THE NATION’S NEWSPAPER

Collegiate Case Study
Caregivers struggle with denial, disintegration
By Kathleen Fackelmann ................................................................................4-5

www.usatodaycollege.com

Elderly Care
It has been projected that by the year 2020, nursing homes will need approximately 25,000 nurses with advanced preparation in gerontology. Given the current nursing shortage, the baby boomer population is now at risk, and physicians who provide nursing home care are threatened with an overwhelming burden. This case study explores how aging parents and their children cope with ailments and the growing cost of health care.

Juggling work, care for aging parent
By Stephanie Armour ................................................................................6-7

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

Seniors head south to Mexican nursing homes
Low costs, climate luring elderly across the border
By Chris Hawley USA TODAY AJIJIC, Mexico — After Jean Douglas turned 70, she realized she couldn't take care of herself anymore. Her knees were giving out, and winters in Bandon, Ore., were getting harder to bear alone. Douglas was shocked by the high cost and impersonal care at assisted-living facilities near her home. After searching the Internet for other options, she joined a small but steadily growing number of Americans who are moving across the border to nursing homes in Mexico, where the sun is bright and the living is cheap. For $1,300 a month — a quarter of what an average nursing home costs in Oregon – Douglas gets a studio apartment, three meals a day, laundry and cleaning service, and 24-hour care from an attentive staff, many of whom speak English. She wakes up every morning next to a glimmering mountain lake, and the average annual high temperature is a toasty 79 degrees. "It is paradise," says Douglas, 74. "If you need help living or coping, this is the place to be. I don't know that there is such a thing back (in the USA), and certainly not for this amount of money." As millions of baby boomers reach retirement age and U.S. health care costs soar, Mexican nursing home managers expect more American seniors to head south in coming years. Mexico's proximity to the USA, low labor costs and warm climate make it attractive, although residents caution that quality of care varies greatly in an industry that is just getting off the ground here. An estimated 40,000 to 80,000 American retirees already live in Mexico, many of them in enclaves such as San Miguel de Allende or the Chapala area, says David Warner, a University of Texas public affairs professor who has studied the phenomenon. There are no reliable data on how many are living in nursing homes, but at least five such facilities are on Lake Chapala.

Your aging parents and you
By Mindy Fetterman .............................................................................. 10-12

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

Case Study Expert:
Karen S. Dunn, Ph.D. Associate Professor, Oakland University .............................................................................. 16

USA TODAY Snapshots®
Are options for care of the aging better?
How are the care options for aging available to you no w compared with what was available for your parents?

Source: Financial Freedom Senior Funding survey of 1,063 seniors 62 to 75 years old. Margin of er ror ±3 percentage points.

Better 55%

Same 13% Worse 11% Not sure 21%

By Jae Yang and and Bob Laird, US A TODAY

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

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

"You can barely afford to live in the United States anymore," said Harry Kislevitz, 78, of New York City. A stroke victim, he moved to a convalescent home on the lake's shore two years ago and credits the staff with helping him recover his speech and ability to walk. "Here you see the birds, you smell the air, and it's delicious," Kislevitz said. "You feel like living." Many expatriates are Americans or Europeans who retired here years ago and are now becoming more frail. Others are not quite ready for a nursing home but are exploring options such as in-home health care services, which can provide Mexican nurses at a fraction of U.S. prices. "As long as the economies of the United States and Europe continue to be strong, we're going to see people coming here to Latin America to pass their final days," said Oscar Cano, manager of Apoyo a los Miguelenses Ancianos, a group that runs a nursing home in San Miguel de Allende. Cozy cottage, meals, health care Retirement homes are relatively new in Mexico, where the aging usually live with family. There is little government regulation. Some places have suddenly gone bankrupt, forcing American residents to move. Some Mexican homes have rough edges, such as peeling paint or frayed sofas, that would turn off many Americans. "I don't think they're for everyone," said Thomas Kessler, whose mother suffers from manic depression and lives at a home in Ajijic. "But basically, they've kept our family finances from falling off a cliff." Residents such as Richard Slater say they are happy in Mexico. Slater came to Lake Chapala four years ago and now lives in his own cottage at the Casa de Ancianos, surrounded by purple bougainvillea and pomegranate trees.

Cost of care
Nursing h omes and in-home health services are relatively new in Mexico, where m ost seniors live with a family member. In L ake Chapala, a private room in a nursing home costs $18$50 per day c ompared with an average of $206 in the USA. How the countries compare: Number of for-profit nursin g homes: USA Mexico 288 9,900

baked dogfish stuffed with peppers, garlic bread and a choice of four cakes and two Jell-O salads. Slater's neighbor doesn't like Mexican food, so a nursing home employee cooks whatever she wants on a stove beside her bed. Like many retirees, Slater has satellite television, so he doesn't miss any American news or programs. When he wants to see a movie or go shopping downtown, the taxi ride is only $2-$3. Guadalajara, a culturally rich city of 4 million people, is just 30 miles away. For medical care, Slater relies on the Mexican Social Security Institute, or IMSS, which runs clinics and hospitals nationwide and allows foreigners to enroll in its program even if they never worked in Mexico or paid taxes to support the system. He recently had gallbladder surgery in an IMSS hospital in Guadalajara, and he paid nothing. Many of the nursing home employees speak English, and so does Slater's doctor. The Casa de Ancianos began taking in foreigners in 2000 as part of an effort to raise extra money, director Marlene Dunham said. It built the cottages especially for the Americans and uses the income received from them to subsidize the costs of the 20 Mexican residents at the home. The program was so successful that the nursing home has plans for 12 more cottages, a swimming pool, a Jacuzzi and a gazebo with picnic area. The nursing home now advertises on the Internet and through pamphlets distributed in town. Some U.S. companies have also begun investing in assistedliving facilities in Mexico, said Larry Minnix, president of the American Association of Homes and Services for the Aging, which represents 5,800 nursing homes and related services. However, Minnix cautioned that lax government regulation poses dangers at smaller homes.

Cost of a home health c are aide: (per hour) U .S. average Mexico $19 $9

Cost of a homemaker -companion: (per hour) U .S. average Mexico $17 $2-$5

N ote: Mexican costs are from a survey of facilities in five cities. Sources: Me tLife Mature Market Institut e; Mexico’s National Institute of Statistics, Geography and Information Processing; U.S. Centers for Disease Control and Prevention; US TODA Y research A By Frank P ompa, USA TODAY

He has plenty of room for his two dogs and has a little patio that he shares with three other American residents. He gets 24-hour nursing care and three meals a day, cooked in a homey kitchen and served in a sun-washed dining room. His cottage has a living room, bedroom, kitchenette, bathroom and a walk-in closet. For this Slater pays $550 a month, less than one-tenth of the going rate back home in Las Vegas. For another $140 a year, he gets full medical coverage from the Mexican government, including all his medicine and insulin for diabetes. "This would all cost me a fortune in the United States," said Slater, a 65year-old retired headwaiter. On a recent afternoon, lunch at the Casa de Ancianos consisted of vegetable soup, beet salad, Spanish rice,

Reprinted with permission. All rights reserved.

Page 2

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

"It's the same danger you have of going across the border looking for cheap medications," Minnix said. "If you don't know what you're getting, and you're not getting it from people you trust, then you've got an accident waiting to happen."

cover care or medicine as long as patients are outside the USA. Some American residents said they had doubts about the quality of Mexican medical facilities and would go back to the USA if they became seriously ill. Jim May, 74, a resident of the Casa de Ancianos, said he recently decided to move to Texas to be closer to Veterans Affairs hospitals. The language barrier can be daunting, and Mexican food can be very different, some residents said. Some residents said they miss home and find it hard to make friends with Mexican residents. "It's a very nice place, but it's lonesome," said Polly Coull, 99, of Seminole, Fla., a resident at Alicia's Convalescent Nursing Home in Ajijic. Mexican entrepreneurs are doing their best to prepare for a tide of Americans. In the Baja Peninsula town of Ensenada, the Residencia Lourdes opened in 2003, offering care for patients with Alzheimer's disease and senile dementia. The towns around Lake Chapala have at least five small retirement homes. Most of them opened in the last five years and house from one to 25 foreigners. The largest, Alicia's Convalescent Nursing Home, consists of four renovated homes, one of them specializing in stroke victims and another for Alzheimer's patients. Prices range from $1,000 to $1,500 a month and include everything except medicine and adult diapers. The rooms are outfitted in Mexican style, with murals, handcarved beds, arched ceilings lined with brick and individual patios. In other American enclaves, in-home nursing services have sprung up to serve the retirees. In Rosarito, just south of the U.S. border, INCARE provides nursing aides to retirees starting at $8.33 an hour, less than half the cost of the same service in nearby San Diego.

Developers look to Mexico
Developers of "independent living" facilities for seniors are also beginning to look to Mexico. A Spanish-U.S. venture is building Sensara Vallarta, a 250unit condominium complex aimed at Americans age 50 and older in the Pacific 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 officials are beginning to take notice. In March, the University of Texas at Austin held a forum for developers, hospital officials, insurance companies and policymakers to discuss health care for retirees in Mexico. "With the right facilities in place, Mexico could give (American retirees) a better quality of life at a better price than they could find in the United States," says Flavio Olivieri, a member of Tijuana's Economic Development Council, which is seeking funding from Mexico's federal government to build more retirement homes. "We think this could be a very good business as these baby boomers reach retirement age," he says.
Hawley is the Latin America correspondent for The Arizona Republic and USA TODAY.

'Nice place, but it's lonesome'
Since many nursing homes are run out of private homes, regulation by state health departments is often spotty. Managers such as Beverly Ward of Casa Nostra and Maura Funes of El Paraiso, both in Ajijic, said that Mexican officials inspect them only once a year, unlike U.S. inspectors, who may visit a home several times a year. The U.S. Embassy said it had no record of complaints against Mexican nursing homes, but some residents in the Lake Chapala area reported bad experiences at now-defunct homes. The first home that Jean Douglas lived in after she moved from Oregon was staffed by "gossips and thieves," she said. It went out of business. Irene Chiara of Los Angeles also lived in a home that was shut down by Jalisco state authorities. "It was filthy, and the food was very bad. It was all made in the microwave," she said. Some Mexican managers also underestimate the costs and difficulty of running a retirement home. Two hotels turned into assisted-living facilities, The Spa in San Miguel de Allende and The Melville in the Pacific Coast city of Mazatlan, recently abandoned the business, their managers said. "It was very expensive to run it," said Luis Teran, manager of The Melville. Some managers said they were especially selective when admitting foreign residents, to make sure they'll be able to pay. Medicare, Medicaid, the Department of Veterans Affairs and most U.S. insurance companies will not

Rosarito
Mexico

Texas

San Miguel de Allende

Gulf of Mexico Mexico Cit y

A jijic
Pacific Ocean
0 Miles
Source: ESRI

Chapala
500

Guatemala

N
USA TODAY

Reprinted with permission. All rights reserved.

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

Caregivers struggle with denial, disintegration
Watching a loved one sink into Alzheimer's can be harrowing
By Kathleen Fackelmann USA 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 institutions. Both have Alzheimer's, and one is in the final stage 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 with the task of caring for a relative with Alzheimer's or some other form of dementia, according to the Chicago-based Alzheimer's Association. Family caregivers help out with household chores and perform all kinds of services, including personal care. One in four caregivers have the equivalent of a full-time unpaid job: They're spending at least 40 hours a week providing services to a loved one, the association says. Caregivers who don't get any relief can develop anxiety and depression and are prone to getting sick themselves, says Jan Busby-Whitehead, a spokeswoman for the American Geriatrics Society Alzheimer's often forces caregivers to step in and make decisions for a relative who's showing signs of impairment, says Larry Wright, director of the Schmieding Center for Senior Health and Education in Springdale. About two years ago, after her mother ran a red light and got into a minor fender-bender, Center had to take away the car keys. Her mother disagreed with the decision. "She got very angry," says Center, adding that her mother still insists she is a safe driver. Kathryn Betts Adams, a researcher at Case Western Reserve University in Cleveland, says people with Alzheimer's and their family members will try to stick with 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 with Alzheimer's when Romine, who had already been showing 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 she soon found that her efforts sparked arguments with her mother, who didn't or wouldn't acknowledge the disease 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 left with constant worry. "It's so frustrating, because they don't allow me to help the way I should," she says. She has tried to hire caregivers to help out, but her parents have rejected each one for different reasons. So the family muddles along. Center, who works part time as a clerk in a Cracker Barrel store, does the grocery shopping for her parents. She buys lots of frozen dinners that her father can easily pop in the microwave. Center says her mother still wants to cook, even though she has started at least one fire. To avoid an argument, she tells her mother that the stove is broken: "There's just no reasoning with her." Alzheimer's destroys the brain regions that govern thinking ability, judgment, and even emotion and behavior. People who have the disease can lash out in anger, and that makes the job much harder, Wright says. Page 4

Reprinted with permission. All rights reserved.

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

Adams says many families resist getting help until a crisis occurs. Center says her mother, who has balance problems, still takes a bath by herself. She worries that Romine will slip and fall, but she can't get her parents to agree to any assistance with the routine. "It's going to take an accident of some kind before my father ever agrees to get help," she says. The stress and worry has driven Center to seek out some solace, which she gets by going to a support group for people who care for relatives with Alzheimer's. She says just talking to others who are going through the same thing can help. Her children — she has three grown daughters who live nearby — also help out from time to time. People with Alzheimer's can live for 10 years with ongoing destruction of brain tissue, Wright says. The disease

starts off with mild memory loss and other subtle problems. But then they have more and more trouble forming even routine tasks. In the end, people with advanced disease are completely helpless and mute. They usually die of an infection or some other complication. Center has seen this dreadful progression up close: One of her aunts is bedridden and doesn't recognize her. She has stopped eating. For now, Center's mother still lives at home but has become increasingly difficult. She puts household items in odd places. She lashes out and is sometimes paranoid. She repeats things over and over and sometimes can't remember past events — even the good times. "I see the deterioration and it scares me," Center says. "I don't know what we'll have to go through in the future.”

USA TODAY/ABC News/Gallup Poll n

Who’s caring for elderly parents
USA TODAY/ABC News and G allup polled b aby boo mers ab out caring for elderly parents. Here’s what we found: Do you have any paren ts, step-parents, ado ptive paren ts or Of those who said yes, if you are not cur rently providing parents-in-law who are cur rently alive? assi stance, do you expect to have to take care of a parent in the fu ture? No opinio n No 27% Yes 73% 8% Y 37% es No 55%

If you have a living parent, where do they live? Ass isted-living or lo ng-term care facility 12% Li i v ng with you in your h ome 8% Li i v ng with a relative in their home 8% None of these 73% Have you talked to your parents ab out how to handle t heir health care after t hey can no longer care for themselv es?

Are you providing any ass i tance? s Financial h el p

How concer ned are you ab out being able to provi de care in th e future? Very concerned Somewhat concerned Not too concerned Not concerned at all No opinion

4%
Personal care

30%
Both financial and personal c are

21% 27% 28% 23% 1%

7%
Not providing ongoing care

59%

If you have t alked to your p arents a bout how to handle their care in th e future, how did the discussio n go ? Ver y easily Somewhat easily Somewhat difficult Very difficult No opinio n

No 48%

Yes 52%

32% 28% 28% 10% 2%

Source: USA TOD AY/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 point s.

By Robert W. Ahrens, USA TODAY

Reprinted with permission. All rights reserved.

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

Juggling work, care for aging parent
Some companies help their workers
By Stephanie Armour USA TODAY Sheree Anderson of Sioux Falls, S.D., calls her mother, Virginia Harvey, her best friend. She considers it a labor of love to care for her in her home now that her mom is 87 and prefers not to live on her own. But for Anderson, the need to balance her work demands with her role as a caregiver poses a persistent challenge. When she goes on business trips, she has her sister drive several hours to stay with Virginia. She also structures her work hours around the need to run errands 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 meals and give her medicine. I'm tied to a routine, and I try to work in-between." For both employees and the self-employed, shouldering the burden of caring for an elderly parent while also meeting job demands can be a Herculean task. The nation includes an estimated 34 million unpaid caregivers for adults, typically older relatives, according to a study released this week by AARP. Nearly 60% of male caregivers work full time, as do 41% of female caregivers, according to the National Alliance for Caregiving and AARP. But as the ranks of employed caregivers swell, a small but growing number of employers are beginning to establish novel programs to provide help and scheduling flexibility. Twenty-six percent of companies offer an elder care referral service, which helps employees connect with service providers or other services, according to a 2006 survey by the Society for Human Resource Management of small, midsize and large companies. Five percent provide emergency elder care help (such as contracting with a firm that has nurses or other providers who can help care for an elderly relative), and 3% subsidize the cost of elder care. Programs for federal employees vary by agency, but some provide telecommuting, caregiver fairs and lunchand-learn events on elder caregiving issues. Still, attention to the issue isn't meeting employee needs, says Randall Abbott, a consultant at Watson Wyatt Worldwide, a benefits consulting firm. "Employers are doing incrementally more but not as much as you'd expect, given the changing demographics," Abbott says. "I continue to be amazed there is not more attention paid to this. (The caregiving) population is huge, and it's an enormous drain on productivity." Employees who lack access to programs or flexible work schedules typically must use vacation time or sick days or limit their caregiving to weekends, notes Cali Williams Yost, author of Work+Life: Finding the Fit That's Right For You. They can take unpaid time off to care for an aging parent under the federal Family and Medical Leave Act. That time off can be taken in segments, such as a few hours to 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 help employees find caregivers and nursing homes, on-site classes for employee caregivers, webcasts, online lectures and moderated chats. A 2004 internal survey found that 36% of IBM employees are affected by elder care issues, up from 9% in 1986. "These programs are important because it's a retention issue, but it's also to motivate talent," says Maria Ferris, IBM's director of global workforce diversity. "To the degree employees are worried about an elderly parent, they're not productive." Page 6

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

uErnst & Young provides consultations to help employees learn about available resources, from assisted living to nursing homes. The service also addresses the emotional and psychological aspects of being both a caregiver and an employee. The accounting giant also provides backup emergency adult care services, whereby a service provider will visit an employee's or relative's home to help provide care. Employees are allowed 12 days each year for each dependent, and the cost is subsidized. There are also seminars on elder care issues and, in some locations, caregiver discussion groups in which employees can share experiences. In addition, the company offers some flexible-scheduling options to help with work and elder care demands. uXerox provides elder care consultations and referrals that help employees find caregiving services. The consultants help with such issues as finding transportation for elderly parents, meal services and Medicare. Xerox also has a program to help deal with the pressures of juggling work and family duties. Demand for such services is growing. Bright Horizons, a company that offers a network of in-home providers, says it's seen a rise in employers interested in backup emergency elder care programs. The company, which launched the service less than a year ago, has had about 75 major employers sign up. "They're trying to help employees," says Dave Lissy of Bright Horizons, based in Watertown, Mass. "(The service) builds loyalty to the employer and helps employees be more productive at work." But for many employees, especially those also caring for children, the need to help an elderly parent can impose an emotional strain for which referral services are hardly enough, says Richard Chaifetz, CEO of ComPsych, an employee-assistance provider. "The psychological drain can be enormous," Chaifetz says. "It results in more absenteeism, distraction and lost productivity for employers. We're seeing this grow dramatically." For some employees with aging parents, employer services have been a relief and an invaluable help. Rosemary Ray, 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 company provided to learn more about the issue and to speak with 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," says Ray, an IBM business analyst. "I could see I am not the only one dealing with this. Peace of mind helped a lot. It made me feel better talking to a professional in this field.”

Tips for balancing care, work
Employees with aging parents or other relatives often find they must negotiate with their employers to take time off to care for family while also remaining productive on the job.

It's a tricky balancing act. Some advice:
uFind out if your employer must follow the federal Family and Medical Leave Act. If so (for example, if your company has 50 or more employees), you're entitled to up to 12 weeks of unpaid time off annually to care for a parent with a serious health condition. Generally, that time can be taken in increments. uFind out if flexible arrangements are possible. These might include formal programs as well as informal agreements. "The more you can make the workplace fit your needs, the better," says Elinor Ginzler, co-author of Caring for Your Parents: The Complete AARP Guide. uFlexibility is especially vital for employees who are long-distance caregivers. Employees Some helpful web sites: should find out if they can work remotely (for www.aarp.org example, they may be able to work from the www.caregiving.org home of the relative they're caring for). www.caregiver.org

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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 disaster
By Robert Davis USA TODAY As they age, drivers tend to take their cars on shorter trips. But even so, health problems often catch up with them. Reflexes, flexibility, visual acuity, memory and the ability to focus all decline with age. Because no two people age exactly the same way, one 80-year-old can be more fit to drive than another 70-year-old. Doctors and advocacy organizations who specialize in treating the elderly say medical professionals, family members and friends must do more to watch for early warning signs of medical problems that affect safe driving. uAlzheimer's disease, a disorder that causes memory loss, can cause slower reaction times, problems judging space and distance, and a diminished ability to plan ahead. It also can increase the risk of getting lost, being confused by divided highways and one-way streets, and being in an accident. uDiabetes, a blood sugar disorder, can damage the nerves in hands, eyes and feet. This can slow reaction time and limit vision. If blood sugar levels dip too low, a driver may feel dizzy or shaky and become confused or even lose consciousness. Diabetics should check their blood sugar levels before getting behind the wheel. *Parkinson's disease, a neurological condition that causes rigidity, slowed movement and tremors, may affect the ability to turn the steering wheel and make quick movements. uStroke, which is caused by an interruption in blood flow to the brain, damages brain tissue and may cause balance problems, diminished vision and a loss of muscle control. "All of the sensory input you take in constantly as you drive is really amazing," says Laurel Coleman, a geriatrician from Augusta, Maine, who serves on the board of the Alzheimer's Association. "You do so many things automatically 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 problems can be an indication of how they will act behind the wheel of a car. "I get concerned when somebody doesn't problem-solve very well," Coleman says. "When they tend to do the same thing in response to a problem, I get concerned because driving requires you be very adaptive. "You will see things happen that you have not seen before. Somebody will pull in front of you. There will be a detour. There will be something different. That is where it gets very challenging." As a result, the signature crash for elderly drivers occurs when their paths cross with others who are following traffic rules. They turn in front of oncoming cars that they never see, studies have found. They miss red lights or stop signs. And they crash while making routine trips. For instance, weekends are risky times for teenagers to be on the road. But according to data from the Center for the Study & Improvement of Regulation at Carnegie Mellon University in Pittsburgh, the mile-for-mile fatality rate is about three times higher for drivers 85 and older on weekdays. "People should not have to get into car accidents or get pulled over by state police for health care providers or families to take notice," Coleman says. "We should have heightened awareness and that is all of us, not just medical professionals but your neighbors and your family." Coleman has to push some patients hard. She has written letters asking the Department of Motor Vehicles to retest patients who then lost their license. "Sometimes patients will never speak to me again," she says. "But driving is a privilege and it's not a right. I don't want to be cavalier about it, because the potential risks and consequences are so great."

Reprinted with permission. All rights reserved. Reprinted with permission. All rights reserved.

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

Before you get behind the wheel
Safety experts say that senior citizens can take steps to ensure that they are competent drivers. "It's part of the responsibility of the individual to be aware of their own driving behaviors and do everything they can to be safe on 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 familiar areas. 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 car
Experts suggest you retire the keys if you: uAre inattentive, make erratic moves, react too slowly, get anxious at busy intersections, feel unsure of what to do or are afraid to drive. uHave trouble with gas or brake pedals. uHave received several traffic tickets or warnings from police in the 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 sometimes dent or scrape the car. uMiss traffic signals or are uncertain of what they mean, or if you get lost. uGet honked at by other drivers. uUpset your passengers, or if people refuse to ride with you. Reprinted with permission. All rights reserved. Page 9

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

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

How aging affects the ability to drive
Mind
Reactio n time sl ows, confusion grows, quick decisions become more difficult and distractio ns have greater impact.

Eyes
Aging causes several vision problems that can interfere with dr iving: Cataract s cloud the lens of the eye, causing blurred or hazy vision. The dr iver be comes more sensitive to light and glare; night driving c an be difficult.

Neck
The neck stiffens, moti on becomes painful, glancing over one shoulder to look for traffic becomes difficult. Arthr itis can make it hard to grip the steering wheel .

Glaucoma raises pressure inside the eyeball, re ducing peripheral vision and making it more difficult to see a pedestrian or vehicle coming from the side.

Macul ar degenera tion causes loss of the central porti on of vision, making it more difficult to see other cars or pedestri ans coming toward you.
Effects simulated by Frank Pompa, USA TODAY

Knees, ankles, feet
Joints stiffen, foot and knew movement b ecomes difficult and p ainful, gas pedal gets pushed instead of brake.

Medications
Prescription drugs that may cause drowsiness or slow reaction time: Benzodiazepin es v Ativan v Valium Opioids v Morphine v Oxycodone Antidepressants v Paxil v Elavil Hypnoti cs v Ambien v Lunes tra Antips ychotics v Risperdal v Mellaril Antihistamines v Benadryl v Clar inex Glaucoma agents v Xalatan v Trusopt Muscle relaxa nts v Flexaril v Skelaxin

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

By Frank P ompa and Alexandria Newman, USA TODAY By Frank Pompa and Alexandria Newman, USA TODAY

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

Your aging parents and you
First you get phone calls that seem kind of strange
By Mindy Fetterman USA TODAY MOM is quitting her bridge club because "they think I'm stealing from them." A week later, she mentions an old boyfriend from the war who's coming to take her to dinner. * You think, OK, it could be true. Then the police call from her house. "Your mom thinks there's someone hiding under her bed." * Now you know. The forgetfulness, the fantasies, are dementia, Alzheimer's, something like that. Your sister suspects the worst. * This isn't just the story of one petite brunette with terrific legs who was called "Shorty" by her husband, granddaughters and daughters, including me. * This is the story of millions of Americans caring for elderly parents and maneuvering in the murky worlds of medicine, law, hospitals, nursing homes, guilt, fear and family ties. A USA TODAY/ABC News/Gallup Poll of baby boomers finds that 41% who have a living parent are providing care for them — either financial help, personal care or both — and 8% of boomers say their parents have moved in with them. Of those who are not caring for an aging parent, 37% say they expect to do so in the future. About half say they're concerned about being able to provide such care. It's estimated that 34 million Americans serve as unpaid caregivers for other adults, usually elderly relatives, and that 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, flying into town every few weeks or months or just stopping by to take Mom or Dad to the doctor. Among boomers who are helping their parents, 89% say the responsibility is only a "minor sacrifice" or "no sacrifice at all," according to the USA TODAY poll. But as their elderly parents get older, some boomers are beginning to worry they won't be able to care for them in the future. AARP estimates that the economic impact of this "free" care was about $350 billion in 2006. That's more than the U.S. government spent on Medicare in 2005. It exceeded the size of the federal budget deficit in 2006. AARP estimates that unpaid caregivers who contribute financially spend an average of $2,400 a year on care. Those who put in more than 40 hours a week spend much more: an average of $3,888 of their own money each year, AARP says. But when a parent actually moves into the children's home, the total cost isn't really added up. Families pay and pay and pay, emotionally and financially. The typical unpaid caregiver is a 46-year-old woman who works outside the home while taking care of a relative, according to AARP. That burden forces her to cut the hours she works at her regular job by about 41%, causing her salary and benefits to fall sharply. The National Alliance for Caregiving (NAC) estimates that $659,000 per person is lost in pensions, Social Security benefits and wages as adult children — mainly women – take time off from work to care for their parents. The physical toll can be severe, too. Caregivers report having one or more chronic conditions, such as high blood pressure, at nearly twice the rate of all Americans. Of those who say their health has worsened because of caregiving, 91% report depression. Caring for elderly parents also can threaten the emotional health of caregivers and their families. Being the "parent of your parent" can unlock your family's hidden dysfunctions — "You were always Mom's favorite!" — and reopen old sibling rivalries and conflicts: "You're trying to kill our father! If you never really got along with your parents or your siblings, it can be even more stressful. Elder care can exhaust and sometimes demoralize the caregiver who's on the front line. And it can frighten and confuse elderly parents. "My dad was never a gentle soul when we were growing up; he was a military guy," says Nia Wilson, a lawyer with the state of Pennsylvania. "His kids were additional troops he had to keep in check." Now she spends most weekends driving about five hours from Harrisburg, Pa., to Washington, D.C., where her 84-year-old mother is caring for her 90-year-old father, who has Alzheimer's. Her two brothers live nearby 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-inlaw, aunts or nieces — typically assume the burden of care, according to the NAC. Wilson says her parents Page 10

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

want to stay in their home, even though they probably belong in an assisted-living facility, she thinks. "We keep raising the idea with Mom," Wilson says. "But she says, 'Don't worry about me. I'm OK.'" Starting to take over After a second midnight call from the police, the sergeant tells my sister: "You all need to do something about 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 an appointment. Let's go." She smiles and nods. The next thing we know, the skittish 75-year-old woman has sneaked out of the front door and scampered across the street to a neighbor's house. We find her 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 to think and reason. But right now, she's afraid of what might happen to her. She's afraid she'll be taken from her home and placed in a nursing home. So she runs. What now? A friend suggests calling in a man. "Women of that era will do what a man tells them," she says. I call my ex-husband, a man Shorty has known since he was 8 years old. "Put on a suit and tie and bring the Mercedes over," I tell him. "Shorty will go to the doctor with you." He does. He talks her out from behind the tree and into the front seat of the big car. "Can I go, too, Mom?" I ask, tentatively. Shorty talks only to John: "Tell her she can come, but she has to sit in the back seat." Starting to take over for your parents can be one of the most distressing experiences of a lifetime. "It's so much more difficult, because they are our parents; we are the children," 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 children.

"Right now," she says, "we're fighting about his driving. Not out of malice, but because I know it's better for everyone if he doesn't drive anymore. Heaven forbid if he injures himself or someone else." Her father, who has had some fender benders and mistakenly parked in the wrong driveway, disagrees. "They can take away my driver's license, but I'm still driving," he declares. After Shorty had been driving fairly cluelessly for two years or so, we hid her keys. Her dementia had progressed to the point that she didn't remember that she couldn't find the keys. She had been a widow for 25 years; driving was vital to her. A battle over keys can be the first struggle between elderly 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 what we suspected. "Your mother is very charming," the young doctor says. "She even flirted with me. But she really doesn't know what's going on." She couldn't tell time or count change. She didn't know who the president was. She didn't know what day it was. The doctor prescribes an anti-psychotic drug to help with the voices in her head. He checks her into a psychiatric ward for four days, primarily to give my sister and me 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 facilities and nursing homes. Both of us are single working women, so taking Shorty into either home isn't an option. Some facilities we see are elegant replicas of colonial homes with oriental rugs and cherry wood furniture. Lovely, but we realize she likely needs more medical care than those retirement homes could provide. (We suspect they were decorated more to please the adult children than the residents.) Other facilities are starker, more medicinal. In one, a man was screaming. Shaken, we go home. We try in-home care. But Shorty keeps firing people. We try her former house maid of 30 years, a woman who was 78 herself. She stays about five days, until Shorty throws her clothes out an upstairs window, yelling, "Get your — out of here!" Page 11

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

We try an apartment at an assisted-living condo. Shorty calls a taxi three days later and has herself taken home. She lives at home alone for another year, with my sister stopping by each day after work to check on her. Very stressful. Finally, we have her committed. We get a lawyer, take her to court and have her declared incompetent. We sit across from a jury and testify against our own mother. My sister is named her guardian. We check her into a nursing home with an Alzheimer's wing. That means 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 declared incompetent. Now she must file forms with the court every six months to prove she's not wasting or stealing her grandmother's money. "I'm the legal guardian of my grandmother, who has dementia," says Payton, 35, whose parents are deceased. "I thought, 'How could me, a grandchild, take her to court 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 effort you ever made to become independent can be put to the test once your parents become old and sick. You find yourself arguing with your siblings, arguing with your spouse, arguing with your parents, arguing with yourself "The No. 1 thing you'll fight about is money," says David Horgan, a producer of TV commercials from Ludlow, Mass. His 69-year-old mother-in-law moved in with him and his wife, Julie, and three kids about three years ago. "We fight about Grandma a lot. My wife will say: 'What do you want me to do? It's my mother!' And it goes back and forth, and then it escalates. As a good daughter, she always feels guilty, and I always come out the bad guy."

They've spent thousands of dollars on a new air-conditioning system for their home because of his mother-inlaw's lung problems. He loves and admires her but feels crowded in his own home. "The toughest thing is that she is a beautiful woman, the kindest and nicest person," he says. "She'd do anything for you. But as soon as you live on top of each other, it's hard." Lucero has nine half-siblings. Her father, who divorced her mother when Lucero was young, lived with one son for two years. He has only Social Security and some veteran's benefits, about $600 a month. No savings. He can't afford a nursing home or an assisted-living facility. She wishes his other children would help more. "It was my choice to take him on, but now that he lives with me, they say, 'Oh, Julie's got it covered.'" In my mom's case, one daughter lives near Shorty, the other — me — lives hundreds of miles away. So the nearest sister gets the burden of visiting every week, often twice. She's saddled with the emergency runs to the hospital and trips to the doctor's office. The faraway sister spends thousands of dollars on plane tickets and rental cars and buys most of her mother's clothes and necessities. She spends money to keep up her mother's house, so we can sell it. She spends money because she's not there to help, and she feels guilty about 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 and most of her stuff. We divide the valuable and sentimental things. I ship home my new antiques. We realize we've done exactly what Shorty feared that day she ran across the street and hid behind the tree: We've sold her belongings, taken her rights and put her in a nursing home. In our minds, we know we did the right thing. But we feel terrible. Epilogue: Evelyn Fetterman died in February at age 84. She had been living in assisted living or a nursing home for 10 years. Her daughters are sad and tired. They miss their mom the way she used to be. They're relieved that it's all over. And for that, they feel terrible.

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Discussion Questions:
1. Most often, the role of taking care of older adults is viewed negatively because of ageist stereotypes. The major reasons for this are a lack of knowledge regarding what are normal age-related changes and consequences of illness or disease. For example, most people think that if they live long enough, they will become senile. This is a myth. Even among those who live to be 80 or older, only 20-25 percent will develop Alzheimer's disease or some other incurable form of brain disease. "Senility" is a meaningless term which should be discarded. Therefore it is essential to know what is normal and what is not. Discuss what you believe are normal age-related changes and what are consequences of illness or disease. 2. Mistreatment and neglect of elders still prevail even though our government has attempted to intervene through stricter laws and regulations. Much of this can be attributed to caregiver burden and stress. Discuss other governmental 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 our global economy, discuss what impact this may have on our economy. What are the pros and cons? Discuss how 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. By 2030, 70 million people (20%) of the population will be 65 years and older. Older adults however, are at increased crash risk per mile driven and are predicted to cause 40% of all fatal crashes by 2025. Discuss why older adults are at a higher risk for fatal car crashes. Discuss strategies that can be implemented to promote older drivers’ safety and mobility.

Future Implications:

1. Many assisted-living and long-term care facilities have adopted principles and practices highlighted in the “Eden Alternative.” The major goal of the Eden Alternative was to eliminate helplessness, hopelessness and boredom that plagued nursing home residents by creating richer human habitats. Dull institutional environments would be transformed into home-like habitats with the inclusion of animals and plants that the residents could care for. In addition, children would be brought in to provide companionship, recreation and play for the residents. This alternative 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? What implementation strategies can be done to improve the outcomes of this alternative model? Develop a new model that you 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 in America. 3. Most people believe that older adults with Alzheimer’s disease are institutionalized. This is a myth. The majority are cared for in the home by spouses, daughters, or daughter-in-laws. Discuss strategies that can be implemented to improve 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 environmental modifications are needed for older adults in the home and in the community.

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Experts’ Perspective:
As the growth of our older adult population continues to expand with the baby boomer cohort nearing retirement age, the need for cost-effective and innovative leadership in eldercare programs will concurrently expand and grow. American life expectancy has increased dramatically since the early 1900s from 49 years of age to 79 years for women and 74 years for men. New Census Bureau projections for the United States (US) estimated that by the year 2030, the over-65 age group would 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 costly medical services that require case management of medical, nursing, rehabilitative, mental health, social and environmental assessments and interventions. Current health care reform and the restructuring of the health care system that focus on cost-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 advanced preparation in gerontology. Given the current nursing shortage, the baby boomer population is now at risk, and physicians who provide nursing home care are threatened with an overwhelming burden. Interdisciplinary geriatric health care teams that adopt primary care-prevention models, and demand particular attention to cost-containment of health care expenditures, have been found to be extremely successful in the care of older adults. These geriatric teams consist of physicians, 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 framework that 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. acute care, long-term care, physician offices, rehabilitation centers, and home care settings). As reported in the research literature, 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 care management and will be instrumental in the development of cost-effective and innovative elder healthcare models.

Additional Resources:

uElderWeb: Cost of Eldercare www.elderweb.com/home/node/891 uUS official site for Medicare/Medicaid Benefits www.medicare.gov uA Practical Guide to Caring for Caregivers www.aafp.org/afp/20001215/2613.html uOlder Adult Drivers: Fact Sheets www.cdc.gov/ncipc/factsheets/older.htm

uAlzheimer’s Foundation of America www.alzfdn.org uMedline Abstracts: Caregiver Burden and the Geriatric Patient www.medscape.com/ uInstitute of Gerontology: Aging and Health Resources www.iog.wayne.edu/resources.php uGerontological Advanced Practice Nurses www.ngna.org

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

Karen S. Dunn, PhD, RN is an Associate Professor in the School of Nursing at Oakland University located in Rochester Michigan. Her clinical experience is in Medical/Surgical Critical Care Nursing. Her program of research is in the fields of gerontological nursing practice, holistic selfcare practices, aging and spirituality, end-of-life care and pain management. Her research efforts are to promote wellness through the effective 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-American central city adults uPsychometric properties of a new geriatric spiritual well-being scale uPsychometric properties of a new geriatric spiritual well-being scale uTesting a middle-range theory of adaptation to chronic pain uNursing experience and the care of dying patient uReligious and non-religious coping in older adults experiencing chronic pain uTowards a middle-range theory of adaptation to chronic pain uEveryday spirituality among central city elders uThe efficacy of physical restraints in institutionalized elders uPain 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, MSN at Valdosta State University in 1997, and a BSN at Wayne State University in 1982.

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