NOTE:  this is a repost of a blog I wrote a few years ago.  As I have been receiving frequent questions and requests for help on this topic recently, I thought it made sense to republish.

Where to start:  Knowing when a parent needs help, and what kind

Many times we will receive a call from someone stating that their loved one needs nursing home placement when, in fact, that may not be the most appropriate level of care.

Often individuals are faced with making a decision about finding the best care for their older loved ones when. . .

• They are not aware of the care needs of their older loved one.
• They are not aware of all of the options available to meet their increasing needs.

So, how do you make a decision about which type of care is best?  It is often helpful to back up and try to determine the level of care that is needed.

A good rule of thumb is:  as your older family member ages, you may see changes in physical activity, medication tolerance, memory, vision, and hearing, among others.   While these seem alarming, many of these changes do not put the older adult at risk and can be managed by adapting the environment.  It is important to determine whether or not these changes have a significant impact on Activities of Daily Living (known as ADLs).  Evaluation of ADLs leads to what is known as a ‘Functional Level’ which is important in the next step – seeking accurate care at their level of need.  The key to knowing when your older parent needs help is to learn to identify which changes affect health, safety, and quality of life.

Physical and Medical Indicators

Is there a medical condition that will lead to an increased need for care now or in the near future?  Here are some guidelines that may help you identify problem areas that indicate a need for assistance:

• Have there been recent accidents or close calls? (such as falls or car accidents)
• Does there appear to be a slow recovery from illness, or a chronic health condition that’s worsening?
• Can they hear and respond to fire or smoke alarms, telephone rings, and doorbells?
• Are they able to follow directions for sequential tasks without getting confused? Example:  the phrase “Come in, take off your coat, and hang it in the closet” contains three sequential tasks, as does “Walk over to Starbucks, order me a coffee, and I’ll meet you at the table in the back.”
• Are there changes in vision that make it difficult to read basic instructions or medication information?
• Is there any indication that judgment may be impaired? Examples might be financial decisions that seem inconsistent with their usual patterns (eg, large bank withdrawals or checks written to unusual or questionable recipients).
• Are you noticing confusion or forgetfulness, unreasonable anxiety, or major mood changes?
• Is there increasing difficulty managing Activities of Daily Living (ADL) and Instrumental ADLs? These are the skills needed to live independently, and could range from shopping, cleaning, cooking, and looking after pets, to bathing and eating.
• Has there been noticeable weight loss or gain?
• Are they able to rise from a chair easily? Do they seem unsteady or have difficulty with balance? (signs of frailty)
• Are there changes in hygiene? This could include body and/or mouth odor or other changes in appearance.
• Is there any difficulty with bladder or bowel control?

Social indicators

• Are they maintaining active friendships, and staying involved in activities that they normally enjoy?
• Are there signs of increased sadness, abuse of alcohol and/or medications?
• Are they unusually argumentative, or are there indicators of paranoia?

Other environmental indicators

Have you noticed any of the following in the home?

• An abundance of unopened mail
• Thank you letters from charities
• Food that is stale, expired, or moldy
• Multiples of the same item. (Could be thrifty or could be an indicator that they don’t remember what they already have at home)
• A freezer full of TV dinners, or an increased use of take out
• Broken appliances, or any signs of fire
• An increase in clutter, or signs of decreased housekeeping
• Plants that are dead or dying
• Lack of yard maintenance
• Newspapers that have been delivered but ignored

Here is a comprehensive checklist developed by the National Caregivers Library:

If you have noticed significant changes, it is often important to have a thorough evaluation – ideally done by a Geriatric Specialist (such as the UNC Geriatric Specialty Clinic or Duke Geriatric Evaluation and Treatment Clinic)

The majority of older adults prefer to age in place, and are able to do so safely as their needs increase with the addition of in-home supports such as personal care assistance, homemaker services, escort services, meal delivery, etc.   In other cases, a move to residential community may be a safer option, and, fortunately today there is a spectrum of residential care including Independent Senior Living, Assisted Living Facilities, and Skilled Nursing Care designed to meet those needs.  There is a growing trend towards Continuum of Care Retirement Communities, where all levels of care are available, providing an easier transition from one level of care to the next, if necessary.

If you need assistance with planning this transition, a Geriatric Care Manager can be extremely helpful, especially for long distance caregivers. The Aging Life Care Association has a search feature to assist you in finding one in your area.