Warning Signs and Care Questions

Excerpts from Caregiver’s Satisfaction Guide

For additional information please visit: www.NiagaraCaregivers.org

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Warning Signs and Care Questions

I’m worried about being responsible for Mom. What should I watch for? What should I do if there’s a problem? - R.S from a conversation about her mother.

Of course, caregivers worry. There are dozens of things that can ‘go wrong’ in an elderly person and, frequently, many go wrong at the same time.

What should caregivers do if there is a problem? The answer is almost always the same: Discuss it with the leaders of your care team.

This section can help guide that discussion. It summarizes the warning signs for twenty of the most common problems faced by the elderly. It also outlines many of the physical, behavioral and/or treatment-related factors that may have caused, or contributed to, the problem.

Required Assessments in Nursing Homes

The “Warning Signs and Care Questions” in this section are based on the resident assessment protocols (RAPS) developed by the federal Centers for Medicare & Medicaid Services.[23] Long-term care facilities are required to use these protocols. Each RAP contains “triggers” (for example: blurry vision, involvement in few or no activities) which require further assessments. In this booklet, these triggers are called “warning signs,” and the required assessments are called “care questions.”

The Centers for Medicare and Medicaid Services have developed RAPS for eighteen problems of the elderly, such as dementia, activities of daily living and urinary incontinence. This booklet provides information regarding two additional problems: pain and stress management.

Assessments for Home Health Services

The warning signs and care questions in this section can also help home-health caregivers to identify problems and assure that complete assessments are being conducted.

Home health organizations are required to use the Outcome and Assessment Information Set (OASIS)[24] to measure changes in a patient’s health, but are not required to use RAPS. However, OASIS assesses almost all the same problems addressed in the RAPS.

Thus, the warning signs and care questions in this section, is useful both in home health as well as long-term care settings.

What to watch for and what to ask

It’s almost impossible for a caregiver to know what to do every time something goes wrong (other than calling the doctor or care team leader - which is always a good idea if you are in doubt). But caregivers should know:

· What signs to watch for

· What questions to discuss when those signs appear so that:

o The care team has all the information they need about physical, behavioral, and other factors that may be contributing to the elder’s problem

o You can be assured that all the important factors are being considered in the care plan

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As a caregiver, you may know more about the elder than anyone else on the care team. Thus, it is very appropriate for you to raise the “care questions” in this section – especially if you believe that one or more of these factors may be contributing to the problem.

Before you use the information in this section, please remember:

1. Always immediately contact a physician, nurse or other leader of your care team if you are concerned a symptom may be serious or life-threatening

2. This section is not designed for caregivers to “diagnose” a problem. A diagnosis can only be made by a physician, or a trained professional who is supervised by a physician. Never discontinue a treatment or change how medications are given without specific directions from the care team leader.

Use this section as a reference, not a substitute for medical advice. The warning signs and care questions in this section only contain the signs and the contributing factors that can be easily observed by health aides, family members or other caregivers. It does not include signs or questions that require access to, and understanding of, laboratory tests and other diagnostic clinical information.

Thus, although “Warning Signs and Care Steps” can help caregivers to explore care options with the team leaders, it should never be used as the sole basis for making a treatment decision.

3. Use the “Signs and Steps” Learning Log (see page 37) to write down the warning signs you’ve seen and the care questions you have . It will help you communicate them accurately to the care team, and also help to trace any changes over time.

As mentioned in “Check the Signs” (p. 10-12 ) when an elderly person displays symptoms in one part of his or her body, frequently the “cause” is in another part of the body. Thus, it is important to explore all the possibilities you will find in the “care questions.”

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Behavioral Symptoms

Behavioral symptoms are distressing to caregivers, family members and other elders. Use of psychotropic (i.e., mood altering) drugs and/or restraints is common in dealing with behavioral symptoms. However, there is a wide range of treatment and management options that should be tried first.

Many elders with behavioral problems also have problems with mood, confusion or relationships.

Warning Signs/

Triggers for Further Actions

Whenever any of the following occur,

ask each of the care questions.

Care Questions to Consider

Record any possible causal factors

in the “Signs, Steps and Learning Log”

and discuss with the health care team.

· Wandering

· Verbally abusive

· Physically abusive

· Socially inappropriate (e.g., undressing in public; shouting or laughing for no apparent reason)

Physical

· Could the problem be caused by an acute illness or infection – or the worsening of a chronic illness?

· Could hearing, vision or communication problems be contributing to the behavior problem?

Behavioral/Social/Environmental:

· Could any of the following be contributing to the problem:

o Treatable mood problem or depression?

o Relationship problems?

o Family problems?

o Noise, crowding or other environmental factor?

Care Issues

· Could a problem relationship with a staff member be contributing to the behavior problem?

· Should behavioral treatments and/or medications be started, stopped or modified?

· Was the onset of change associated with a new medication?

· Are staff members consistent in their approach?

· Could other team members (e.g., social worker, activities director, PT) be helpful?

Remember: Always discuss warning signs, triggers and possible care steps with team leader.

Use the satisfaction skills (awareness, affirmations, assertiveness, acceptance) to discuss problems.

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Activities

The goal of active aging is “continuing involvement in social, economic, spiritual, cultural and civic affairs, not just the ability to be physically active.”[25] Involvement in activities is important for elders whether they are in the community or in a long term care facility.

Even when thinking is impaired, it is still possible to use old skills and learn new ones. Too often, illness causes a progressive decline, leading to further decreases in activity levels. This pattern can be broken by awareness of warning signs and careful consideration of the care questions.

Warning Signs/

Triggers for Further Actions

Whenever any of the following occur,

ask each of the care questions.

Care Questions to Consider

Record any possible causal factors

In the “Signs, Steps and Learning Log”

and discuss with the health care team

· Involvement in few or no activities

· Complaints about daily routine

· Requests change in daily routine

Physical Factors

· Do cognitive or functional problems reduce involvement in activities?

· Does illness inhibit participation?

· Do communication, mood or behavior problems keep the elder from participating in activities?

Behavioral/Social/Environmental Factors

· Have individual learning strengths (e.g., visual, auditory, musical, interpersonal) been considered?

· Have wishes and prior interests been considered?

· Have lower energy activities (e.g., reading, photography, discussions) been considered?

· Has the elder been encouraged to use the satisfaction steps to improve relationship and manage stress?

· Are appropriate resources available?

o Intellectual (e.g., reading materials)

o Social (e.g., telephone)

o Emotional (e.g. counseling, support group)

o Spiritual (e.g., music, books, chapel)

o Physical (e.g., cane, wheelchair)

· Has the elder been encouraged to use the satisfaction steps to improve relationships?

Care Factors

· Does the treatment regimen allow little time or energy for participation in activities?

· Do effects of medications limit involvement?

· Has the elder been motivated to participate in activities?

Remember: Always discuss warning signs, triggers and possible care steps with team leader.

Use the satisfaction skills (awareness, affirmations, assertiveness, acceptance) to discuss problems.

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Dehydration

Dehydration is a condition in which water or fluid loss (output) far exceeds fluid intake. Water is necessary to distribute nutrients to cells throughout the brain and body, eliminate wastes, and regulate body temperature, as well as countless other complex processes. If dehydrated, the body is less able to maintain blood pressure, deliver oxygen and nutrients to the cells, and rid itself of wastes. Many distressing symptoms can originate from these conditions.

Elders can become dehydrated without feeling thirsty. Thus, the first sign of dehydration may be one of the problems noted below. Work with your health care team to determine if any of the following steps may be helpful in clarifying or treating the problem.

When dehydration occurs, treatment objectives focus on restoring fluids, preferably by drinking.

Warning Signs/

Triggers for Further Actions

Whenever any of the following occur,

ask each of the care questions.

Care Questions to Consider

Record any possible causal factors

in the “Signs, Steps and Learning Log”

and discuss with the health care team

· Diagnosis of dehydration

· Dizzy when sitting or standing

· Confusion, agitation or problems with decision making

· Communication difficulties

· Difficulty moving or using hands

· Constipation

· Weight loss of 3+ pounds

· Decreased dryness of skin and/or mucous membranes

· Fever

Physical factors

· Are there any current infections?

· Is there any internal bleeding?

· Is there excessive urine output?

Behavioral or Environmental Factors:

· Does the elder not seem to notice when he or she is – or should be – thirsty?

· Is a sad mood, grief, or depression causing the elder to refuse foods or liquids?

· Are liquids not being consumed for other reasons

Care Steps to Review:

· Are laxatives, enemas, or diuretics being used?

· Are fluids restricted because of diagnostic procedure or other health reasons?

Remember: Always discuss warning signs, triggers and possible care steps with team leader.

Use the satisfaction skills (awareness, affirmations, assertiveness, acceptance) to discuss problems