Your Caregiver's Handbook

• A handbook for taking care of senior parents

• Introduction
  • Checklists
    • Checklist for care-receiver
    • Checklist for the caregiver
  • List of needs
  • Types of help available: through family or friends
    • Care-giving exchanges
    • When community agency help is needed
      • Types of services available to impaired elderly
  • Caring for the caregiver
    • Caregiver's self-rating scale
    • What can I do to help myself?
  • Personal care activities
  • Nutrition
  • Emotional and intellectual well-being
    • Depression: signs and causes
    • Suicide prevention
    • Promoting emotional well-being
    • The importance of lifetime learning
    • Memory problems
    • Sensory problems
    • Confusion
    • Behavioral problems
    • Mental stimulation
  • Legal and financial affairs
    • Compiling an inventory
    • Managing a will and financial affairs
    • Durable power of attorney for health care
    • Lantern-Petris-Short (LPS) conservatorship
    • Selecting an attorney
  • Liability of caregiving
  • Choosing a residential care facility
    • What should I look for when I visit a care facility?

A handbook for taking care of senior parents

Being a caregiver for a family member or friend is a tough undertaking. It's not just taking on added tasks—it's choosing a lifestyle.

Most people who need care are in decline. Generally, the person requiring care starts with minimal needs and escalates over time. New tasks keep getting added to the caregiver's list, and rarely are any removed.

This handbook is designed to give you an idea of what may lie ahead and, more importantly, a reality check about what is reasonable and when you've reached your limit.

Introduction

You, the caregiver, are very important

Few people are prepared for the responsibilities of caring for an older person. This guide provides a roadmap with options for caregivers, helping you figure out what works for your situation.

More importantly, it's a reminder that you cannot care well for someone else if you're not taking care of yourself. The caregiver is essential to the equation.

Your wellbeing directly affects how well you can provide care. If you burn out, you can't be there for the person who depends on you. Read this handbook before you reach that point.

This handbook covers topics that can make caregiving easier while also improving the quality of life for the person you're caring for. Throughout, "caregiver" refers to the person providing care, and "care-receiver" refers to the older person receiving care.

Below are two checklists: one for the care-receiver and one for the caregiver. They're general guidelines to help ensure health, safety, and comfort for both of you.

Checklists

Checklist for care-receiver

• All legal and financial matters are in order and available
• Physical and dental appointments are kept annually or more often if needed
• The home environment is clean, safe, and pleasant
• Nutritional needs, exercise, sleep, and social activities are maximized as much as possible
• Personal hygiene and grooming are done daily
• Respite services are used monthly or weekly
• Level of care is reviewed monthly to ensure the care-receiver can remain at home

Checklist for the caregiver

• I am getting out or exercising at least once a week
• I am getting seven to nine hours of sleep a night
• I talk with or visit up to three friends or relatives weekly
• I keep annual medical and dental appointments
• I am taking medications as prescribed
• My legal and financial papers, including my will, are in order and accessible
• I have looked into a new caregiving resource this week
• I am aware of the Caregiver's Bill of Rights
• I am eating three balanced meals a day

List of needs

The first step in organizing a care plan is listing what's needed. As you care for an older person, you'll face these questions:

What are their needs? What kind of care allows them to stay in the community? Who will provide the care, when, and how? Should they stay in their home, move in with you, or move elsewhere? How can you adjust living arrangements to help them stay home or be more independent? If outside services are needed, can they afford them? How do you give care to this person without neglecting your spouse or children? Are you feeling tired or frustrated?
Building a list of needs helps you recognize what the care-receiver requires and what you need as the caregiver. There are no simple answers—every situation is different. Caregiving creates stress that affects your ability to continue. That stress can be physical, financial, environmental, or emotional.

Physical stress comes from hands-on care. Housekeeping, shopping, and meal prep drain energy on top of your own responsibilities. Personal care—managing medications, maintaining hygiene, handling incontinence or special equipment—is stressful, especially if the person is combative or aggressive.

Lifting or transferring someone with limited mobility is tiring and can injure you or the care-receiver. You may also need to maintain equipment like wheelchairs or hospital beds.

Financial stress is real. Medical care, medications, therapy, and other services cost money. Many families help cover costs, which strains everyone's finances.

Environmental stress arises when deciding where the care-receiver will live. If they stay home, you may need to install railings or ramps. If they move, you need to find alternatives like retirement communities, assisted living, or nursing homes.

If the care-receiver stays home, you'll need to adjust your daily routines significantly.

Social stress comes from being available 24 hours a day. You may become isolated from friends and family. You might not have energy for an evening out even once a month. This isolation can breed resentment toward the very person you're caring for, since they're the reason you're stuck at home.

Emotional stress compounds all the other kinds. You juggle competing demands and feel the weight of increased dependency. For family members, stress can bring up anger, resentment, and bitterness about lost time and freedom.

Old conflicts between parent and child often resurface. You may even have the thought—brief and unwelcome—that you'd be relieved if this ended through institutionalization or death. That thought can bring crushing guilt.

These feelings are normal, even though they might feel shameful. Most caregivers have them. You're not alone in feeling this way.

Resources exist to help. The rest of this handbook covers those options: support groups, community resources, and most importantly, taking care of yourself.

Types of help available: through family or friends

Start by listing what each family member and friend can contribute. Include time, skills, space, equipment, the care-receiver's strengths, and money.
Sit down with family members and work out a plan. Define what tasks will be done, by whom, and on which days. For example: Aunt Martha cooks, Uncle Peter mows the lawn, and Mary checks on Mom twice a day.

Care-giving exchanges

Some situations allow for caregiving exchanges. Through Area Agency on Aging, you might find another caregiver willing to watch both people one day a week in exchange for your doing the same another day. Or you could offer a spare room to a college student in exchange for their help with caregiving.

When community agency help is needed

When family or volunteer help isn't available or sufficient, you can turn to agencies for support.

A wide range of services is available. Some are covered by private insurance or Medicare. All can be purchased. Some services are based on the care-receiver's income. Each agency has its own fee structure—ask before you order.

Types of services available to impaired elderly

Adult day health care serves people who are physically or mentally frail. It offers therapeutic, rehabilitative, and support activities—nursing, rehabilitation, help with daily activities, social work, meals, and sometimes transportation—in a protected setting for part of the day, one to five days a week.

Chore workers provide heavy-duty housecleaning, minor home repairs, yard work, and safety equipment installation.

Companionship services send visitors for conversation, reading, letter writing, and light errands.

Escort services provide personalized accompaniment to appointments and help with personal tasks.

Geriatric assessment units in some hospitals and medical centers offer specialized diagnostic services to older patients.

Home-delivered meals bring nutritious food to homebound seniors. Some programs ask for a voluntary contribution; others charge full cost for a hot lunch and sometimes a cold evening meal.

Home health aides provide personal care at home, often covered by insurance if prescribed by a doctor. They help with eating, dressing, hygiene, bathing, medications, and light housekeeping.

Home health care agencies provide nursing, social work, occupational therapy, physical therapy, and rehabilitation services in the home.

Homemaker services include shopping, laundry, light cleaning, meal prep, and escort services. They can supplement family care or give you a break.

Homemakers come through in-home health agencies, Area Agency on Aging, the Department of Social Services, and religious organizations. Some provide bonding and training; others just give you a list of names. Check references carefully and draw up a contract.

Hospital and surgical supply services rent or sell equipment like hospital beds, walkers, bath chairs, and oxygen.

Housekeeping services include cleaning, shopping, laundry, and meal prep.

Housing assistance programs help with senior housing, shared housing, and emergency shelters.

Congregate meal programs bring older adults together for group meals in senior centers or community centers. A noonday meal provides about one-third of the recommended daily nutrients, usually for a voluntary contribution. Many also offer recreational and educational activities.

Occupational therapy (OT) is restorative, helping people rebuild skills for daily living. A qualified occupational therapist, referred by your doctor, should provide it.

Physical therapy (PT) helps maximize mobility through rehabilitation. A qualified physical therapist, usually recommended by your doctor, should provide it.

Respite care provides temporary relief—sometimes up to 24 hours—to give primary caregivers a break. Care may be in the home, at an adult day center, or at another facility.

Senior service teams (regional or county mental health teams) provide mental health screening, needs assessments, and short-term counseling for seniors.

Skilled nursing services address specific medical needs through trained professionals via local home care agencies. Your doctor must prescribe these services.

Speech therapy is provided by a qualified speech therapist to address speech and communication problems. Your doctor usually refers this.

Social day care offers support services in a protected setting for part of the day, one to five days a week. Services include recreation, social work, a hot meal, transportation, and sometimes health services.

Telephone reassurance connects older people with friendly callers for conversation and reassurance. It can be a lifeline for those left alone during the day.

Transportation services provide travel to medical appointments via car or specialized vans. Agencies and providers like Dial-a-Ride and the Red Cross offer these services.

Caring for the caregiver

Caregiving brings mixed emotions. You can love your family member and feel satisfied helping them while also resenting the loss of privacy and feeling powerless about their decline. You may struggle to accept what's happening. These feelings depend on your prior relationship, how much care they need, and what else is happening in your life—work, social time, hobbies. The conflict can trigger guilt and stress.
To avoid burning out, you must take care of yourself. Maintain your health and develop ways to cope.

Caregiver's self-rating scale

Below is a scale adapted from an article in Co-op Networker. It helps you evaluate your caregiving style and the balance between what you give and what you keep for yourself.

The scale runs from 1 to 10:

1. Abandonment—withdrawing support or actively abusing the care-receiver

2. Neglect—allowing life-threatening situations or showing consistent coldness

3. Detachment—maintaining emotional distance, performing care out of obligation only

4. General support—given freely with some warmth, occasional manipulation, concerned with emotional and physical wellbeing

5. Expressed empathy—feeling what the care-receiver feels, a quality relationship where feelings can be freely shared

6. Sympathy—feeling sorry for the care-receiver, focusing on their losses

7. Occasional over-involvement—periodic attempts to do too much rather than just being present

8. Consistent over-involvement—the care-receiver becomes a series of tasks to perform

9. Heroic over-involvement—frantic attempts to meet every possible need, increasing dependence, preventing independence

10. Fusion—the caregiver's needs disappear; they abandon themselves to the care-receiver's needs

The low numbers give little value to the care-receiver. The high numbers (8, 9, 10) give little value to your own needs. The middle numbers show balance. Neither extreme helps—both mean you're actually not serving the care-receiver well.

What can I do to help myself?

Acknowledge your feelings. Your feelings shape how you cope. All feelings are legitimate, even disturbing ones like anger and sadness. Recognizing and accepting your emotions is the first step to resolving guilt and stress. Talk to family, friends, or professionals about what you feel.

Take the stress test below to assess how much stress you're under.

Caregiver stress test

Which of these are seldom true, sometimes true, often true, or usually true for you?

I find I can't get enough rest.

I don't have enough time for myself.

I don't have time to be with other family members besides the person I care for.

I feel guilty about my situation.

I don't get out much anymore.

I have conflict with the person I care for.

I have conflicts with other family members.

I cry every day.

I worry about having enough money to make ends meet.

I don't feel I have enough knowledge or experience to give care as well as I'd like.

My own health is not good.

If you answered "usually true" or "often true" to one or more of these, it's time to look for help—both in caring for the care-receiver and in taking care of yourself.

Seek information. Check your library for books, articles, and videos on caregiving. Hospitals, adult education centers, and regional resource centers offer caregiving courses and information about resources. Help is available.

Join a caregiver support group. These groups offer information and a place to share your feelings with others going through the same thing. You'll feel less isolated. Groups help you manage stress, exchange experiences, and improve your skills. Sharing strategies in a group setting helps others while helping yourself. You may realize that some problems have no solutions—and that accepting the situation is the path forward.

• Set realistic goals. Caregiving is one of many demands on your time. Recognize what you can and cannot do. Define your priorities and act accordingly. Ask family, friends, and neighbors for help. Write a list of tasks others can do: running an errand, preparing a meal, taking your care-receiver for a ride, picking up your children after school.
• Practice good communication. Don't expect others to ask if you need help—you have to ask.
• Talk with your family and friends. Their visits can make you feel less alone and better able to cope. They can give you a break by spending time with your care-receiver. However, relatives or friends may criticize how you provide care, saying the house isn't clean enough or the care-receiver isn't dressed well. They're seeing a moment in time, lacking the full picture and the gradual changes in your care-receiver's condition. Their criticism may stem from their own guilt about not helping more.
• Listen politely to what they say, even if it's difficult. If you and your care-receiver are comfortable with how you're managing, continue as you are. Schedule family meetings occasionally to help others understand the situation and share responsibilities.
• Use community resources. Look into in-home services or adult day care. Hire a homemaker to cook and clean, or an aide to help your care-receiver bathe, eat, dress, and move around the house.
• Use respite care. When you need a break, respite care lets someone stay with your care-receiver for a few hours regularly, giving you time off. Or have your care-receiver attend an adult day program where they can socialize with peers. Hospitals, nursing homes, and residential care homes offer short stays. Contact your doctor or Area Agency on Aging to arrange this.
• Maintain your health. Your wellbeing affects how you see life and cope with stress. Taking care of yourself means eating three balanced meals, exercising, getting enough sleep, and allowing yourself leisure time.
• Food fuels your body. Skipping meals, eating poorly, or overusing caffeine harms you. Learn to prepare simple, nutritious meals. Limit alcohol to 2–3 ounces daily.
• Physical activity gives you an outlet that's relaxing and makes you feel good. Walking, jogging, swimming, or biking are examples. Consult your doctor before starting an exercise routine.
• Leisure time helps you feel better and cope more effectively. Reading, visiting a friend, or watching TV brings enjoyment and breaks the constant pressure of caregiving.
• Sleep refreshes you and helps you function. If your care-receiver's restlessness disturbs your sleep, ask your doctor and other caregivers for solutions. You may need outside help at night so you can sleep.

If tension keeps you awake, practice relaxation exercises. Deep breathing or visualizing pleasant places helps. Ongoing sleep problems may signal depression and need medical attention.

Relaxation exercise: Sit or lie comfortably and close your eyes. Let your mind relax. Wiggle your fingers and toes, then hands and feet. Loosen tight clothes. Sway your head gently side to side. You're preparing yourself to relax.

Now focus on something pleasant you want to think about—a place you've visited or imagined. It might be the seashore, a hilltop, or a field. Immerse yourself in it. Smell it, see it, hear it, feel it. If it's a beach, sift sand through your fingers, smell the salt, watch for gulls. Your body is weightless. You're in control. Breathe slowly and peacefully. This is your place, and no one can take it from you.

When you've experienced your peaceful place, return to it whenever you need to. Close your eyes, tune in, and relive those moments in your world where everything is perfect and yours. This exercise can sustain you throughout the day. Check your library or bookstore for books, audio, or videos on relaxation and stress management.

Laughter is healing. Norman Cousins wrote about using laughter to help recover from cancer. Research shows laughter reduces tension, eases pain, improves breathing, and lifts mood. Hospitals use humor carts and positive emotion rooms. Humor therapy helps during difficult times.

For yourself and your care-receiver: try to find humor in caregiving; write "Have you laughed with your care-receiver today?" on a card and post it in the bathroom or kitchen; read funny books or jokes, listen to funny audio, or watch humorous movies; share something funny with your care-receiver, a friend, or relative; join social groups with camaraderie and joy; notice how often you smile—it takes less energy than frowning. If you feel hopeless and humor isn't helping, talk to a counselor.

Avoid destructive coping. Some people handle stress by overeating, drinking, using drugs, or smoking—ways that mask problems but harm health. If your stress leads to neglecting or abusing the care-receiver, that's serious and against the law.

Seek help. Don't go it alone. Turn to family, friends, clergy, counselors, or a support group.

• Build your self-esteem. Continue activities and social contact outside your home. Do what you enjoy—go to a movie, play music, or have a card game with friends. It's hard to schedule these, but the rewards of balance are great. Taking care of yourself benefits you and your care-receiver. Meeting your own needs strengthens you for caregiving tasks.
• Caregiver's Bill of Rights
• You have rights. Read these and keep them in mind.
• Caregivers have the right to receive training in caregiving skills and accurate information about the care-receiver's condition.

Caregivers have the right to appreciation and emotional support for their decision to provide care.

Caregivers have the right to protect their assets and financial future without ending their relationship with the care-receiver.

Caregivers have the right to respite care during emergencies and to care for their own health and relationships.

Caregivers have the right to expect all family members to participate in caring for aging relatives.

Caregivers have the right to provide care at home as long as it's physically, financially, and emotionally feasible; when it's no longer feasible, they have a responsibility to explore alternatives like residential care.

Caregivers have the right to modify their home as necessary to provide safe, livable housing for the care-receiver.

Caregivers have the right to accessible and culturally appropriate services.

Caregivers have the right to expect professionals to recognize the importance of palliative care (easing discomfort without curing) and be knowledgeable about older people and caregivers.

Caregivers have the right to a sensitive, supportive response from employers when facing unexpected or severe care needs.

Personal care activities

Personal care activities include eating, bathing, shaving, skin and hair care, mouth care, and transferring (moving from chairs, toilets, or bed). These tasks are easy until weakness or disability makes them difficult. Providing help requires knowledge, patience, skill, and physical strength.

Bathing an older person may require special equipment and skills. Ask their doctor or physical therapist for guidance on safe bathing techniques.

• Shampooing and shaving: Visits to a barber or hairdresser are positive experiences. Many will come to the home. Alcohol or cream rinse helps remove tangles. Dry shampoos work for bedbound people. People on blood thinners should use electric shavers to avoid cuts. Electric razors are easier and safer to use on another person.
• Skin care: Keep skin clean and dry, especially for those with incontinence. Use mild soap, rinse well, and dry thoroughly. Keep bed linens clean and wrinkle-free. Disposable bed pads from drug stores reduce how often you change sheets.
• Massage skin gently with light, circular motions. Reposition people at least every two hours, especially those confined to bed or a wheelchair. Encourage them to shift weight between position changes to redistribute pressure.
• Encourage good nutrition and adequate fluids. A daily multivitamin supplements diet—check with the doctor about what's appropriate.

Use soft, form-fitting mattresses and chairs rather than rigid, hard ones. An egg crate mattress or sheepskin spreads weight over a larger area, reducing pressure on bones.

Encourage movement or mild exercise to stimulate circulation, which is good for skin. Combing hair, bathing, and dressing help maintain strength and independence.

Watch for anything restricting circulation: tight shoes, elastic socks, or tight undergarments.

Vulnerable areas prone to skin breakdown are heels, feet, knees, hips, buttocks, elbows, and shoulder blades. A special air mattress prescribed by a doctor can prevent skin breakdown.

Watch for redness or broken skin and report it immediately to the doctor or nurse. Keep the care-receiver off the affected area.

Toileting: Install safety features like grab bars and raised toilet seats. A commode or urinal helps when getting to the bathroom is difficult, especially at night.

Loss of bladder or bowel control is embarrassing and people may hide it. Be sensitive and mention it to the doctor. Incontinence isn't a normal part of aging and often can be controlled. Taking the person to the bathroom every two hours may help. Specialized programs exist to retrain bladder and bowel function—ask your doctor or nurse.

Constipation happens often in older people due to medications and inactivity. A doctor or nurse can suggest a stool softener. Other help: eat high-fiber foods and drink at least eight glasses of water daily; avoid constipating foods like cheese, rice, and bananas; exercise as tolerated; make sure the doctor knows all medications being taken.

Eating: Help your care-receiver eat independently when possible—it saves time and supports their self-worth. Relax and enjoy the time together. Check gums for redness. Dentures that don't fit can cause pain when chewing.

Provide adaptive equipment like plate guards or special silverware with built-up handles (available from medical supply houses). An occupational therapist can recommend what works best.

Prepare finger foods that don't need utensils. Encourage using straws, two-handled cups, or ribbed glasses for independent drinking. If vision is limited, place food and utensils consistently and use a clock method: "Your meat is at 9 o'clock, your potato is at 12 o'clock, your carrots are at 3 o'clock."

Treat the person being fed as an adult, not a child. Don't discipline poor eating habits. When they lose interest in food, ask if they're thirsty, not feeling well, or if the food doesn't appeal to them today.

Transferring: Moving people safely who can't move themselves requires skill and knowledge. Ask a doctor, therapist, or attend caregiver training for specific techniques. Remember: keep balance; get close to the person; use leg muscles, not your back; don't twist—pivot your feet to face them with your spine straight; spread your feet for support. Your doctor can refer you to a physical therapist for training.

Rest and sleep: Sleep patterns change with age. Older people need less sleep and take longer to fall asleep. Night awakenings increase. Regular rest times matter. A nap during the day can refresh. If your care-receiver only sleeps briefly at night, tell your doctor.

Tips for encouraging self-care: Let the care-receiver do as much as possible—even small things like holding the soap help. Doing personal care is exercise that maintains strength and independence. Adapt the home to help them do more: install grab rails, make sinks and mirrors wheelchair-accessible, add a bath bench, install easy-reach lights. Ask therapists or nurses to teach you safe techniques. Learn about their disability and what they can do to stay independent. Include them in care planning whenever you can. Sometimes slowing down lets them do more. Notice changes in their health and adjust your plan accordingly.

Nutrition

Good nutrition is vital. It's a balance of proteins, carbohydrates, fats, vitamins, minerals, and water. A healthy diet provides energy, builds and repairs body tissue, and regulates body processes.

Eating with others has benefits beyond nutrition. People enjoy socializing, which encourages good eating habits and promotes mental health.

Essential nutrients and their functions:

Protein builds and repairs tissue and fights infection. Carbohydrates provide energy and fiber to prevent constipation. Fat provides energy and healthy skin. Vitamin A supports eyes, skin, hair, and infection resistance. Vitamin C heals wounds and boosts immunity. Thiamin (B1) aids digestion and nerve health. Riboflavin (B2) supports eyes, skin, and oxygen use. Niacin supports digestion and the nervous system. Calcium builds bones and teeth, aids muscle contractions and blood clotting. Iron builds red blood cells that carry oxygen.

• Planning meals by food groups simplifies preparation. Include the recommended servings from each.
• Meat group (2 servings daily): provides protein, niacin, iron, and thiamin. Dry beans, peas, soy, and nuts can substitute. One serving equals 2 ounces cooked lean meat, fish, or poultry; 2 eggs; 1 cup cooked dry beans; 4 tablespoons peanut butter; 1/2 cup cottage cheese.
• Grain group (4 servings daily): provides carbohydrates, thiamin, iron, and niacin. Whole grain, fortified, or enriched products are best. One serving is 1 slice bread; 1 cup cereal; 1/2 cup cooked cereal, pasta, rice; 1 small muffin; 5 saltines; 2 graham crackers.
• Milk group (2 servings daily): provides calcium, riboflavin, and protein. One cup milk equals 1 cup yogurt, 1.5 ounces cheddar cheese, 1.75 cups ice cream, or 2 cups cottage cheese.
• Fruit-vegetable group (4 servings daily): provides vitamins A and C. Dark green or orange vegetables and fruits are recommended 3–4 times weekly for vitamin A; citrus fruit daily for vitamin C. One serving is 1 cup raw fruit or vegetable, 1/2 cup cooked, 1 medium fruit, or 1/2 cup juice.
• For special diets (low salt, diabetic, low-fat), get specific instructions from a dietitian or doctor about which foods to eliminate, modify, or limit. Check with a pharmacist about interactions between foods and medications.
• Common problems interfering with nutrition:
• Strange taste: Check teeth for decay or infection. Avoid alcohol. Marinate meat in sweet juices or sauces. Drink plenty of fluids or suck on candies. Serve foods at room temperature or cold. Use stronger seasonings like basil, oregano, or lemon juice. Try new foods.
• Cramps, heartburn, bloating: Eat slowly and in small frequent meals. Avoid gas-forming foods like cabbage and nuts. Don't lounge after eating—sit upright for an hour. Avoid fried, greasy, and spicy foods. Try bland, low-fat foods. Ask a doctor about antacids.
• Constipation: Eat high-fiber foods and drink plenty of liquids. Exercise. Add bran to cooking (1–2 tablespoons per cup of flour). Drink hot beverages as stimulants.

Diarrhea: Eat small frequent meals. Drink clear liquids. Avoid high-fiber and greasy foods. Replace fluids between meals.

Nausea and vomiting: Avoid unpleasant odors. Eat small frequent meals. Chew slowly. Sip cool, clear liquids between meals. Rest with head elevated. Avoid hot, spicy, strong-smelling, fried, or greasy foods. Try cold or room-temperature, low-fat foods. Eat dry or salty foods. Get fresh air and wear loose clothing.

Dry or sore mouth: Drink plenty of liquids. Suck on ice chips or popsicles made from milk or non-acid juice. Soak foods in liquids. Use extra gravy, sauces, and dressing. Rinse mouth frequently. Suck on hard candy or chew gum. Eat sweet or tart foods if no sores. Try artificial saliva.

General tips: Include favorite foods in meals. Use variety from all four food groups. Provide foods with different textures, colors, and temperatures. Create a pleasant setting with flowers, placemats, good lighting. Check library and bookstore resources. Organizations like the American Heart Association, American Diabetes Association, and cancer and arthritis foundations offer tips and support.

Emotional and intellectual well-being

Each person is body, mind, and spirit. These parts interact. Older people often have powerful emotional responses to life's challenges. Some seem naturally cheerful; others anxious. In later years, these basic moods continue, but how people express feelings often becomes more obvious.

• Depression: signs and causes
• Facing losses—physical changes, death of friends or loved ones, reduced income—older people may show signs of depression. Watch for: difficulty concentrating or deciding; loss of enjoyment in things they loved; changes in appetite (weight loss or gain); withdrawal from people or loss of sex drive; feelings of worthlessness; sadness or crying spells without reason; sleep problems (too much or too little); persistent tiredness despite rest.
• Constant worry about memory loss and managing affairs can deepen depression and cause physical problems.
• To understand depression, ask: Is there a physical or medical cause? Have there been changes in hearing, vision, or movement? How much social contact does the care-receiver have? Are there chances to feel useful? What losses have there been? Is nutrition adequate? Is the person getting mental stimulation? Was retirement difficult? Do they focus on the past or look forward? Could it be medication side effects? Is there dependency on alcohol or drugs?
• Once you answer these questions, steps can address the depression. It takes work from both caregiver and care-receiver to change habits. Prolonged depression causes brain chemistry changes that usually need medication. Talk to the doctor. County mental health centers, psychologists, counselors, and clergy can also help.
• Suicide prevention
• Suicide among older adults is significant and increasing. In some areas, seniors make up 12% of the population but commit 21% of suicides. Unlike other groups, older adults rarely mention suicidal thoughts. Know the warning signs: depression with hopelessness and statements like "Life isn't worth living"; chronic or terminal illness; withdrawal and isolation; sudden behavior changes like irritability or changes in eating or sleep; making final arrangements like giving away possessions, writing a will, or stockpiling medications.
• Suicide can be prevented. If you see warning signs: Ask directly if they're thinking about suicide—it's not taboo and won't plant the idea. Listen and let them express feelings. Show you care and want to help. Remove weapons and pills. Stay with them. Get them to a professional counselor or crisis hotline (numbers are usually at the front of the phone directory). A crisis counselor can help figure out next steps and give referrals.
• Terminally ill older adults fear dying, loss of control, letting go, isolation, losing the caregiver, the unknown after death, and a meaningless life. Help ease these fears through open discussion and action: Support their faith and religious practices; help them get their affairs in order (will, funeral arrangements, burial plot); involve family in discussions; have them write a "life script" listing good things they did for others and accomplishments to see the meaning in their life. No one is an island.

Promoting emotional well-being

• Help older adults stay involved in decisions as long as possible. Needing help with daily tasks doesn't mean they can't decide for themselves. Giving others decision-making power doesn't mean abandoning them. Be sensitive to balancing assistance with independence.
• Ways to promote mental health: encourage visits, calls, or letters from friends and family; arrange fun activities like parties or outings; help start new hobbies or revive old ones; listen, talk, and share feelings; assure privacy; treat with respect, not as incapable children; encourage movement and exercise; help them find ways to feel useful; keep communication open.
• The importance of lifetime learning
• Research shows that older people can still learn, though reaction time may be slower and short-term memory may not be as sharp. Patience helps.

The brain connects people to the world. Understanding what they see, hear, and sense makes experiences meaningful.

• People sometimes incorrectly label older adults as "senile," assuming they can't think for themselves. In reality, most maintain creative powers. The brain, like other parts of the body, functions better with regular use.
• Lifetime learning means exploring new ideas—through reading, radio, TV, hobbies, recipes, or lively conversation. It's a willingness to keep discovering what life offers.
• Benefits include more enthusiasm for life, less boredom and depression, higher self-esteem, greater interest in the world, and new ideas to share.
• Memory problems
• Memory loss can be hard for both care-receiver and caregiver. Some causes are treatable, others aren't. A doctor needs to determine the cause. Forgetfulness or not recognizing familiar faces may come from malnutrition, alcohol, medication side effects, loneliness, isolation, poor hearing or vision, injury, viral infection, or depression.

Sensory problems

Hearing and vision loss make understanding difficult and affect emotional wellbeing. Hearing aids need new batteries; glasses may need adjustment or cleaning. Good, glare-free lighting helps. Magnifying glasses or large print make reading easier.

• Confusion
• For confused people: Make routine changes gradually. Give clear reminders about appointments. Write directions in large, clear print. Label drawers and shelves with words or pictures. Keep clocks and calendars visible. Ensure medications are taken regularly. Encourage nutritious foods and movement—exercise improves circulation and thinking.
• Behavioral problems
• For disruptive behavior, don't antagonize—step back with the message "I care about you, not this behavior." Avoid confrontation. If behavior involves disrobing, offer bright clothes that feel good. Don't argue—change the subject if they get agitated. Lower lighting, reduce noise, minimize clutter. Promote familiar objects and pictures. Walk slowly with them to reduce anxiety.
• Mental stimulation

Many older people enjoy sharing stories from their past. Encourage this. Brain-stimulating activities like visiting with others support lifetime learning. Homebound people can sew, knit, read, do puzzles, make art, write memoirs, care for pets or plants, listen to music, take courses, play instruments, maintain photo albums, volunteer, bake, plan potlucks, tutor children, type, participate in radio shows, or learn computers.

• Those physically able can swim, bowl, garden, dance, golf, walk, jog, or play shuffleboard. Drawing, writing, reading, crafts, classes, and hobbies encourage creativity. Indoor games like chess, checkers, cards, and billiards relieve boredom.
• Legal and financial affairs
• Older people care about managing their assets, but illness, confusion, or memory loss may prevent them from doing so. Involve them whenever possible.
• Compiling an inventory
• Make a list of all assets and liabilities: bank accounts, certificates of deposit, money market funds, stocks, bonds, metals, jewelry, real estate deeds, contracts, insurance policies, safety deposit boxes, retirement benefits. List record locations. Include important documents: birth and marriage certificates, social security numbers, divorce decrees, tax returns, death certificates, wills (with attorney and executor names), and trusts.

If possible, the older person should compile the list. If not, a family member, attorney, banker, accountant, or financial planner can help. Copy and keep the inventory in a safe, obvious place with a trusted person. Update it yearly.

Managing a will and financial affairs

• Financial and estate planning ensures ordered distribution of the estate according to the person's wishes. Everyone over 18 should have a will or similar legal document. If they don't, consult an attorney immediately. Proper planning with powers of attorney or trusts while they're competent is essential. Without it, court action is needed to transfer responsibility—costly and dilutes the estate.
• As a caregiver, don't get involved without legal authority. Acting without clear legal authority, even with good intentions, causes serious problems.
• Legal mechanisms for surrogate decision-making are: durable power of attorney (DPA), probate conservatorship, and durable power of attorney for health care (DPAHC).
• A durable power of attorney is a written document giving someone authority over the principal's financial decisions. It must be signed while the principal is legally competent. It's valid indefinitely until revoked, the principal dies, or the court revokes it due to mismanagement. The principal can specify preferences and decide whether the power takes effect immediately or upon incapacity. Decisions made under DPA are binding on the principal and successors, so get legal advice.
• Probate conservatorship allows management of the principal's money and property when they lack the capacity to decide or appoint someone. Court proceedings are required—difficult and extreme, but necessary if the care-receiver is incapacitated and cannot manage finances.

Durable power of attorney for health care

A durable power of attorney for health care (DPAHC) is a written document signed when the principal can still decide. It gives someone authority to make medical and health care decisions on their behalf for up to seven years. It lets the principal specify wishes about extraordinary care, including breathing machines and tube feeding. All adults should have a DPAHC.

Lantern-Petris-Short (LPS) conservatorship

Laws vary by state. LPS conservatorship is a court-ordered process enabling someone to get psychiatric or medical care they refuse due to mental illness. The court decides if the conservatee can keep or lose the right to vote, drive, make contracts, or refuse non-psychiatric medical treatment. The conservator may be family, a friend, or a court appointee, with authority to require psychiatric or medical treatment, make living arrangements, and place the person in residential care or a nursing home. To start, consult an attorney or call your local mental health office. The person must be declared gravely disabled—unable to provide for food, clothing, shelter, or medical care due to mental illness.

Selecting an attorney

Choose an attorney knowledgeable in estate planning, will drafting, probate, or conservatorship. Ask friends, professionals, a lawyer referral service, the county bar association, or senior legal services for recommendations. Ask the attorney if they've done this work before agreeing.

Liability of caregiving

Caregivers must understand the legal duties and liabilities of their role. Many states have elderly abuse laws that bind caregivers in two ways: not to abuse the older person and to report suspected abuse.

You must provide a clean, safe home, nutritious meals, clean bedding, and clothes. If you manage finances, use that money properly for necessary services. Failure to provide care, failure to get care, and failure to pay for care are forms of abuse or neglect.

You cannot physically, sexually, or psychologically abuse the person. Yelling, screaming, and withholding affection are as much abuse as striking them.

Accept the physical, psychological, and legal duties of caregiving. If you can no longer provide proper care, consider alternatives and seek help from a counselor or available resources.

• When is it time to stop caregiving? Caregiving is very stressful. Stress causes or worsens 70–90% of medical complaints: headaches, high blood pressure, asthma, stomach problems, and back pain. Research links stress to heart disease, stroke, cancer, anxiety, depression, phobias, poor work performance, substance abuse, insomnia, and violence.
• If you experience any of these, learn stress-reduction techniques, decide it's time to stop caregiving, or both. Signs of burnout include constantly snapping at the care-receiver, being irritated, rarely laughing, feeling constantly tired or pressured, losing sleep, yelling or crying frequently, withholding affection or basic care, blaming the care-receiver, refusing to go out, or denying them needed expenses.
• These indicate caregiver burnout. The solution is simple: get help and take extended breaks through respite care or changing your caregiving arrangement. No one can be a full-time caregiver forever—the job is too strenuous. When you reach your limit, be honest with yourself and stop. Research alternatives, get professional help, and rest easy knowing you did the right thing.
• Choosing a residential care facility
• Before seeking an alternate living arrangement, consult your doctor. They're your best ally—most facilities require a current physical exam, and they can assess what level of care is needed. This determines the type of facility: acute hospital, sub-acute skilled nursing facility, intermediate care facility, or residential facility for elderly (board and care or retirement homes). Residential facilities provide non-medical care and supervision including personal services (bathing, grooming, medication help) and daily living assistance.
• Choose a licensed facility. People needing care are often vulnerable to abuse or exploitation. The law requires licenses. Check for the license to ensure legal protection and quality care.
• What should I look for when I visit a care facility?
• Ideally, you and your care-receiver preview a facility together before deciding, which lets you both discuss your feelings. Organize your visit by writing down questions beforehand, carrying a checklist, and making notes as you tour and talk to people. Items to cover: Ask to see the facility license. Look closely at the building and grounds. Talk to residents. Talk to the administrator. Talk to staff. Ask to see the admission agreement. Contact your local Department of Social Services for their consumer's guide to community care facilities.
• Calcium: For preservation and repair of bones, teeth; muscle contractions; blood clotting.
• Iron: For building red blood cells to carry oxygen to all parts of the body.

To simplify daily meal planning, foods are grouped according to the nutrients they supply. Plan your diet to include the recommended number of servings from each group.

The Four Basic Food Groups

Meat Group: Provides protein, niacin, iron, and Thiamin-B1. 2 servings daily. Dry beans and peas, soy extenders, and nuts combined with animal or grain protein can be substituted for a serving of meat. 2 ounces of cooked, lean meat, fish or poultry have the same amount of poultry as: 2 eggs; 1 cup cooked dry beans, peas, or lentils; 4 tablespoons peanut butter; 1/2 cup cottage cheese.

Grain Group: Provides carbohydrates, Thiamin-B1, iron, and niacin. 4 servings daily. Whole grain, fortified, or enriched grain products are recommended. 1 adult serving is: 1 slice bread; 1 cup ready-to-eat cereal; 1/2 cup cooked cereal, pasta, cornmeal, rice or grits; 1 small muffin or biscuit, 5 saltines, 2 graham crackers.

Milk Group: Provides calcium, riboflavin-B2, and protein. 2 servings daily: Foods made from milk contribute part of the nutrients supplied by a serving of milk. 1 cup milk has the same amount of calcium as 1 cup yogurt, 1 and 1/2 slices (ounces) cheddar-type cheese, 1 and 3/4 cups ice cream, 2 cups cottage cheese.

Fruit-Vegetable Group: Provides vitamins A and C. 4 servings daily: Dark green leafy or orange vegetable and fruit are recommended 3 or 4 times weekly for vitamin A. Citrus fruit is recommended daily for vitamin C. 1 adult serving is: 1 cup raw fruit or vegetable, 1/2 cup cooked fruit or vegetable, 1 medium fruit, such as an apple or banana, 1/2 cup juice.

Common Problems Interfering with Good Nutrition

Illness, disability and depression can affect an older person’s desire and ability to eat properly. The following suggestions deal with common problems that interfere with good nutrition.

When the care-receiver say the food tastes strange, it might help to:

• Check teeth for tooth decay or gum infection,
• Avoid alcohol,
• Marinate meat, poultry and fish in sweet fruit juices, Italian dressing, or sweet or sour sauces,
• Drink plenty of fluids or suck on candies to get rid of bad tastes,
• Serve foods at room temperature or cold (Try milk-shakes or cheese),
• Use stronger seasonings such as basil, oregano, rosemary, tarragon, lemon juice or mint when cooking,
• Try new foods.

Cramps, Heartburn, Bloating:

• Eat slowly,
• Eat small meals frequently,
• Avoid gas-forming foods, e.g., cabbage, onions, nuts, beer, cola drinks,
• Avoid lounging immediately after eating; stand or sit upright for one hour after eating,
• Avoid fried, greasy and heavily spiced foods,
• Try bland, low-fat, easily digested foods,
• Chilled antacid may help, HOWEVER, check with your doctor regarding the brand of antacid to use.

Constipation

• Take high-fiber foods and plenty of liquids,
• Exercise,
• Add bran when cooking or baking (1 – 2 tablespoons of bran for each cup of flour),
• Drink hot beverages which act as stimulants.

Diarrhea

• Eat small meals frequently,
• Drink clear liquids,
• Avoid high fiber and greasy foods,
• Replace fluid loss with liquids between meals.

Nausea, Vomiting

• Avoid unpleasant odors,
• Eat small meals frequently,
• Chew slowly and thoroughly,
• Sip cool, clear liquids between meals,
• Rest after meals with head elevated,
• Avoid hot, spicy, strong-smelling foods or fried, greasy foods,
• Try foods which are cold or at room temperature, and low-fat food,
• Eat dry or salty food,
• Try fresh air and loose clothing.

Dry or Sore Mouth

• Drink plenty of liquids,
• Suck on ice chips,
• Suck on popsicles made of milk or non-acid juices,
• Dunk or soak foods in liquids,
• Use extra gravies, sauces, salad dressing,
• Rinse mouth frequently,
• Suck hard candies or chew gum,
• Eat sweet or tart foods if no sores in mouth,
• Artificial saliva can be used.

General Tips for Helping the Older Person to Eat Well

• Plan meals and snacks to include the person’s favorite foods.
• Use a variety of foods from each of the four food groups,
• Prepare foods that provide a variety of texture, color, and temperature,
• Provide a pleasant setting, i.e., flowers, place mats, matching dishes, good lighting.

In addition to books, recipes and literature, the organizations listed below are valuable in providing tips, ideas, counseling, and reminders that you are not alone. They can help make the gradual transition to improved eating habits: (Addresses listed were local San Diego. For same or counterparts in your locality check your telephone directories or contact United Way: American Heart Association; American Diabetes Association; American Cancer Society; Arthritis Foundation; Dietetic Association; United Ostomy Associates.)

Emotional and Intellectual Well-being

Each human being is a combination of body, mind, and spirit; we should be aware of how these parts interact. For example, people may have powerful emotional responses while facing the many challenges which life presents. Thus, some may often appear cheerful and optimistic while others are anxious and unhappy. In later years, we usually continue our basic moods, but the ways we express our feelings often become more obvious.

Depression: Signs and Causes:

In the midst of losses, such as physical changes, death of friends or loved ones and reduction of income, older people may begin showing signs of depression. Some things to look for are:

• inability to concentrate or make decisions,
• lack of feelings of enjoyment, or enthusiasm even for doing those things that were favorites,
• little interest in eating (causing weight loss) or changes in eating habits (overeating causing weight gain),
• lack of interest in being with other people, or loss of sex drive (libido),
• feeling unwanted and worthless, sometimes leading to the thought that life is not worth living,
• sadness or crying spells for no apparent reason,
• problems with sleeping (sleeplessness during the night or excessive sleep during most of the day),
• feeling tired most of the time, regardless of adequate rest.

If older people brood about their unhappiness, much of their energy is focused on worry. Part of that worry may relate to the fear that they will become forgetful and unable to manage their affairs. This worry can lead down the path to more depression, which may cause physical problems.

In exploring the cause of depression, the following questions should be asked:

1. Is there a physical or medical problem causing the depression?
2. Have there been changes in hearing, seeing, moving, or other body functions?
3. What social contact does the care-receiver have?
4. What are the opportunities for usefulness?
5. What kind of personal losses (death of friends, relatives, or pets) have there been?
6. Is the older person getting proper nutrition?
7. What kind of mental stimulation is the person getting?
8. Has there been a difficult adjustment following retirement?
9. Is the focus entirely on the past or is there some enthusiasm about coming events?
10. Is there a possibility of reaction to medications?
11. Is there a dependency on alcohol or drugs?
12. Once these questions have been answered, steps can be taken to relieve the depression. It will take some work from both the caregiver and the care-receiver to change habits and routines. Prolonged depression causes biochemical changes in the brain, usually requiring treatment with medication. The doctor is a good person the contact to find help for treatment of depression. Other resources are County Mental Health Centers, psychologists, counselors or clergy.

Suicide Prevention

Suicide among the elderly is a significant and ever increasing problem. Statistics show that 27 percent of all suicides in San Diego county (1985-87) were committed by people 60 years of age and older. Nationally, elderly (65+ years) made up 12.3 percent of 1987 population and committed 21.0 percent of suicides. Elderly complete one suicide every 1 hour and 21 minutes, or each day 17.7 seniors committed suicide.

Unlike other segments of the population, the elderly do not often make threats or mention suicidal thoughts to others. Therefore, it is important that caregivers also know other warning signs:

• Depression – feelings of sadness, hopelessness, a sense of loss and statements as “Life isn’t worth living” are common before a suicide.
• Chronic or terminal illness.
• Withdrawal and isolation – suicidal people may pull away from family, friends and others close to them.
• Behavior changes – sudden changes such as irritability, aggressiveness or changes in eating and sleeping habits can signal problems.
• Making final arrangements – a suicidal person may give away valued possessions, making out a will, make a plan for suicide, or write a suicidal note in preparation. They may purchase weapons or stockpile medications.

Suicide can be prevented. If the person you care for shows any of the warning signs, you can:

• Ask – don’t be afraid to ask directly if the person is thinking about suicide. It is not a taboo subject. You will not be putting ideas into the person’s head. It can be a relief to the suicidal person to talk openly about their feelings.
• Listen – let the person express his/her feelings and concerns. Don’t worry about saying the right things – just listen.
• Show you care – tell the person you care and want to help. Take active steps to make sure the person is safe; remove weapons, pills, etc., and stay with him/her.
• Get help – make sure the suicidal person gets in contact with a professional counselor or other helpful person who will know what to do. Or have the suicidal person call (suicide prevention/crisis intervention Hotline in your community. Telephone numbers for such local resources should be at the front of your telephone directory.) A crisis counselor can help figure out the best way to handle the situation and give referrals to other resources.

Death and Dying Interventions Elderly terminally ill encounter anxiety and fear regarding death:

• fear of the process of dying; will there be pain?
• fear of losing control; will I be at another’s mercy?
• fear of letting go; I can not leave family and friends to an uncertain future.
• fear of seeing how others will avoid me.
• fear of losing my caregiver; will he/she be turned off emotionally to me?
• fear of the unknown after death.
• fear that my “life’s script” has been meaningless, unfulfilled, a waste.

You may wish to ease these fears through an open discussion of these fears and intervening:

• Regarding the death process, a “faith system” may be of great help; if you can get the person involved in his/her religious faith, the subject of death is well covered.
• Regarding fear of letting go and isolation, assist then person to get his/her “house in order.” This entails a will, funeral arrangements, burial plot, etc. Also attempt to have the person and family involved discuss the situation.
• Regarding meaninglessness of one’s life, have the person do a “Life Script,” whereby he/she writes all the good things done for others, all accomplishments, etc. Then discuss with the person that had he/she not been there to do what he/she did at that time, no one else would have, and society would have been the worse for it. So he/she did make a difference. Truly, no person is an island!

Promoting Emotional Well-being

It is important to help the elderly remain involved in decision-making as long as possible. You must stress that needing help with everyday activities does not mean that they cannot make decisions for themselves. Also, granting others the right to decide does not mean you are ignoring or abandoning them. Caregivers need to be sensitive to the right combination of giving just the right amount of assistance and no more.

Ways to promote good mental health in the elderly:

• encourage socializing with friends and relatives through visits, phone calls or letters.
• arrange fun times such as parties or outings.
• help start new hobbies or revive old ones.
• listen, talk, and share feelings.
• assure privacy.
• treat with respect, not as little children unable to think for themselves.
• encourage movement and exercise.
• help find ways to be as useful as possible.
• strive to keep the lines of communication open.

The Importance of Lifetime Learning

Research shows that reaction time may be slower in older people but they can still learn. Families and friends may need to be patient in waiting for responses. It is also important to remember that short-term memory may not be as good as it was.

The brain helps link people to the world. If we are able to process and understand what we see, hear and absorb from our senses, our experiences will become more meaningful.

Sometimes older people are incorrectly labeled as “senile”; the misconception is that they are no longer able to think for themselves. However, for the most part, older people continue to make good use of their creative powers, and as is true for all parts of the body, the brain usually will function better if it is used regularly.

Lifetime learning means exploring new ideas, whether this is from reading, listening to radio or television, trying a new hobby, or trying a new recipe. It can include lively conversation with friends and family. What it boils down to is a willingness to keep exploring the many adventures that life has to offer.

The benefits of lifetime learning include more enthusiasm for life, less boredom and depression, increased feeling of self-esteem and self-respect, more interest in the surrounding world, and new ideas to share with family and friends.

Memory Problems:

Memory loss can be one of the hardest problems for both the care-receiver and the caregiver. Some memory problems are treatable, some are not. Therefore, it is important for the doctor to determine the causes of memory loss in the individual.

Forgetfulness, even inability to recognize familiar faces and places, might result from such treatable causes such as malnutrition related to improper eating habits, alcohol, side effects of medications, loneliness, isolation, few chances to socialize with others, sensory impairment (decreased vision, decreased hearing), surgery or accident resulting in injury to body, viral infections or other illness, or depression or other mental illness.

Sensory Problems:

People who have losses in hearing and vision may have trouble understanding things consequently negatively affecting their emotional well-being. Basic aids to hear and see are vital. At times an older person may be cut off from the world because of wax in the ears or worn out hearing-aid batteries. Glasses may need to be adjusted or perhaps just cleaned. Good lighting, without glare, is important. Magnifying glasses or large print can make reading easier.

Confusion:

For people who are confused, the following tips can be useful:

• Make changes in routines gradually,
• Be clear about reminders for appointments or meetings,
• Write simple directions in large, clear print,
• Use large labels (words or pictures) on drawers and shelves to identify contents,
• have clocks and calendars clearly visible and mark off passing days,
• Make certain that medicine is being taken regularly,
• Confused or forgetful patients must have assistance with their medications,
• Encourage consumption of nutritious foods,
• Encourage movement and/or exercise as this will increase circulation of the blood and help improve bodily functions, including the ability to think.

Behavioral Problems:

For people who are acting out, being disruptive, or have other undesirable behaviors, it is best to not antagonize or confront but to temporarily remove your presence from the person, giving the message that “I love/care for you but not this behavior.” Below are some suggestions to minimize undesirable behaviors:

• Avoid confrontation. If the behavior deals with disrobing, offer brightly clothes which make the person feel good.
• Don’t argue. If the person becomes too agitated, change the subject/object to something completely different.
• Reduce stimulation. Lower lighting, reduce noise (radio, TV) to soothing music, minimize items in the area to a few possessions known to the person, and avoid clutter.
• Promote familiar objects, pictures.
• Walk slowly with the person to reduce anxiety and stress the muscle tension.

Mental Stimulation:

Because many older people enjoy recalling events from past years, families and friends should encourage the sharing of stories. Activities which stimulate the brain (visiting with others) can contribute to the goal of continued lifetime learning.

Often, older people can become happier, more productive individuals when they are encouraged to perform fun, brain-stimulating activities. The following activities are especially good for homebound elderly:

• sew or knit,
• be a friendly telephone caller,
• be a foster grandparent,
• be a pen pal,
• be a reader to children at an elementary school,
• save stamps for collectors,
• write favorite recipes on cards and share them with others,
• read books, magazines, newspapers,
• do puzzles (jigsaw, crossword),
• try artwork (calligraphy, painting, drawing),
• write or record memoirs, poetry, thoughts,
• keep a joke book,
• care for pets or plants,
• listen to soothing music,
• take correspondence courses,
• play musical instruments,
• start or re-arrange a family photo album,
• volunteer, at libraries, hospitals, museums, schools, Retired Senior Volunteer Program (RSVP),
• bake for self and others,
• plan a potluck or brown-bag lunch at home,
• tutor or visit with children and youth,
• type for self and others,
• participate in radio call-in shows,
• learn to use a computer.

In addition, older people who are physically able should be encouraged to participate in swimming, bowling, gardening, dancing, miniature golf, nature walks, mall-walking, jogging, shuffleboard and other activities outside the home.
Drawing, writing, reading, crafts, taking classes, and other hobbies encourage creativity. Indoor games including chess, checkers, monopoly, cards, billiards and Parcheesi provide interesting relief from boredom as well.

Legal and Financial Affairs

Older people continue to be concerned about management of their assets and property. However, they may be unable to participate because of illness, confusion or loss of memory. It is important to involve them whenever possible.

Compiling an Inventory:

Develop an inventory which lists all assets and liabilities of the older person. The following items should be included: bank accounts, pass books, certificates of deposit, money market funds, stocks, bonds, precious metals, jewelry, real estate deeds, promissory notes, contracts, insurance policies, safety deposit boxes (including location of the key), and retirement or pension benefits.

Location of the records for each asset and liability also should be included. Other important documents, such as birth and marriage certificates, social security numbers, divorce decrees and property settlements, income tax returns (state and federal), death certificate of spouse (if any), and wills (including the attorney’s name and executor) or trust agreements, should be listed and the locations designated.

If able, the older person should compile the list. If unable, a family member, attorney, banker, accountant or certified financial planner can help compile the inventory which should be copied and kept in a safe, obvious place, possibly with a relative or friend. It is important that the document be updated every year.

Managing a Will and Financial Affairs:

An objective of financial and estate planning for older people is to plan for the orderly distribution of the estate upon their death, according to their desires.

Consequently, it is important for people to have a will drafted, which incorporates the above inventory and states how property is to be disposed of upon death. Everyone over the age of 18 should have a will or a similar legal document.

If a person does not have a will, an attorney should be consulted immediately. Proper planning is essential and powers of attorney or trust agreements should be executed while a person is still competent.

Otherwise, transfer of responsibility for management of the person’s financial affairs to someone else must be completed through a court action, and costs spent in clearing up Probate problems come directly out of the person’s assets, diluting whatever estate is left after death.

Remember, as caregivers concerned about the financial affairs of a care-receiver, you should not get directly involved without legal authority. Acting without clear legal authority, even with the best intentions, can cause serious problems.

The legal mechanisms available for surrogate decision making are: durable power of attorney (DPA), probate conservatorship, and durable power of attorney for health care (DPAHC).

Durable Power of Attorney is a written legal document giving someone other that the Principal the authority to handle the Principal’s financial decisions. It must be signed by the Principal while the Principal is still legally competent. The DPA is valid without time limit until the Principal either revokes the DPA or dies, or the court revokes the DPA due to mismanagement.

The preferences of the Principal regarding the management of assets can be specified. This power to manage assets can be transferred immediately or can be designated to go into effect when it is determined that the Principal has become mentally incapacitated.

Financial decisions made by an individual given DPA by the Principal are binding on the Principal and his/her successors, so caregiver and care-receiver are urged to seek the advice of an attorney.

Probate Conservatorship or Conservatorship of Estate allows for the management of the Principal’s money and other property when the Principal presently lacks the capacity to either decide or appoint another to decide financial decisions in his/her behalf.

Court proceedings to designate a conservator are required. This is a difficult and extreme procedure but may be necessary if the care-receiver is already incapacitated to the extent that he/she is unable to manage personal financial affairs.

Durable Power of Attorney for Health Care (DPAHC):

is a written document which must be signed by the Principal while he/she still has the capacity to make decisions. The DPAHC gives someone other than the Principal authority to make medical treatment and health care decisions on behalf of the Principal for up to the maximum of seven years after the document is signed.

It allows one to specify ahead of time how he/she wishes these decisions to be made. Wishes regarding extraordinary supportive care, including breathing machines and tube feeding, can be addressed in the Durable Power of Attorney. All adults should have a Durable Power of Attorney for Health Care.

Lantern-Petris-Short (LPS) Conservatorship:

(Laws vary from state to state, check your state for comparable laws) or conservatorship of person is a court-ordered process which enables a person to get the psychiatric and/or medical care needed but by reason of mental illness is refused.

The court determines if the Conservatee, in addition to receiving the necessary psychiatric treatment, may also retain or be denied the right to vote, possess a driver’s license, enter into contracts, or refuse non-psychiatric medical treatment.

The Conservator may be a relative, friend or an appointee from the Conservator’s office. The Conservator may be given the right to require and authorize the conservatee to receive involuntary psychiatric and/or medical treatment and supervises and assists in making proper living arrangements, including placement in a Residential Care or a nursing home when indicated by the doctor.

In order to start the process, one consults either with his/her attorney or calls the Office of the Counselor in Mental Health. An individual has to be adjudicated to be gravely disabled before being placed on an LPS conservatorship. Grave disability is defined as the inability to provide for one’s food, clothing, shelter and proper medical care due to a mental disorder.

Selecting an Attorney:

It is important to select an attorney who is knowledgeable in the areas needed (estate planning, will drafting, probate or conservatorship). Ask friends or other professionals for recommendations, or contact a Lawyer Referral Service, County Bar Association, or Senior Citizens Legal Services. Before agreeing upon a particular attorney, ask if he/she has previously done what you require.

Liability of Caregiving

Anyone who accepts the responsibilities of a caregiver must also understand that there are a number of legal duties or liabilities that come with it.
Many states including California have passed elderly abuse laws. Caregivers are bound by these laws in two ways: not to abuse the elder person (physically, mentally or monetarily) and report any incidents of abuse or suspected abuse.

As a caregiver, you must provide a clean and safe environment, nutritious meals, clean bedding, and clothes. At the same time, if you are in charge of the elderly person’s finances, you must use that money properly, purchasing necessary services for the benefit of the person to whom care is given. Failure to provide care, failure to get care, and failure to purchase care are all forms of abuse or neglect.

In addition, caregivers may not physically, sexually or psychologically abuse the person receiving the care. Yelling, screaming, withholding affection, etc., are as much an abuse of the person as is striking the person with the hand or with objects.

Therefore, if you are contemplating becoming, or are now a care giver, you must be ready to accept the physical, psychological and legal duties to provide the necessary care.

If you are reaching a point where you are no longer able, physically or emotionally, to provide the proper care, we urge you to consider the alternatives to personal care-giving and to seek help with this decision from a counselor or one of the resources available in Appendix A.

1. When is it Time to Stop Caregiving?

As we have stated repeatedly throughout this booklet, care-giving is a very stressful situation. Stress either causes or exacerbates some 70 to 90 percent of all medical complaints, including tension and migraine headaches, high blood pressure, asthma, nervous stomach, bowel problems, and chronic lower back pains. There is research evidence indicating stress plays a role in a person’s susceptibility to heart disease, stroke, and cancer.

Stress has also been implicated in psychological disorders such as anxiety reactions, depressions and phobias, as well as poor work performance, drug and alcohol abuse, insomnia, and unexplained violence.

If you are experiencing any of the above, it is extremely important that you learn and use various techniques for stress reduction (some are mentioned in this booklet), come to the decision, both for your well-being and that of your care-receiver that it is time to stop caregiving.

Below are some telltale signs which can help you assess when you have reached this fork in the road; seek help professional help, utilize more stress reduction methods, or stop care-giving:

• snapping at the care-receiver constantly even over little things,
• being constantly irritated,
• seldom laughing anymore,
• feeling constantly tired or pressured,
• losing sleep, failing to fall asleep for hours, sleeping restlessly all night long,
• yelling or screaming, or having crying fits, or rages frequently,
• withholding affection, feelings of goodwill from the care-recipient,
• withholding food, baths, dressing changes, etc.,
• constantly blaming the care-receiver for your being in this situation (his/her isolated caregiver),
• refusing to go out anymore, even for a walk because he/she needs me,
• withholding expenditures for goods or services he/she needs because he/she is going to die soon and it is wasted money

While these are not exclusive, they indicate a classic picture of caregiver burnout. The treatment for caregiver burnout is simple — get help and get away for extended periods, either through stress management respite help or through a complete change in care-giving.

No one can remain a full-time caregiver forever; the job is much too strenuous and stressful. The point we wish to set forth is: When should I say this is my limit; I am not able to do any more. Be honest with yourself, and when that limit has been reached, STOP! Research alternatives, request help from qualified professionals, and rest easy, because you did the right thing!

Choosing a Residential Care Facility

In making the decision to seek an alternate living arrangement for your care-receiver you will first need to consult with your physician. The physician can be your best ally since most facilities require a current complete physical exam and the physician can assess the level of care your care-receiver needs.
This is important in order to determine which type of licensed care facility you will be seeking, from the Acute Hospital to Sub-acute Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF) or Residential Facility for Elderly (RFE) (more commonly referred to as Board and Care or Retirement Homes). The RFE is for non-medical care and supervision which may include personal services (help in bathing and grooming, guidance in dressing, aid in taking self-administered medications) and help with other daily living activities.

Seek a licensed facility, since people who need care and supervision are often defenseless against abuse or exploitation. The law requires that care facilities be licensed. So when you select a care facility, check for the license to assure the protection provided by law and quality care for your loved one.

What Should I Look for When I Visit a Care Facility?

It is ideal if both you and your care-receiver could preview a care facility prior to deciding. Both prior to and during the preview process you have the opportunity to further discuss your feelings in making the decision. Since you have many things to do during your visit, you will find the outing less stressful and easier afterward to evaluate if you organize your thoughts beforehand, write down the questions you wish to ask, carry this checklist during your visit and make notes while looking around and talking to different people. Some items you may want to cover during your initial visit to insure quality care are:

• Ask to see the facility license,
• Look closely at the building and grounds,
• Talk to some facility residents,
• Talk to the facility administrator who is in charge of daily operations,
• Talk to some facility staff members,
• Ask to see a copy of the Admission Agreement.

Contact your County or State Department of Social Services for a copy of their Consumer’s Guide to Community Care Facilities or equivalent.