Balancing Independence and Safety in the Cognitively Impaired Senior

The older population is one of the largest growing segments of our population.  In 2000, there were 39.6 million persons 65 years or older (Administration on Aging, 2009).  Alzheimer’s disease is the leading cause of cognitive impairment.  Over 5.3 million Americans have Alzheimer’s disease and this number is increasing in epidemic proportions.  Alzheimer’s disease affects 13% of those age 65 and over (Alzheimer’s Association, 2010).

As a person ages, their physical and cognitive abilities may become compromised.  Independence is an important part of an older person’s identity and older adults will fight to keep their independence as long as possible.  In the person with Alzheimer’s disease or other cognitively impairing processes, it is a delicate balance to maintain the individual’s independence while maintaining a safe living environment.

Independence is the ability to direct one’s own affairs without interference and freedom from dependence on others.  Milestones in a person’s life which contribute to independence include the following:

1. Obtaining a driver’s license
2. Holding a job
3. Having your own place to live
4. Having access to money without oversight
5. Having a checkbook or credit card for purchases

A person with cognitive impairment may be unable to safely perform the tasks which were previously associated with independence.  In addition, the impaired person may not have the insight into their deficits and, therefore, may not be aware of their declining abilities.  This situation puts the cognitively impaired person at risk.  In these situations, the most common types of risk are harm to self, harm to others, financial exploitation, and self-neglect.

There are many cues that a person is having difficulty safely maintaining their independence.  According to the Alzheimer’s Association (2001), the ten warning signs of Alzheimer’s disease include:

1. Memory loss
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation to time and place
5. Poor or decreased judgment
6. Problems with abstract thinking
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality
10. Loss of initiative

A person with early dementia may be able to function in some areas of their life and carry on social conversation but be unable to complete more complex functions.  Additional warning signs that a senior may need assistance include:

1. Forgetfulness
2. Sudden change in functioning
3. Failure to pay bills
4. Inability to obtain help in case of emergency
5. Leaving appliances on or unattended
6. Frequent falls
7. Poor personal hygiene
8. Lack of attention to appearance
9. Dressing inappropriately for the weather
10. Getting lost in familiar surroundings
11. Poor eating habits
12. Recent weight loss
13. Anxiety or depression
14. Sudden deterioration in physical condition
15. Non-compliance with doctor’s recommendations
16. Non-compliance with medications
17. Accumulation of mail, laundry or trash
18. Lost cash, jewelry or assets without recollection
19. Multiple traffic violations or accidents
20. Dents in the car or broken tail lights

If one or more of the above warning signs or symptoms is noticed, it is important to determine the cause of the problem, not just treat the symptom.  It can be difficult for family or friends to address these issues with an older adult because it acknowledges a loss of ability and potentially a loss of independence.  There is also an emotional tie between family or friends and the older adult that can make it more difficult to address these issues.  When these concerns are addressed with the older adult, often it is met by resistance or denial.  Frequently family members are faced with the responsibility of obtaining assistance for the older adult, but are unaware of the resources or options to provide the support needed.  Due to the increasing size of the aging population, there are ever-increasing resources to assist families and older adults to remain at their highest functional level and assist them to remain as independent as possible.  The problem is that many people are not aware of the various resources and support systems available.

Although resources vary by state, most states have both an Area Agency on Aging and a local chapter of the Alzheimer’s Association.  The Area Agency on Aging is a government-subsidized not-for-profit that provides resources and programs to assist senior adults.  The Alzheimer’s Association is the largest national voluntary health organization committed to finding a cure for Alzheimer’s and helping those affected by the disease.  They are an excellent resource for family and friends of a person diagnosed with Alzheimer’s disease or related disorders.  The Alzheimer’s Association provides educational classes and literature, support groups, and information/referral services.  The Safe Return program provided through the Alzheimer’s Association is the only national system to assist in identifying, locating, and returning individuals with Alzheimer’s disease or related disorders who wander and become lost (Alzheimer’s Association, 1999).

A growing resource is a local Certified Care Manager.  A Certified Care Manager is an individual who has advanced degrees in nursing, social work, or gerontology and has passed a national certification exam.  Certified Care Managers are trained to assess, plan, coordinate, monitor, and provide services for the elderly and their families.  They have extensive knowledge about the costs, quality, and availability of services in their community.  The Certified Care Manager works with the client and the family to provide services that are tailored to the needs of the client and family.  They objectively view the decisions to be made, always keeping the best interests and needs of the client first.  The services provided by the Certified Care Manager can include the following:

1. Extensive evaluation and on-going monitoring of physical, emotional, psychological, spiritual, financial, legal, and environmental needs
2. Individual and family counseling and crisis intervention
3. Implementation and on-going revision of the older adult’s Plan of Care
4. Coordinate medical care and offer referrals to appropriate specialists
5. Identify the most viable options, resources, and support services to optimize care and provide for the health, safety, well-being, and autonomy of the client

A list of Certified Care Managers can be found provided by the National Association of Professional Geriatric Care Managers (www.caremanager.org).  Engaging a Certified Care Manager to assist with the care of an older adult will connect you with all the services an older adult may need.

Technology has provided numerous devices to assist the senior to remain independent for as long as possible.  For example, emergency response systems provide a “call button” which the older adult wears either on their wrist or as a necklace.  One push of a button summons assistance in an emergency.  Some of the systems also provide medication reminder calls or a daily check-in program to ensure an older person living alone is all right.  If the person does not respond to the daily call, help is sent to investigate.  Another system to assist an older person remain independent is the automated pillbox.  There are numerous versions of this device, but the ideas are relatively the same.  The box is filled on a weekly basis and the administration times are programmed into the box.  When it is time for a medication to be taken, the box alarms and the door to that particular dose unlocks.  Once the pills are removed the door relocks.  This device assists in medication reminders and helps prevent accidental overdoses.  In addition, there are systems which monitor movement within the home, looking for unusual movement patterns and there are systems which monitor vital signs, weight and blood sugar on a daily basis.  The continued advances in technology will allow many seniors to remain in their home much longer than was previously possible.

Non-medical companions are another way to enable the senior to remain safely in their home.  A non-medical companion typically can assist a client with light housekeeping, errands, and daily grooming/hygiene.  The companion can provide cueing, redirection, and some hands-on assistance.  Frequently the addition of a companion, even for a few hours a week, allows the older adult to remain semi-independent in their home for longer than if the older adult had remained alone.

As a person’s cognitive abilities decline, it is important to balance the safety and well being of the client with their need for independence.  Today there are many resources and support services available to assist the older adult to remain at the highest functional level possible for as long as possible.  Proactive planning by family and the older adult can help prevent emergencies and accidents and allow the older adult to remain safe and independent as possible for as long as possible.