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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?
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 among the elderly is a significant and ever increasing problem. 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 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.
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.
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.
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:
1. Avoid confrontation. If the behavior deals with disrobing, offer brightly clothes which make the person feel good.
2. Don't argue. If the person becomes too agitated, change the subject/object to something completely different.
3. Reduce stimulation. Lower lighting, reduce noise (radio, TV) to soothing music, minimize tems in the area to a few possessions known to the person, and avoid clutter.
4. Promote familiar objects, pictures.
5. Walk slowly with the person to reduce anxiety and stress the muscle tension.
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 chass, 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, durable power of attorney for health care (DPAHC), and (California only -- check to determine if your State has comparable laws.)
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.
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 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 caregiver, 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 caregiving and to seek help with this decision from a counselor or one of the resources available in
When is it Time to Stop Caregiving?
As we have stated repeatedly throughout this booklet, caregiving 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.
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 caregiving:
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 caregiving.
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!
Carol Simpson (c) copyright 1993
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