This scenario about Susan, an 81 year old African American female, is something that is all too common in our world today. Many elders live alone without any family near them and grow older, and in some cases more forgetful too. Dealing with older adults is something that is not always easy. In some cases, like Susan’s, with an elder adult, the roles become reversed and the children become the parents and vice versa. In this situation, Susan’s children have a difficult task at hand, while living so far away–figuring out what is the best and most appropriate intervention for their mother. When families have issues like these to deal with, they turn to their healthcare providers to help them make the best, most educated choices possible. As a nurse, this is something that we must understand. In this situation, evaluating all the facts and looking at it from a health, safety, socioeconomic, ethical, and legal standpoint is very important. By taking a multidisciplinary approach and collaborating with the family, we as healthcare providers can help to determine a safe and effective outcome. Since some of the things that have happened to Susan seem to point to the direction of dementia, it is important to address this seriously but in a smart and organized manner. The rates of Alzheimer’s disease in African Americans is 2 times higher than Caucasians, so that is something very important to take into consideration (Alzheimer’s Association, 2010).
The first and thing that Susan’s family should try to do for her as a result of some of the problems she has been experiencing is a physical examination done by her family physician. Susan has been experiencing what seems like bouts of forgetfulness; the first step might include a Mini Mental State Exam by her doctor to assess mental function and to determine if there are any health disparities that need to be addressed. Bringing the family in town for a consult would also be very helpful and beneficial to not only them, but to their mother Susan as well. She is in need of some support due to some of the things that have happened to her recently.
It is very important that before the diagnosis of dementia is declared, alternative causes are investigated. The doctor should test Susan’s vitamin B 12 levels for a deficiency, since this can manifest similar symptoms to dementia in older adults (Vishnu, 2010). Evaluation of Susan’s nutritional status is also important when screening for dementia. Inappropriate nutrition can lead to health problems that can cause dementia. Assessing for falls is important too. We have learned that some older adults deny falls because they fear being put into a nursing home. In Susan’s case, this is something that wouldn’t be out of the question. If Susan suffered some sort of head trauma, it could potentially be bringing about the symptoms she is demonstrating.
Medication administration is something that should be investigated as well. Since Susan has a lengthy list of medical diagnoses, it is safe to assume that she is taking some form of medication to manage her symptoms. Susan is a type 1 diabetic; because of this she probably requires insulin injections. Being elderly and living alone puts her at risk for improper medication administration. Susan also has a diagnosis of dry macular degeneration which could cause her to be unable to read medication labels accurately. If Susan is not reading insulin syringes correctly or cannot read the glucometer, she may be over or under dosing her insulin. Because of this, she could be experiencing some dementia-like symptoms. Hypoglycemia can be caused from too much insulin, and confusion is a major symptom.
When Susan makes a visit to her family physician, he may perform a Mini Mental State Exam to determine her level of cognitive impairment. Depending on the results of the exam the doctor may involve a psychiatrist (Vishnu, 2010). This test asks things that will gauge how good memory skills are and if someone is able to recognize objects. Depending on how she would score on this exam, he might look more into a dementia diagnosis. Looking at brain imaging might be done to see if there are any bleeds or visible damage that could be caused by some other disease process. A psychiatrist would need to be involved to manage any psychotropic medications that Susan might require based on her diagnosis.
If the diagnosis of dementia were to be given, Susan and her family would have some things to consider. Susan seems to be a threat to herself and possibly others, with a history of car accidents and now nearly burning the house down. The psychiatric doctor could evaluate these situations and decide if Susan is safe being at home alone. Another thing to take into consideration is the neighborhood where she currently resides. Since she has lived in the same house that she and her husband originally built after WWII she could potentially be living in a dangerous neighborhood. Many elderly people live in the same residence that they have resided in for years, but sometimes the area around them has deteriorated greatly. If Susan’s doctor and family decided that she was unable to live alone anymore, they could potentially still move her into an assisted living facility, even if Susan says she doesn’t want to or won’t.
If Susan’s family feels that she is unsafe being at home alone, they could have her psychiatric doctor evaluate her. If the doctor decides that she is “incapacitated” and cannot care for herself safely at home, her children can go to the court. One approach they can choose to take is the power of attorney. This is a legal document “that designates another person to act on his or her behalf” (Touhy & Jett, 2010). One type, the attorney-in-fact, could provide the children the legal right to make financial decisions and pay bills, but no medical decisions. If the children want to go the durable power of attorney route, the designated person could make health care decisions for Susan when she can’t make them herself (Touhy & Jett, 2010). This would be the lesser restrictive of the legal choices. The other option would be to gain a guardianship over Susan. If one of the children wanted to become a guardian over Susan, she would have to be deemed incapacitated by a court (Touhy & Jett, 2010). That child would have a complete say over everything that Susan would do. This would give them the power to tell Susan she must move into an assisted living home. This is the more restrictive choice and it can only be done by a court order.
There would be many drawbacks to either of these situations. One of the major ones would be the fact that none of the children live any less than 6 hours away from Susan. More than likely, Susan would have to relocate to live closer to whichever child was going to have POA over her or guardianship. If she was going to be placed into an assisted living or nursing home, it would be very hard for one of her children to manager her finances and health issues from out of state. Relocation syndrome would be something to watch for, and it might be hard for Susan at first, but she actually may be happier being closer to her children. If her family decided to try to go the guardianship route, whoever was appointed her guardian would have complete control over Susan’s finances and would get paid her Social Security benefits (Palmer). This is something that could potentially cause tension or a problem between children because of wrongfully using the money or other discrepancies that could arise. Taking a step such as one of these options would have to be carefully considered among the children.
Although Susan said she would never allow a home health nurse to come to her house to help her, this might be a good option to consider. She would be able to have help with her medications and treatments, but still be able to maintain some of her independence she feels when living at home. One of the potential problems that could occur is that Susan will not cooperate with the nurse and could refuse to let her provide any care. Due to the progression of dementia, she could keep forgetting day to day who the home health nurse is. Overtime, she may become less compliant with home health care. This would most likely not happen right away, so it might not end up initially being a problem. This would be something to consider when deciding what the best action would be to take.
Susan’s safety is something that should definitely be addressed when the decision is going to be made on where she should live. Keeping her medical conditions under control should be a high priority. Getting her fitted for a hearing aid to help with her hearing loss may also help her to function at a higher level. Driving is something that needs to be addressed. Due to the forgetfulness and her other physical diagnoses such at macular degeneration, it may not be very safe for Susan to continue driving. Having a family meeting to discuss this would help everyone stay on the “same page” about the issue.
Talking with a social worker would be something very beneficial to Susan’s family. A social worker could help the family decide what the best decision for them is and lead them in the right direction. Having a family member diagnosed with dementia is not easy for anyone. It might be very helpful for Susan’s children to visit some support groups. Recommending the Alzheimer’s Association website (Alzheimer’s Association, 2010), could provide some good resources to help deal with the grief of the diagnosis. When a family member is diagnosed with dementia, the disease process does take some time to have a marked effect. As the dementia progresses, the patient becomes more and more removed from reality. To the family, “it can almost feel as if their loved one has passed away and can be very difficult to confound with” (T. Graydon, personal communication, October 17, 2010). Their loved one is not the same person they used to be. They might not recognize people they once did and might not remember things others think they should still remember. This is terribly devastating for family members and they may need support. Going to Alzheimer’s support groups may also help Susan’s family and let them know that they are not alone in the new hardship they may be faced with.
Keeping Susan safe and healthy in her later years is very important. Her family will have much to consider, and utilizing resources available to them can help them with their decision. As a part of the health care system, situations like this may come up more and more frequently with the aging population. Nurses need to be competent and aware of choices and options available to families going through an issue similar to Susan’s. It is very important to remember that that family has the ultimate decision, and being supportive and informational is the best way for a nurse to effectively assist the patient and their family. For a family like Susan’s living far away, it is not always easy to see that their loved one has actually deteriorated. It also may be harder for them to recognize symptoms since they don’t see her every day. Ethically, as a healthcare professional, situations like this need to be dealt with for the safety of the patient and the public at large. If a nurse suspects some sort of neglect on the family’s part, it is imperative that the nurse involve social services and a social worker. If the family does not want to do anything about the elder’s situation, then the nurse is ethically responsible to be the advocate for that patient and help them get the care they are entitled to.
This situation is something that needs to be taken care of from a health, safety, socioeconomic and ethical standpoint. Although the ultimate decision rests in Susan’s family’s hands, it is the nurse’s responsibility to guide them and provide the support they need to make a fully educated decision. Hopefully, the family and the patient can come to some sort of agreement on a health care plan for the future.