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Monday, April 17, 2006 - Page updated at 12:00 AM


Growing Older

Four factors in defining level of care you need

Special to The Seattle Times

Sixth of a series

As I've written in this series, there are six basic steps to selecting high-quality eldercare, similar to buying a car.

First, you need to know what services are available — they vary widely in different areas. Second, understand their costs and how you'll pay.

Step 3 is one of the most important: Determine the care needs involved, focusing on the impaired person's functional gaps — what they can and cannot do for themselves anymore.

Why is this critical? Because understanding a person's need for assistance takes the fog off the window — it helps you respond appropriately to real problems, not your guesses or fears. I've seen families react to their parents' memory problems by moving them to locked dementia units — though the cause was their medications, not dementia — and leaving others to live independently even though they needed care. Let's do it right the first time. Assessing a person's needs is the basis for what you do next, its costs, and where you search for the solutions.

Last Monday, I introduced my two-page "Basic Older Adult Needs Assessment" tool for families. You can download it at Most of the questions are self-explanatory. Seven factors are extra-important, however, and I placed each in a shaded box. Last Monday, I explained the first three — diagnosis, cognitive impairment and personality. Today I'll discuss the final four — and a bonus question that will help keep things in perspective.

Toileting/Nighttime Behavior: Getting human assistance at night can be very expensive (and hard on family members if they're providing care). Going to the bathroom is the most common reason most of us get up at night. If we need much help several times a night, the caregiver must stay awake and be available, which means paying her to stay up, and it usually commands higher pay than day work. If someone needs even more extensive nighttime assistance, the only option could well be a nursing home, where staff is available 24/7.

That's why I urge families to be inventive and try to meet the impaired person's needs with minimal human involvement. Sometimes simple solutions work: nightlights in the hall and bathroom to light the way, clearing the floor of debris that can cause a fall, a commode near the bed (if the person can get to it safely).

Mobility: Another budget-buster. If you can't walk or get in and out of bed unaided (called "transferring"), then someone needs to help — and that "someone" is usually one or two strong people trained in how to lift. One of the most common reasons people move to nursing homes is that they can no longer walk or get out of bed by themselves.

My dad's a good example. Living independently for years in his retirement-community apartment, he rarely exercised, and his muscles turned to mush. One morning he fell in the shower, cracking his vertebrae. Unable to walk, he started rehab, but his muscles refused to cooperate. He was in a wheelchair the rest of his life in a nursing home and needed two people to get him in and out of bed. In one split second, he went from paying $2,000 a month for his own apartment to $5,000 for a shared room in a nursing home.

The next time you get out of a deep sofa, check out all the muscles you use to do it. Walking and getting in and out of a bed or chair require strong muscles. If you don't have them, you have to hire help. Exercise is the No. 1 way to avoid disability in old age. Too many older people don't exercise, then lose their muscle tone and the ability to get around on their own. If you want to remain as independent as you can as you age and avoid unnecessary care costs, stay active.

Significant others: All of us need someone we trust to help us with the big and little tasks as we get older — pay our bills, pick up groceries, talk to our doctors — and protect us from harm if we become vulnerable and unsafe by ourselves. I call them our "significant others." They're usually family — spouses and adult children — but not always, because many older people have no family nearby (you need to be close to help a parent). We also need these trusted people to serve as our Durable Powers of Attorney for Health and Finances — to act on our behalf when we cannot.

Financial Resources: As I've said many times, how we pay for services has a huge impact on what services are available as we grow older. Here's where you write this information.

Bonus Question — Personal Strengths: Although not highlighted on my assessment form, this is important. Assessing someone's need for care requires us to focus on their declining abilities. It's also important to remember what's still working and positive. It gives dignity to the older person and helps us keep our perspective. Although my dad was blind, near deaf and very frail, his strength was that he always smiled and said "please" and "thank you" to the people who cared for him (including me).

Next week: Putting the pieces together — where do we go from here, and how do we find the services we need?

Liz Taylor's column runs Mondays in the Northwest Life section. A specialist in aging and long-term care for 30 years, she consults with families and their elders. E-mail her at or write to P.O. Box 11601, Bainbridge Island, WA 98110. You can see all of her columns at

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