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Sometimes words don’t seem like enough when trying to communicate with someone with dementia

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February 16, 2012

- Alzheimer's Care, Blog, Elder Law Articles

Nonverbal communication is important, more so perhaps with someone who has Alzheimer’s or dementia than with others. That goes for communication in both directions: from you and to you. Body language can be responsible for up to 80% of all communication. It is very important therefore, when communicating with our loved ones to do more than just get the “right” words. Facial expression and tone of voice are a big part of your message. Alzheimer’s patients are still sensitive to people around them and can be rather intuitive. They know when someone is not being sincere. Similarly, they can be very aware if they’re being excluded from something or being talked down to. People with Alzheimer’s can sometimes look into your eyes and seem to read your soul — like a “sixth sense.” Be aware of the body language they may be sending your way. Bouncing up from a chair and pacing around could indicate, for example, that a visit to the restroom is warranted. Or it could be an indicator of some type of pain or discomfort. Always keep in mind that pain could be a part of the equation. As for calming your loved one’s agitation or anxiety, sometimes less is more — as in talking less, or not at all. Sometimes you don’t need to say anything. Touch is an important part of the human condition, so resort to hugs and gentle touches on the hand, arm or shoulder often, if you can. A simple hug can dramatically change a person’s mood instantly. Sometimes, an angry caregiver might not want to give a hug, but that’s the time when your loved one might need it most. Embrace her, and the opportunity to improve one’s existence. It might be stepping out of your comfort zone, but the results could amaze you. A hug can release tension immediately (in your loved one and you). A gentle massage or back run also can soothe the mood and have a relaxing effect. For more information, download the Indispensable Alzheimer’s Resource Kit which can be obtained at no cost by clicking here     
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How can I minimize my loved one’s agitation while trying to communicate with her?

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February 15, 2012

- Alzheimer's Care, Blog, Elder Law Articles

An important part of any type or relationship is communication. An often tough task becomes increasingly difficult, however, when a person with dementia is involved. Both processing and expressing information become more difficult, which can lead to frustration, which can ultimately manifest itself as agitation. Anything from mere pacing to lashing out can be a sign of agitation. As a caregiver, you want to avert agitation as much as possible. Effective communication can help. Below is a list of ways to improve communication. It is by no means complete, but if you follow these tenets, you’ll be doing well:
  •  Talk with a calm presence
  • Don’t argue — you’ll never win
  • Validate feelings
  • Smile and be pleasant
  • Approach from the front so you don’t startle your love one
  • Identify yourself, if needed
  • Maintain eye contact
  • Ask one question at a time
  • Go slowly. Remember that hurrying heightens frustration
  • Use short sentences
  • Give plenty of time to respond
  • Repeat information as needed. Repetition is good and usually helpful
  • Use touch, such as on the shoulder, knee, back or hand
  • Give hugs — many times a day
  • Laugh together
  • A high-pitched voice might convey that you are upset so speak with a lower tone when possible
  • Speak clearly and directly (and, to repeat, slowly)
  • Don’t correct your loved one
  • Ask things nicely: Don’t make demands
  • If you feel your words becoming heated, stop. Take a deep breath. Try again later
  • Don’t take adverse behavior personally.
  • Respect the person as an adult; don’t talk down to him or her
  • If he or she cannot find or make the words, gently finish a sentence as needed.
  • When at all possible, allow choices — such as “Should we pay the gas bill or electric bill first?” or “Would you like tea or coffee?” etc.
  • Frequently praise your loved one and spread affirmation — for even the smallest things. Make phrases like these a frequent part of your vocabulary: “Thank you,” “Good job!” and “You’re the best!”
For more information, be sure to downloard the Indispensable Alzheimer’s Resource Kit which is available at no cost to you simply by clicking here.
       
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I want to better understand my loved one’s agitation but don’t know how

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February 9, 2012

- Alzheimer's Care, Blog, Elder Law Articles

We must make an effort to try to determine what a person with dementia is trying to communicate when he or she displays agitation or other “symptoms.” Many professionals who work with dementia patients think that there is a cause of reason to every behavior. “If we spent as much time trying to understand behavior as we spend trying to manage and control it we might discover what lies behind it is a genuine attempt to communicate,” is how Malcolm Goldsmith of the UK Journal of Dementia Care put it. People with dementia must continue to be viewed as individuals — as people who continue to need to be heard and have feelings. Whoever we are, often we find the source of anger or agitation stems simply from not being heard. Everyone needs to have his or her feelings validated and/or understood. Insensitive or uncaring responses can alienate or agitate anyone. If, for example, a trusted friend is told about a sensitive issue that made you cry and responds with, “Why should that make you cry?” you will not feel as if you’re being truly heard. Your feelings certainly won’t feel validated. A better response from your friend would be something like, “I’m sorry you’re upset. Would you like to talk more about the situation?” Even though your friend’s feelings might differ from yours  — you might not become upset about the same things — she can still validate you. Take another example of validation, using an upset child. The child might tell his parents that he is being picked on at school. If the parents shrug it off or treats the subject too lightly, the child won’t feel as if he’s been heard, understood or validated. However, if a parent responds with, “That really upsets me, too” and asks to talk the problem out so “we” can make things feel better, the child’s feelings will be validated. The end result is the child will feel better about himself. This is critical. A parent might not view the situation at school with the same alarm or concern as the child, but that doesn’t change the importance to the child. It’s very important to remember that, in order to determine if the issue needs to be address, we must LISTEN. This is no less true with a person with dementia. He or she needs to be heard and genuinely validated, just like anyone else. His or her experience might not seem like such a big deal to us, but it might be to him or her. That is a critical aspect to remember. Many every day tasks can become difficult or overwhelming to people with dementia. They can start to feel unsure, inadequate, and even fearful as anxiety builds. Such people need to feel supported and the love that any of us need to get through difficult days. Be generous with lines such as: “You did a good job,” “Thank you for your help!” “You are a wonderful person” “You are in a safe place,” and “I love you.” Affirming statements such as these can boost self-esteem and give a person validation. What you say to them might quickly be forgotten, but the good feeling may last. Validate feelings, affirm often and genuinely listen.
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Where can I find information about Pick’s disease? What kind of support is available?

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February 6, 2012

- Alzheimer's Care, Blog, Elder Law Articles

Many other conditions and illnesses have deeper support networks and more easily attainable information than Pick’s disease. But help is out there, and you can do certain things to help you or your loved one, regardless. Pick’s disease is a form of dementia manifested by a slowly progressive deterioration of social skills and changes in personality, accompanied by impaired intellect, memory and language, according to the National Institute of Neurological Disorders and Stroke (NINDS). The disease varies in how it affects individuals, but there are some common symptoms that can appear at various stages of the disease. These include difficulty thinking, loss of memory, emotional dullness, lack of spontaneity, loss of moral judgment and progressive dementia. The range of onset can be from 20 to 80 years of age, though it most often affects people 40 to 60. The cause of the disease is not known, though researchers have discovered that patients typically have atrophy of the frontal and temporal lobes of the brain. Some nerve cells have characteristic abnormalities when viewed under a microscope at autopsy. There is no known cure for Pick’s but certain symptoms can be treated. Along with NINDS, the National Institute on Aging (NIA)performs research on Pick’s. A fantastic online Pick’s disease support group is based in the United Kingdom and can be found here.  You also can contact the Alzheimer’s Association or your local area Agency on Aging to inquire about support groups in your area. If there isn’t one available, be proactive and contact a local social service agency to start one. Receiving support from others, and giving it back to others in your situation, is invaluable.
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Could the Draconian New Medicaid Rules for Long-Term Care in Illinois (effective Jan. 1, 2012) Really Be A Cloud With A Silver Lining?

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February 1, 2012

- Alzheimer's Care, Elder Law Articles, Medicaid and Paying for Nursing Home Care

New Rules As you may have read in recent columns, Illinois has adopted new rules for Medicaid coverage for long-term care for our citizens and the state of Illinois (“DRA”). These new rules took effect January 1, 2012.  The new rules are going to require that our clients engage in what we call “Five-Year Planning.” This “Five-Year Planning” has become  necessary because of the fact that there will be a new five-year lookback for all Medicaid applicants when there are asset transfers that take place after January 1, 2012. The Silver Lining What may come as a surprise to many of our clients is that the unintended consequences of these rules may be that long-term care planning for our clients may actually be enhanced in some ways. The silver lining in all of this is that while the lookback period and the need to plan further in advance is one of the negative aspects of the new law, the need to use trusts of a very specialized type in order to comply with the five-year look back may actually provide some very positive consequences. How to take advantage of the New Rule Following is an example of how the new rules could work in your favor.  Instead of leaving assets for their children outright, parents can now consider leaving assets in trust for their children. Leaving assets in trust for children carries with it the following benefits:
  1. the ability to protect the assets inherited by a child from the creditors and predators of the child, such as divorcing spouses, business creditors, tort creditors, etc.;
  2. the ability to allow the management of the assets to continue under the supervision of the parents’ financial advisor who may have assisted the parents over the years in accumulating a critical mass of assets that can provide for many years of security for the children;
  3. the ability to meet the five-year lookback requirement of the new Medicaid laws;
  4. and, finally, the ability to prevent the children from squandering or losing the assets that the parents carefully accumulated during their lifetime.
We are currently experiencing the greatest intergenerational transfer of wealth in the history of the world. However, there are often problems with transfers of wealth. Quite often, the parents pass away and the baby boomer generation will take funds in what used to be a well-managed and profitable brokerage account, and the money is randomly moved or, worse yet, squandered shortly after it is received. So I often ask both our clients and their financial advisors if they would  be interested in establishing a systematic relationship for the management of assets so that a client’s family can continue to retain the benefit from financial management even after parents pass away? The recent adoption by the state of Illinois of the DRA will provide an entrée and solution to this problem for all. In the past, this was sometimes difficult to do. The opportunity to avoid the unintended squandering and loss of assets at the death of the parents now exists with the increased usage and importance of so called Five- Year Planning as part of our “senior” estate planning process.  This planning always existed, but is now more critical than ever, with the passage of DRA in Illinois and the required “5 year or 60 month lookback period.” My preference is to work with clients and their advisors  who appreciate the wisdom of keeping client assets protected from creditors and under  management of the financial advisor. Call To Action If this interests you, then please call my office so that we can schedule a time to meet and I can discuss this new law with you. I think you’ll be amazed at the opportunities that the law presents to the older generation, as well as to the younger generation. You have our best wishes for the new year! I hope to speak with you soon.
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My wife has Alzheimer’s. Can she be affected by “Sundowning?”

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January 17, 2012

- Alzheimer's Care, Blog

“Sundowning” is the name of condition that results in a person becoming increasingly confused or agitated as the day wears on. While the actual cause of it is unknown, its occurrence can be somewhat predictable once a pattern begins. Fatigue, low lighting and increased shadows — the basis for the sundowning label — are factors known to bring on the condition. As they become more prominent during the day, an individual with Alzheimer’s tends to become more confused. Certain steps can be taken to make things easier on individuals with Alzheimer’s and their caregivers. For example, urging your loved one to nap after lunch, or at least have some “quiet time” during his or her daily schedule is a good idea. Relaxation can help a person “recharge” to deal with the rest of the day with less confusion or agitation. Create a good setting to promote relaxation by considering all five senses:
  1. put on relaxing music,
  2. get your loved one to a comfortable chair or bed,
  3. burn incense or a fragrant candle,
  4. dim the lights,
  5. turn on something that can create “white noise,” such as a bubbling water or a fan.
You can also gently massage her hands and arms with pleasant lotion. Always soothingly inform your loved one of the changes you are introducing, especially if you’re going to turn the lights off altogether or otherwise drastically change the atmosphere. This relaxation period is an excellent time for an outside volunteer (a neighbor, friend, church volunteer or other family member) to get involved your loved one’s care. It’s also a good way to get you, or whoever the regular caregiver is, a break from regular duties. Since shadows and darkness are what tends to make “sundowners” confused, make sure there is plenty of lighting after the relaxation period, and throughout the rest of the day. Placing nightlights throughout the living quarters is a good way to keep lighting up. To avert problems with sundowners who are in non-typical settings, such as a hospital room, be sure to keep familiar things on hand. These could include pillows, stuffed animals, a special radio or quilt and so on. As a person’s typical sundowning time period begins, try to keep him or her very busy. If they feel they are involved in something worthwhile, it could be enough of a distraction to lean toward neutralizing the agitated, confused behavior. More information on this topic, and others about living with Alzheimer’s disease, can be found in our free Alzheimer’s Resource Guide.  Whether you’re in Illinois or beyond, Alzheimer’s disease is a difficult challenge with which to deal. Don’t try to do it without help.
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Can a person lose speech with early-stage Alzheimer’s Disease?

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January 16, 2012

- Alzheimer's Care, Blog

Because Alzheimer’s affects individuals in different ways, at different rates, with different symptoms and at different times, it is impossible to say that no one with early-stage Alzheimer’s will ever lose the ability to talk. But it is not likely. If loss of speech happens at all, it is typically occurs in mid- to late-stage Alzheimer’s. The brain deteriorates and systematically starts to shut down certain body functions, one of them being speech. At first, a person might struggle with words, and then phrases or concepts. Eventually, entire sentences could be lost. There is also the possibility that someone will talk gibberish: He or she could be talking in full sentences but the words make no sense. Complications of neurological diseases such as Alzheimer’s could include mini-strokes, which could lead to the loss of speech. These mini-strokes, also known as TIAs (for transient ischemic attacks), are not uncommon in people with dementia. Sometimes, strokes come first and a person develops dementia secondarily. Severe strokes can result in the loss of speech. In these cases, time spent with a speech therapist can result in regained speaking abilities. It’s important to consult a doctor if speech is lost soon after a patient’s dementia/Alzheimer’s diagnosis. And, as always with such professionals, if you’re not satisfied with what you hear or how you’re treated, keep looking until you are. Consulting a specialist such as a neurologist is very important, too. Mini-strokes often may be too small to detect with an MRI, experts remind. Doctors who are experienced will be able to determine diagnoses through observation and interviews with family members. Although it is not common to lose speech with early-stage Alzheimer’s, you should always consult your physician whenever a medical condition like this is in question. Remember: Alzheimer’s treats people uniquely. While some characteristics — such as memory loss and insecurity — may be common, some symptoms may never appear in certain individuals. There are, for better or worse, few definites with Alzheimer’s. For more information about Alzheimer’s and how it might affect a loved one, check out the free, Indispensable Alzheimer’s Resource Kit from The Law Offices of Anthony B. Ferraro, LLC.      
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New Medicaid Law Changes Pose Challenges to Nursing Homes and Residents

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December 22, 2011

- Alzheimer's Care, Blog, Elder Law Articles, Medicaid and Paying for Nursing Home Care

The New Landscape In February of 2006, due to changes brought about by Congress through the federal Deficit Reduction Act of 2005 (DRA), there were massive changes in the federal Medicaid law as it relates to the gifts or asset transfers. Now, on January 1, 2012, Illinois will finally adopt those provisions of the DRA and, thus change Illinois Medicaid law for long-term care forever. You may recall that under the old Medicaid law (expiring on December 31, 2011), a gift or other uncompensated transfer created a period of  ineligibility starting on the date of transfer.
  • For example: Prior to January 1, 2012, a $70,000 gift made by someone in Chicago, Illinois would  create a 10 month penalty from the date the gift was made. (Assume Skilled Nursing Facility (“SNF”) cost of $7,000 a month. $70,000 divided by $7,000 = 10  months). Thus, if the gift were made 12 months prior, the penalties would have already expired.
  • Under the new Illinois DRA law for  Medicaid, for gifts made after January 1, 2012, the same 10 month penalty period will not begin until the following requirements are all met:
1. The person is in the nursing home, 2. Assets are spent down to $2,000 and  3. An application for Medicaid is filed. Only at that time will the penalty period start!  In such a case any gifted funds would then have to be used  for the cost of care to get through the penalty period. But there will be many circumstances in which the gifted funds are no longer available. If, for  example, one of the gifts were made by an Alzheimer’s patient to fund college tuition or given to an individual in the family who simply no longer has the  gifts. What will happen in that case? This is a major pitfall brought about by the new Medicaid  law and one with which nursing homes will have to deal in the days that are coming.  In other words, prior to the  passage of this new Illinois law, various asset transfers would not cause major  problems for nursing homes since the penalties associated with the prior  transfers were self-correcting, in that the penalty would have expired  by the time the applicant was spent down. But now, under the new Illinois law, every transaction will be examined. All small transfers will be accumulated and added together and they will cause penalties which won’t even begin to run until the person is  otherwise spent down, in the nursing home, and the Medicaid application is filed. Nursing Homes Need to Change Procedure In the past, it has been very common to see nursing homes  kindly helping residents with Medicaid applications. There was not a lot of risk associated with this under prior law. That has now all changed. Under the new laws, the same practice may be very risky from a legal and cash flow perspective. That is because it will be now be essential to verify exactly what assets have been spent and transferred without value received in exchange, because the new law will have no safe harbor for prior asset transfers without adequate compensation.
  • So let’s review another example:  Assume Mr. Applicant is a resident of the Gracious Nursing Facility located in Chicago, Illinois and that he has been paying  the Gracious Nursing Facility privately for some months. He will be ready to apply for Medicaid in September, 2012 because at that time he will be spent down.
  • However, in January, 2012, after the new law came into effect, Mr. Applicant made a gift to his granddaughter  for tuition at a local college.
  • Assume that the amount of tuition payment was $70,000. Under the old law, that would have meant that there would be a penalty of 10 months ($70,000 gift divided by $7,000, which is the cost  for a semi private room on a private pay basis at Gracious Nursing Facility=10  month penalty).  Under the old laws, the 10 month penalty calculation would begin on the date of the transfer. Thus, the penalty would have ended by August, 2012.
  • However, under the new laws, the penalty won’t start until September, 2011, when Mr. Applicant is spent down to $2000.  This means he may not be eligible until the same 10 month penalty period ends in June, 2013!
How is Mr Applicant going to pay from September of 2012 to June of 2013, after he has already spent down? Now if the social worker at the nursing home kindly tries to  assist the family by filling out the application and doesn’t understand how the new law will affect Mr. Applicant’s situation, then the application will be  filed with an expectation that Medicaid will be approved. However, you can imagine the disappointment of the nursing home administrator and the family when they later find out (usually some 90 to 120 days after the submission of the application) that the application was properly denied because the new rules are in effect. What will the nursing home do a case like this? What will the family of Mr. Applicant do in such a case? The proper recourse could consist of filing a request for  hardship exception. Illinois, however, has not had a great history of granting hardship exceptions. Furthermore the granting of hardship exceptions is for the  benefit of the resident. The hardship exception is not designed to make sure that the nursing home can maintain its cash flow for properly serving a resident. Thus you can see that these issues will, in the coming days, be very difficult for nursing homes and families dealing with the documentation required for the resident. Many residents will not have the ability to  reconstruct the financial history to the extent required by law (60 months).  In addition, seeking hardship waivers is a  very difficult process and will require proving up certain pleadings. For these reasons this new Illinois law is something that the commentators have called “The Nursing  Home Bankruptcy Act of 2006.”  HARSH BUT TRUE! While I’m not suggesting that the world is ending, I am sure  that this new law will cause enormous hurdles for nursing homes and their residents to overcome. What was at one time a simple Medicaid application should no longer be viewed that way. The services of an elder law attorney who thoroughly understands the new rules and  Medicaid changes as well how to deal with asset issues, property transfers and Medicaid denials will become more important now and in the days ahead.   Anthony B. Ferraro Attorney – CPA
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Illinois Medicaid Rules for Nursing Home Coverage

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December 9, 2010

- Blog, Elder Law Articles

New Medicaid rules are coming soon to a state near you. By February 9, 2011, the State of Illinois is expected to adopt the Deficit Reduction Act of 2005, as amended by federal changes in 2006. Implementation is anticipated by next year. The time frame, however, is not set in stone. Discussions between the Elder Law Bar and state officials are ongoing, and I have had the privilege of participating in them. Representatives of the state have graciously solicited feedback from elder care experts like myself, in order to analyze various aspects of the new rules and their consequences, but we have yet to determine exactly how they will be implemented. Issues we are still discussing pertain to retroactivity, hardship waivers, and partial returns. When more concrete information becomes available about how the new rules will be implemented, we will certainly update you. In the meantime, here are a few thoughts about elder law and long-term care planning: First, if you are physically and financially able, we recommend you obtain long-term care insurance. Long-term care insurance is the first line of defense for protecting assets, especially for the middle class in our country. Second, please be aware that traditional estate planning is not the same as long-term care planning. Estate planning deals with what happens upon your death, or in certain cases, disability. By contrast, long-term care planning prepares you to manage the costs of chronic illness and the sophisticated care for many years it often requires. The tools and objectives of long-term care planning are different than in traditional estate planning. Don’t confuse the two! Finally, do not underestimate the value of proactive planning. While you still have plenty of time, take advantage of it! When we are faced with an urgent trigger, like sudden illness, we are compelled to engage in crisis planning. While crisis planning can potentially save substantial amounts of your assets, proactive planning is ideal. Proactive long-term care planning can turn your desirable objectives for your hard-earned assets into a reality. Don’t wait to get started! During our fast-paced lives, the holidays provide a unique opportunity to share time with family. Investing some of that family time in a conversation about long-term care planning will reap the best rewards you could ask for: preservation of your wealth and your peace of mind. Happy Holidays!
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Seniors Take Note! The Way The State Of Illinois Addresses The Overwhelming Financial Costs Of Long Term Care Is About To Change

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October 12, 2010

- Blog

Welcome to our new Blog! This will be the first of many entries. The State of Illinois has now issued Proposed Regulations regarding the Deficit Reduction Act of 2005 (DRA) with substantial impact on the funding of Long-Term Care for our Senior and Disabled Citizens. As the heading above indicates, on August 13, 2010 Illinois issued proposed regulations to implement the DRA transfer rules for any transfer that takes place after February 8, 2006, the effective date of the DRA. Many other changes were proposed as well. I had the privilege of providing verbal and written testimony to representatives of the Illinois Department of Healthcare and Family Services (DHFS) in Chicago on September 13, 2010 regarding the impact of the new rules on Illinois’ citizens. The State of Illinois is still in the public comment period regarding the new proposed rules. The proposed rules may change once the public comments are examined by DHFS officials. This blog will keep readers posted on the progress of the new rules as they work their way through the rulemaking system. The changes have far reaching impact on our senior and disabled population.
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