Caring for Elders

Elders need different kinds of care and support than younger people do. As we age, our bodies change and our needs for health care and support services change and increase. For example, elders may become weaker over time, making walking more difficult.

With increasing health care needs comes an increase in medications and treatments prescribed to help maintain elders' health and independence. Some have several medications and can forget which ones to take at different times of the day. In addition, elders sometimes quit taking important medications because they are not being refilled.

One of the challenges facing our communities is that more people are living longer but have more chronic illnesses, like diabetes and chronic heart disease. These chronic diseases are manageable with medications, treatment, and support services. However, some elders do not have adequate support systems due to a variety of potential factors. For example, if they are not engaged with their family and community, these elders may be overlooked. In addition, elders do not always ask for help or complain of health issues because they do not want to feel like a burden to others.

Elders who lack adequate support systems do not receive medication management, health care monitoring, and support from family, friends, and community members. This can make it difficult for them to remember to take their medications, exercise as much as they are able, follow the orders of their doctors, or even remember to visit their health care providers. It important to check on these elders on a regular basis.

Some memory loss is normal in older adults, so it's common for elders to experience some forgetfulness. However, some elders experience memory loss and confusion that is more severe than normal. In these situations, the elder’s medical provider may give a diagnosis of dementia. Glossary

An elder with dementia may experience:

• Severe memory loss.
• Confusion.
• Problems with communication.
• Personality changes.
• Agitation or fearfulness.
• Wandering (sometimes unsafely).

We often do not know the underlying cause of dementia. However, there are some medical conditions that can make it more likely that an elder will develop dementia, including:

• Alzheimer’s disease.
• Stroke.
• Head trauma or brain injury.
• Parkinson’s disease.
• Severe, chronic alcohol use disorders. See Behavioral Health and Medical Conditions and Substance Use and Abuse.

Many elders with dementia are cared for in their homes by family members. In these situations, family caregivers may be particularly at risk for stress and burnout. They may need support, encouragement, and assistance to identify sources of respite.

When adequate supports cannot be offered at home, elders with dementia are sometimes placed in a nursing home. In Alaska, elders often have to leave their home community to enter a nursing home. Although it is sometimes necessary, this transition can be very stressful for both elders and family members. Families of elders entering nursing home care may need additional support.

In our families and communities, we fill different roles. As we grow and age across our lifespan, our roles change as we approach different milestones related to our development, education, family, and career. All of our roles and changes are important to our cognitive, physical, and social development and provide us with a sense of meaning and involvement in our families and communities.

Early in life, common roles we may fill include:

• Elementary, secondary, or college student.
• Newlywed or committed partner.
• Employee.
• Parent.

Possible roles in later adulthood include:

• Grandparent.
• Elder.
• Mentor.
• Supervisor.
• Teacher.
• Great-grandparent.
• Guardian or caregiver of grandchildren or great-grandchildren.

Some role changes may not be viewed as positive changes, especially as we approach old age and become elders. For example, clients may view these life changes negatively:

• Retiring from a career.
• No longer actively volunteering in the community.
• Being unable to get around without assistance or being immobile.
• Requiring assistance with daily chores and activities of daily living, such as bathing and shopping.
• Needing more health care services, medications, and visits to the doctor.
• Experiencing cognitive changes, such as memory loss.
• Being viewed differently by society and experiencing more losses of friends and peers.

Many of the roles we fill early in our lives consist of caring for family members (e.g., taking care of spouse or partner, raising children) and providing for others in our families and communities. This may involve hunting and providing for their families and communities to support the family and give them a safe place to live. It can also include nurturing, caregiving, and supporting their partner, children, and other family members. Involvement in extended families and communities creates additional opportunities for different types of roles and support. These roles are central to our identity and sense of wellbeing throughout our lives.

The shift from being a caregiver and nurturer in their families to needing care and support with daily tasks in their own homes can be especially difficult for many people. It signifies that they are no longer able to live on their own or get around their home and community as freely as before. They now require more health care services and doctor visits because of illnesses and diseases. Poor health and loss of independence is a reality for some elders, but with support and care from their family and community, elders can fulfill roles such as grandparent, community elder, mentor, and teacher while receiving support.

As elders grow older and their ability to be active declines, one way to keep them engaged is to ask them about their lives, their families, and what they are involved with in their communities. Ask questions that encourage elders to discuss positive memories:

• What was your favorite thing to do when you were younger?
• How many grandchildren/great-grandchildren do you have?
• What did you do in your community?
• What is your favorite memory of your community?
• What cultural activities do you do in your community?
• What did your elders teach you that you still believe applies to life today?

You can work with elders and others involved in their lives to learn about their needs, desires, and wishes as they age and experience loss. Despite the physical changes we see in our elders, they are still the same people we know and love. It is important to include them in meaningful activities as much as they are able.

On the other hand, for some people, these changes in roles and health can also be an exciting and positive time of transition. Some elders embrace the physical and mental changes that come with growing older and they have developed a support system and coping strategies that help them to age well, despite these changes.

Visit with elders to learn of their wishes as they experience these changes, work with them to figure out how to best support them, and honor their wishes. One of the approaches is to ask how they are doing and what they enjoy doing, then find ways to engage them in those activities.

As elders experience changes in their health, support them by helping them find other meaningful roles and activities that give them a sense of purpose.

As elders grow older and their health needs change and require more care throughout the day, the roles of other family members often change as well. In many communities, elders live in homes that include their spouse, grown children, and even grandchildren and great-grandchildren. Multigenerational households enable elders to live in their homes as long as possible because they receive support and care from their family members. In these situations, elders often take care of the youngest family members, help around the house, and support their grown children as much as they are able. Traditionally, elders took care of the grandchildren, teaching them the language and culture; this still happens in our communities today.

In these multigenerational homes, the roles change and evolve as elders grow older and become more dependent on care from others. A grandparent may have been able to play with the grandchildren, help with their homework, and teach them about their family, community, and culture. As the elder becomes more dependent on support, the grandchildren transition to being helpers around the house. The grandchildren may help with meals, help the grandparent around the house, and help the parents provide care. The grandchildren's interaction with the grandparent changes from playful children to supportive household members.

As a result of these changes, the grown children who have historically relied on the grandparent for childcare may now need to care for the elder. They may need to change their hours at work, spend more time at home, or find others to assist in the care of the elder.

When working with families who have an elder in their home, it is important to not only ask about the care of the elder, but also the health of the grown children or caregivers. They may not ask for help or realize they are doing more than they can handle long-term. Ask them about their own personal care needs and what can help them provide care to their elderly loved one.

In addition to primary caregivers, elders need strong connections to other safe, stable relationships. This helps build resiliency in families in your community. For more information on resiliency, see Wellness and Prevention.

As a BHA/P, you will sometimes work with clients who have legal guardians or caregivers, such as elders, minors, or clients with certain medical conditions. When working with clients who need assistance (including elder clients), it is important to involve the caregivers in their lives. This process is called engaging and supporting caregivers.

An elder client may have more than one caregiver providing support. When beginning a therapeutic relationship with an elder, be sure to ask about the caregivers, their roles and relationship to the elder, and level of engagement with the elder.

A caregiver is anyone who plays a significant helping or protective role in the life of a person who is unable to care for themselves due to age or illness. A caregiver might provide:

• Companionship.
• Guidance.
• Support with medical, social, and personal concerns.
• Other forms of support that encourage and enable the elder's independence. This includes BHA/Ps conducting check-ins with elders in the community.

Some of the people who might act as caregivers to children, vulnerable adults, and elders include:

• Sons and daughters (biological, foster, step, or adoptive).
• Parents (biological, foster, step, or adoptive).
• Teachers and childcare providers.
• Extended family, such as aunts, uncles, and grandparents.
• Other elders and adult figures within the person’s family, community, and culture.

Engaging caregivers includes:

• Involving them in the process of taking care of the elder's social and health care needs.
• Offering them the chance to have a role in supporting the elder’s independence in the community.
• Helping the elder to stay connected with other elders and build new relationships with others who share the client’s cultural background.

Encourage caregivers to participate in treatment planning and interventions when appropriate. Invite family members, community supports, and other potential caregivers to engage in treatment. It is important to invite those people who are actively engaged in the care and support of the elder and who can provide detailed information on their health care and support needs. Each individual will provide different perspectives on the elder’s needs for care and support. When you work with multiple caregivers, you will have a better picture of the elder’s situation, and you will be better able to build a supportive network to help the elder recover.

Help elder clients to invite their caregivers to be part of their support network, both within the family and out in the community.

Help identify activities in which caregivers can easily get involved, such as fishing, beading, and berry-picking, storytelling with the elder and family, and other activities that are meaningful to the elder. This may be a great opportunity to engage elders and youth in the same activity, such as storytelling and sharing, to benefit both the elders and youth.

Educate caregivers about how their involvement will benefit the elder and support their independence. It is important that conversations about the health care of the elder involve all caregivers helping the elder. This way, groups of caregivers can support each other and share responsibility for helping the elder live as safely and independently as possible. Caregivers of elders can help by:

• Developing a common understanding of the elder’s medical conditions and recommended care.
• Creating a schedule to share the responsibility of attending appointments or providing medical care for the elder.
• Helping the elder to develop a plan for remembering to take medication.
• Planning and carrying out social activities to help the elder stay connected with their community, friends, and youth.
• Asking the elder to share their wisdom, skills, and stories.

When engaging caregivers in an elder’s care, remember to:

• Follow all client privacy rules. See Confidentiality and Release of Information.
• Understand any Power of Attorney, legal guardianship, or other legal decision-making arrangements that are in place for your client. See Consent to Treatment.
• Maintain healthy boundaries. See Values and Ethics for BHA/Ps.
• Consult with your supervisor in cases of suspected abuse and neglect of an elder or vulnerable adult. See Mandatory Reporting and Duty to Warn.
• Be realistic. Sometimes your efforts will not succeed. You can’t force caretakers to participate.
• Document your efforts to involve caregivers and whether or not they participate.
• Consult with your supervisor if any of the following happens:
  • The elder and/or caregivers are asking you to make decisions about the elder’s care.
  • You are concerned that the elder’s needs are not being met.
  • You are concerned that the elder is being mistreated, neglected, taken advantage of, or abused.

Caregiver support and health is also important to consider. Most elders receive support and care from informal caregivers (e.g., their children or their children's families). As the elder’s health care needs increase, so does the burden on the caregiver. Some caregivers can develop burnout and, in the worst cases, may abuse or neglect the elder if they lack appropriate support. It is important to check in with caregivers to ask how they are doing, what they need to stay healthy, and if they have someone who can assist the elder so they can have a break (also known as a respite provider).

Sometimes,respitecare is available through agencies that hire home care workers. Home care workers are paid to go into an elder’s home for a specified number of hours a day or week. They are trained to help with cooking, cleaning, bathing, dressing, medication management, or other tasks that the elder may find it difficult to do independently. When agency home care is unavailable, respite is often provided informally within the community by extended family, clergy, or tribes. If you are working with a caregiver who is experiencing stress, you can help them by:

• Encouraging them to seek respite.
• Helping them identify local resources for respite.
• Reminding them that their own self-care is important for the health of the whole family and the elder they are caring for.

Every elder has a unique situation, and while each elder's situation and health care needs are unique, some best practices have been developed through years of elder care programs. Best practices for elder care honor their values and beliefs, meaning they are grounded in the cultural values and beliefs of Alaska Natives.

Follow these best practices to assist elders in your community with their care:

• Schedule time for weekly check-ins with elders who have recently visited their medical provider.
• Ask elders if there is a family member or close friend who can join them on their next visit to the clinic.
• Ask elders if they would like assistance with daily chores, informal support in the home, or anything else that would make it easier for them to remain in their home.
• When there is a community event, ask community members to escort the elder to and from the community event.
• Offer to review their medications and write down a daily/weekly schedule when the elder is supposed to take their medication.

These best practices can help elders feel safe in their homes and communities and to remain in their homes or with their families.

It is important to engage the family as much as the elder wishes, and as much as the family wishes. There may be instances where it is not safe or possible to include the elder’s family, but it is important to have this discussion and offer to include their family in these activities and decisions. There may also be close friends or other community members whose help elders may wish to have in their home.

Elders have held specific roles of respect and honor in our families and communities, and many of us still follow the traditional ways of interacting with elders. Historically, elders were the leaders in the communities, sought out for their wisdom and knowledge to guide the community, resolve conflict, and protect the health and wellbeing of the community members. Despite the changes in communities over the past few decades, elders still hold these important roles.

It’s important to know that the use of the term “traditional” does not mean these are the ways of the past. Rather, traditional ways of interacting with elders are based on longstanding family and community behaviors and beliefs that focus on honoring and respecting elders.

Interactions with elders can include both traditional and contemporary practices. They will vary by family, community, and each elder’s preferences on how they wish to interact with others. If you are not sure what is appropriate, it is important to ask. Consider these examples of how to engage and work with elders in their homes and communities:

• Have patience.
• Speak slowly and clearly while continuing to communicate with respect. For example, you may need to speak louder, but this is not the same as yelling, and speaking slowly is not the same as how you would speak to a child. Make sure you treat the elder with dignity and respect as you adjust how you speak.
• Look directly at the elder while you are talking.
• When you first visit, ask if there is anything you can to do help.
• If you notice that something needs to be done in the elder’s home, do it without being asked (e.g., wash dirty dishes, take out the trash, bring in wood for the wood stove).
• Offer to make tea or something to eat for the elder.
• Offer to run errands or help out if time permits, and if appropriate.
• Do not be afraid to ask the elder questions.
• Seek out the elder’s advice; ask how the elder would like things to be done.
• Be prepared to laugh and share stories.
• If time permits, be prepared to visit and share about your life, your family, and your day.

You can learn many other ways of interacting with elders by observing how others interact with elders in the community. As you interact with elders in your role of BHA/P, remember to maintain professional boundaries. See the boundaries section of Values and Ethics.

We often want to provide support and help to our elders because of how we were raised (see Alaska Native cultural values), but we also have to be careful not to take away the independence of elders or exclude them from making decisions about their care and support. We need to encourage elders to advocate for themselves as long as it is safe, and we need to honor and recognize their decisions as long as they are cared for and supported in a safe environment.

Sometimes, we can encourage an elder’s self-determination and independence by just asking their opinion on issues related to their care:

• Which people do you trust who can check on you a few times a week?
• Which people would you like to come by and help with chores (wash clothes, chop wood, bring groceries, sweep, etc.)?
• Is there anything else that would help you feel comfortable at home?
  • This question is important to ask because there may be simple things that can be done to support the elder.
  • The challenge with this question is the lack of available support and health care services in the rural communities. While it is important to ask what would improve their situation, sometimes the elder is frustrated because what they need to remain at home is not available. Be sensitive to this situation.
• Are there things you would like to change at home?

While elders wish to stay in their own homes, their increasing needs for health care and support can sometimes make it difficult to remain at home. Many elders in our communities already live in homes with their extended families, so they have the support necessary to remain at home. Those who do not have their family available for support are placed in a position of finding others to provide support or moving somewhere where they are safe.

It will also be important to carefully ask about an elder’s safety at home. These questions need to be asked carefully, because some elders may not feel comfortable reporting unsafe situations out of fear that their family members will get in trouble. However, you may occasionally become concerned that an elder is experiencing neglect or abuse. Signs of elder neglect or abuse may include:

• Poor hygiene.
• Not having enough to eat.
• Not accessing medical care when needed.
• Unexplained bruising, abrasions, or other injuries.
• Unexplained withdrawal or depression.
• Not having access to their own funds.

If you suspect that an elder is being mistreated, it is important to talk with your supervisor right away. As a mandatory reporter, you have a responsibility to report suspected elder abuse and neglect to Adult Protective Services. It may also be important to make sure the elder sees a health care provider. Your supervisor can help you make sure you are following the law and your agency's policies when you make a report. See Abuse and Neglect.

When an elder is unable to make good decisions about important legal, financial or medical issues, they will sometimes have a legal decision-maker. The legal decision-maker may have either a power of attorney or a partial or full legal guardianship for the elder (see ). The legal decision-maker may be a family member, a tribal representative, or a state guardian. If you are working with an elder who has a legal decision-maker, it is important to be aware of this and to keep the decision-maker informed of any updates or changes in the elder’s situation.