I asked him if this is available in other locations outside of Oregon. He said: Yes, in all U.S. States and Territories, and in the District of Columbia. 1400 of them last count. Not all have equal services and staff, especially in some rural counties.

Thank you, Bill, for your continued help to our communities.

In your post describing your struggles establishing with a new primary care provider, you may have overlooked Federally Qualified Health Centers (FQHCs). They are hiding in plain sight.

They are sometimes shunned by people who still believe they are “free clinics” serving the poor, migrant workers, the homeless, people with substance abuse problems and unhoused street people. These images are holdovers from when some of them began as offices in donated space staffed by volunteers with limited training and skills.

FQHCs offer a full range of services by physicians, advanced practice physician assistants, nurse practitioners, on-site pharmacies, dental care, behavioral health providers including social workers and psychiatric nurse practitioners. They are open to everyone of all ages, with or without insurance, readily accept the Oregon Health Plan (Medicaid), Medicare, and private insurance.

They are not free. But no one is turned away for inability to pay. Fees are adjusted depending on financial ability, but care is continued even if payments are deferred.

All providers are certified, many bilingual, some are serving a required term of commitment in order to pay back professional training loans. They are salaried, not prone to financial incentives by offering expensive care or procedures. Performance is monitored to assure performance with established best practices. I know because I used to volunteer there when in practice during the 90s.

Their patients have access to some providers who accept assignments for extended time outside standard daytime hours, but they do not offer round-the-clock urgent care. They know how and when to refer patients out to specialty care.

In our area, as in many locations which are considered more rural, a new medical provider is not easy to find. Even if you find one taking new patients, some offices have a 6-8 month waiting list before you get your first appointment.

If where you live means getting a new doctor is difficult, stay with the one you have. Unless it’s an awful situation, it’s better than not having anyone. Going to an urgent care center is OK in a pinch, but not ideal for ongoing care, either.

As for how I resolved my dilemma, it’s with the greatest appreciation that I found a wonderful nurse practitioner who is willing to partner with me in addressing my health care needs. It’s the perfect fit, and I’m very grateful for her help.

I hope we all find the appropriate medical care we need as aging happens. And if you do connect with the right provider like I did, be sure to let them know how much you appreciate their care.

One of the first things people look for when they relocate is a medical provider. Also, sometimes your doctor retires, and people are left trying to find someone else. However, finding a medical doctor or other primary care provider might not be that easy. In the past years, many doctors have either moved out of the area, retired, or stopped taking on new patients, especially those on Medicare. The options might not be great, but there are a few you might not have considered.

Before looking at the options, here is some information on why there might be fewer doctors than you might hope. In particular, people often wonder why we don’t have any actual geriatricians here, given the number of older adults and retirees. Look at these figures for some of the answers.

Here’s the annual physician compensation, in thousands per year. The average annual salary for a geriatric medicine physician in 2024 is approximately $289,201. Geriatrics tracks closely with primary care and general internal medicine economics, typically yielding hourly rates between $100 and $180, depending on the practice setting. This is actually the lowest of eleven medical specialties.

Add to this the time constraints that insurance companies and busy medical practices put on the provider, and you can see how this might not be ideal for older adults, or their doctors. Medicare historically has not adequately compensated doctors for a basic office visit. I remember years ago, my family doctor told me it actually cost his office $3.00 for every Medicare patent he saw.

Here are some provider options to consider if you’re facing this situation; a nurse practitioner (NP) or family nurse practitioner (FNP), a physician’s assistant (PA), or a concierge medical practice.

A quote from the Nurse Journal, March 3, 2021: NPs and PAs offer some of the same healthcare services, but the focus of their training and their responsibilities differ. NPs earn their degree at nursing schools and emphasize patient care for specific populations, while PAs study biology and pathology in medical school programs based on the physician training model. NPs must have experience working as RNs prior to entering a Master’s NP programs. However, PA programs do not require students to have experience providing direct patient care. Furthermore, PAs cannot practice independently and must be under direct physician supervision, while NPs, depending on the state, can practice independently.

Personal experience with clients has shown that a visit to an NP can include more time for conversations than a usual office visit with a doctor. In addition to their private practice, they might actually visit their patients at home or in a memory care facility. Since FNPs in Oregon are able to prescribe medication, they can also work with staff at the assisted living and dementia care facilities when a problem arises to make medication adjustments.

As for a PA, if you’ve had a long wait to see a dermatologist, for example, you can often get an appointment to see the PA. Having your yearly skin check can be a lot less difficult to schedule this way, and they are quite capable in meeting this need.

You may not be as aware of what’s known as concierge or direct-pay medicine. Here the patient pays a monthly membership fee (generally in the $100 range), and Medicare pays for the usual visits and tests. The benefits of this are direct access to the care you need when you need it, often by phone, text, portal or email. There is generally no specified time limit for visits, either, so this works well when you have lots to discuss about your medical care.

If having a medical doctor has become less available, or you’re not happy with your care, consider these other options as well. It might turn out to be the best choice of all.

Just when you thought you had everything in place with your estate planning, along comes another layer of preparation.

Even after you’ve appointed the successor trustee of your estate, or the personal representative on your will, you may have a few more steps. There are many obstacles that could potentially be avoided by completing some paperwork now.

Here are suggestions to help you confirm that you have it all in place.

If you invest with investment firms, such or financial advisors, check in with them. Please don’t assume that a power of attorney document, the will, or the trust is sufficient. This does not mean that those legal documents are inadequate, but what we’re looking for here is ease of transition. Each company might have their own specific documents so your representative can step up when the time arrives, either before and/or after you die. Ask a simple question like, “What will my representative need, that I can sign now, to allow for an easier transition to their hands later?” It might be a release of information form or it could be a lot more than that.

If you’re working with large firms like Fidelity or Vanguard, for example, it can be a bit more challenging. Recently, another roadblock was encountered with Vanguard. To access the accounts in order to move them to a local advisor, they required a medallion signature guarantee stamp on their documents. It’s similar to having a signature notarized, but harder to acquire. Many banks no longer offer this service. That’s something else to determine ahead of time.

When it comes to your bank accounts, be sure to ask if there are any items that need to be signed now while you’re fully competent. Again, even with your power of attorney document, the bank still can require their own legal documents be signed as well. In addition, they might also recommend that your representative be a co-owner or signer on the account.

Anyone who’s a beneficiary of a will or trust might wonder what’s taking so long in closing out the estate. People are often anxious to receive their inheritance. Taking the time now to sort out necessary paperwork might help cut down on some of the complexities later. Still, be prepared to wait at least six months, and not uncommonly as long as a year or more, to finalize closing the estate. It’s helpful if beneficiaries know this in advance.

Another suggestion is to take a look at any other accounts or policies for their particular requirements, too. Long-term-care insurance is one good example of needing a release of information signed so your representative can apply for a claim later.

Check out your funeral plan for an “authorization for final disposition instructions” or “disposition of remains” form. Signing this can avoid headaches for all family members, if it’s done ahead of time.

A side-but-related task is calling all those catalogs, if you’re still receiving them, and asking them to remove your name from their mailing list. They often sell their lists, and that’s how you end up with 50 different catalogs after only one order. This is really appreciated by those who’d have to deal with them after you’re gone, not to mention all the wasted paper they produce.

As with anything related to any legal issues, please check with your lawyer to get their advice as well. Forethought in preparing for yourself and your representative is actually a kindness to you both.

If you are currently a solo ager, now’s the time to prepare for meeting your longer-term care and social needs. The truth is, many more people will be in this same situation when their partner or spouse pre-deceases them.

I’ll reiterate the attorney’s famous line: It’s never too soon to plan, but you might be a day too late.

What is the new language used to describe someone who has never married or had children and is now aging on their own? Here are three terms used interchangeably for this group of folks: solo agers, elder orphans, and solo seniors. You can take your pick, but I’ll stick with solo agers. That definition is now being expanded to include those who may have been married at some point but are now either divorced, or their spouse has deceased. If they did have children, they are now no longer in the picture, either estranged, or not willing or able to help an aging parent. For many who didn’t start out as solo agers, they might well become one later in their lives.

Why this is important is that the numbers of this group are growing. Here are some statistics to consider. Twenty-two percent of people over 65 are either childless or not in contact with their adult children, and 23% will be at risk for this status as solo ager. Where I live in Ashland, Oregon, a whopping 49% of the population is between 55-65 and older. If a quarter to one-third of them will be solo agers, there’s some serious preparation that’s going to be needed.

Pre-planning for solo agers’ later years is different than for those who have a partner or adult children. The most basic and obvious need is the lack of family caregivers. One third of baby boomers are childless to start. Since our country has yet to come up with a plan for addressing the long-term care needs of aging adults, it’s mostly the children or grandkids who step in to provide support. In their absence, you can see how caregiving needs might need to be considered ahead of that time.

Now we come to the planning portion. To truly meet this need, you’ll need what I call precision planning and navigation. Put together your professional team, a care committee, if you will. This team should include a medical provider, an estate or elder law attorney, CPA, corporate fiduciary, insurance advisor, investment planner, and the all-important aging life care manager. Each one has their area of expertise and is integral in helping this person to meet their later-in-life needs.

If this is your situation, please do not delay in getting information on this topic and putting your plan in place. One place to start is getting a book called, “Essential Retirement Planning for Solo Agers: A Retirement and Aging Roadmap for Single and Childless Adults”, by Sara Zeff Geber. It’s one of many books published in recent years on this topic.

Another good resource is an article in New Retirement, June 29, 2020, called “13 Key Tips for Retiring Alone (Or, If You Become a Solo Senior or Elder Orphan During Retirement)”. Here are a few of those tips: overcome your financial insecurities; cultivate a support network; stay social; think carefully about where you live; and identify financial and health proxies (representatives).

Even if you’re not single right now, you may be single down the line. Also, consider how realistic it might be for your grown children to step in and help manage your personal affairs, finances, or other daily tasks. Now is the best time to find those who you can work with to create a plan that fits you and your budget.

This is not an article sharing tips on how to make this realistic. This is one of her columns on this topic instead. In future columns, I will continue to feature this topic of aging-in-place, as it’s of prime importance to most people.

Please note that the costs she quotes below have gone up substantially in the last decade. Instead of offering you the current rates, please check out the costs where you live. There is a wide disparity on costs based on the availability of housing and community options for aging adults.

And yes, she does mention me by name, and I’m grateful for this. But there are other professionals across the country who are able to help you, too. I always think that it’s a good choice to get an expert on board when needed.

Here’s her column, with a few edits:

I read the back of cereal boxes, those little flyers that get stuck in your door when you’re out of town and the random postings on bulletin boards outside grocery stories. I found the topic for this column by reading an article in a stray newspaper at the airport.

Maybe I could say… ‘I read it so you don’t have to….’

That said, please read this. It’s about assuring every day, at-home satisfaction in your final decade. First, a question. Where do you want to live when you‘re eighty-five plus? I’m suspecting most people respond by saying…” I want to live independently…ideally in my own house like I do now.” That’s how I would respond.

Recently my husband and I decided to bring that question closer to home. We called in an accessibility expert to help us evaluate whether our home was completely livable if we became wheelchair users or were temporally bed-bound. We have accepted the fact that we will eventually get old and maybe even have some incapacitating health problem. Interestingly, a lot of folks our age are slow to accept that could happen. (I have friends—I know these things…)

Me, I like to embrace aging. ‘Old’ looks farther away the closer I get to it—but when it does come near, I want to be ready.

Enter the concept of “universal design.” Basically, it means living environments are physically accessible to people regardless of age or abilities. These approaches are “compelling and seamless to the design of the home.” I got that last phrase from reading the newspaper article mentioned earlier. “As life expectancy rises and modern medicine has increased the survival rate, there is a growing interest in universal design.”

Get this, if you want to stay in your current home till the end of your years, you may need to initiate structural changes. At first glance the price tag seems high. When you calculate cost avoidance, not so much. A $10,000 bathroom remodel (you didn’t think you needed) can start looking like a real deal.

Think about it this way. Met Life Foundation regularly looks at the cost of long-term care and found the average cost of a private room in a nursing home is $80,000/year and rising. Assisted Living situations average $40,000 a year. Aging adults may end up moving to these environments solely because of the lack of an accessible downstairs bathroom --or stairs that were hard to navigate, cupboards that were too high. Sure, modifying your home requires an investment. But you can calculate the cost-benefit fairly easily. And when you throw in the likelihood any modification that leans in the direction of universal design will make your house more ultimately marketable, remodeling decisions are a whole lot easier.

We started our reality check with the future by consulting a professional geriatric care manager. We chose Ellen Waldman (www.SeniorOptionsAshland.com) and she led us to the local universal design/accessibility experts. I thought I knew some things about this business of ‘aging in place,’ but these folks know more.

Ever older. Always learning.

Below are a few suggestions that might help you to help your parents plan for their future. It also works the other way around. There are times when it’s the adult children who don’t want to enter into this conversation. In that case, you can modify these suggestions and apply them as well.

In all cases, start slowly and don’t expect immediate enthusiasm. This is tough for a lot of people, for a variety of their own reasons.

As one attorney used to remind me with regards to getting legal documents in place, it’s never too soon, but it could be a day too late. Start small, and start now.

Also, just to keep things moving forward, at the end of this article, I also attached the form, DRIVER PLANNING AGREEMENT. You might want to include this in pre-planning as well.

• Appeal to penny-pinching: “Mom, let’s get these papers in order. It will save money because if you don’t have them now, it will be expensive for me to do without you if you’re ever hurt or sick.”

• Emphasize how it helps you. “Want to do me a big favor, Dad? Help me figure out what you’d like to have happen with your affairs if you ever get sick.”

• Be an example. Make your own future decisions and say, “Hey, listen to what we just did; you should do it too and I can show you how.”

• Say it’s the new thing. “I know you might not have done this with Grandma, but everybody’s doing it now”.

• Suggest a neutral third party. Sometimes a lawyer, financial planner, or family friend can ease the awkwardness of discussing finances and health care.

Even if your parent already has a diagnosis of dementia, she or he may still have the capacity to work with you to establish these things -- you just have to move faster.

Driver Planning Agreement

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This article may look familiar to some of you who have been in this exact spot. Maybe as the designated daughter or the dutiful son. Get some real help, if at all possible, and don’t burnout.

Here goes…

Women’s Day, June 2, 2010, by D.G. Fulford

D.G. Fulford is the author of Designated Daughter: The Bonus Years with Mom, written with her mother Phyllis Greene.

I’d like you to picture this scene. Pretend you’re watching a movie. And substitute yourself for me. Every Designated Daughter knows this story.

I am at a gathering. Everyone I love is there, except for Mom who is in the dawning stages of a health crisis. I am standing in the kitchen, in tears, because I need to find someone or somehow to help her. Right away. Right now. Someone I can trust.

Big Issue.

I am standing in the kitchen. There a is window-like opening there, looking into the dining room, where the buffet table is, and all the people. Each one, as they round the scrumptious buffet has some advice, a suggestion for me. Fresh fruit in hand and chicken salad, every person tries to calm me, but I am at my wit’s end.

I tried that! I tried that! I tell each person who passes, I called her! I called him! I cry.

I had no idea, then, just five years ago, that there was such a thing as a professional geriatric care manager (now called an Aging Life Care Manager, aginglifecare.org).

There is a professional in almost every zip code. Breathe out and let the panic abate. This is an organization of objective–– caring, of course; compassionate, absolutely certified professionals in the fields of nursing, and gerontology, and related fields, and all the things a Designated Daughter doesn’t know.

If I were standing in that kitchen today, I would not be crying. As my loved ones circled the Panic-Go-Round with their well-meaning suggestions, I would stand on my side of the partition assuring them that my next step would be contacting the Aging Life Care Association.

Have you heard about them? I’d ask, as I breathed out the fear and slowly began to breathe in the faith.

Please know that I so appreciate and am grateful for your financial support to my writing, too. It’s very meaningful to me. I hope you continue to show your interest and see the value in what I’m offering by this support. But if this isn’t the right fit for you, you can still read all the articles anyway.

Keep reading Aging Matters and take advantage of my years of first-hand experience. And do consider a paid subscription if you feel it’s been worthwhile. For now, I’m happy to be here passing along some helpful, professional guidance.

Thank you again for reading my columns.

When you take a look at the task list on the AARP site (link below) it might look overwhelming. And it certainly can be. So be sure that the person you’re appointing really wants to, and is able, to do this.

I recently saw a book that might be helpful if you’re not sure what you need to do now, or what your person will need to have available. It’s called My Mother’s Money: A Guide to Financial Caregiving, by Beth Pinsker. She goes over just about everything you’ll want to know about this whole process. That includes the person who’s going to need this help later, and the person who will be doing the work itself. There are other books and websites out there, too, but pick something that you connect with, and start this process.

What if you’re the person appointed to take care of your loved one’s affairs after they pass on? Would you know all the tasks that are required? Probably not, and for that reason, there’s some important items that you need to be aware of. A list is a great way to proceed.

One of the best overall lists comes from AARP: https://www.aarp.org/home-family/friends-family/info-2020/when-loved-one-dies-checklist.html.

This covers what to do immediately after someone dies, within a few days of death, and two weeks after death. From my experience, no one gets to all of this in two weeks. There are so many emotions, so many people to attend to, and flat-out exhaustion, that it would be more reasonable to expect this initial process to take a minimum of several months to a year. Even then, there will be loose ends everywhere. And this works only if your person had most things already well-organized, and you knew where to find everything.

Before getting into the details of what’s involved, it’s also important to enlist the help of friends, family and professionals, like the attorney, the CPA, and others. No one can possible do this on their own. This is another example of seeing the wisdom of having your ducks in a row now. It just makes things so much easier for others after you’re gone. When I’m helping someone to navigate the documents they need to have in place, I’ve found that most people overlook what’s required after they have deceased. You can avoid this by not expecting someone to be a detective, and organizing this now.

Here are some specifics I’ve found the most helpful.

Most people know what to do immediately following a death, like calling the funeral home, getting death certificates (several of them, long and short forms), and letting friends and family know. Receiving a death benefit from the life insurance company will mean they will need a death certificate, as an example. What you might not know is that you have to hire a CPA or tax preparer to do the taxes for the year in which they’ve died and perhaps even into the next year. If the person who died did not leave a detailed list of their assets, it may take you a long time, more than a year, to find out what all their investments and assets might be.

You might not have considered that closing out credit cards and canceling a driver’s license lessens the chances that there will be any identity theft later. Deleting and closing down email and social media accounts can be a harrowing job, one perhaps best handled by someone experienced with tech.

I have not found anyone worth their salt more than the right attorney to guide you through this process, and most people already have an attorney they like to work with. Finally, some people don’t realize that if you have appointed someone as your power of attorney (POA), this holds no value after you die. Your trust or will states who’s in charge once you pass on, and it’s not always the same person who was your POA.

Here’s a quick example. I have been helping with the closing of an estate that started in August 2020. We are now fully one year along and it’s finally getting down to the last tasks. This is with myself (who’s been through these many times before), an estate planning attorney, a CPA, the accounting department at the law firm, the investment or financial advisor, and the local bank. I had a great list of steps to follow, but I also relied on their skills as professionals to be sure I had completed everything according to what’s required. As I’m re-writing this in 2026, it was just this past year was this estate fully and finally closed.

For now, get the list from the AARP article, do your homework, and pick the right person or firm to represent and assist you. Then you can have a free mind that it will all be managed with skill and accuracy. It’s a bigger task than you might think.

The pandemic has passed, but there are still many people who are recognizing and agreeing, maybe for the first time, that their emotional well-being is not great. The ideas that I offered back in 2021 still have relevance.

The mental health of older adults has been one of those topics that people don’t like to discuss. It’s ageism, pure and simple, that many medical providers think that getting older means we no longer have to be concerned about mental health. They may ask one or two perfunctory questions, but that’s about it.

Please advocate for yourself if you need this sort of help. And please find others that you can relate to and socialize with. I like this one quote by Carl Jung: “Loneliness does not come from having no people about one, but from being unable to communicate the things that seem important to oneself”. This is the situation too many people find themselves facing as they age. May you find the right supports and other people to communicate with, whatever your age.

These past 18 months have changed all of our lives, to put it mildly. Many people have had to make major adjustments to what they normally enjoy doing. For older adults, the inability to socialize has been very costly to their health and well-being. One woman living at a local retirement community missed having the communal meals and other activities so much, that she has developed a severe skin condition. The doctor felt it was likely caused by stress and loneliness.

Here’s some info to consider regarding this impact. In June of last year, 13 percent of those surveyed by the C.D.C. said they had either started or increased substance use to deal with stress or emotions related to the pandemic. A nationwide survey found that one in four adults reported drinking more this past year to manage their stress. There are also higher incidences of eating disorders, depression, anxiety and suicidal thoughts. In addition, many are experiencing burnout, loneliness, sleep problems and the ongoing stress of being a caregiver. Others just feel like they are languishing.

The New York Times, (8/20/21) offered these questions to consider. They might indicate that a mental health issue needs to be addressed. Especially in older adults, too often these signs are overlooked by the doctor or the person themself.

· Are you or a loved one struggling to get through the day, or feeling persistently sad, irritable or anxious?

· Have you withdrawn from your loved ones or are you arguing more often?

· Have you thought about harming yourself?

· Have there been changes in your sleeping or eating patterns?

· Are you using drugs or alcohol to cope?

· Have you had difficulty concentrating or making decisions?

If you recognize yourself, there are resources available to assist you. Let’s start with simple self-care routines that were found to be quite effective. Many people started a daily meditation or exercise practice, like yoga or walking. Some people found maintaining routines helpful; others loved the freedom of an unscheduled day. People discovered new hobbies and new ways to connect with friends. Zoom seemed to be one method, as did meeting outdoors, when the air quality allowed. It’s important to find people in your life who you trust and can talk to about both the good and bad that may happen. Experts recommend taking regular breaks from your electronic devices and eating healthy meals. Simply getting enough sleep, including napping, really helps.

Any mental health difficulties, including thoughts of suicide are serious, and here’s an excellent resource for that.

From their website: “The 988 Suicide & Crisis Lifeline is an important resource. You can text or call 988, or email: https://988lifeline.org/. It’s never the wrong call to make, even if you’re not certain someone would actually harm themselves.

“At the 988 Lifeline, we understand that life’s challenges can sometimes be difficult. Whether you’re facing mental health struggles, emotional distress, alcohol or drug use concerns, or just need someone to talk to, our caring counselors are here for you. You are not alone. If you or someone you know has indicated they have considered ending their life, please call.”

We need connection, we need community, we need professional help, we need one another. During times of extreme stress, conditions ask us to make the extra efforts required. Find what works for you and please take the next steps to make that happen.

When it comes to a discussion on aging, research shows that most people are primarily concerned about two specific topics: fear of getting a brain disease like dementia, and the role of caregiving. I recently read two books on both topics and want to share them with you.

The fear of getting dementia has been shown, in every study, to be the biggest fear people have around aging. No one wants to go through this loss of their personalities, their ability to think clearly, or make decisions, and they always hope to simply be able to remember.

The first book in fact is called “Remember”, by Lisa Genova. Here’s a short blurb from Goodreads: “A book about how we remember, why we forget, and what we can do to protect our memories, from the Harvard-trained neuroscientist and bestselling author of Still Alice. This book was made into a movie that was very impactful. Just because your memory sometimes fails doesn’t mean it’s broken or succumbing to disease. Forgetting is actually part of being human”. That’s reassuring, and true.

Genova’s new book is not specifically about dementia, and she provides a view into what a healthy brain looks like. People who notice signs regarding their memory interpret the changes to mean they have the beginnings of dementia. This book will clear up many misunderstandings around our aging brains and how to increase remembering.

This title of the second book, “Already Toast”, by Kate Washington, says it all. You might relate if you’ve ever been a caregiver over a long period of time. The question is, why do caregivers have to be “toast”? The writer, and her husband who’s ill, are only in their 40s. Regardless of their ages, they’re entering a world where caring for others is not easily addressed, not paid for by insurance, and often takes too great of a toll on those performing these tasks. Being a caregiver is not an easy role to consider, but one that’s likely to impact almost every one of our lives.

From Goodreads: “A revealing look at the role unpaid family caregivers play in a society that fails to provide them with structural support. It’s a clear call for paying and supporting family caregivers. She gives voice to those tasked with the overlooked, vital work of caring for the seriously ill.”

Besides these two books, here are some other resources for additional support on these topics.

For information related to any type of dementia, go to the Alzheimer’s Association online: https://www.alz.org/. Their 24-hour helpline is available to answer any questions. They can also direct you to support groups and educational classes.

AARP has an excellent section on caregiving, and this has been one of their main focuses for many years: https://www.aarp.org/caregiving/?intcmp=GLBNAV-PL-CAR

Your brain health and your ability to provide (and receive) caregiving are topics worthy of consideration and education. These resources just might provide the information you need.

Issues of aging are a concern for most of us. We want to stay independent, healthy, and active in mind and body, remain in our homes and retain our friendships. We may not be able to control what life hands us, but we can make decisions and choices ahead of time that reflect our wishes.

Planning for future needs is important no matter our age, financial position, health or familial relations. Frequently, it is not until a crisis or emergency arises when individuals and/or family members become aware of just what planning issues have been overlooked.

Pre-planning often means that having to make decisions during a crisis can be averted. Pre-planning also allows families to save a great deal of energy and expense by pre-selecting options and making choices. To assist in setting up a pre-need plan, a consultation with a professional Aging Life Care Manager (CM) is recommended (https://www.aginglifecare.org). CMs are trained to assess, educate, manage and coordinate potential situations before they arise.

Pre-planning empowers individuals and provides opportunities to help others gain a better understanding of the issues and needs of aging.

Read more

I’m so grateful for my freedom to choose how I engage with my aging. And instead of feeling “fiercely independent”, I’m aware of my interdependence with the rest of life. This is what a good life looks like to me. And hope your choices work well for you, too.

Here’s hoping that’s not your situation, but if it is, preparing in advance for this possible eventuality is a good Plan B. Now, go and enjoy a wonderful holiday weekend. Stay safe and celebrate your life!

Years ago, one of our local elder law attorneys made an interesting comment. I had asked for his advice regarding an older person who refused the help and support their family was trying desperately to provide. It was clear that this person could no longer manage on their own, and still, they made the choice to refuse this help. The attorney said, “Ellen, people are allowed to make a bad decision unless they are deemed incompetent”. This stunned me and has stayed with me all these years later.

Here are some local examples of this exact situation. One woman who had high needs was moved into a lovely assisted living community. To her family’s disappointment, she took a cab back to her home the next day and refused to leave again.

Another family was very concerned about their parent living alone in Texas, and took the long drive there and back to move him to Oregon. But once here, he proclaimed he’s going back to Texas, and that ended the plans for getting him the care and community he needed.

We have this idea that we alone know what’s best for ourselves, and maybe that’s true. But when it gets to the point when everyone, except yourself, thinks you need help, why turn it away? It might be possible that parents resist help from their adult children because they fear aging, debility and their own mortality. They might feel they’re no longer in control, which may also be true. If adult children find themselves in this role, they might need a different way to approach this situation. Most of all, they need to recognize that trying to control a parent is never going to work.

As the aging adult, there are two factors that impact the wish to “have it your way”. One is the housing itself, and the second is the care you might need to receive in your home.

Starting with care in the home, there are a large number of caregiving agencies to choose from. Some of these agencies also have certified Aging Life Care Managers on their staff. The care managers work with families to provide realistic planning which will help guide this transition. Family members often need their own support team as they navigate the more fragile years of a parent’s life. A professional care manager can provide this guidance as well.

When making sure your home itself is a safe and accessible option at this point, there are many resources available to assist. Here are several.

· The Lifetime Home (http://lifetimehome.org) from the USC School of Gerontology provides “an interactive resource for older adults, families, and professionals to learn how to make the home a safer and more supportive place for a lifetime”.

· AARP has a great deal of info. One is: How to Make a Home Safe for Your Aging Parent (https://www.aarp.org/caregiving/home-care/info-2019/safety-tips.html. They say, “Small changes — and big ones, too — can be put in place to accommodate your loved one”.

· Even though this is a local resource, it’s worth checking out. The Rogue Valley Council of Government’s Lifelong Housing Certification Project https://rvcog.org/home/sds-2/lifelong-housing-program/ is a voluntary certification process for evaluating the accessibility and/or adaptability of homes. It’s designed to help meet the growing market demand for accessible housing, and to enable older adults and people with disabilities to age in place safely and independently. They also offer the Oregon Lifelong Housing Checklist on their site which you can use to assess your own home.

You’ll want to keep in mind that these checklists for home accessibility are generic. To really get specific information that pertains to your home, you will want to find a business that offers in-home audits and fall safety checks that go into much greater detail. They also offer referrals to the professionals who can do these modifications, if needed. Locally, we have a company, The Care Steward, (https://thecaresteward.com) who provides this exact service. I am also one of their “experts”, and I have collaborated with them based on how important this service actually is.

Finally, it might be useful to remember the attorney’s words from the beginning of this column. Allowing people to make a “bad decision” is hard to watch, but in some cases, it’s the only option, for now. Things will continue to change and then hopefully, you’ll be prepared with an updated plan of care when the need arises.

Here’s a photo of a group of my very dear professional friends from the Ashland area. We all went to this conference in 2019 and had a wonderful time learning together.

Top row from left: Marya Kain; me; Gretchen Lizotte

Bottom row from left: Lucy Jackson; Brooke Fredericks

Below is a summary of the highlights from one of these conferences.

I attended the yearly conference of the Oregon Geriatrics Society (https://oregongeriatricssociety.org/) via Zoom (This was during Covid). A few years ago, along with a small group of local professionals in the field of aging, we traveled to Sunriver, Oregon, to attend in-person. (See above photo for actual proof!) It’s designed by and for medical providers, and we all learned a great deal. Here are some highlights from the presenters. All this information is backed by serious research, peer review and significant data.

A study was done in single-family households which showed that missed credit payments up to six years prior, can be a very early indicator of Alzheimer’s disease or related dementias. Also, that there is a significant drop in a person’s credit score up to two years prior to diagnosis. Interestingly, there was no relationship between missed payments and other health conditions.

In my experience, couples often pick up the slack for one another, so it’s likely that’s why this was confined to single individuals. The takeaway is financial symptoms of dementia seem likely to be the first to develop prior to a formal diagnosis. This could help families to recognize cognitive changes at much earlier stages.

On the same topic of dementia, it was found that for people with this diagnosis who also experienced depression, that non-drug interventions are actually more effective than drug therapy. The types of treatments shown to be most effective were environmental stimulation, massage and touch therapy, social interaction, exercise, reminiscence therapy and other interventions. These might be more challenging for families to provide at home, and many memory care facilities do offer these for their residents. This was the strongest evidence that non-drug interventions may be better at treating depression in dementia.

Here are some additional findings presented at this conference from a variety of scientific studies.

· If you’re receiving care in medical settings such as skilled nursing facilities (SNF) or hospitals, how long can you expect it to take until recovering your former level of functioning? After an acute illness, it takes on average, five to six months to return to normal function after being in a SNF. If this was a catastrophic illness or injury, 2 out of 3 will recover their former functioning, but only 1 out of 3 will recover to that level if the illness is progressive. The important takeaway here is to be patient with your recovery. In many cases, you will return to full functioning over time.

· Fall risk assessments and fall-avoidance are often concerns for older adults. The expression that a broken bone is a game-changer has been proven to be true now. There are two types of fractures: traumatic, such a fall down the stairs, and non-traumatic, a fall from ground level, as from a standing position. No matter which type of fall caused the initial broken bone, all subjects were at a greater risk for subsequent fractures, regardless of the type of initial fracture. The presenter said that any fracture is an indication that more fractures are likely to occur and checking for osteoporosis is indicated.

· Sleep is often hard to come by as people age. In one study, it was found that by mid-life, cognitive function declined faster in those who slept less than 4 hours or more than 10 hours a night.

· Heavy alcohol use has been shown to increase the risk of dementia.

· Treating hypertension reduces the risk of dementia in later life.

· Caregiving for someone who has dementia requires an increase in hours of care needed in the last 10 years of their life. If you’ve even been in this role, you know how each day can exact its toll. Please contact the Alzheimer’s Association (https://www.alz.org; 24/7 Helpline: 800.272.3900) for excellent support.

· This trajectory of the need for increased caregiver hours is also noted in the last 1-2 years of life for someone who does not have dementia. In both cases, caring for the care provider is essential.

The four principles:

1. Knowledge is the key to success.
2. Professional help is crucial in saving time, money and stress.
3. When money is available for care, caregiver stress is reduced and
care options are expanded
4. Success is assured through a written agreement with all parties
involved.

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I think there’s a combination of factors going on here. The intention is to take these factors into account which would greatly improve the medical care for this group of people. But the amount of time each medical provider can offer is still really small, compared to the complexities of caring for older adults.

Especially when it comes to dementia, many medical providers are not really up on how best to communicate with their patients. So, in addition to the short amount of time to visit with each one, they are now expected to get trained on best communication practices with them as well.

Altogether, it’s a good plan and has positive intentions, still, there’s a long way to go. My advice is that someone needs to be the advocate here in these medical situations. Having a conversation with your person (or yourself) prior to appointments so that these four areas are discussed and understood is helpful. We all have our stories of how things went sideways in hospitals and medical offices for a wide set of reasons. As older adults, our medical care needs are different. We can continue to educate ourselves and bring along a companion. That’s what has always worked best, in my opinion.

Meanwhile, I still appreciate that we can access medical care, most of the time, in most locations. This is something for which I’m grateful, imperfect as it may be.

Over the years, I’ve accompanied many clients to medical appointments, into the emergency room, and visited them in the hospital. One thing that was noticeable was that these systems were not really designed to address the unique needs of many older adults, and especially those with dementia. Here’s the good news, though. Many hospitals are now incorporating an approach called an “Age-Friendly Healthcare System” in order to address this population.

In Oregon, the over-65 population is expected to double in the next 30 years. About 23% of Jackson County residents are already over 65, for a total of almost 51,00 people. This will certainly impact the medical services across all areas of care.

To be better prepared, the health care systems are following guidelines called “ The Age-Friendly 4 M Framework”. This is a reliable set of evidence-based interventions for medical providers treating the older population. This is not a specific program, but a shift in the care that this person would receive throughout the health system. The areas being addressed are mobility, mentation, medication and what matters.

Each area has its specific goals and focuses.

For medication, it’s to minimize high risk medications in older adults. As the patient, it’s a good idea to make sure each visit to your medical providers includes a current list and a review of your meds. It’s possible that one doctor is not aware of what another one has prescribed for you. Some medications should not be used with those who have dementia, for example. Multiple medications taken simultaneously can have negative side-effects. The goal here is to also de-prescribe unnecessary medications, especially those considered specifically impactful to older adults.

For mentation, or thinking activity, the goal is to prevent, identify, treat and manage dementia, depression and delirium across all care settings. It’s also very important that the family and care providers, as well as their doctors, know how to best communicate with someone who has this diagnosis. Training for families is easily accessed through the Alzheimer Association’s website: https://www.alz.org.

Mobility goals are designed to insure older adults can maintain function and move about with ease and safety every day. Clearly, this includes fall-risk management. To address this, it’s suggested to patients to use online exercise programs, if going to a gym is not possible. Also, look into the STEADI program (https://www.cdc.gov/steadi/index.html). This is on the CDC website and has two wonderful 2-page brochures to read: Stay Independent; and Family and Caregivers: Protect Your Loved One from Falling. As the saying goes, a fall is a game-changer.

Finally, according to these guidelines, what matters to the person is the fourth factor and of prime importance as well. This means that each medical provider is encouraged to know and align the medical care with each person’s specific goals and preferences. The areas to consider here are the patient’s thoughts on longevity, cognitive abilities, and their sense of independence. Knowing and understanding these will have a direct influence on which types of treatments the person is willing to pursue. Here’s where it’s important for you as the patient to express your own choices, so that treatments options can be adjusted to meet your personal goals. What matters to you, matters!

The focus is now on training medical providers to be more in touch with and have a better understanding of what their patients care needs really are, based on these four areas. It’s also up to each person to be sure that their medical provider is taking the time to fully grasp what their goals truly are. This might mean being a bit more outspoken about your choices as you’re aging. What fit for your care needs up till now might well have changed. It’s also a good idea to take someone along with you to all medical appointments who can take notes and act as your advocate. This 4-M focus is a positive change to our health care environments, and we can expect better outcomes for all patients through this approach.

—Anne Lamott

“It’s a radical act of sanity to stop the flow of doing and drop into being for a moment.”

—Jon Kabat-Zinn

I’m posting these two quotes based on how many of us seem to be in go-mode, almost all the time. Younger or older, we’re going and rarely pausing. I could say a lot more about this, but I’ll let these quotes speak for themselves. Maybe these are helpful reminders for you, too.

In older adults, the belief that pain and aging go hand-in-hand means that sometimes it’s underreported and left untreated. We know that aging often mean changes in the body with its attendant new aches and pains. We don’t like to complain to our friends and family about this, although for some, it becomes THE topic of conversation. Although there are some things that we will have to accommodate to as our bodies change, persistent, chronic pain might not have to be a permanent condition.

One book that seems to have found a lot of interest is “The Way Out” by Alan Gordon, LCSW. There’s also a documentary about his approach to pain management called “Pain Brain”. I’m not advocating for these in particular. But for those in pain, looking at a range of options might have some real value. As long as it can’t cause you harm, it might be worth a try.

If you’re having any pain, join the crowd. From the journal, Pain Management and the Elderly, June 27, 2019: “A recent analysis of data from a National Institutes of Health (NIH)-funded study found that more than half (53%) of the older adults surveyed reported having bothersome pain in the last month; three-quarters of them reported having pain in more than 1 location”. This is even higher (up to 83%) among the elderly in nursing homes. That’s why pain was officially declared “The Fifth Vital Sign” some years ago. The evaluation of pain has been as important and basic as the assessment of temperature, blood pressure, respiratory rate, and heart rate.

And then there’s pain that doesn’t go away. From the article, Managing Chronic Pain in the Elderly, September 2018: “Chronic pain is defined as the pain that lasts for three to six months or more than expected. If you are an older person experiencing pain, keep in mind that you run a higher-than-average risk of side effects from all drugs, including analgesics like non-steroidal anti-inflammatory drugs, such as Ibuprofen”.

Pain and pain management are a growing concern among Americans age 65 and older. Pain may be under-reported due to the misconception that it is a normal process of aging. It’s not, and it needs more attention than it might be receiving.

Many years ago, I worked at a clinic in Ashland, the Pacific Spine and Pain Center. The late Dr. James Dunn, a neurosurgeon, created a multidisciplinary team. It consisted of a pain management program that included osteopathic and chiropractic manipulation, physical therapy and exercise, massage therapy, medical hypnosis, biofeedback, mindfulness practices, pain injections, and several medical providers and interventions, including back surgery. It was a one-of-a-kind medical practice that served the community for a long time. It no longer exists here, so what are your options for care now?

First, it’s well known that there are positive benefits of incorporating an exercise program, even light exercise, into a pain management program for older adults. The benefits include improving physical function, reducing isolation and depression, and enhancing balance and mental acuity.

Next, according to the National Institute on Aging, 41% of older adults (ages 60 to 69) are frequent users of complementary and alternative medicine, including acupuncture, vitamins and herbal supplements, counseling interventions, and most of the modalities mentioned above offered at the former Spine and Pain Center.

In your location, you will want to find medical practices that specifically address pain conditions. Pain specialists are often able to prescribe the correct medications which allow people to resume some or most of their daily activities again. If you are interested in incorporating any of the complimentary approaches, you will need to locate separate providers for each one of those as well.

In unremitting pain, people sometimes express the wish to no longer live. When asked about this, though, it turns out that what they don’t want to do is continue to live with that constant degree of pain. For these people, it might mean putting together the best combination of medical providers, medications, complementary and alternative approaches, and a great support team. People usually find they can return to a level of functioning that works well enough to enjoy their life again. Not all pain can be totally erased, but finding what works best, and learning how to reside in a body that is not always comfortable, might be a practical solution.

As I wrote in one of my CM Files columns on 5.6.26, driving is a huge issue for many families. What you will find here is an agreement that an older driver might be willing to sign. It often helps that it’s not directly coming from the family members, but from a trusted organization.

I hope this helps for those who need to consider giving up the keys at some point. Truthfully, that would be all of us.

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