Consultation/Liaison with Physicians - Caregivers

Consultation/Liaison with Physicians & Families in Care Management

When my Mom went into Assisted Living we would have been lost if it hadn’t been for my older sister Patricia who was a social worker.  Pat had worked for the Veterans Administration for thirty-five years evaluating veterans who were transitioning into long-term care.  She knew many of the Medicare laws, and what was needed for a Trust, Health Care Power of Attorney and Power of Attorney for Estate.  She also knew the best and the worse Extended Care Facilities in the Wichita area.  Since she had a number of her clients at the Catholic Care Center and it was near her and my older twin sisters it was a perfect fit for Mom.  Getting Gracia into the Catholic Care Center would be another miracle!
 

We knew that when my Mom walked into the bank which was next to her home and asked a teller “where did they move the bank” that she was confused and disoriented.  When the local sheriff found her walking down Main Street in her nightgown crossing a major State highway “to go home”: we also knew that she could no longer live by herself.  “Home” was the farm that we had sold fifteen years before she was found wandering down the street.
 

When we took my Mom to her attending physician, he told her:  “Gracia you can no longer live alone.  I believe it’s time for you to move into a nursing home where you can get the necessary care that you need.  Many well-intending physicians tell elderly patients that they need to leave their homes and go into a facility, but they do not take the time to answer the plethora of questions that need to be addressed.
 

I have worked in consultation with many physicians and have been in the role as a liaison between the physician and the patient with his or her family.  I will meet with the primary caregiver (spouse or adult child) and discuss the progression of the dementia for their loved one and how they are coping with the many aspects of caregiving.  I will also assess the patient’s Independent Activities of Daily Living, i.e., fixing a meal, grocery shopping, management of finances, driving, helping manage the home, etc.  We will also discuss his or her Activities of Daily Living.  These include bathing, toileting, dressing, oral hygiene, shaving, and fixing one’s hair.
 

After meeting with the primary caregiver, I will meet with the patient and give him or her a Mini Mental Status Examination to establish a baseline of the progression of the dementia.  Through casual conversation I will also assess depression, anxiety, and any “red flags” that are concomitant with the dementia.  Examples of “red flags” include wandering off, getting lost, not knowing how to use a cell phone, disorientation, confusion, and what to do in an emergency.

My role in consultation with physicians and families is to assist families with Care Management.  This may range from helping with in-home help to deciding on when it is time for placement.  Having facilitated Alzheimer's support groups for twenty-five years, I know the excellent facilities and the not so good facilities in the Los Angeles area.  If you are out of the State of California you can email me at drlarry@centerforadultdevelopment.com and I can assist you in finding the best facility for your spouse or parent.  

Many of the Care Management questions that spouses and adult children have are similar, but some of those questions are particular to the relationship the caregiver has with the patient.  Let’s explore some of the common questions that I can help you answer as a consultant in the management and transition of your loved one’s care.

1.  If the doctor did not tell my spouse or parent that they need to go into a facility how do I tell him or her?

When I discuss the decision for placement I always “blame it” on the doctor.  The use of this recurrent metaphor shifts the focus of blame from the caregiver to the patient’s attending physician.  I have instructed spouses to tell their spouse: “Dr. Blame said he wanted you to come in here for a series of tests about your memory and they have not finished those tests.”  Many patients with dementia may have periods of confusion and paranoia and blame you for placing them in the facility.  They may become agitated because they believe you were the one who made the decision for placement.  Because of this belief, Extended Care Facilities will request that you not visit your loved one for two weeks after placement.  The patient needs to adjust to this new living situation.

2.  What if s/he refuses to go into a facility and becomes agitated when getting there?

I suggest to family members that their physician prescribe a mild anti-anxiety medication to be started a week before placement.  I also suggest that the spouse not take their husband or wife at the time of placement.  It is easier on the spouse and the patient if one of your children manages this situation.

3.  Do I just take him or her to the care facility and drop her off and leave?

You and your spouse or parent will have taken a tour of the facility hopefully during a mealtime.  Depending on the level of dementia and counsel from the psychologist that you have been seeing, you may even discuss placement with the patient.  Prior to the first day of residency, you will have filled out all of the necessary paperwork.  At this time you should have the administrator of the facility “walk you through” what will happen when you bring your loved one to the facility.

There are many questions that you may need to have answered about caregiving and care management.  Because of my personal and professional experience in all aspects of caregiving and care management, I can act as a resource and liaison with your family and your physician.

The most common questions that I have received from Adult Children Caregivers are:  “Should we have Mom or Dad move in with us?”  This is a very difficult question to answer even if there are separate living quarters for your parent.  It is a difficult task if you don’t have children. It is even more difficult if you are caring for your own children and caring for a parent with dementia.  The duality of caregiving is referred to as the “Sandwiched Generation.”  Most patients with dementia lack the insight to their behavior and lack boundaries with shared space.  As the dementia progresses the patient’s social skills decline and they may do or say inappropriate things.  It’s challenging to explain bizarre behavior to children especially when Grandpa is living under the same roof. Maria Shriver’s book What’s Happening to Grandpa? is an excellent book to explain Alzheimer’s disease to young children.

Here is a valuable resource for finding the best Medicare and Medicaid nursing home in your State.  Find and Compare Nursing Homes: http://www.medicare.gov/nursinghomecompare

“The Alzheimer’s Association addresses the needs of caregivers in vital ways, beginning with a special section of our website, the Alzheimer’s and Dementia Caregiver Center (alz.org/care).  The site provides strategies and tips and tools to help us with all aspects of caregiving, including daily care, stages and behaviors, safety concerns, care options and planning for the future.” Source Alzheimer’s Association.org

Consultation/Liaison with Physicians & Psychopharmacology

I have thirty-two years of experience in psychopharmacology and consultation/liaison with physicians and their patients.  Often physicians do not have the time to go over every side effect of medications, the interaction effects with other medications or what not to take with the prescribed medication.  Patients and their families are frequently overwhelmed when they meet with their primary care physician who may be prescribing a combination of medications.  They often leave their doctor’s office with more questions than answers.  This is not to say that physicians are remiss in educating patients about medications.  It is often a time factor such that doctors have to see a number of patients per hour to keep his or her statistics optimized.

This is where I come in!  Given my Ph.D. in Clinical Health Psychology and my Post-Doctoral Fellowship at Yale University School of Medicine in Consultation/Liaison Medicine, I have years of experience in working with physicians and families in making medicine make sense. At Yale I was on call at Waterbury Hospital’s ER and Trauma Center.  I worked with post-bypass patients at the hospital. I put myself through undergraduate and my first Master’s degree in Psychology as a Unit Clerk/Telemetry Technician at Jewish Hospital in Cincinnati, Ohio.  My Master’s degree thesis focused on developing the Family Heart Questionnaire ® to use paradoxical therapy for the intervention of Cardiac Disease Risk Factors.  I was also the Director of Counseling Services for Hospice of Pasadena from 1993-2001.

My role is to be a liaison between you and your patients.  I can educate them about their medications, your treatment plan and answer any questions that they may have about your diagnosis of their presenting problem.  I have twenty-five years of experience in facilitating Alzheimer’s Support Groups and I am quite familiar with geriatric medicines.  I have personal experience with hypertension, diabetes, Alzheimer’s disease, Multi-Infarct Dementia, and Medtronic on-demand pacemakers.  Over the course of my twenty-eight years in practice, I have been a consultant to cardiologists, electro physiologists, gerontologists, psychiatrists, family medicine physicians, neurologists, and other practitioners.  I have consulted with many physicians who have patients in Extended Care Facilities to assess their level of placement.  I will go to an Extended Care Facility to consult with your patients/families about care management, psychopharmacology and Hospice.

I recently met with one of my patients who was loosing weight which I thought was due to the sudden death of his wife who had Alzheimer’s for eight years.  He was her primary caregiver.  I asked him if he had been on any new medications.  I was surprised when he told me that he had been started on Prozac a month earlier, which corresponded, to his weight loss.  I suggested he call his PCP for blood work.  His PCP was out of town so he called his cardiologist who ordered blood work and suggested that he come off the Prozac.  As I suspected he had severe hyponatremia, which was causing his weight loss.