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“Where Do I Fit?”

The journey of care choices in reactive mode.


Wendy Simons


   Elmertta Higgins was a 92 year old friend of mine.  She has been through quite journey in her older years and I’d like to share her story.  This is the story of not being pro-active but having to be reactive in the health care decisions for a senior.


   Two years ago, Elmeretta was living independently in her own home.  She wasn’t doing will, but she “was doing” as she stated frequently. She had experienced several small strokes, but seemed to be maintaining her abilities to manage herself and her home. So the choice was made to let nature take it’s course and not rock the boat.


   One day she had a fall, resulting in hospitalization. From there, the cascade of events began (a set of circumstances many have experienced and we hear about all too often).  Her admitting diagnosis was dehydration and a urinary tract infection (UTI).


   Predictably, in the hospital, Elmeretta became more confused, delirious and difficult to manage. This resulted in restraints for her safety and some light sedation.  Within two days, the Elmeretta I know was no longer present. (Was this clinical delirium or dementia?) On the third day, the recommendation for her discharge was a skilled facility or a dementia specific facility.  She had been admitted under a medical diagnosis, so the three night hospital stay qualified her for Medicare in a skilled facility for rehabilitation benefits. This led to the choice to place her in a skilled facility for rehabilitation and therapy. (It is well known, for every day confined to bed it takes 3+ days to return to baseline.)  Unfortunately, Elmeretta seemed to have lost some cognitive function and she refused to participate in the therapies offered. Her Medicaid coverage depended upon her ability to participate and discussions ensued that she may lose the benefit.


   The next decision became to take her home with in home support. Originally, that support came in the form of family members, who tried their best to be available. In addition, a Home Health agency provided medical follow-up and home based therapy for a brief period.  Needless to say, family support did not fill the need for 24 hour supervision and assistance which resulted in the need to consider a private duty aide to live in the home.  In spite of diligent searching, screening and interviewing, it was impossible to find the “perfect in home attendant”, and a Home Care Agency was engaged to provide 24 hour  homemaker/attendant staffing. 


   Elmertta resented so many strangers in and out of her home and she became very belligerent and combative towards her caregivers. One day she struck a caregiver with a candlestick, resulting in the consideration of an inpatient geriatric/psychiatric program for assessing her behaviors. This was her first outburst, so fortunately, she was not branded as combative and dangerous which would have  limited her treatment options.  She spent 10 days in that program with the recommendation that she be placed in a dementia specific facility.


   Ultimately, Elmeretta was placed in a facility that understood her cognitive changes, physical and emotional needs and supported them each day.  They understood that the last year had been quite a trial and that her behaviors were triggered by a cascade of events outside of her control. Was she initially happy…no. Was she respected and cared for…yes. She spent a year at the facility and passed with the loving support of hospice and the staff.  Did she ever return to the functional status she had before the hospitalization….not really. 


   I think the message is, don’t wait until a crisis occurs to get support for an aging senior. Once the wheels of being “reactive, vs. being pro-active” begin turning, choices and control of the situation may well be lost.                                                                                                                      


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