Archive for the ‘Senior Professionals’ Category

Upcoming Seminars for Lawyers and Clients

Monday, February 8th, 2010

 

I’m conducting two seminars this week on the topic of Income Only Trusts. The first one is a teleseminar for attorneys around the country who are members of the professional group ElderLawAnswers.  Entitled Using Income Only Trusts for Medicaid (and General) Asset Protection, this teleseminar is Thursday, Feb. 11, at 2pm Eastern. If you’re a member of ElderLawAnswers, you can click here to register for the Teleseminar, 

The other is a free seminar I’m teaching on Saturday morning for clients and potential clients, entitled How to Protect Your Assets from the Expenses of Probate and Long Term Care.  This will be held at the Tysons Corner Mariott, 1960-A Chain Bridge Road, McLean, VA 22012.  Please click here to register for the Saturday morning seminar. 

The answer to the question “How Can You Protect Your Assets from the Expenses of Probate and Long Term Care?” is, of course, to use the Living Trust Plus™ Asset Protection Trust, my highly-developed and proprietary income only trust that’s currently used by dozens of successful Estate Planning and Elder Law Attorneys across the country. 

 As stated by Elder Law Answers, “Income Only Trusts have been around since the 17th century, but have only recently gained in use and popularity, in large part due to the publications and educational efforts of our speaker and long-time ElderLawAnswers member, Certified Elder Law Attorney Evan Farr.”

What most Elder Law attorneys don’t understand is that income only trusts also provide clients with protection from lawsuits and other general creditors, and in the ElderLawAnswers teleseminar, I will be demystifying the income only trust, explaining how and why it works, and explaining to my fellow ElderLawAnswers Members the dos and don’ts of income only trusts so that they may properly serve clients in this exciting and growing practice area.

For middle class Americans seeking asset protection, the income only trust is the preferable form of asset protection trust because, for purposes of Medicaid eligibility, the income only trust is the only type of self-settled asset protection trust that allows a trust settlor to retain an interest in the trust while also protecting the assets from being counted by state Medicaid agencies.

 For my clients and potential clients in the Washington, DC Metro area, by coming to my FREE class on Saturday, you’ll learn what thousands of my clients already know . . .

- That a Will puts your assets through probate, and is a very poor estate planning document.
- That a regular living trust protects your assets from probate, but offers you no asset protection.
- That my proprietary Living Trust PlusTM Asset Protection Trust protects your assets from the expenses of probate PLUS lawsuits PLUS the catastrophic expenses of nursing home care.

If you answer YES to any of the questions below, you need to attend this class:

 - Is someone in your household over age 65?
- Does someone in your household have a serious medical condition?
- Has someone in your household been turned down for long-term care insurance, or found it too expensive?
- Do you want to protect your assets for your family from the devastating expenses of long-term care?
- If you need long-term care in the future, do you want to receive the best possible care?

To learn all the details and find out if the Living Trust Plus™ is right for you, please register now at http://VirginiaElderLaw.com/seminars.html 

Protect and Prosper! 

–
Evan H. Farr, Certified Elder Law Attorney
Creator of the Living Trust Plus:  http://www.LivingTrustPlus.com
ALI-ABA Co-Author, Planning and Defending Asset-Protection Trusts (2009): http://www.ali-aba.org/bk64
ALI-ABA Co-Author, Trusts for Senior Citizens (2009): http://www.ali-aba.org/bk65
Farr Law Firm, 10640 Main St., Suite 200, Fairfax, VA  22030
Tel: 703-691-1888 | Fax: 703-940-9160
www.VirginiaElderLaw.com & www.VirginiaEstatePlanning.com
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NOTICE – Unless expressly stated otherwise, this communication: (1) is not legal advice absent an existing attorney-client relationship between us; (2) does not create an attorney-client relationship; (3) does not constitute an offer, acceptance, or contract amendment; (4) may contain confidential or legally privileged information protected by the attorney-client relationship and/or work product privilege; (5) is only for the use of the individual to whom it is intended by the sender to be sent, and if you are not such recipient, disclosure, copying, distribution or reliance upon this  communication is prohibited; and (6) is not intended, and cannot be used, to avoid tax-related penalties pursuant to treasury department circular 230.

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Posted in Asset Protection, Elder Law, Estate Planning, Medicaid Planning, Senior Care, Senior Professionals, Tax Planning | Comments Off

Using a Reverse Mortgage to Pay for Home Care

Saturday, January 30th, 2010

Many of my clients ask me how I feel about reverse mortgages, and even more so this past week because of a favorable story that appeared in last week’s Washington Post entitled “Reverse Mortgages are Not the Next Subprime.”  This excellent article was written by the ”Mortgage Professor,” a Professor of Finance Emeritus at the Wharton School of the University of Pennsylvania (incidentally, my Alma Mater), and clears up much of the confusion and myths and fears surrounding the reverse mortgage.  I encourage all of you to read it.  Another good source of information about reverse mortgages is the Federal Trade Commission Fact Sheet. 

As a Certified Elder Law attorney, one of my primary goals is to help preserve the dignity and enhance the lives of my elderly clients.  For many of my clients, remaining in their homes as long as possible is one of their highest priorities.  I have been a long-time fan of reverse mortgages because they help my clients do exactly that — remain in their homes as long as possible.  

Why? Because in order to remain in your home as long as possible, you will most likely at some point need some home care.  “Home Care” can be health care and/or supportive care provided formally in your home by health care professionals (typically referred to as home health aides) or by paid or unpaid family members or friends (typically referred to as caregivers).  Often, the term “home care” is used to mean non-medical care, or custodial care, which may be provided by persons who are not nurses, doctors, or other licensed medical personnel.  The term “home health care” typically refers to care that is provided by a licensed health care professional — most often a Certified Nurse Assistant (CNA).  However, the terms are often used interchangeably, and for simplicity in this article I will use the term “home care” to refer to both types of care.

The goal of home care is typically to to allow you to remain at home and age in place, rather than being forced to move to an assisted living facility or nursing home.  Home Care providers render services in your own home. These services typically include a combination of health care services and life assistance services.

Health care services may include services such as wound care, administration of medication, physical therapy, speech therapy, and occupational therapy.  Life assistance services typically include help with daily tasks such as meal preparation, medication reminders, laundry, light housekeeping, errands, shopping, transportation, companionship, and help with the activities of daily living (ADLs), which typically refers to six activities (bathing, dressing, transferring, using the toilet, eating, and walking). 

Although some home care is provided by family members for free, most family caregivers need to be paid, and these payment arrangements should always be made pursuant to a written caregiver contract (prepared by an Elder Law Attorney) between the caregiver and the care recipient.  Because home care is quite expensive, having the proceeds from a reverse mortgage is often one of the  only ways that elders can afford to pay for appropriate home care. According to The 2009 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs, the 2009 national average hourly rate for home health aides increased by 5.0% from $20 in 2008 to $21 in 2009. The national average hourly rate for homemaker/companions increased by 5.6% from $18 in 2008 to $19 in 2009. 

Most of my clients, when they start out needing home care, will typically start with receiving 4 hours of care 3 days a week, which costs about $1,000 per month and is easily affordable for many people.  But over time, most of my clients progress to the point of needing upwards of 12 hours per day of home care, costing over $7,000 per month, and very few people can afford to pay for this type of care without eventually tapping into their home equity via a reverse mortgage.

The most common type of reverse mortgage is the Home Equity Conversion Mortgage (HECM), which completely protects your ability to remain in your home. So long as you pay your property taxes and homeowners insurance, and maintain your property, you can remain in your home forever. If the reverse mortgage lender fails, any unmet payment obligation to the borrower will be assumed by FHA. 

According to the Mortgage Professor’s article mentioned in my first paragraph, in 2009 about 130,000 HECMs were written, and feedback from borrowers has been mostly positive. In a 2006 survey of borrowers by AARP, 93% said that their reverse mortgage had a mostly positive effect on their lives.

For many of my clients, a reverse mortgage is the best way, and often the only way, for them to be able to afford to remain at home, despite the fact that reverse mortgages are expensive to obtain.  However, reverse mortgages are not for everyone, as there are other programs that may be able to help you remain in your home.  For instance, many of my clients are eligible for the Veterans Aid and Attendance benefit or for home-based Medicaid, or can be made eligible for these benefits through our process of Asset Protection. 

Whether you own your home outright or in a Revocable Living Trust or in my proprietary  Living Trust PlusTM Asset Protection Trust, if you think a reverse mortgage might be the solution you need, please contact me for a free consultation so I can evaluate your specific situation and advise you as to whether a reverse mortgage is your best option for allowing you to live comfortably in your home.

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Posted in Elder Law, Senior Care, Senior Professionals, Uncategorized, Veterans Aid & Attendance, health care | 3 Comments »

Major Change in Estate Tax and Capital Gains Tax for 2010

Wednesday, January 13th, 2010

Because of a Congressional failure to act before the end of 2009, there’s good news and bad news to report on the Estate Planning and Elder Law front.  The good news is there’s no Estate Tax if you die this year.  The bad news is you may owe significant capital gains taxes if a loved one dies this year and leaves you significant appreciated assets. If you have total assets of around $1 million or more (including face value of life insurance, retirement plans, home equity, etc.) you should make sure your estate plan is up to date.

Congress has had nine years to prevent this from happening, but has failed to act. Under the provisions of a Bush-era tax-cut bill enacted in 2001, the estate tax exemption has been gradually raised over the past eight years while the tax rate on estates has been reduced. For estates of those dying in 2009, only assets worth $3.5 million or more were subject to estate taxed, at a rate of 45 percent. But now, for the year 2010, the estate tax has disappeared entirely, only to be restored in 2011 at a rate of 55 percent on estates of $1 million or more, which is exactly where things stood before the 2001 change.

Everyone — lawyers, politicians, and political commentators — has expected for the past 9 years that this law would be “fixed” before the end of 2009, but it wasn’t.  According to some commentators, the Republicans concluded that it was in their interest to let the estate tax repeal occur; and the Democrats apparently don’t agree among themselves as to what they think the estate tax law should be, as Democrates have differing opinions over what the tax rate and the exempt amount should be. Senate Democrats tried to persuade Republicans to extend the 2009 estate tax law for a couple of months until a more permanent solution could be devised, but even that effort failed.  Accordingly, there is currently no tax on the estates of those dying during 2010. Congress could reinstate the tax retroactively in 2010, perhaps as part of broader tax reform, but this is not likely according to many commentators.

As the law stands, a few thousand very wealthy families have great financial incentive to hope that their loved ones die this year.  On the other hand, tens of thousands of taxpayers of more modest wealth may have great incentive to keep their loved ones alive into 2011, because if their loved one dies in 2010 and they inherit an appreciated asset, they may have pay capital gains on that inherited asset, and someone acting as an executor will face additional and confusing administrative burdens.

Loss of Step-Up in Basis May Be Quite Expensive for Many Taxpayers

For most people, the main concern with the law as it now stands is not that the estate tax is repealed for 2010; a bigger problem for many is that it’s replaced with a 15 percent capital gains tax on inherited assets that are later sold.  Previously, someone inheriting an appreciated asset (for example, a house that had greatly appreciated in value over the lifetime of your parents) upon a loved one’s death got a “step-up in basis” in the property. A step-up meant that heirs could sell the inherited, appreciated asset right away without owing any capital gains taxes, because the tax “basis” in the property was “stepped-up” to the value of the property at death.

If you inherit an asset now (in 2010), only the first $1.3 million in assets gets a step-up in basis. Anything over the $1.3 million in assets (plus $3 million for assets transferred to a surviving spouse) will not get a step-up in basis.  Instead, when you sell the property you’ll have to pay capital gains taxes based on the original cost basis (typically the price paid for the asset). This raises an additional concern — having to determine what the cost basis of the asset was.  This in itself could be quite expensive, not to mention time-consuming in trying to ascertain the original price paid for assets, including any renovations or improvements made to real estate over the years.

The capital gains tax rules can be quite complicated, but let’s look at a relatively simple example:  a client called me a few days ago with a home worth approximately $1 million and 40 acres of commercial land that her father gifted to her prior to his death, now worth approximately $2 million. The home was originally purchased by my client for $8,000 in 1961 and she put a $40,000 addition on the home in 1982, so her tax basis in the home is $48,000. Her father originally purchased the 40 acres of land around 1943, for $1,000; at the time of his death in 1992, the 40 acres was worth about $600,000.  Had he left the land to his daughter upon his death, she would have taken a stepped-up basis under the old law, but because he gifted it to her prior to his death, she took over his cost basis of $1,000.  So now her two parcels have a total cost basis of $49,000.  If my client had died last year, then her heirs would have received a step-up in basis, meaning if they sold the properties for their current value of $3 million, they would pay no capital gains tax.  Under today’s law, if my client dies this year, in 2010, her heirs will inherit her cost basis of $49,000, meaning that if her heirs then sell these properties for their current value of $3 million, they will pay a 15% capital gains tax on $1,651,000 ($2,951,000 – $1,300,000), or $247,650 in tax.

The chief tax counsel for the House Ways and Means Committee estimates that continuing the estate tax at its 2009 rates would have affected about 6,000 people, but the new capital gains provisions that we now have will affect more than 70,000. And, in general, these 70,000 will be far less wealthy than the heirs who would have been affected by a continuation of the estate tax.

Couples With Credit Shelter Trusts at Risk

The new world of no estate tax places at particular risk certain couples who have built in “Credit Shelter” trust provisions (also called ”Bypass Trust” or “Family Trust” provisions), that are designed to allow both spouses to take advantage of their estate tax exemptions. These are common arrangements used in estate planning for married couples. With the estate tax gone, one possible problem is that the wording of some of these trusts could cause all assets to completely bypass the surviving spouse when the first spouse dies, meaning a surviving spouse might get nothing without the expensive process of claiming her “elective share.” For a more detailed explanation of this potential problem, click here.

Why Did This Happen?

The House passed a bill in early December permanently extending the 2009 estate tax rules, which would have brough in an estimated $25 billion for 2009 by imposing the 45 percent rate on estates over $3.5 million (or $7 million for a couple). The Senate’s Democratic leadership wanted to pass a similar bill and put it on President Obama’s desk before the estate tax expired at the end of 2009, but they were blocked by united Senate Republicans who prefer a lower tax rate of 35 percent and a higher exclusion amount of $5 million ($10 million for couples).

“Republicans who claim to have accomplished something by blocking an extension need to explain why raising taxes on the middle class while lowering them for the very rich is something to be proud of,” the Los Angeles Times editorialized.

For more on the implications of the disappearance of the estate tax, see CBS MoneyWatch’s “Estate Tax: What You Need to Know for 2010,”SmartMoney’s “The Federal Estate Tax Is Dead: Now What?,”and Kiplinger’s “FAQs on the Death of the Estate Tax.”

Everyone — Especially Married Couples — Should Have Their Estate Planning Reviewed ASAP

Because of these somewhat unexpected tax changes, a review of your existing estate planning documents is essential.  If you are a member of the Farr Law Firm’s Estate Plan Protection Program or Lifetime Protection Program, you are entitled to a free review (and, if necessary, a free modification) of your existing estate planning documents every year, and you should call us to take advantage of this annual review as soon as possible.  Most of our trusts will not need to be modified because of special language we inserted in the document, but changes to some trusts may be required.  If your estate planning was done by a different attorney, you should consider going back to that attorney for a review; alternatively, please feel free to contact our office and we will be happy to do a free review of your estate planning documents, determine if any changes are required, and quote you a fee for us to prepare the necessary revised documents.

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Who Was Supposed To Be Watching Grandma?

Monday, December 14th, 2009

There is a popular tune played this time of year called “Grandma Got Run Over by A Reindeer” which relates that Grandma — after drinking too much eggnog — went out into the winter cold to get her medication and was run over by a reindeer. The question is . . .  “Who was supposed to be watching Grandma?”

Though this little tune is just for fun, it may very well raise alarms to many caregivers of the elderly. Caregivers know that even at a holiday party they cannot let down their diligent watch over their elderly loved one. As far-fetched as it may sound, with all the people and noise, an elderly family member with dementia or Alzheimer’s may be enjoying the family gathering and then suddenly become confused and walk to the door and leave.

For family caregivers the added stress of the holidays with decorating, shopping, parties and keeping up with all the family traditions is an overwhelming quest. Feelings of isolation, depression and sadness come with this added stress. There are millions of Americans who are caring for elderly frail loved ones and most of these caregivers will go through some of these emotions, especially this time of year.

There are some things you can do as a caregiver to help you and those you care for enjoy the holiday season.

First take care of yourself. Try to eat right, get plenty of sleep and exercise. This will help reduce stress and strengthen your ability to cope with caregiving responsibilities.

Prioritize your holiday traditions. Perhaps instead of cooking a large family dinner, have everyone bring his or her favorite dish. Use paper plates. Forfeit the traditional outside light decorating for a lighted wreath on the front door. Choose one or two parties or concerts to attend instead of trying to do it all.

Arrange for help. Call on other family members to help with the caregiving while you do your shopping or go out for the evening. If family is not available, ask your church group or a neighbor if they would donate a few hours.

Use community services. Many senior centers provide meals for the elderly and supervised activities, onsite, at no charge or a minimal charge. For locating senior services in your state, call your state Area Agency on Aging or check the national locator website at http://www.n4a.org/

Use adult day care services. Some assisted living facilities provide day activities and meals for seniors on a day by day basis. Other organizations called “adult day service providers” specialize exclusively in this sort of care support at a reasonable cost. These support services provide respite for caregivers from their caregiving responsibilities as well as social interaction for their elderly family members. There is a cost for adult day services, but the benefit for all is worth it.

Technology to the rescue. Here is a solution that would have kept “Grandma” from going out in the winter cold and getting run over by a reindeer. Companies that have created monitoring systems, security alarms and other safety equipment are “tweaking” them to adapt to the needs of seniors and their care givers.

Here are a few examples:

  • Ankle or wrist bands that monitor location and alert the provider when a person has gone beyond the designated perimeter, such as out the front door of the house.
  • Motion detectors. Set throughout the home, motion detectors allow someone outside the home to follow a senior as he or she moves through the house.
  • Smart medication dispensers. Live monitoring and dispensing of pills.
  • Emergency response alert. At a touch of a button on a desktop monitor, bracelet or necklace, emergency help is summoned.

Whether providing care in your home or helping senior family members in their own homes, your use of monitoring and “tech” help aids can provide extra safety for your loved ones, and peace of mind for you.

You are not alone. Join a caregiving help group. Your local senior center may have one or go on the internet to find one. Hearing about other caregivers’ problems and solutions and being able to share your own and ask questions is a great way to relieve stress and gain a new perspective. Check out websites like the National Family Caregivers Association at http://www.nfcacares.org/

Work with a Senior Care Professional. Recognize that you are doing the very best you know how. You are not a geriatric health care practitioner, geriatric care manager, home care nurse or aide, hospice provider or family mediation counselor, nor do you have the years of training and experience these professionals have, but you can definitely use their experience. In fact, using a senior care specialist will make caregiving easier for you and more beneficial for your elderly family member.

You can find a wide variety of care professionals in your area on the National Care Planning Council website at www.longtermcarelink.net and on our website at http://www.virginiaelderlaw.com/TrustedReferrals.htm.

One more thing to remember. As a family caregiver, the greatest gift you are giving this holiday season is “Love.”

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Helping Your Older Parents Stay Happy and Healthy

Thursday, December 3rd, 2009

by Robert Stall MD, Geriatrician

If you’re fortunate enough to have one or both parents still living, you may have noticed a role reversal taking place in your relationship. Remember the days when Mom shuttled you to the doctor whenever you were sick? Now, it may be you who’s driving her to her medical appointments. Perhaps you’ve become even more involved in managing her healthcare needs – serving as her healthcare proxy, moving her into your home to care for her, or even having to select a nursing home for her to live in.

Whatever the case, it’s natural to feel challenged – and, yes, intimidated – in the role you’ve undertaken. But if you stay positive and proactive, you’ll be in a great position to advocate for your parents’ optimal care. And, really, what better way is there to say “Thank You” for all they’ve done for you over the years?

The following six recommendations will help you understand what may be happening to your parents as they age – and what you can do to help.

1. Stay vigilant to sudden changes.

Typically, sudden changes arise from sudden problems. Your elderly father who becomes confused one week but was alert and oriented the week before, or becomes unsteady walking and starts falling, is likely experiencing an acute problem – an infection, medication side effect, or perhaps, a heart attack or stroke.

If you pay attention to your parent’s baseline health and behavior, you’ll be alert to sudden, and subtle, fluctuations. Being attuned to what’s “normal” for your parent is critical in advocating for his care. By informing his physician of these changes, you help ensure that he receives a proper diagnosis and timely treatment – especially important in acute conditions.

2. Investigate the source of gradual decline.

Several years ago, I met an elderly woman living in a nursing home. Her family, assuming she had dementia, had moved her there after she had gradually stopped speaking.

After performing a brief procedure on her, I asked how she was doing. “I’m OK,” she replied.

A miracle? Not exactly. I’d removed bullet-sized pieces of wax from her ears. She’d stopped speaking because her ears were too plugged to hear.

A host of conditions can cause gradual decline. Before jumping to the conclusion – as many people do – that Alzheimer’s disease is the culprit, recognize that your parent may be experiencing an altogether different problem: a vitamin B12 deficiency, an underactive thyroid, Parkinson’s disease or depression, to name a few.

When discussing your parent’s decline with her physician, make sure the two of you consider all the possibilities. To prepare for the appointment, make notes detailing how her decline has manifested itself – loss of appetite, a failing short-term memory and so forth – and how long you’ve noticed these changes. That way, you won’t leave anything out. To help you, I’ve created a free checklist that either you or your parent can complete at seniorselfassessment.com – make sure you print or email the “Test Result Details” at the bottom of the page to analyze your responses and give you advice based on your answers.

3. Know thy parent’s medicine cabinet.

Familiarize yourself with the medications your parent takes: what each one is for and how often he takes them. Make sure you notify each doctor your parent visits of all the medicine he takes, including over-the-counter products. Ask what side effects you might observe from each medication and whether it’s potentially dangerous if your parent takes them together. You also want to tell the doctor whether your parent drinks alcohol or caffeinated drinks and whether he smokes, as these substances can affect some medications’ efficacy and safety. To recognize which medications might cause the symptoms your parent experiences, check out drugscanmakeyousick.com .

4. Discourage ageist attitudes.

Simply put, ageism is prejudice against the elderly. It exists in many forms but can be particularly damaging to an older person’s self-esteem when it assumes that all of her woes are age-related. Here are a couple of ways of expressing ageism to an elderly parent:

“What do you expect at your age?”

“You’re not getting any younger.”

If you’re ever tempted to utter something similar, remind yourself that by chalking up everything that ails her to her age, you sell your parent short. If she’s depressed, it may have nothing to do with the fact that she’s 80 and everything to do with a biological predisposition to depression. And remember that right-knee pain in a 90 year-old can’t be just from age if there’s no problem with her left knee. (More about Dr. Stall and a more in-depth article on the attitude of society towards medical care for the elderly can be found at http://www.longtermcarelink.net/eldercare/medical_care_issues.htm )

5. Address not just symptoms—but emotions, too.

There is disease and then there is “dis-ease” – that is, a lack of ease, security or well-being. “Dis-ease” can manifest itself as myriad emotions in an elderly person: fear, grief, boredom, embarrassment and sadness among them. The fact is, these emotions can be every bit as debilitating as disease.

Take the case of a parent who’s incontinent. Too embarrassed to socialize, she cuts herself off from friends. Without companionship, she becomes lonely. Instead of allowing her to become a hermit, discuss with her doctor how to address the incontinence. Together, you can consider different solutions that will ease her embarrassment and reinvigorate her social life.

6. Strive to maximize your parent’s quality of life.

No matter our age, we all want to enjoy life to the fullest and have the capability to do the things we want to. Improving the enjoyment of life and a patient’s functional ability are the cardinal goals of geriatric care. But you don’t need a medical diploma on your wall to help your parent achieve either of those goals.

Being there to solve a problem or provide company are tremendously worthwhile services you can provide – no expertise required. Remember, as your parent gets older, his quality of life becomes more important to him than how much longer he lives. And he doesn’t necessarily need medications or surgery to ensure that he’s living the latter part of his life to the fullest.

If he enjoys books but has difficulty reading regular-sized type, check out sight-saving titles at the library. If he’s grieving the loss of his best buddy, introduce him to new acquaintances at the senior center. If he’s living in a nursing home, bring your kids there to share a meal with him.

Sometimes, it’s the small gestures that have the most profound impact. As the child of an elderly parent, you are uniquely positioned to deliver these life-changing gifts.

Dr. Robert Stall is a geriatrician practicing in Tonawanda, New York and a clinical associate professor at the University of Buffalo’s School of Medicine and Biomedical Sciences.  To learn more about senior care issues, visit his website at stallgeriatrics.com.

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Holiday Blues: Depression in the Elderly

Thursday, November 13th, 2008

The holiday season is quickly coming upon us. If you are a caregiver for an elderly loved one, you may notice a change in your loved one’s mood as the holidays approach. Perhaps you are one of many who live a distance away and visit elderly parents and family during the holidays. When you visit, you may notice that your loved one is not as physically active, or is showing symptoms of fatigue or sadness and has no interest in the holiday or in their surroundings.

According to the National Institutes of Health, of the 35 million Americans age 65 or older, about 2 million suffer from full-blown depression. Another 5 million suffer from a less severe forms of the illness. This represents about 20% of the senior population — a significant proportion.

Depression in the elderly is difficult to diagnose and is frequently untreated. The symptoms may be confused with a medical illness, dementia, or malnutrition due to a poor diet. Many older people will not accept the idea that they have depression and refuse to seek treatment. 

What causes depression in the elderly?

It is not the actual holiday that causes depression, but the fact that holidays tend to bring memories of earlier, often happier times. Additional contributing factors that bring on depression may be the loss of a spouse or close friend, or a move from a home to assisted living, or a change with an older person’s routine.

It is not the actual holiday that causes depression, but the fact that holidays tend to bring memories of earlier, often happier times. Additional contributing factors that bring on depression may be the loss of a spouse or close friend, or a move from a home to assisted living, or a change with an older person’s routine.

Depression may also be a sign of a medical problem. Chronic pain or complications of an illness or memory loss can also cause depression. In addition, diet can also be a factor when proper nutrition and vitamins are lacking.

Symptoms to look for in depression might include:

- Depressed or irritable mood
- Feelings of worthlessness or sadness
- Expressions of helplessness
- Anxiety
- Loss of interest in daily activities
- Loss of appetite
- Weight loss
- Lack of attending to personal care and hygiene
- Fatigue
- Difficulty concentrating
- Irresponsible behavior
- Obsessive thoughts about death
- Talk about suicide

How do you know if it is depression or dementia?

Depression and dementia share many similar symptoms. A recent article on Helpguide gives some specific differences.

In depression there is a rapid mental decline, but memory of time, date and awareness of the environment remains. Motor skills are slow, but normal in depression. Concern with concentrating and worry about impaired memory may occur.

On the other hand, dementia symptoms reveal a slow mental decline with confusion and loss of recognition of familiar locations. Writing, speaking and motor skills are impaired and memory loss is often not acknowledged by the person suffering dementia.

Whether it is depression or dementia, prompt treatment is recommended. A physical exam will help determine if there is a medical cause for depression. A geriatric medical practitioner is skilled in diagnosing depression and illnesses in the elderly. If you are a caregiver of an elderly person, it may be beneficial for you to seek out a geriatric health care specialist.  

Treating depression in older people.

Once the cause of depression is identified, a treatment program can be implemented. Treatment may be as simple as relieving loneliness through visitations, outings and involvement in family activities. In more severe cases antidepressant drugs have been known to improve the quality of life in depressed elderly people. Cognitive therapy sessions with a counselor may also be effective.

Once the cause of depression is identified, a treatment program can be implemented. Treatment may be as simple as relieving loneliness through visitations, outings and involvement in family activities. In more severe cases antidepressant drugs have been known to improve the quality of life in depressed elderly people. Cognitive therapy sessions with a counselor may also be effective.

As a caregiver or family member of a depressed older person, make it your responsibility to get involved. The elder person generally denies any problems or may fear being mentally ill. You can make the difference in and remove the Holiday Blues from seniors suffering from depression.

The Geriatric Mental Health Foundation offers a “Depression Tool Kit.” To read more about the tool kit and depression in the elderly go to:

http://www.gmhfonline.org/gmhf/consumer/depression_toolkit.html

For more information on senior health services, see the following lists from Evan Farr’s book, the Virginia Nursing Home Survival Guide:

List of Geriatric Physicians
List of Geriatric Care Managers

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Understanding a Caregiver’s Stress

Wednesday, February 6th, 2008

A 2003 study of caregivers has proven that the off-repeated adage “stress can kill you” is true. The focus of the investigation was the effect the stress of caregiving had on caregivers.

A team of researchers at Ohio State University Medical Center has found a chemical marker in the blood that shows a significant increase under chronic stress and is linked to an impaired immune system response in aging adults. The team, led by Dr. Janice Kiecolt-Glaser, reports in the June 30, 2003 issue of Proceedings of the National Academy of Sciences on a 6-year study of elderly people caring for spouses with Alzheimer’s Disease. With the caregivers, the team found a four-fold increase in an immune system protein — interleukin 6 (IL-6) — as compared to a control group of non-caregivers. Only the stress of caregiving correlated to the marked increase of IL-6 in the caregiver group. All other factors, including age, were not significant to the outcome. Even the younger caregivers saw an increase in IL-6.

The study also found that the caregivers had a 63% higher death rate than the control group. About 70% of the caregivers died before the end of the study and had to be replaced by new subjects. Another surprising result was that high levels of IL-6 continued even three years after the caregiving stopped. Dr. Glaser proposes that prolonged stress may have triggered a permanent abnormality of the immune system.

The problem is if this response is initiated repeatedly over a long period; it can have a dangerous effect on the body. This repetitive initiation of the stress response is common among caregivers — especially those caring for loved ones with dementia. Providing supervision or physical assistance many hours a week and over a period of years turns out to be extremely stressful. This type of stress is often unrelenting, occurring day after day and week after week. And the long-term effects of this stress are more pronounced in middle-aged and older people who are precisely the group most likely offering long-term care to loved ones.

If you are a caregiver, please give us a call.  Through a properly-designed Life Care Plan for your loved one, the Farr Law Firm can help you minimize or eliminate much of your stress.

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Caregivers Take Care

Tuesday, November 13th, 2007

Caregiving can be very stressful and demanding. In the case of a healthy spouse or a child living with a disabled person at home, caregiving can be a 24 hour, 7 day a week commitment. But even for the caregiver not living in the home, looking after a loved-one or friend can consume all of the caregiver’s free time.

Surveys and studies consistently show that depression is a major problem with full-time informal caregivers. This is typically brought on by stress and fatigue as well as social isolation from family and friends. If allowed to go on too long, the caregiver can sometimes break down and may end up needing long-term care as well.

Since most people go into informal caregiving without training or counseling they often aren’t aware of the possible outcome. It is therefore extremely important to receive counseling and to formulate a plan of action prior to making a caregiving commitment. In 1965, Congress passed the Older Americans Act which provides guidance and funding to the States to give help to caregivers. All states offer programs at no cost or very low cost which might include: counseling, caregiver training, respite care, adult day care, meals, support groups and much, much more.

For example, one such resource that is readily available is to join a support group.  The Department of Family Services’ Fairfax Area Agency on Aging has put together a useful flyer that highlights some of the support groups available for caregivers in Fairfax County.

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Using a Professional Geriatric Care Manager

Friday, June 8th, 2007
Utilizing the services of a professional geriatric care manager should be something that every family considers, but in reality very few families know about care managers or use them.  Geriatric care managers can go a long ways toward helping a family find better and more efficient ways of providing care for a loved one .

The concept is simple. The family hires a professional care maanger to act as a guide through the maze of long-term care services and providers. While a family is often experiencing it for the first time, professional care managers have been there many times. 

Hiring a care manager should be no different than hiring an attorney to help with legal problems or a CPA to help with tax problems. Most people don’t attempt to solve legal problems on their own. And the use of professional tax advice can be an invaluable investment. The same is true of using a care manager.  

Unfortunately there are too few care managers and the public is so poorly informed about the services of a care manager, that valuable resources that could be provided go lacking.  

The irony of not using a care manager is that most families — when given the opportunity to use the care manager — think they can do it themselves and will not pay the money. Yet the services of a care manager most likely will save them considerably more money then do-it-yourself. The cost of the care manager might be only a fraction of the savings the care manager could produce. Care manager services can also greatly reduce family and caregiver stress and help eliminate family disputes and disagreements.  

Below is a partial list of how a care manager might help your family:

  1. Assess the level and type of care needed and develop a care plan
  2. Take steps to start the care plan and keep it functioning
  3. Make sure care is received in a safe and disability friendly environment
  4. Resolve family conflicts and other family issues relating to long-term care
  5. Become an advocate for the care recipient and the family caregiver
  6. Manage care for a loved one for out-of-town families
  7. Conduct ongoing assessments to monitor and implement changes in care
  8. Oversee and direct care provided at home
  9. Coordinate the efforts of key support systems
  10. Provide personal counseling
  11. Help work with your attorney in connection with Medicaid qualification and application
  12. Arrange for services of legal and financial advisors
  13. Manage a guardianship and/or conservatorship for a care recipient
  14. Provide assistance with placement in assisted living facilities or nursing homes
  15. Monitor the care of a family member in a nursing home or in assisted living
  16. Assist with the monitoring of medications
  17. Find appropriate solutions to avoid a crisis
  18. Coordinate medical appointments and medical information
  19. Provide transportation to medical appointments
  20. Assist families in positive decision making
  21. Develop long range plans for older loved ones not now needing care

To find a geriatric care manager, go to  www.caremanager.org, which is the Web site of the National Association of Professional Geriatric Care Managers.

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