Elder Care the Baby Generation

Elder Care

The baby generation has begun the march into their silver years, their retirement years. These years in a person's life represent, too, the years when the body's betrayal of the mind, or vice versa, often result in an individual's inability to care his or her self during the post retirement years. These years have come to be referred to as the elder care years, because the care for the elderly often becomes the responsibility of the younger family members, children, or involves the institutionalization of loved ones. In either situation, the problems family members are faced with and the choices they must consider in resolving those problems concerning the care of their loved ones can be difficult and emotionally overwhelming. In some cases, taking care of an aging parent could mean the difference between giving up a career, and even moving to a different part of the country, or going "home" after years of being away. Those are probably some of the less emotional choices that are made early in the process of elder care. Later, depending upon the nature of the elderly person's condition, there may be choices that have to be made as a family concerning bringing help into the home, or placing the loved one in a facility that can help the family cope with the care of their loved one.

When faced with these kinds of decisions, there is a lot of information that a family has to consider before making these choices. This essay is an exploration of the conditions and the information that a family needs to have when faced with the conditions and choices surrounding the care of elderly loved ones. Some of the information dealt with in this essay is emotional, and it will be new and nightmarish information to some people. However, the aging population in America is increasing daily, and they are entering the final years of the life stage. Rashmi Gupta and Vijayan K. Pillai (2002) cite census bureau reports that help put the concern of an aging American population into perspective (p. 565). They say:

One of the most notable demographic trends in the American society today is the fast pace of population aging. According to 2000 census there were nearly 37 million Americans older than 65 years of age. This population is expected to more than double and reach 82 million by mid 21st century. As baby boomers begin the process of attaining elderly status by reaching ages 65 years or older, the number of elderly will nearly double from 40.4 million to 70.1 million between 2011 and 2030 (p. 565)."

The goal should be one that affords the loved one as much love, comfort, peace, and care as possible through the years during which they transition from life to death.

Disease and Debilitation Warranting Elder Care

The range of diseases and debilitating conditions that cause an elderly relative to need care range from debilitating arthritis, dementia, Alzheimer's disease, and other conditions which leave the aging adult in a state where they cannot adequately look after themselves. The activities of daily living (ADLs) are those day-to-day functions which, when the individual is unable to perform them because of physical limitation or condition, require assistance of others in order that the elderly person is able to bathe, dress, and have meals. When unable to perform these functions, elderly people find themselves relying upon relatives, or outside social agencies to help them.

Paula B. Doress-Worters (1994) talks about the role of women, and how their roles in a changing society have been evaluated in terms of employment, marriage and child rearing (p. 597). Doress-Worters says that the concept of elder care as a facet of the traditional role of women, which evolved from the post World War II nuclear family role of marriage, home and children, to the 1960s concept of employment, marriage, family; has now taken on the element of elder care (p. 597). While women probably did perform elder care in prior years, it is perhaps the emergence of the baby-boomers, who represent the overall population in the United States by millions who in the next five to ten years will be moving from employment to Social Security retirement benefits, and, in many cases, will be in need of elder care services as they do so. However, Doress-Worters explains it more succinctly when she says that the roles of women, who were the primary care givers of the family and home prior to the 1960s, were classified by a division of labor, and to include elder care as part of their defined labor routine was, in a sense, mixing apples and oranges by the social definitions that defined the role of women prior to the 1960s (p. 597).

Since the 1960s, the division of labor, by which women were defined, broadened in perspective, that perspective is broader today. However, today there is a myriad of choices and decisions that must be made as a family. Making those choices means facing the hard fact that a loved one is suffering an irreversible disease, and that the sense of the person family members once knew is slowly slipping away from them. These are difficult times for a family as they are forced to consider altering their own lives, in addition to the cost and the intrusion of outside help (Thorslund, Mats and Parker, Marti, G., 1994, p. 29). For many families, resources are limited, and those families must look towards the private and public welfare sectors to meet the needs of their sick family members.

In the United States, managed care has altered healthcare in a large way, and elderly folks are no longer allowed to go in and out of acute hospital care for conditions that cannot be improved upon (Birenbaum, Arnold, p. 59). If the condition that the elderly person suffers from is one like Alzheimer's disease, dementia, or terminal cancer, the patient must seek alternative levels of care, other than inpatient hospitalization, which is reserved for patient care that can be positively resolved. That drastically reduces the choices available to the family for the care of an elderly loved one.

The other options are long-term nursing facility, which is not covered by the elderly person's Medicare (Birenbaum, p. 14). The other choice is homecare, when an individual comes into the home and helps care for the laundry, cleaning, and preparation of food for the individual (Birenbau, p. 23). However, the number of hours the individual can provide the family, and the activities the individual is permitted to perform on behalf of the family is strictly dictated by Medicare and Medicaid (Medicare.gov, found online at (http://www.medicare.gov/LongTermCare/Static/Home.asp).The in home health care assistant, who is not a nurse or a certified nursing assistant (CNA), is permitted a certain number of in home hours doing these responsibilities. The in home assistant does not count toward the hours that can be provided an individual with a debilitating condition who needs an in home nurse or CNA visit (Medicare.gov, online).

Each of the alternatives to nursing home care or long-term care that allow an individual elderly person to receive in home care with the benefit of financial assistance carry with them financial and health milestone requirements that establish both the medical need and the financial need for assistance. In some states, there is a participation in a Medicare supported program called PACE, which allows family members to act as paid caretakers of their family members (Medicare.gov). This is no easy decision, because the family member(s) are giving up much of their own life to become the primary caregiver to an ailing parent, whose own condition is only going to continue to deteriorate, and, if improvement is seen, it will be momentarily, eventually ceasing to occur at all.

Eventually, as the elderly person's health deteriorates, it becomes necessary to consider a nursing home or long-term facility, or even hospice care. Any one of these options can mean the family has less interaction in the care of their loved one, and are less likely to be present around the clock. They then have to rely upon the institutional system of elder care to provide care for the aging and often times incapacitated loved one who is by this time completely reliant upon others for most of their ADLs. In these instances, there is a need to be keenly aware of the situation of elder abuse that is seemingly prevalent throughout the long-term and skilled nursing facility settings, and even in the home are levels of care being rendered by family members.

Elder Care and Abuse

Elder care abuses occur in every facet of elder care, and it often goes unreported by elderly family members whose condition has caused them to have less contact with the world in which they live, and which for the most part in their life revolves around them on the outside of the home, not the inside living areas where the abuse occurs. Even an elderly person living in a major metropolitan city, with the daily activity of the city around them, is just as likely to experience ongoing abuses at the hands of family members or other assigned caregivers as are their suburban or rural counterparts. Ruth E. Mathias and a.E. Benjamin (2003) report that social workers are becoming increasingly concerned about elder abuse in long-term care settings (p. 174). A study conducted by these social scientists/authors, reveals that Medicaid related agency care demonstrates no harmful or increase in the abuse suffered by elderly people receiving care through private agencies, but that there is little social worker oversight, and because of that, reports and information supporting that fact can be misleading at this point in time (p. 174). Mathias and Benjamin reported, too, that direct care provided by family members was proven to be less abusive to the elderly than services rendered by state and private providers (p. 174).

The most concentrated areas of consumer complaints reported was the difficulty in scheduling services, language barriers, and high care-giver/assistant turnover (p. 174). These are areas of concern, because the elderly are often suffering levels of dementia that prohibit them from being fully mentally agile as they once were, there is a need for consistency and familiarity in their lives. These are obvious needs, and ones that can have an adverse impact on the patient's behavior and response to the level of care or assistance he or she is receiving. The elderly response to conditions that they do not have control over in their lives is often reported as combative behavior, resisting the services of the caregiver. Howard Litwin and Sameer Zoabi (2004) report that one of the biggest contributors of elder abuse is fatigue or stress experienced by the caregiver, which reduces the caregiver's ability to cope with the extreme physical and mental demands of caring for the elderly person (p. 133).

This adds a logical dimension to the findings of Mathias and Benjamin who reported that family caregivers reflected less instances of elder abuse (p. 174). A family member would draw on a deeper level of patience and caring during times when caring for the needs of the elderly person are met with resistance or combative behavior as a result of the patient's dementia. A family member has a deeper emotional connection to the patient that a non-family member might not be able to connect to. The family members usually have a family history of familiarity with the elderly person, which causes them to be more aware of the patient's physical ailments that render them incapacitated, and perhaps exhibiting a difficult or combative behavior. The family members' response to those kinds of incidences would be one reflecting their family ties with the patient.

For these reasons, the best solution to elder care is family members, with whom the patient has a long-term relationship and familiarity with. The research in this area supports the need for expanded programs that pay family caregivers and allow families the benefit of choosing family members as first choices in the care of their elderly family members. Perhaps, too, just as is done with family leave when young couples have children, there should be some benefit set aside with employers to ensure that for a period of time family members are compensated for time off when that time is used to provide an aging family member with 24-hour care.

Another area of the Litman and Zoabi study on elder care that reflected a marked increase of abuse is the intensity of ADL capacity (p. 133). That is, when the need for the caregiver was intensified by the patient's inability to perform a significant number of ADLs or any of the ADLs for his or her self, the instance of elder abuse was higher. Litman and Zoabi cite Pritchard (1993), who said that elder care abuse is a personal failure, because it reflects an individual's inability to deal with their own stress levels that challenged by the elderly person's level of neediness (p. 133). The needs of an elderly person can often interrupt the sleep and tranquility of hours of the day that the caregiver was, prior to the onset for the need to care for a family member or non-family client, routine in their lives. This disturbance of restful routine can increase the individual's inability to make the best decisions when handling the elderly patient.

Modernization, too, has a role in elderly abuse, Litman and Zoabi report (p. 133). They say:

Based on a comparative review, Kosberg and Garcia (1995) concluded that socioeconomic problems stemming from modernization are a decisive factor behind the increasing rates of elder abuse in developing societies. Given the geographic mobility and individualism characteristic of modern society, younger generations no longer feel obligated to venerate the older generation. On the contrary, the instrumental bases of exchange that dominate modern society act to weaken the traditional family safety net and increase the risk of vulnerability, neglect, and abuse of elderly people (p. 133)."

When caregivers are not able to relate to the socioeconomic or cultural traditions of the patient, the risk, as Litman and Zoabi have pointed out, is increased for the incidence of elderly abuses (p. 133). This is perhaps because it is too difficult for a caregiver who lacks the capacity to empathize with those elements of an elderly person's life. In the case of family caregivers, modernization continues to be a problem. Litman and Zoabi cite the example of elderly abuse Arab Israelis, whose break with tradition as a result of their Arab Israeli status creates an instrumentalized kinship or a relationship where the exchange of tradition between the elderly and the caregiver has less of a traditional value, and more of a pragmatic value (p. 133). This actually detracts from or decreases the sense of emotional bonding when the relationship becomes one based solely on the pragmatic aspects of the exchange. One conclusion might be to say that the connection of kinship has been removed, reducing the caregiver to the same level of an individual hired to provide care, but who has no familial relationship to the patient. It is understandable that the farther away from the familial ties the caregiver has with the patient, the greater the potential for abuse.

Gupta and Pillali provide insight into the potential for elder abuse in institutional settings by pointing out that institutional long-term care facilities have a 93% national average turnover rate (p. 133). This is extraordinary figure, and it reflects the stress to work relationship the employees associate with their jobs. There is perhaps no greater challenge to an institutional health caregiver than addressing the physical daily needs of patients in long-term settings. Many of the patients have suffered strokes, which limits their ability to assist with the simplest tasks like washing their bodies. The task then becomes the responsibility of the caregiver to provide daily washings of the disabled elderly person's body. In a society where so much emphasis is placed on healthy bodies and youth, the younger the caregiver, the greater the caregiver's adverse reaction to the task of dealing with the elderly person's frail and failing body that reflects all the signs and symptoms that people choose to otherwise ignore in others.

Neglect and Abuse

While many of the Works Cited here address the subject neglect and/or abuse, they really do not go into any detail in defining the appearance of those conditions. While the implications of the worst kind of abuse and neglect are signified by an article appearing in a Arlington Heights, Illinois news story, it suggests, too, that steps must be taken by relatives of elderly persons receiving non-family care either in a long-term care facility, or private individual or agency in-home services. The Arlington Heights case, as reported by Tona Kunz (2006), was an after-the-fact case, which by the time family members became concerned of foul play and alerted authorities, the primary non-family caregiver had received the patient's property in a transfer of deed, and, having been authorized with the custody and care of the patient, was able to authorize disposal of the patient's body at death without the benefit of an autopsy that would have resolved the family's concerns of foul play in the death of their elderly aunt (p. 1). The story begins with the following sentences:

garage sale sign and their aunt's possessions on the lawn were all that alerted the Kane County family that their elderly aunt had died.

When they went to find out about funeral services, they found the North Aurora woman had been embalmed and buried at the direction of a caretaker who ended up being a twice-convicted felon.

The woman's belongings were willed to the caretaker, who had also gotten her name on the property deed. Red flags went up. But it was too late.

A toxicology screen (on the deceased) would have been nice," said prosecutor Scott Larson, who handles elder abuse cases for the county. "The family could have rested easy, either way."

The death is one of several in Kane County in recent years, including three in Elburn, that make officials wonder whether some deaths from old age are really murder in disguise (p. 1)."

The article raises questions about where the family was during the period of time that the elderly aunt received care. Did they visit the residence where the aunt was receiving the in-home care? Even more important, if the family were present, how would they be able to recognize the signs of neglect or abuse of their elderly aunt? The signs are not always outwardly apparent, but can be readily detected through a physical examination of the patient the conditions in which the patient resides. If a physician determines that a patient's nutritional needs are not being met, he will prescribe supplemental nutritional drinks and other remedies to address those deficiencies. However, nutritional needs and the adherence to prescribed orders by physicians are conditions that are documented by in home care givers, and in long-term settings and nursing homes. Meticulous keeping of patient care records will support good and proper care, or make a case of neglect or abuse in those cases where the patient's failure to thrive is the suspected result of abuse or neglect.

Peg Gray-Vickrey, RN, C, DNS Associate Professor at the College of Health Professions Department of Nursing (1999), identifies some of the signs that family members should watch for when suspecting abuse or neglect of a loved one (found online at (http://findarticles.com/p/articles/mi_qa3689/is_199909/ai_n8871345/pg_2?tag=artBody;col1).Some of the signs Gray-Vickrey says to watch for are injuries and bruises, and while the elderly person's skin is often frail, Gray-Vickrey reminds us, the appearance of these injuries are worth questioning (online). Questioning these kinds of bruises and injuries is especially important when they are inconsistent with a patient's level of activity. Other signs, Gray-Vickrey says to watch for are signs of anxiety, depression, withdrawal, fearfulness, talk of suicide or hallucinations (online). These signs may be consistent with an escalating medical condition, but they may be signs, too, of abuse. It is difficult to determine some of the signs, but any time a family member detects a serious change in their loved one's attitude or behavior, that should be investigated for neglect or abuse, beginning with a physician's physical and medical examination of the patient.

Neglect and abuse are not necessarily physical acts of hitting, but have often times has to do with ignoring or neglecting the patient's physical needs for bathing, washing, and feeding. If a patient who is bedridden, that is, unable to leave his or her bed to use the bathroom or bathe, is not routinely bathed, put into fresh bed clothes, regular changing of sheets and pillow cases, and who are allowed to lay in their own urine soaked garments or their own excrement for long periods of time will have a physical reaction to those conditions. The reaction is bed sores, which intensify and become life threatening with continued neglect. The smell of urine or odor of excrement is not normal to the living conditions of persons in nursing homes or long-term care facilities, or in private in home care. These, too, say experts, are signs that the patient might not be receiving the level of care necessary to maintain the healthy conditions that will contribute the loved one's quality of life and care (Gray-Vickrey, online).

Other signs, says Gray-Vickrey, missing eye-glasses, dentures, canes, or other essentials to ensure that the patient can sustain his or herself in some of the ADLs to the extent capable (online). Legal authorities recommend an elder care checklist, and suggest that family members whose loved ones are receiving nursing facility, long-term, or in home care keep a check list (seen Addendum One) (Findlaw.com, 2008, online at (http://public.findlaw.com/elder/le25_d.html).

Reporting Elder Abuse

One of the things that healthcare experts and legal experts agree upon, is that abusing elderly patients entrusted to the care of family members or institutional or agency professionals is a crime (Harris, Kaisha, 2005, p. 7). In some cases, even banks whose action or oversight fails to notice red flags on the accounts of their senior citizen customers can be held accountable for the financial losses of those customers (Harris, p. 7). Suzanne R. Kunkel and Valerie Wellin (2006) recommend that healthcare agencies providing long-term, skilled nursing, and in home care services to elderly patients provide oversight and review (p. 45). Facilities that make oversight and review a practice, and keep in good professional and facility standing with outside organizations who certify facilities as meeting certain provider standards, mitigate their risks associated with allegations and suits arising out of elder care abuse by staff.