How to Assess When an Older Adult Requires Caregiving Assistance
Physical, mental and environmental tests that may signal the need for more day-to-day support
En español | Sometimes an older adult's need for additional help is obvious. It could be that he or she is having a hard time getting to appointments, seems confused by instructions or perhaps isn't paying bills on time. More often, though, the change happens gradually. That's where a professional assessment comes in. This comprehensive review of all aspects of person's mental, physical and environmental condition is one way to determine if your loved one needs assistance. This helps to evaluate his or her ability to remain safely independent and identify risks and ways to reduce them.
A family member or caregiver also has an opportunity to evaluate how a loved one is doing in terms of health, safety and quality of life. “The goal,” says Ardeshir Hashmi, M.D., section chief of the Center for Geriatric Medicine at Cleveland Clinic, “is to pick up clues early, before they start to impact day-to-day life a significant way, so we can do something about them.” Here are red flags to look for, which may signal a loved one needs further evaluation — and possibly more support.
According to the Centers for Disease Control and Prevention, each year, more than 1 in 4 older adults will have a fall. To make sure your loved one isn't part of that statistic, evaluate their living space, including potential fall hazards: unsafe indoor or outdoor stairs (especially without railings) or slippery throw rugs. Are they using unsafe stepladders or stools to reach for items on kitchen shelves? Do the soles of their shoes have good traction?
Pay particularly close attention to how well your loved one is getting around. A lack of mobility not only takes a physical toll, it can also have psychological repercussions. Lindsey Yourman, M.D., a geriatrician affiliated with the University of California, San Diego Health-Jacobs Medical Center, points to something known as life space, which is the area that you can walk to safely — meaning the environment that is available to you on a regular basis. “Decreased life space can mean decreased interactions with other people and decreased engagement in activities,” Yourman says, “which can lead to isolation and depression.”
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There are some ways to evaluate a person's mobility to see if he or she is steady on their feet. One is the timed up-and-go test: Mark a line about 10 feet from a chair. At the word “go,” ask your loved one to stand up from the chair, walk at a normal pace forward to the line, turn, walk back to the chair and sit down. On average, people who take 12 seconds or more to complete the test are at a high risk of falling. Also, observe them walking across a room and take note of their gait speed and the movement of their feet. Are they shuffling or dragging them? How far apart are their feet when walking? When someone spreads their feet far apart, that tends to indicate difficulty in balance. Other signs that may indicate strength or balance issues: difficulty rising from a chair, using furniture or a wall for support when walking, and difficulty pivoting. “If they walk down the hall and come back, how many steps does it take to turn? More than three steps may indicate a mobility issue,” Yourman says.
What to do: A certified aging-in-place specialist (CAPS) can suggest modifications to make your loved one's home safer. These may include handrails on both sides of stairs, grab bars for getting in or out of the shower or a walk-in bathtub, a higher toilet seat or added ramps. In the kitchen, make it easier to reach everyday items by storing them in lower cabinets. Add inexpensive sliding pantry organizers and shelving to cabinets for easier access. A physical or occupational therapist can also evaluate the person's home environment and mobility. A therapist can also recommend the best aid for your loved one and make sure they use it correctly. Pick-up walkers take a lot of effort, and their use can lead to a decrease in activity for someone with congestive heart failure or COPD who gets winded easily. “With a cane, you want to be sure it's the right height,” Yourman says. “If it's too tall or too low, it can throw off the mechanics of how you're walking.”
Depression can be tricky to spot in older adults. It's normal for an older person to feel down every once in a while — perhaps frustrated by health problems or worried about money. What's more, there isn't necessarily a mood component. “We have a stereotype of depression as not getting out of the chair all day, kind of folding inward,” says Luci Draayer, a Denver-based clinical social worker and therapist. “That can be part of it, but there are other symptoms.” Among them: changes in energy levels; irritability or anger; loss of interest in once-enjoyable activities; difficulty sleeping, or sleeping more than usual; eating more or less than usual; and thoughts of death or suicide.
Dementia, meanwhile, is more a memory change or impairment. The common theme is forgetfulness, more than people would expect with normal aging. “Early on, changes and difficulty with what we call instrumental activities — financial management, managing medications and driving — on a daily basis may indicate impairment caused by dementia,” Hashmi says. Another cognitive issue, says Draayer, is “a loss of insight or poor judgment — say, the bathtub was left running and overflows because they left to go watch a movie.”
Depression sometimes gets misdiagnosed as dementia, since an older adult with depression may exhibit dementia-like symptoms. “People who have depression may not concentrate as well, and that may sometimes look like memory loss and dementia — we call that pseudodementia,” says Katherine O'Brien, M.D., an assistant professor of medicine, Division of Internal Medicine and Geriatrics, Northwestern University's Feinberg School of Medicine. Being able to distinguish between the two is important. “Depression is eminently treatable,” Hashmi says. “And when depression is treated early, memory and concentration can also improve."
What to do: Ask your loved one if they're feeling sad or anxious about something. A chronic illness or limited mobility increases a person's risk of developing depression. Listen and offer emotional support. If you don't live nearby, ask friends and neighbors to look in on your loved one. Also, work with the Area Agency on Aging to develop a support plan. Or consult a geriatric psychiatrist, a doctor trained to recognize and treat mental illnesses in older people. Treatment can include antidepressants, talk therapy or a combination of the two. Visit the American Association for Geriatric Psychiatry's website to find a specialist near you. Finally, ask your loved one's primary care physician or pharmacist if a specific medication — or combination of drugs — could be causing their depression. If you suspect dementia, you may want to contact a neurologist.
What you're looking for: stacks of unopened mail and unpaid bills, uncashed checks, and key home or legal documents that haven't been dealt with. Another flag: unusual transactions or amounts of money going to charities. “During the pandemic, my clients have been bombarded with telemarketing scams,” says Robin Mansfield, a geriatric care manager and social worker at Aging Network Services.
What to do: The solution may be as simple as help sorting the mail and prioritizing. Offer to help with the more complicated matters while your loved one continues handling day-to-day household and personal finances. For example, help your loved one open another checking account that he could use for cash and basic needs, and pay the bills from his primary account. “You could suggest getting online access to at least look over their banking to see if something's run amok,” says Virginia Morris, author of How to Care for Aging Parents. “You're not managing or taking over their financial affairs, just acting as another set of eyes.” Also, many banks will arrange, with your parent's permission, to have bank statements sent to you. You may also need to help your loved hire a financial manager. Finally, Morris says, be sure they have legal documents in place, so you are able to help manage affairs in an emergency.
By 2030, there will be more than 70 million people age 65 and older, and about 85 percent will be licensed to drive. In fact, seniors are outliving their ability to drive safely by an average of seven to 10 years, according to AAA. Multiple accidents or a number of tickets means it's time to have a talk. “It can be subtle, like scratches or dings on the car,” Hashmi says, “particularly if your loved one can't remember how they got there."
What to do: Tag along for a ride and keep your eyes peeled. Is your loved one having close calls or getting lost on very familiar roads? Does there appear to be a cognitive problem or vision difficulties? It may be time for a medical evaluation. Poor vision may be easily fixed with a new pair of prescription glasses. Suggest that they refresh their driving skills by taking a driver safety course. AAA RoadWise Driver is an online course designed to help seniors adjust to age-related physical changes. The AARP Smart Driver course, available online or in a classroom, helps drivers 50 and older sharpen their skills — and may entitle you to a discount on insurance.
If it is time to hang up the keys, look for other transportation options to help your loved one get around and maintain their independence — from Uber and Lyft to senior shuttles in their town. The Independent Transportation Network of America (ITNAmerica) is a national nonprofit network of community-based transportation programs for seniors age 60 and older.
Changes in appearance
Has your loved one's appearance changed? Have they gained or lost a significant amount of weight? Is your father's hair matted or has he gone without shaving for a while? “If your mother was always meticulous about her appearance but is suddenly wearing the same clothes every day or isn't cutting her nails, it could indicate cognitive issues or depression,” Mansfield says. Unexplained bruises — where a loved one can't remember when or how they got them — are another red flag. An odor may be a sign that they're not bathing.
What to do: These changes may have multiple causes, so go on a fact-finding mission. For example, says Draayer, changes in hygiene may reflect a lack of motivation or a lack of awareness (possibly pointing to depression or a cognitive issue that may need evaluation and treatment). Or, you may find that changes in mobility — say, a fear of getting in and out of the bathtub or showering — are hindering their ability to care for themselves. Perhaps grab bars need to be installed or a handheld shower and shower seat purchased.
Life at home
Your loved one may be withdrawing from friends and family. Perhaps they're not keeping up with the usual chores or favorite hobbies (for example, Mom's beautiful garden is now filled with weeds). There may be a problem with hoarding, soiled sheets or the smell of urine throughout the house. “Look in someone's refrigerator to see if food is spoiled or that hasn't been eaten,” says Nisha Rughwani, M.D., associate professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City. If they need to follow a special diet, make sure they're adhering to it. Keep an eye out for sugar-laden and processed foods (no-no's for those with type 2 diabetes) or treats that are high in sodium (if your loved one has high blood pressure). Check out the bathroom linens, Mansfield says: “Does it seem like they're using the same towels over and over because they're not doing laundry?”
What to do: People who are lonely and disconnected from others have faster rates of cognitive decline. What's more, according to the National Academies of Sciences, Engineering and Medicine, adults age 50 and older have a higher risk of mortality due to social isolation and loneliness. Find out whom your loved one interacts with on a regular basis. Seek out potential activities they'd enjoy, such as a senior center, a program where she can volunteer, or simply a regular gathering of friends for coffee. Regular phone calls can help keep your parent socially connected, as can other technology, such as video chats, online communities and social media such as Facebook. Some groups specialize in helping seniors set up technology, such as Senior Planet from AARP and SeniorNet. Find out how he is making or receiving meals and whether he is adhering to a special diet. If necessary, arrange for home-delivered meals (such as Meals on Wheels), housekeeping and laundry assistance.
"Medication is a double-edged sword,” notes Ian Neel, M.D., medical director of the Geriatric Medicine Consult Service at UC San Diego Health. This is especially true when it comes to seniors — many of whom may be taking five or more drugs on a given day, or more drugs than are medically necessary, a phenomenon known as polypharmacy. “How those pills are going to interact with each other and potential side effects that may occur when that cocktail is in your system is unpredictable,” Neel says.
What to do: “Look at your loved one's pill bottles to be sure medication is being taken as directed and are being refilled,” Rughwani says. Set up a pill organizer and keep a list of all medications taken — that includes over-the-counter products, herbal supplements and vitamins — with frequency and dosage. If you're noticing troubling symptoms, such as fatigue or depression, ask a doctor or pharmacist if a medication or combination of drugs could be the cause. A pharmacist can review all of your loved one's prescriptions, not just those prescribed by a specific doctor. Geriatric pharmacists are especially knowledgeable about how medications affect older people. Visit the Board of Pharmacy Specialties website to find a one near you.
The next step
Noticing more than a few red flags? It may be time to get a professional trained to make a more in-depth geriatric assessment about degree of impairment and what is causing the impairment, as well as to offer recommendations — as part of a team — about what can be done. The best person to go to initially is the primary care physician, who knows your loved one's history, or a geriatrician, says Rughwani. “Or, you might go to a neurologist for an initial assessment, especially if you're worried about cognitive issues.” Your doctor can send a visiting nurse, social worker or physical therapist to the patient's home to evaluate the situation, recommend changes and get them help.
Another option: Family members and caregivers can hire an individual geriatric care manager (also known as an aging life care professional) to conduct assessments in the home over time to see how loved ones are functioning on a day-to-day basis. The manager will counsel them and you about the results and refer them to other resources to address other issues, such as a physical therapist, a neurologist for an assessment of cognitive impairment, or a home-care agency if the person needs help in the home. You can search for one in your area at the Aging Life Care Association. AARP's Prepare to Care guides are another great resource.
Encouraging Your Loved One to Get Help
"Those are hard conversations to have,” O'Brien says. Here, some ways to help get your loved one on board.
Don't put off the talk. “The conversation is so much easier to have when it's a theoretical — when you're saying, ‘What if …,” Morris says, “Wait until ‘Mom, I've noticed all these things,’ and that's going to feel a little more threatening.”
Ease into it. “The more we can normalize an assessment, the easier it will be,” says Hashmi. “Treat it like a yearly routine check-in.” If help is needed down the road, introduce it bit by bit. For example, start by offering to hire someone for a task your relative doesn't like, such as cleaning house.
Don't command. Include your loved one in any decisions. “People often think, ‘I'm the parent now’ and that's a terrible mindset,” Morris says. “This is an adult who may have a disability or illness, but also has a lifetime of experiences and wisdom and preferences. We need to be careful about not treating our parents as children. Badgering, being bossy and telling them what they need to do usually triggers resistance. It's about listening,” Morris says. “Start a conversation with, ‘When you look at your future, what do you hope for? What is important to you? What worries you?'”
Reframe their thinking. “I tell patients, ‘This isn't about losing your independence, This is you being proactive and trying to preserve your independence,'” O'Brien says.
Turn the tables. “One of my number one guidelines for determining whether change is needed is a noticeable increase in the stress in the primary caregiver from taking on too much,” Draayer says. Remind your loved one that by accepting help, he is easing your fears and making your life less stressful.