Noticed changes in your loved ones over the holidays?

[00:00:00] Dr. Mia: Welcome back to ask Dr. Mia podcast. This is season two of the podcast, and I'm so excited to be back talking to you all this particular episode, I'm going to focus on the holidays and a little bit of reflection from the holidays. 

[00:00:22] So 2022 was a busy one for me and my family. And you may have heard in some of the previous episodes in season one some health issues that my mom has been going through. And I find that this could be an opportunity for me to share with you all. You know, what I think are some things to adult children could potentially do in communication with their aging parent around physical or cognitive changes. 

[00:00:56] So, first of all, I think that the holidays could be great sometimes. But For my own personal and other people's experiences, the holidays is oftentimes a mixed bag of complex emotions. There's joy, there's wonder, but there can also be grief over the people who are no longer here, or grief over the type of relationship you wish you could have with someone. There's a frustration with traveling and logistics. So. I think, I just want to acknowledge that sometimes we don't act like our best selves during the holidays. And it can be particularly tricky when we get back to our families of origin and some of the old patterns of communicating rush back. 

[00:01:53] I joke with some of my friends that sometimes when I go back to my parents' house, I revert right back into a 16 year old moody teenage girl. And I don't like it either. It's not to say that I have the perfect relationship with my parents; by no means that is the case. But I think from the perspective of a geriatrician, I can share some tips and things to consider, just from patient and how their family members have come to see me for a medical evaluation. 

[00:02:31] So let's start with a hypothetical case based on real people that I have seen. Mary went to her parents' house for Christmas this past year. And it's something that they've always done. They took a break during the pandemic. But they were all very excited to gather again in 2022. But this time, you know, Mary had noticed that things were a little bit different. Usually her parents' house was decorated elegantly, gone all out in terms of the holiday decorations, but this year, It just didn't have the same level of attention to detail that was typical of her mom, like in the past. The holiday food was still pretty good, but there were just some dishes that didn't quite taste right. But most of all, Mary noticed that her mom was a little bit more irritable and easily frustrated with her grandkids, who are Mary's children. And this was pretty unlike her mother's typical behavior. And she's always been a very doting grandmother. 

[00:03:50] Meanwhile, Mary also noticed that her dad was having some physical issues. There were several incidents where he almost fell. Dad definitely minimized it and said I'm totally fine the floor was slippery. I wasn't wearing the right shoes. But Mary was concerned because her dad almost tripped going down the stairs to the washer and dryer while she was there. So, this is just a brief examples of what people commonly notice over the holidays. And then me as to the geriatrician on the other side of the holidays commonly get a flurry of requests for people to be seen because of these very perceptive changes that were noticed over time. It's very common to be worried about changes related to aging, not sure what to do, not sure what it means for your parents or for Mary and her own family. 

[00:04:54] So the first thing that I would ask people to do, particularly if you're an adult child who has noticed these changes in your aging parents, the first thing is to check in with your own emotions. I find journaling to be great in terms of exploring my own thoughts, especially when they are just kind of swirling around in my brain. And I can't seem to articulate it well without getting down on paper or typing on the computer. Or even just dictating into your phone. Talking like, you know, you're talking with a friend or you could actually talk to a good friend and kind of draw out kind of how you feel about the changes. 

[00:05:38] It might be good to reflect on how your relationship has been with your parents thus far, specifically how your relationship is, or is not the way you want it to be. And if you're ready to have some potentially uncomfortable conversations, to get to the other side could get to a point of growth in the relationship, and potentially closer in some ways. And of course, The worry step Mary has, are really born out of love and concern, and a true desire to help. 

[00:06:16] So once you finish journaling and you get a good sense of where your own emotions are, I think I also want to remind people that even though I deal a lot with older adults, I'm always surprised by how many people don't notice aging changes in their daily life. People might live really far away from their parents and only see them a couple of times a year. And their job may have nothing to do with older adults. I think, I just want to say that aging is not a disease to be fought. But not to say that there aren't things that people could be proactive about when they are subtle signs of changes.

[00:07:01] So two things are true. Everyone is aging and their bodies and their minds are changing. That is normal and a natural path of our lives. And there are things that we could all do to be healthier in our body and in our minds. So with that understanding and after you have finished getting a sense of how you feel about everything, and you feel like it might be good to have a conversation with your parents. Then I think it will be good to ask them what they think they want for their health. There are many ways to kind of bring on this conversation without it necessarily being a big, heavy talk. Quote, unquote. You could ask them about their friends. It's not uncommon for older adults to see their friends go through a lot of health issues and some of those experiences that may get your parents to think about things that they do or don't like or don't want to have after sharing what their friends of their age might be going through. 

[00:08:10] It might be helpful to not point out exactly what you have noticed in terms of the deficits just yet. People oftentimes get defensive when you start out a conversation with, oh, well mom's decorations weren't that great this year. That that's probably not a good way to start a helpful and a fruitful conversation. But I do think it's good to have a conversation in general about where they think their health is. How do they think their health? Actually there are research showing that our own self rating of our health, whether it's excellent. Very good. Good, fair. Poor is actually pretty reflective of their actual health, unless someone has significant memory problems. I would say most people without memory problems or judgment issues are fairly accurate and their own assessment of health. So in that conversation with your parents, They might offer things that they have also noticed in terms of their health. And you don't necessarily have to bring it up and point them out to them. We'll get to kind of what to do if your parents are completely oblivious or in denial about their health issues a little bit later during this episode, So presuming the conversation with your parents are at least not confrontational. I wouldn't say all conversations with parents are fruitful, but if they are, at least insightful in some way about changes that they've noticed or changes that they've noticed in their friends. And they can reflect along with you in terms of what are some things that are important to them? Some things that are commonly very important to all older adults are maintaining a certain level of independence or function. Sometimes people really don't want to lose their independence. And that could be a really great motivation to get them to seek additional medical help or evaluation. And to say that this may not be something that mom wants to do, but because mom's goal is to be as functional and as independent as possible than this, you know, exercise program maybe something that's needed in order to maintain that level of independence. 

[00:10:37] So after that conversation and after checking in with your own emotions, I do recommend documenting in a notebook or somewhere that you can later find about specific incidents that you have noticed. That's just to say that sometimes when families provide history, they may not remember Exactly what happened months later when the appointment is actually there. Or that their parents may tell a different story to the doctors. It will be also helpful if you can get to a point of talking about, A surrogate decision maker. Some families I've already done legal documents like living will and power of attorney, but many have not, or have never thought about it. 

[00:11:20] I'm not going to get into the details of what is power of attorney and what is living well during this conversation. But just to say that it will be helpful to at least have one single question asking, you know, in the case of emergency, who would you want to be your medical decision maker? If you were too sick to make medical decisions for yourself? 

[00:11:44] Legally it would be their spouse, but if their spouse is also having health issues of their own and may not be either ready or want to make medical decisions, then it really will be helpful to have something at least everyone in the family is aware of and agreed upon, particularly when there are large families with multiple siblings. This is definitely something that siblings should hopefully talk to be on the same page. I think we don't necessarily do a good job of asking our own parents until the moment of a crisis, you know, gosh, if you go into surgery and something bad happens, who would you want to make your medical decisions? And if it's not the default spouse person, Then that's really an opportunity to document who the healthcare power of attorney might be. 

[00:12:42] And different states, depending on where you're listening, different states have different rules about medical power of attorney versus are there types of documentation. So going back to Mary's example, you know, Mary noticed some physical changes in her father. And possibly some emotional and cognitive changes in her mother. 

[00:13:02] She really doesn't know what to make of it. But she was worried and she Felt like her relationship with her parents was something that she wanted to work on this year. She wanted to nurture those relationships especially since she has seen those changes and her parents and reflecting on the fact that time is short and our life can change in a moment's notice. 

[00:13:26] And it's important for her to be proactive creating the type of relationship that she wants with her parents. So she had a conversation with both of her parents, both separately and together, and they are fairly on the same page. 

[00:13:42] Her parents really want to live in their own home. They don't necessarily want to move into a retirement community. But they wouldn't be absolutely opposed to it if they really had to. Their independence is very important. And based on some of their friends' experiences, they didn't want anything that was necessarily heroic in terms of efforts to try to prolong their life. And they, they designated Mary to be their healthcare power of attorney in the case that the other person is not able to make a decision either. And have got that in writing as well. 

[00:14:26] So now we can transition into talking about Advocacy for your parents. As it relates to the healthcare system. I have to say, first of all, that our healthcare system has a lot of problems and access and getting your voices heard as oftentimes not adequate. This is particularly challenging for minoritized populations, people who have lower socioeconomic status, where health is just one among many things that they're dealing with in their daily life, that they have to work toward financial security being another major one. 

[00:15:05] If there is a established primary care provider, this would be the first person that I would advise for Mary to contact either with her parents or have her parents contact their own doctor. And, and for children who live far away, this may be an opportunity to use tele-health or to ask specifically for a telehealth appointment. There are a lot more clinics that use tele-health visits now, especially now we're three years into the pandemic. The laws surrounding tele-health billing and payment has changed a little bit in the sense that earlier in the pandemic, both telephone and video based remote visits were paid the same amount as an in-person visit. But now that we are a little bit farther out from the pandemic, a lot of insurance companies would only pay the same for in-person visits if it's a virtual visit, meaning there's some sort of visual component, not just a telephone. So this could be an opportunity if your parents are not necessarily comfortable with smartphones to say, you know, perhaps I could bring my smartphone to have a video visit that way. You know, everyone can talk to the doctor together. If that's not possible then it may be something that you have to specifically communicate to the doctor to say, you know, can my parents bring me on the phone when they're in the office with you? Ideally if you are able to go to medical appointments with your parents, and that will be great. Because in-person visitsis always the gold standard, but oftentimes going to a doctor's visit with your parents is not something that you necessarily can do or something that they really want you to do. 

[00:17:02] And I think it, it can also be helpful to provide a different perspective to your parents, doctors. Who may have only heard. The story. Of what's going on from your parents. Especially if you're noticing that. There. Perspective of what happened, maybe different from your perspective. This will be an opportunity to really to have your perspective shared with their doctors. 

[00:17:29] The the other thing I wanted to say is that patient portals are very common now with the electronic medical record. It could be both a blessing and a curse. But from the blessing perspective it could be really an opportunity to get more involved in communicating with your parents, doctors, if your parents give you that permission. 

[00:17:54] And the portal can also have ways of sending messages directly to the doctor or other advanced practice providers like nurse practitioners or physician assistants. There are laws in place about open notes. So oftentimes within the patient portal, you can actually see the documentation of previous notes, which could be tremendously informative. If, you know, Your parents said one thing, but the doctor's notes said something completely different. And that that's not to blame anyone in particular, but just to say that there may be miscommunications or there may be different interpretations of exactly what was said. 

[00:18:41] So the portal can be an effective way. I would say, just knowing many primary care providers are incredibly busy and stressed. I would not recommend sending a long list of things that you have noticed over the holidays through a portal message unless you already have some sort of appointment scheduled . Just because from a physician's perspective, it's really challenging to have those types of conversations and evaluations over the portal. 

[00:19:11] The default really involves some sort of appointment, whether it's virtual or in person and that way the provider could also be compensated for their time. You may have heard of certain clinics in the country starting to charge patients for their portal messages. I would say that's still probably the minority, but it just to say that, that the number of messages coming to primary care providers, offices through their online portal is tremendous. And you don't necessarily want something really important to kind of get lost in the portal. So definitely schedule an appointment. And with an appointment in mind, you can possibly use the portal to provide some rather confidential information that you don't necessarily want to share with your parents 

[00:20:00] . And this is where we can talk about mary's mom's experience and impossibly having some cognitive changes. If Mary's mom had been completely not aware of the situation and very offended by what Mary had said, it's possible that her mom is just really not ready to bring it up to the doctor herself. That may be an opportunity where Mary may try to have a conversation with her mom's doctor through the portal to let them know that there are some concerns and potentially attend an appointment together. But in order to really accurately translate information to the healthcare professional, sometimes you have to say the uncomfortable truth in some way, even if it's not in person. So all of that to say the portal could be a tool in your tool belt in terms of communicating information accurately to your parents' doctors. 

[00:21:05] So coming back to an older adult with cognitive impairment and that they are not aware, not interested in exploring further, this is where you may have to go back to your parents goals and their health. This might be a series of conversations to have over time. I think this is another opportunity to check in with your own feelings first. 

[00:21:34] If you are feeling frustrated and angry, continuing the conversation at that particular time, may not be very helpful for anyone involved. Sometimes adult children may have to go around their parents in order to communicate something with their doctors. It's not to say that we don't want to honor the autonomy and the privacy of our older adults, our parents. But sometimes when it comes to issues of safety there may be quite a number of incidents building up over time such as significant personality changes or significant changes in terms of the activities of their daily life. They're not able to handle their finances by falling into financial scams, or they're making really out of the norm purchases. That those are red flags in terms of cognitive changes. The other thing is driving. One thing that could be particularly helpful is if you ride in the car with your parents, and you don't trust that person to drive your child. Then that is probably a sign that a conversation with their doctor needs to happen. 

[00:22:50] Unfortunately, no one likes to talk about driving problems, but it is so common. And so important, both in terms of health, but also in terms of liability. So if you made it this far, Gotten the conversation done in terms of checking in with yourself. Gotten the conversation done in terms of talking with your parents. 

[00:23:13] You're on the same page. You got an appointment. You're at the appointment you shared what's going on. I would then categorize these common concerns in, in three buckets. If they're caught physical changes, like Mary's dad, cognitive changes in terms of Mary's mom. And sometimes there might be a combination of cognitive and emotional changes that it seemed to all intermingle and it could be quite difficult to tell from a patient's perspective: what is a mood issue versus a memory issue. And that's really where you need some sort of cognitive tests to be able to tell what is what. Because when we are stressed and anxious our thinking is not clear and that could be what's happening to Mary's mom. 

[00:24:02] So I hope this is helpful in terms of a framework, in terms of thinking about changes that you may have noticed in your parents. You're welcome to share this episode with your own parents as a conversation starter. And I will also include in my show notes some information about self administered memory tests. Thank you very much. See you next time.