlder Adult Drivers: Fact Sheetswww.cdc.gov/ncipc/factsheets/older.htm

uAlzheimer’s Foundation of America www.alzfdn.org

uMedline Abstracts: Caregiver Burden and the GeriatricPatientwww.medscape.com/

uInstitute of Gerontology: Aging and Health Resourceswww.iog.wayne.edu/resources.php

uGerontological Advanced Practice Nurseswww.ngna.org

Experts’ Perspective:

Additional Resources:

Karen S. Dunn, PhD, RN is an Associate Professor in the School of Nursingat Oakland University located in Rochester Michigan. Her clinicalexperience is in Medical/Surgical Critical Care Nursing. Her program ofresearch is in the fields of gerontological nursing practice, holistic self-care practices, aging and spirituality, end-of-life care and painmanagement. Her research efforts are to promote wellness through theeffective use of holistic self-care practices.

Dunn has presented her research at numerous professional conferences.Publications include:

uPredictors of self-reported health among older African-Americancentral city adultsuPsychometric properties of a new geriatric spiritual well-being scaleuPsychometric properties of a new geriatric spiritual well-being scaleuTesting a middle-range theory of adaptation to chronic painuNursing experience and the care of dying patient uReligious and non-religious coping in older adults experiencing chronic

p a i nuTowards a middle-range theory of adaptation to chronic painuEveryday spirituality among central city elders uThe efficacy of physical restraints in institutionalized eldersuPain in nursing home residents: Comparison of residents’ self-report

and nursing assistants’ perceptions uThe prevalence of prayer as a self-care treatment modality in elders.

Dunn achieved a PhD in nursing at Wayne State University in 2001, MSNat Valdosta State University in 1997, and a BSN at Wayne State Universityin 1982.

Page 15For more information, log on to www.usatodaycollege.com

A B O U T T H E EXPERT: Dr. Karen S. Dunn Associate Professor in the School of Nursing Oakland University, Rochester Michigan

usa today collegiate case study: elderly care

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