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When Should Dad Go to a Nursing Home?

After a diagnosis of Alzheimer’s Disease (AD), many families and caregivers face the tough question of, “Should I put my loved one in an assisted-care facility or care for them at home?” Discuss these 10 important questions with your family to figure it out. From The 10 Best Questions for Living with Alzheimer’s by Dede Bonner, Ph.D.

Since people with AD often have good days and bad days, as you are working through this assessment, you may want to evaluate your loved one every day over a week or ten days for each Best Question, rather than just perform a one-time assessment. This will give you a clearer picture of your loved one’s true functional capabilities and ability to remain at home.

THE 10 BEST QUESTIONS to Decide if Your Loved One Can Remain at Home

1. How well can my loved one handle his own personal hygiene, bathing, and dressing?
The ability to dress and groom oneself independently is a prime factor when considering keeping your loved one in his home. If the person with AD has a full-time caregiver who lives in the same home, independence in hygiene, bathing, and dressing is of less concern than for people with AD who are living alone or have only part-time assistance.

Ask yourself if your loved one:

  • Routinely performs all daily bathing, dressing, and shaving activities without assistance? (Needs no/some assistance)
  • Requires reminders about daily hygiene, help with shoelaces, zippers, hooks, etc.? (Needs no/some assistance)
  • Depends on others for most or all personal hygiene, bathing, and dressing activities? (Unable to do)

2. How capable is my loved one of eating, choosing nutritious food, and preparing meals independently?
The ability to eat without assistance is a key activity of daily life. If your loved one is living alone or has only part-time care giving, she needs a higher degree of independence than someone who can depend on others for eating assistance or meal preparation.

The ability to prepare nutritious meals for oneself is also important, but to a lesser extent when community support services are available. These include Meals on Wheels (http://www.mowaa.org), a senior nutrition program operating in the United States, Canada, and Australia, or the UK-based National Association of Care Catering (http://www.thenacc.co.uk). Check out Volunteers of America (http://www.volunteersofamerica.org) or local services available through your church or synagogue.

For AD caregivers, mealtimes can be a challenging battleground. Your loved one may have a poor appetite, forget to eat, or forget that she has already eaten. Try to establish and stick with regular mealtimes, limit distractions, check the food’s temperature, and serve simple foods one at a time.

Consider whether the person with AD can shop independently or needs to be accompanied on routine grocery errands. Some people lose their understanding of money, while others may be too frail to carry packages. In some regions there are shopping services or stores that will deliver groceries to your home.

Does my loved one:

  • Plan, prepare, and eat adequately nutritious meals without assistance?
  • Rely on meals prepared by others or require assistance when eating (opening containers, pouring, cutting, etc.)?
  • Need total assistance from others for nourishment or reminders to eat?

3. How independent is my loved one with his toilet needs and continence?
The National Association for Continence defines incontinence as the involuntary loss of bladder or bowel control. This is a common problem among Alzheimer’s patients with progressed-disease symptoms and a key decision criterion for many caregivers about whether or not they can continue to care for their loved one at home. A person’s degree of incontinence can also determine eligibility for adult day care centers, professional in?home care arrangements, or assisted living facilities.

Does my loved one:

  • Demonstrate complete and independent continence on a daily basis?
  • Have occasional incontinence, a colostomy, or catheter, but can still manage with self-toileting or require only occasional assistance?
  • Have daily, uncontrollable incontinence and lack the ability to communicate about it?

4. How mobile is my loved one around the house?
In the language of a formal ADL functional assessment, mobility is often called transferring. Transferring means the person’s ability to move around inside the home, including such basic tasks as moving unassisted from the bed to a chair or to use the bathroom.

Consider if your loved one needs (or will soon need) a wheelchair, cane, or walker. Your home’s long stairways or narrow doorways may not be well suited or easy to retrofit to accommodate someone who is physically disabled.

Does my loved one:

  • Move independently from a chair, toilet, or bed?
  • Rely on a cane, walker, or wheelchair or require some assistance due to occasional confusion or physical disability?
  • Require full transfer assistance, including turning in bed and moving to and from a wheelchair?

5. Can my loved one do housekeeping and personal laundry chores?
Some experts believe this is an optional IADL for a person who has a full-time caregiver or can afford to pay someone else to perform cleaning and laundry tasks. Historically, this IADL was excluded for men.

However, if your loved one lives alone — and especially if she lives in an older house that needs regular maintenance and up- keep — this can be a major concern. For example, you may be a long-distance caregiver who worries constantly about your parents’ home falling into a state of disrepair beyond routine care.

Does my loved one:

  • Maintain the house alone to an acceptable level of cleanliness and repair with occasional outside help for gardening, painting, etc.?
  • Do light daily/weekly tasks such as dishwashing, most personal laundry, straightening, and bed making at an acceptable level of cleanliness but not do heavy cleaning or maintenance?
  • Need all home maintenance tasks, light housekeeping, and personal laundry to be done by others?

6. Can my loved one be fully trusted to always take her medications as prescribed?
It’s important that your loved one can remember to take any drugs for Alzheimer’s disease as well as medications for other conditions, such as heart disease, diabetes, or glaucoma. For many elderly people, their daily regime involves a complex dispensing schedule and a full handful of pills.

Even well-intended people with AD who are starting to slip mentally can’t remember if they have already taken today’s pills or not. As the caregiver, you need to ensure your loved one is getting proper medications and won’t be harmed by incorrect dosing. People with AD and living alone are at high risk for medication problems.

Does my loved one:

  • Take her correct medications in the correct dosages at the correct times every day?
  • Show responsibility for self-medication if the drugs are prepacked or prepared in advance in separate dosages or make only minor or occasional dosing errors?
  • Become routinely confused or prove to be incapable of self-medication?

7. How well can my loved one handle personal finances?
If your loved one lives alone, pays others for in-home care services, or still maintains the household budget and bill-paying duties, it’s imperative that he be able to manage money well and without mental impairment. The gradual loss of “money smarts” is what often leads to the headline-grabbing stories of elderly people having their lifetime savings stolen by a con artist or through a telephone, television, or Internet scam.

Evelyn, a full-time caregiver in Little Rock, Arkansas, reflects on her experiences during the last three years caring for her middle-stage AD husband, Robert. “I’ve tried to walk a fine line between giving him as much independence as I could but have always been on the lookout, too. Robert thinks he’s fine, but often he’s not. It’s just hard for him to realize he can’t do these things anymore.”

When the person with AD has a full-time caregiver who is totally responsible for the household money management, then this IADL becomes less important.

Does my loved one:

  • Manage financial matters independently (can write checks, pay bills, go to the bank, and balance the checkbook)?
  • Keep track of day-to-day purchases but need some help with banking and major purchases?
  • Become totally confused about finances and is incapable of handling money?

8. How capable is my loved one of using some form of transportation for short trips, to go shopping, or to run errands?
This measure of independence is called mode of transportation. People with early stage AD may still be able to get around fairly well, including driving. Once someone with AD can no longer drive, public transportation may be a viable option, depending on where he lives and his past familiarity with the bus, train, or taxi system.

If your loved one travels around town, you may find some peace of mind if he is wearing a medical alert identification. There are also local and national transportation services for the elderly that can suggest alternative methods of transportation. Check with your local Alzheimer’s Association or Beverly Foundation (www.beverlyfoundation.org) for community-based transportation services.

Does my loved one:

  • Travel independently on public transportation or safely drive his own car?
  • No longer drive but can arrange his own travel via public transportation or taxi?
  • Have little or no ability to travel without assistance from others due to mental confusion or physical problems?

9. How mentally aware was my loved in the last few weeks?
This Best Question is a general-assessment question for live-at-home caregivers or for long-distance caregivers who have recently talked with their loved one by telephone.

If you are a long-distance caregiver, reflect on how well your loved one uses the telephone as an indicator of mental alertness. If your loved one can operate the phone, including looking up phone numbers and dialing, this is a positive sign of alertness compared to someone who answers the phone, but can’t dial it or becomes totally confused while on the phone.

Does my loved one:

  • Show the ability to reason and remember with only occasional memory lapses?
  • Require some assistance during increasing periods of confusion, disorientation, or poor judgment?
  • Demonstrate severely impaired orientation, memory, and judgment skills or is unable to follow directions?

10. How well could my loved one respond to an emergency that required quick action or evacuation of the home?
Many caregivers focus on just getting through another day without thinking about worst-case scenarios, like a home fire or explosion or natural disaster such as floods, tornadoes, hurricanes, or severe snowstorms. Just consider the aftermath of Hurricane Katrina on the unprepared elderly people living in New Orleans who were caught in this deadly disaster.

If your loved one is not fully mobile, uses a wheelchair or walker, or is especially frail or heavyset, you need to think in advance about whether you have the physical strength to carry him out of your home in case of emergency. This is especially critical if you live in a region that is prone to seasons of hurricanes, floods, or tornadoes. If your loved one lives alone or you are a long-distance caregiver, ask yourself, What would happen to her in an emergency? Who could help her?

Does my loved one:

  • Understand and is capable of the proper evacuation procedures in case of emergency?
  • Rely on a cane, walker, or wheelchair and would need assistance during an emergency?
  • Have such severely impaired judgment that he would be totally dependent during an emergency?

ABOUT THE AUTHOR
Dede Bonner, Ph.D., aka “The Question Doctor” and author of The 10 Best Questions for Living with Alzheimer’s (Copyright © 2008 by 10 Best Questions LLC), specializes in creative breakthrough and money-saving Best Questions for corporate clients and CEOs. She is on the graduate business faculty of Curtin University in Perth, Western Australia, and is an internationally acclaimed expert in questioning skills and management. A former political analyst for the federal government, Dr. Bonner is the owner of New Century Management, Inc, and 10 Best Questions, LLC. She has a doctorate of education in executive leadership.

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