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Join us at noon CT (1 p.m. ET/10 a.m. PT) on Tuesday, July 26, to chat about keeping senior citizens out of nursing homes, with Tribune reporter Judy Graham, and panelists David Fisher and Anthony Ohotto, M.D.

What are the most common reasons that seniors end up going to a nursing home? How can older people stave off problems, avoid giving up their independence and prepare to stay safely at home? We ask doctors who have devoted their careers to helping people live well in their communities as they age.

David Fisher, MD is a board certified geriatrician and palliative care physician. He practiced with Advocate Medical Group, caring for seniors living in nursing homes throughout Chicago, before relocating to Raleigh, NC to join one of the nation's largest home care practices, Doctors Making Housecalls. Dr. Fisher's passion is helping seniors and their loved ones maintain control of their health through the aging process. His book "How to Keep Mom (and Yourself) Out of a Nursing Home" gives practical tips for preventing the loss of independence that often leads to the need for nursing home care.

Anthony Ohotto, M.D., is a geriatric and palliative care specialist with Providence ElderPlace in Portland, Ore. That organization operates a program known as PACE (Program of All-inclusive Care for the Elderly), which supports seniors with medical issues living in the community. Dr. Ohotto practiced for six years in a remote area of Arizona on a Navajo reservation. In his current position, he focuses on helping older adults remain independent and occasionally makes house calls to people who can't come to Providence ElderPlace's health centers for services. The doctor's professional interests include pain management and end-of-life care; outside of work, he enjoys mountain biking and mushroom hunting.

Can't make the chat? E-mail questions in advance to jegraham@tribune.com.

Health Chat: Tips to stay out of nursing homes

(07/26/2011)

  

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11:47

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10 minutes  Tuesday July 26, 2011 11:47

11:57

Judy Graham:  Good afternoon, everyone. Thank you for joining us for today's chat, which is about helping older people stay independent as they age. I'm delighted to have two physicians who are passionate about this topic with us today. These chats are all about you and what you want to know, so please send us any and all questions you have. Dr. Fisher, why don't you tell us about the book you've written, "How to Keep Mom (and yourself) Out of Nursing Home"? What was the inspiration? Tuesday July 26, 2011 11:57 Judy Graham

11:58

David Fisher, MD:  I’ve spent a lot of time in nursing homes, and I think they are an integral part of our health care system. However, most of the patients I've admitted to the nursing home never planned on being there long term. Often, patients are admitted for one reason, i.e. to rehabilitate from a hip fracture, but they end up having to stay in the nursing home for other reasons. I wrote the book to help people to prepare themselves for unpredictable health events that could rob them of their independence. Tuesday July 26, 2011 11:58 David Fisher, MD

11:58

Judy Graham:  Dr. Ohotto, what about you? Can you tell me how helping seniors remain independent became a key interest of yours? Tuesday July 26, 2011 11:58 Judy Graham

11:59

Anthony Ohotto:  My work with elders started with my first job out of training. It was on the Navajo Nation in northeast Arizona. When I arrived I was assigned to be medical director at three elder care facilities. In addition to the facilities, I cared for elders living very independently, by choice, out in the desert. Often off-grid. Often in dirt floor traditional homes (hogans), hauling water from miles away, heating with wood. Doing everything they could to stay independent and stay out there. Six years later I moved on to geriatrics fellowship in Sun City, Arizona. Sun City was a big contrast. The people who we cared for there were fairly well to do. Very much on-grid. It was striking to see the contrast with my Navajo patients, but the similarities were even more striking. Elders doing everything they can to stay healthy and live the life they choose. Tuesday July 26, 2011 11:59 Anthony Ohotto

12:00

Judy Graham:  I see we have many people lurking in the shadows. Come out and ask us some questions. Dr. Fisher, tell us your thoughts about the main reasons why people end up going to a nursing home. What are these? Tuesday July 26, 2011 12:00 Judy Graham

12:01

David Fisher, MD:  There are two important concepts here: independence and reserve. The primary reason people are unable to live at home is a loss of independence. In geriatrics, we assess our patients — independence with the “activities of daily living” which include the ability to bathe, dress, go to the toilet, feed oneself, and to get up and walk or move to a wheelchair without help. Once you need help with one or more of these daily activities, your odds of moving to a nursing home skyrocket. There are some key factors that help us remain independent with these activities. They are: strong legs, strong bones, good bladder control, healthy blood vessels, a healthy brain, thoughtful financial planning, and strategic social support. My patients who spend time investing in these seven factors are usually able to remain at home. In the field of geriatrics, we also like to talk about the concept of reserve. All of us have a certain amount of physical reserve that will help us through a crisis. For example, if you have healthy lungs, and you develop pneumonia in the right lung, your left lung can provide all the oxygen you need for weeks while the right lung recovers. The same holds true for most body systems- they all contain some reserve that we have to tap into sometimes. Unfortunately, as we age, that reserve starts to shrink, putting us at risk for complications from a seemingly non-threatening health event. The person with emphysema is at risk for a prolonged hospitalization or even death if pneumonia sets in. Once we get to the point that we are using any body system at maximum capacity just to accomplish our daily activities, even the smallest adverse event can tip us over the edge of losing our independence. Loss of ‘reserve — in any of the key factors listed above will greatly increase the risk for ending up in a nursing home. Tuesday July 26, 2011 12:01 David Fisher, MD

12:02

Judy Graham:  That's really interesting. Dr. Ohotto, do you have any thoughts to share on this as well? Tuesday July 26, 2011 12:02 Judy Graham

12:04

Anthony Ohotto:  We often see people who have been struggling at home and the small struggles build and lead to a catastrophic episode which leads to nursing home admission. If we can intervene with the small issues we can often prevent the catastrophic event. Tuesday July 26, 2011 12:04 Anthony Ohotto

12:05

Judy Graham:  Dr. Ohotto, give us an example of what you're talking about here. Tuesday July 26, 2011 12:05 Judy Graham

12:07

Judy Graham:  I know the doctor's internet connection is a little slow. Be patient. He's working on an answer. Tuesday July 26, 2011 12:07 Judy Graham

12:08

Anthony Ohotto:  There are many organizations which can help. I work for PACE. PACE stands for Program for All-inclusive Care for the Elderly. It is a Medicare and Medicaid funded program. People who qualify can receive all medical and dental care, medications, home care assistance or housing thru the program, as well as social and spiritual support. If they are in their own home or a family home, home care assistance is available. Otherwise we arrange for housing in adult care homes or assisted living facilities. We provide end of life care as well. A big part of the program is home nursing care, social work support and adult day centers. This program allows for people to remain in a community living setting. Hopefully it is their own home, but if not, we help them to be in the least restrictive, most independent living setting feasible. Nursing homes are a last resort. One key to the program is a multi-disciplinary approach to care: On a daily basis I work with nurses, social workers, pharmacists, chaplains, hands-on caregivers, rehabilitation specialists, dieticians and families. This multi-disciplinary approach is key to successful management of very complex health issues for elders. It works. Very few of our patients live in nursing homes, and we have a very low hospital admission rate. Tuesday July 26, 2011 12:08 Anthony Ohotto

12:09

[Comment From DickDick: ]  What organizations have you found to be the best source of in-home assistance for elderly patients? Tuesday July 26, 2011 12:09 Dick

12:09

Judy Graham:  I think both doctors will have something to say on this question. I can hear them typing away. You'll hear from one in just a minute or so. Tuesday July 26, 2011 12:09 Judy Graham

12:10

David Fisher, MD:  Most communities have a city or county department for seniors, which often will provide things like meals on wheels and in-home assistance with daily chores. For personal care, this often requires a private-pay organization unless you have a long term care insurance policy. Tuesday July 26, 2011 12:10 David Fisher, MD

12:11

Judy Graham:  If an older person doesn't have many financial resources, they may qualify for assistance from state programs that help pay for in-home services. Call your state department on aging for more information on this option. Tuesday July 26, 2011 12:11 Judy Graham

12:12

David Fisher, MD:  US Veterans also should look into a little known VA benefit called "aid and attendance" that is available beyond a veterans' pension and can cover in-home care or care in an assisted living facility. Tuesday July 26, 2011 12:12 David Fisher, MD

12:13

Judy Graham:  Many communities have also started programs that send volunteers in an older person's home just to visit and talk. Of course, senior centers can be a very good source of information about services in the community. Tuesday July 26, 2011 12:13 Judy Graham

12:14

[Comment From OliviaOlivia: ]  My parents are still relatively young, but I'd like to start preparing early. What is the #1 advice for children to support their parents' healthy aging? Tuesday July 26, 2011 12:14 Olivia

12:16

David Fisher, MD:  Olivia, I think the #1 advice is to start a conversation. Often we wait for a crisis and then it is much more difficult to make sure things are in place. The broad topics in my book are a good place to start. Talk about possible scenarios i.e. what would happen if one of them got very sick, would they consider looking into a senior living facility, are the financial resources in place? Practically speaking right now, encourage mobility. Daily exercise helps with so many things and is probably the most important preventive activity. Tuesday July 26, 2011 12:16 David Fisher, MD

12:16

[Comment From RosanitaRosanita: ]  A lot of states utilize Home and Community Based Services (HCBS) waivers from Medicaid. Centers for independent living (funded through department of rehabilitation) are great resources. Tuesday July 26, 2011 12:16 Rosanita

12:16

[Comment From RosanitaRosanita: ]  Another way to prep is through the AARPs Prepare to Care workbook. It discusses options and gives amazing resources. Tuesday July 26, 2011 12:16 Rosanita

12:16

Judy Graham:  Thanks, Rosanita. Those are very helpful resources, indeed. Tuesday July 26, 2011 12:16 Judy Graham

12:16

[Comment From CarrieCarrie: ]  What advice do you have for family members who find themselves suddenly needing to be caregivers? Tuesday July 26, 2011 12:16 Carrie

12:17

Anthony Ohotto:  Family caregivers have a very difficult job. It is important to realize this at the beginning. Start to arrange for help long before you need it. Provide for a break. Take care of yourself. Your loved one depends on you. Take care of yourself too. Tuesday July 26, 2011 12:17 Anthony Ohotto

12:18

Judy Graham:  I think Dr. Fisher is going to weigh in on this one as well. Tuesday July 26, 2011 12:18 Judy Graham

12:19

David Fisher, MD:  I wholeheartedly agree, Dr Ohotto. It is a point that is not emphasized enough. Carrie, I think it is important to recognize that it is very difficult to do this alone, and that has nothing to do with how much you care about your loved one. Search out all available resources. Doctors trained in geriatrics often have knowledge about the various resources that may be available. Services like physical therapy and home care nursing is often covered by Medicare for a period of time, but requires a doctor's order, so it is good to bring this up with a physician. Tuesday July 26, 2011 12:19 David Fisher, MD

12:19

Judy Graham:  Dr. Ohotto, you mentioned the PACE program you work with. Tell me about an older person you've worked with through that program and how the program helped. Tuesday July 26, 2011 12:19 Judy Graham

12:20

Anthony Ohotto:  Here is a great story. I am thinking about Mrs. S. She joined our program a decade ago. She had been a widow for approximately 1 year but dementia and isolation made it impossible for her to stay home. Her daughter tried to care for her but was unable. Over the ensuing years her dementia has progressed and we have helped her to live in the least restrictive, most independent situation possible. It has been difficult and she has lived in a couple assisted living facilities, a couple of adult foster homes, and an intermediate care facility. But now as her abilities have really declined, she has developed a life limiting cancer. As it turns out, her daughter is now in a position to spend a lot of time care giving so we are supporting Mrs. S moving back into her daughter's home. It is going fairly well for them there now. We were unable to prevent Mrs. S's decline. We were very much able to support Mrs. S and her daughter through this decline. Tuesday July 26, 2011 12:20 Anthony Ohotto

12:20

Judy Graham:  Dr. Fisher, a similar question for you. Tell me about one of your patients who ended up going to a nursing home but may not have had to do so with some advance planning. Tuesday July 26, 2011 12:20 Judy Graham

12:21

David Fisher, MD:  I recall a lady in her early 70s who was hospitalized for a severe bladder infection. She was mildly overweight, and she had diabetes and arthritis in her knees. The hospitalization lasted for 10 days because the bacteria were resistant to several antibiotics (an increasingly common problem) and she had to receive a week of IV antibiotics to finally clear the infection. Since she had to lay in bed almost the entire 10 days, her muscles became very weak (atrophy). She was unable to safely get out of bed and take herself to the bathroom, so she was transferred to the nursing home (often called "rehabilitation facility") for a course of physical therapy, hoping to be back on her feet quickly. She had difficulty participating in the therapy because of her knee arthritis. She also had neuropathy in her legs, cause by poorly controlled diabetes, so she had balance problems that were exacerbated by the muscle weakness. Since she could not get up by herself, she could not get to the bathroom in time, so she became functionally incontinent, even though her bladder worked fine. All of these factors combined to make it impossible for her family to bring her home, and she eventually had to remain in the nursing home as a long-term resident. Tuesday July 26, 2011 12:21 David Fisher, MD

12:21

[Comment From DickDick: ]  Do you have any recommendations of how to get an elderly widow parent involved in socializing situations and social events? Tuesday July 26, 2011 12:21 Dick

12:22

Judy Graham:  That's so hard. But it's so important for an older person's health to remain connected to others, socially. One of the most difficult things that happens with age is increasing isolation. I know programs like PACE help by getting people out of the house. Doctors, your thoughts? Tuesday July 26, 2011 12:22 Judy Graham

12:24

David Fisher, MD:  Dick, I have found that local senior centers often have regular events that encourage social interaction. I'm glad you're thinking about this, because it is perhaps the most important factor in how well someone thrives after the death of a spouse. Places of worship are also good resources if you are connected with one in your community. Also, look into volunteer organizations that will visit seniors in the home and transport them to activities. This may be a way to help your parent "warm up" to the idea. Tuesday July 26, 2011 12:24 David Fisher, MD

12:25

David Fisher, MD:  Dick, if dementia is involved, adult day care centers are a good resource. Tuesday July 26, 2011 12:25 David Fisher, MD

12:26

Judy Graham:  Sometimes, people just don't want to leave their house and go out and meet others if they're feeling ill or depressed. I guess it'd be important to make sure depression isn't a factor here. If a parent simply refuses to go out, maybe you can bring family events into her home on a regular basis. Tuesday July 26, 2011 12:26 Judy Graham

12:26

[Comment From RosanitaRosanita: ]  Shouldn't you look at what she likes to do, her hobbies and interests? Also her current friends? One doesn't have to go to a program like PACE (you're completely thinking of a medical model). A lot of senior centers do trips. there's elderhostel too. Tuesday July 26, 2011 12:26 Rosanita

12:26

Judy Graham:  Very good points, Rosanita. Tuesday July 26, 2011 12:26 Judy Graham

12:28

Anthony Ohotto:  I am struggling with Dick's question. Sometimes we have ideas for our elders which they disagree with. Perhaps they know best. I wonder if there is an alternative to socializing outside of the home for her? Tuesday July 26, 2011 12:28 Anthony Ohotto

12:28

[Comment From DickDick: ]  Thanks for all suggestions. Tuesday July 26, 2011 12:28 Dick

12:28

[Comment From WillisWillis: ]  Any tips, compelling research/stats to engage/show a very smart, independent yet strong-willed parent who knows better but has become physician/treatment weary due to series of many ongoing health crises and hospitalizations and e.g., now refuses to heed specialists' advice to circle back w/ pcp, determined not to get any further bad news/treatment (e.g. "I'm not going, I do not want to find out I have cancer or anything" (on top of heart/everything else)) Tuesday July 26, 2011 12:28 Willis

12:31

David Fisher, MD:  Willis, that is a tough one. I make house calls, and sometimes that will put a patient like your parent at ease, but I don't know if that is available to you. There is plenty of data to show that people with heart failure, osteoporosis, or poor balance are at much higher risk for ending up in a nursing home. These are all somewhat preventable with early intervention. I wouldn't bring that up as a threat, just as a way to make your point, that you don't want to see that happen to your parent. I'd love to send you a copy of my book with more details! Tuesday July 26, 2011 12:31 David Fisher, MD

12:32

[Comment From Lincoln Park VillageLincoln Park Village: ]  In Chicago, we are a part of a grassroots, neighbor to neighbor support model ("give help, get help") with strong backup from strategic partners like Rush University Medical Center. Are you aware of other community-based models? Tuesday July 26, 2011 12:32 Lincoln Park Village

12:32

Judy Graham:  You're referring to the growing "village" movement here. It began in Boston and is spreading around the country. Older people band together to purchase certain services and help each other out by providing rides to doctors appointments, for instance. Or, they participate in social events or do yardwork for each other. Chicago is a hot spot for villages, and they're developing in other cities as well. Another similar concept is what's known as "naturally occuring retirement communities". Again, the idea is take services into the settings where older people live. Tuesday July 26, 2011 12:32 Judy Graham

12:32

Judy Graham:  Let's talk about what people can do to keep living at home as they age and become more frail. Name three things that people can do to help make this possible, doctors. Tuesday July 26, 2011 12:32 Judy Graham

12:33

David Fisher, MD:  We must look for warning signs of failing independence, in the categories I've listed in my book. To name three, I'll choose the categories of mobility, continence, and brain health. Mobility: strengthen the quadriceps muscles on the front of your thigh. These are the muscles that help us transfer out of a bed to a chair, out of a chair to a walker, etc. Don't ever let yourself get to the point that you have to use your arms to launch yourself out of an armchair after rocking back and forth several times. It doesn't take much, but it does take some daily focused effort. Do quads exercises every day, and they can be done seated in a chair or lying in bed. Incontinence: don't ignore this if it starts. Bring it up with your doctor, because he or she may not ask. Learn about the different types of incontinence and how to prevent them. Do Kegel exercises to strengthen the urinary sphincter. Incontinence is an emotional issue for many patients and families and is sometimes the primary reason a patient can no longer remain at home. Brain health: challenge your brain every day and don't let it get into a rut. Learn a new activity, preferably one that involves social interaction and some physicality. (Line dancing is a good example). Physical exercise is a key to brain health, because circulatory problems in the brain are a key cause of dementia. Regular walking, or other aerobic exercise, is the health activity with the most evidence for preventing dementia. Tuesday July 26, 2011 12:33 David Fisher, MD

12:34

Judy Graham:  Dr. Ohotto, do you have thoughts on this as well? What would be on your "three things" list? Tuesday July 26, 2011 12:34 Judy Graham

12:38

Anthony Ohotto:  Three pieces of advice: 1--Medications: Manage your medications very very carefully. Question the need for each one. Try to make sure your doctor is doing the same. 2--Driving. Try not to rely on your car. The car sometimes becomes a sore spot between elders and their children and their doctors. I have seen many lose their independence because of their reliance on driving a car. If I could give one piece of advice it would be to start relying less on your car now. If you find yourself moving your home in your late adulthood, pick a place where you can walk most places and have access to public transportation. The health benefits from the exercise you get by walking places or using public transportation is priceless. Become accustomed to public transportation now. It is a lot easier to figure out public transportation when you are 52 or 62 than when you are 82 and have lost your driver's license. The expense of having a car is pretty significant. Most elders I know could really use the money they spend on the insurance premium, car payment (perhaps), license fees, up keep. This is one realistic thing most people can do. 3-- If an elder ends up in hospital I encourage family members to do whatever they can to be there at the bedside for as many hours as possible. If several members can do a rotation, great. Delirium, falls, errors, confusion all are unfortunately common for frail elders in hospital. A family member can potentially prevent some of these common hospital catastrophes. You also stand a better chance getting to talk to the hospital doctor if a representative of the family is there at the bedside. Tuesday July 26, 2011 12:38 Anthony Ohotto

12:38

Judy Graham:  Dr. Fisher, is there anything more you'd like to add? Tuesday July 26, 2011 12:38 Judy Graham

12:40

David Fisher, MD:  I really like Dr Ohotto's answers! Other tips I can add: Make sure your bones are in good shape. Ask your doctor if you are due for a bone density study. Determine if you are at high risk for osteoporosis. Make sure you are taking enough calcium and vitamin D, and include some light weight-bearing exercise in your routine. You may be a candidate for a "bone-building" medication if you have osteoporosis or have a high risk for it. There is a world of difference in the aftermath of a fall with just a bruise and a fall that results in a fracture. Consider a long-term care insurance policy. Most people are not aware that Medicare does not cover a long-term stay in a nursing home, nor do they cover most in-home care. A long-term care insurance policy can offer resources and flexibility if a health crisis hits. Talk about it. If frailty is setting in, talk to your loved ones about the future. Don't wait for a crisis. Make sure you have a Power of Attorney for Health Care in place. This is the person who would make health care decisions on your behalf, if you are incapacitated and unable to verbalize your wishes. Talk to that person about what's important to you when it comes to your health care, so they aren't left guessing in the event of a crisis. Tuesday July 26, 2011 12:40 David Fisher, MD

12:40

Anthony Ohotto:  I have been thinking about Willis's question. I have a thought or two. Tuesday July 26, 2011 12:40 Anthony Ohotto

12:40

Judy Graham:  That's good. Sometimes the full answer doesn't come to us right away. What additional advice do you have for Willis? Tuesday July 26, 2011 12:40 Judy Graham

12:41

Anthony Ohotto:  What about changing the focus. Perhaps to try to focus not on diagnosis and treatment but instead on improved comfort, on symptom relief, improvement of function. This might get him interested. Tuesday July 26, 2011 12:41 Anthony Ohotto

12:43

Judy Graham:  Doctors, both of you do house calls. Do you often see issues that potentially compromise a senior's ability to remain independent? Can you describe some of what you often see? Tuesday July 26, 2011 12:43 Judy Graham

12:44

Anthony Ohotto:  When you make a house call, at a glance you get information that you wouldn't get from a dozen clinic visits. You immediately get a understanding of environmental safety issues. Is there clutter?, could there be a fall and injury? If the place is tidy, maybe you can worry less about lost medication. Perhaps the status of the home gives you a gut-sense about mood disorders or other mental illness. Additionally you get to see the interaction between the patient and there family or caregivers. Are they thriving or is there a problem just waiting to happen. In addition there is a therapeutic effect that happens when you visit someone in their personal space. They may get a better sense that you care about them, that you take their needs seriously, that you are willing to spend time. They show you photos, introduce you to the cat, perhaps open up a little more. Priceless. Tuesday July 26, 2011 12:44 Anthony Ohotto

12:45

Judy Graham:  I think Dr. Fisher has something to say about this as well. Tuesday July 26, 2011 12:45 Judy Graham

12:46

David Fisher, MD:  Judy, safety is very important. There can be many safety hazards that increase the risk for falls. These include stairs, bathroom safety, rugs, etc. That being said, it is important the the environment encourage mobility. Tuesday July 26, 2011 12:46 David Fisher, MD

12:46

[Comment From Alesha E. ChurbaAlesha E. Churba: ]  You haven't really touched on the necessity of making the seniors home safe and ready for them to remain there. Medical assistance is necessary as is home preparation assistance and education. Will you please touch on this? Tuesday July 26, 2011 12:46 Alesha E. Churba

12:47

Judy Graham:  Alesha, your question touches on what Dr. Fisher was referring to. Maybe the doctors can supply a few more details. In the meantime, it's important to note that there are professionals who will come into an older person's home and evaluate it for safety risk. This can be a bit pricey, but if you have the money it can be a lot of help. Tuesday July 26, 2011 12:47 Judy Graham

12:49

Judy Graham:  The kinds of professionals who can be of help include geriatric case managers and social workers, by the way. Tuesday July 26, 2011 12:49 Judy Graham

12:49

Judy Graham:  I just learned of a new service available in Chicago's suburbs. A senior person can hire an "administrative assistant" to help them schedule appointments, pay bills, deal with paperwork, and keep the organizational part of their life in good order. That can be very helpful, as well, and important to a person's independence. Tuesday July 26, 2011 12:49 Judy Graham

12:50

David Fisher, MD:  As Judy suggests, there a specific evaluation called a KELS evaluation, usually performed by a physical or occupational therapist, that will score the safety of the home and how well it encourages independence with the activities of daily living (ADLs). This can be ordered by a doctor and may be partly covered by insurance. Tuesday July 26, 2011 12:50 David Fisher, MD

12:51

Anthony Ohotto:  Alesha, this is a very important issue. Many simple things can be done which can make a difference. For example; Rugs and clutter on the floor can lead to falls. Strategically placed grab bars and railings can reduce falls. Perhaps gas stoves lead to fires more often than electric stoves. Sharp corners on furniture can be padded or removed. If you have the resources, a ramp instead of stairs at the entryway can help. Occupational therapy is a specialty which often helps people trouble-shoot home safety issues. Often an Occupational therapy referral can help get some of this done. These are just a couple ideas. Tuesday July 26, 2011 12:51 Anthony Ohotto

12:51

[Comment From George KoedelGeorge Koedel: ]  My father, 94 yrs old, has been in two nursing homes recently, one for respite for 5 days and one as a resident for 6 days. The conditions there are unacceptabe for maintaining a modicum of human dignity. He is now in family hospice where his dignity has been restored. I am writing this as an indictment of our society and the way it relegates the low income eldery to humiliating circumstances. The entire health care system is wrong. My parents have lived and exemplary life having worked every day and had SSI and other taxes withheld since 1936 along with their childrens and grandchildrens generation. They have paid their insurance premiums on time and are current. If I were not here to see my father out of this life with dignity he would be tortured to death emotionally and drugged into a stupor because he has anxiety at his fate. He feels betrayed by his country and as a WWII vet it has a particularly harsh sting. We worked for that money, where is it? The VA is a joke. A cruel one may I add. The disparity in wealth is revolting. The squandering of our resources is appalling. Authoritarians love people like my parents, naieve, trusting always doing the right thing and when weak and elderly and of no further use dispatch them expeditiously.I hope you get my drift. Tuesday July 26, 2011 12:51 George Koedel

12:52

Judy Graham:  Nursing homes can provide excellent care -- or abysmal care. When it's the latter, it's horribly painful to witness. I'm sorry your father has had so many difficult experiences. Tuesday July 26, 2011 12:52 Judy Graham

12:54

Judy Graham:  Mr. Koedel, I also want to acknowledge your point about anxiety. Even with the best of preparations, many older people are very anxious about coming near the end of life. It can be very hard to get them to open up and talk about this. Medicating someone for anxiety isn't a good solution either. Far better, if possible, to understand the root of the problem and help the older person feel acknowledged and understood, emotionally. Tuesday July 26, 2011 12:54 Judy Graham

12:55

David Fisher, MD:  George, I'm sorry to hear your father has had such a difficult experience. I greatly appreciate his military service. I'm glad to hear that you've found a setting that is better for him. I've had my own frustrations with the VA but I want you to look into the "aid and attendance" benefit that may apply to his in-home care. Your point goes to one of the reasons I wrote my book. Most nursing homes and other institutions try very hard to care for their patients, but the nature of institutional living can often lead to the very problems you address. For that reason, it's important for all of us to do what we can to maintain our independence through the aging process, to try and avoid a situation where we are so dependent on an institution. Tuesday July 26, 2011 12:55 David Fisher, MD

12:55

[Comment From RosanitaRosanita: ]  That's why it's so important for families to read the surveys. If they're low-income, to find out information about Money Follows the Person and to spread awareness of such programs. Plus, people need to report poor care to CMS and file reports. Tuesday July 26, 2011 12:55 Rosanita

12:55

[Comment From Ryan D.Ryan D.: ]  How difficult is it to distinguish between natural aging processes (forgetfulness, agitation, etc) and signs of early stage dementia? Tuesday July 26, 2011 12:55 Ryan D.

12:59

Anthony Ohotto:  Ryan, Many of us struggle with memory. We wonder; Am I getting dementia or is this due to normal aging. It is hard to know when the process is early. One thing I ask patients and families is this: Are there people in your life who you have known but now do not recognize? We often fail to remember new acquaintances but do not normally forget people we have known for a long time. If this is happening I worry about true dementia Tuesday July 26, 2011 12:59 Anthony Ohotto

12:59

Judy Graham:  We've come to the end of this chat and we hope it's been helpful to you. If you want to follow Dr. Fisher on twitter, he's at @doctorfisher. Also, you can link to his book at www.doctorfisher.com. Similarly, my twitter handle is @judith_graham. Our next Tribune web chat, next Tues., is about the perks of roughhousing for kids. Join us at noon, cst, for what will likely be a lively discussion. Enjoy these long, warm days of summer. Thanks, doctors, for participating. So long, for the moment. Tuesday July 26, 2011 12:59 Judy Graham

1:00	David Fisher, MD:  Thanks Judy and everyone who participated, I really enjoyed it! Tuesday July 26, 2011 1:00 David Fisher, MD

1:00