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Recognizing The Signs Your Loved One Needs More Care

 The following are my notes from the AARP webinar Recognizing The Signs Your Loved One Needs More Care with Barry Jacobs a clinical psychologist and family therapist. One of the countries leading thinkers, writers, and educators about family caregiving: 

Learn how to observe and assess your loved ones physical, mental and environmental well-being.

Question #1 What to do when your aging loved one needs more care?

It's extremely important for us to recognize that a loved one may be beginning to decline. It's important to know the signs so we can better prepare for providing care for them. To provide any support they need in order to live a safe and as healthy a life as possible. We sometimes have a tendency to ignore or overlook because we don’t want to have to think about our loved one having issues of aging of which they may not be as capable as they may have been in the past.

Are there physical warning signs I should look for beyond Alzheimer’s related concerns?

Yes, most serious for older adults are falls. Falls are often caused by changes in gait as well as environmental hazards and changes in balance. If you noticed that your loved one is beginning to have a little trouble climbing the stairs. Maybe they trip in the living room occasionally or stumble. Those are signs that they are beginning to decline physically or/and that their physical capabilities are not a good match for their environment. We need to recognize that our loved ones may be beginning to develop a shuffling gait. Or maybe they can’t see as well and therefore don’t see things that are on the carpet and they trip over them. We may begin looking at environmental hazards that could cause trips. Want to get our throw rugs out. Make sure there are no exposed wires. Make sure there is no low lying furniture that is easy to trip on.

By being aware of their physical signs as well as their environmental hazards, we may be able to reduce the likelihood of their falling. Importance of that is when older adults fall they run the risk of breaking bones. Which can very seriously jeopardize their independence.

Question #2 How can you tell when something is wrong with their mental state?

It's a difficult question because as people get older they tend to begin to have some memory problems. May begin to scratch their head when they try to think of a word. Most of that is related to again and it doesn’t necessarily relate to something as alarming as dementia.

When people are starting to have significant declines in their memory, for instance, they don’t remember what they had for breakfast. Or they don’t remember an important conversation that they had with you the day before. Or that they found that they misplaced their car keys and later find them in the refrigerator. There may be some other serious mental slips that are that occurring on a regular basis. These are all signs that perhaps a loved one should have a visit with their primary physician. To begin an evaluation process to see if in fact there may be something going on.

We know that the most effective dementia medical treatments are in the early stages. They are less effective later on. We want to detect it as early as possible. Have them evaluated and treated as early as possible.

Question #3 What if I go to my loved ones home and it’s pretty messy if they are normally tidy people?

It depends. As people get older they may not have the same energy or cleanliness standards that they had before. What would be concerning if they don’t notice that their house is not as well kept as it was in the past Or if they seem to make a consistent habit of leaving the house in a rather disheveled state. If that is occurring than it might be a sign that their cognitive abilities are beginning to decline. Which would mean they lack the initiative to take some steps to clean. They may lack the organizational abilities to get a house clean and organized.

Checklist of concerns



  • Cluttered, dirty and/or disorganized house
  • Missing important appointments
  • Uncertainty and confusion when performing once-familiar tasks
  • Forgetfulness
  • Forgetting to take medications
  • Loss of initiative


  • Changes in mood or extreme mood swings
  • Depressed or low energy temperament
  • Loss of interest in hobbies and activities


  • Disheveled clothing
  • Poor personal hygiene
  • Unexplained bruising
  • Trouble getting up from a seated position
  • Poor diet or weight loss


  • House and yard need care/maintenance
  • Broken appliances
  • Spoiled/expired groceries that don’t get thrown away
  • Unexplained dents or scratches on car

Question #4 How do you overcome the fear of the unknown or fear that something is really wrong with my loved one?

A lot of use a kind of magical thinking. We believe that if we talk about bad things happen we will make them more likely to occur. By the same token, we believe that if we avoid talking about them then they will be less likely to occur. Unfortunately, that kind of magical thinking doesn’t work. If our loved one is, in fact, beginning to have some difficulties we have to face it squarely.

We have to begin to tally in our minds the signs. Maybe have a conversation with a physician to see whether the physician is concerned. Certainly having a conversation with your loved one, a very gentle conversation. Where you begin to discuss what might be going on and what could be done about it. Not to alarm them or make them feel like you are trying to take over but to just show your caring and concern. To make sure that your loved one's health and safety are good going forward.

Question #5 How do you start the conversation with those difficult conversations because you have been dreading them? And what happens if the conversation doesn’t go right the first time?

There is an AARP book called “The Other Conversation” which is all about starting these conversations.

First off we have to keep in mind that this is not going to be just one conversation. This is going to be series of conversations maybe over months or even years. Where we are talking with our parents or other older adults about how they are changing as they age. And what might be best to help them live as independently and as well as possible.

If we have specific concerns about them having declines in the physical or cognitive it would be important to sit down at a very quiet time. When you aren’t going to be interrupted. To broach the subject in a very caring, gentle and sensitive way. With a lot of assurance that you aren’t trying to take over. But, that you are trying to bring some attention to some changes that you are seeing that maybe require further investigation. Maybe some changes in the home or changes in the routine to ensure safety.

A lot of times parents will react badly about to that initial conversation or they will poo poo it. Or just outright tell you that it is none of your business. I would persist maybe not at that moment. Come back to it in a week or two or a month or two. Raise the question again and begin to have that dialog on an ongoing basis. So that there are no forbidden topics. Even a parents cognitive issues can be something that you can discuss. That you can plan together for.

Question #6 Seeing paranoia, anger, and a vivid imagination but they are clear-headed in everything else, they live alone in an elderly complex. Should you be thinking of living assisted arrangements? At what point do you decide to look at assisted living?

These are individual decisions that families struggle with. Basically assisted living is a great form of housing for people who are having difficulties functioning on a day to day basis. Helping with medication, assisting a person to wake up in the morning. Even folks in assisted living are grooming themselves and dressing themselves. They need a little bit of help but they don’t need a lot of help. Families often times put off decisions until something bad has occurred. For example, someone stopped taking their medications and were hospitalized because of it or because they weren’t taking the medications correctly.

Then families begin looking for an environment with more support like assisted living. All these steps along the way need to be approached with a lot of gentleness. So that everybody feels like they are planning together. No one feels that they are being forced into a living environment that they don’t want to live in.

Question #7 How do you handle a where a person can’t live on their own but will not voluntarily move?

This is the most delicate topic. These are conversations that we try to have as much gentleness as possible. But when you have very grave concerns about how a parent is functioning you do have to insist. You have to put your foot down and use all your powers of persuasion as a way of ensuring a parents safety. It’s a point that many families hope they don’t reach. They hope for a dialog about what should be done next. But sometimes it doesn’t work that way.

The doctor shared his own story about his own mother. He had to have a talk like this with his mother. It was uncomfortable but he wanted her to move closer to him after he realized she couldn’t care for herself anymore. It was a sad day when she had to move from her home in Florida where she lived for 15 years to Pennsylvania.

Question #8 Is it typical for someone close to a person to not recognize the signs?

Yes, there are many of us who want to see only good never bad. It’s very anxiety provoking to see things that might be tell-tale signs of troubles ahead. Whether it’s the older adult themselves or the children there is a conspiracy of silence. When people see things they don’t like to bring them up.

In many families, there are few changes that are made until there is a crisis. Until there is a fall or the electricity bill hasn’t been paid because the parent was to confused to pay the bill. We really want to avoid those crises by actively seeing the signs, recognizing them and then beginning to have those conversations and take steps to head off trouble because more damaging then it needs to be.

Physical Red Flags To Keep An Eye Out For:

  1. Disheveled clothing
  2. Poor personal hygiene
  3. Unexplained bruising
  4. Trouble getting up from a seated position

Question #9 How do you discuss with parents frequent episodes of forgetfulness and repeating things without worrying them?

That’s a tall order because we live in a society where dementia is the biggest scourge and the biggest fear. All of us young and old worry about cognitive decline. So when you raise the issue of forgetfulness or people repeating themselves almost automatically our loved ones are going to grow concerned we are accusing them of becoming demented.

Maybe you are pointing out something that they have been aware of but have been trying to push aside for a while. There is no gentle way to do that then to forge ahead with the greatest sensitivity as possible. You really have to say this is something that we need to address. You need to say that we must begin a medical work up.

Sometimes these things are reversible. A dietary deficiency, an endocrinological problem that can be corrected. It doesn’t mean that the forgetfulness is due to dementia. All of that is up to our good doctors. To evaluate and help us figure out and then come up with steps for us to address the issue.

Metal Red Flags to look out for:

  1. Cluttered, dirty and/or disorganized house
  2. Missing important appointments
  3. Uncertainty and confusion when performing once-familiar tasks
  4. Forgetfulness

Question #10 How can I stay organized once I know that my loved one needs help?

Read this checklist:

For our loved one's sake we have to be more organized for them then we would with ourselves. Proceeding cautiously and carefully. Conferring with doctors and physicians, mental health experts, legal experts at times. Really making sure we have all the basics covered. Keeping not just our parent informed but other loved ones informed. Our siblings, our relatives, other interested parties to make sure everyone is on the same page as we proceed ahead.

That way the primary caregiver end up becoming the leader of a larger team of people. Keeping not just the parent organized but keeping the whole team organized. In order to provide as good of care experience for everyone as much as possible.

Environmental Red Flags:

  1. House and yard need care/maintenance
  2. Broken appliances
  3. Spoiled/expired groceries that don’t get thrown out
  4. Unexplained dents or scratches on a car

Question #11 How much forgetfulness is age appropriate and how much is an indication of a problem? What questions or test should I ask my loved ones doctor for?

What doctors use are screen instruments. The two most popular are:

  1. Miny Metal Status Exam
  2. Montreal Cognitive Assessment or better known as the MOCA test

Both of these are very short tests. They are scored 1-30. They have cut off scores. Usually, anyone scoring below a 26 is considered actually to met the criteria for dementia.

What that means is that our loved ones may be forgetful or have other cognitive issues.  If they test well enough above 25 on these screening exams then they are not considered to have dementia. These tests have a little bit of built-in leeway to take into account age-related changes. These are all test that primary care doctors administer routinely. This would be a good place to start. To bring a loved one in and express your concerns that they seemed to be forgetful or more disorganized in housekeeping and bookkeeping then they usually are.

Then your doctor can administer the mini-mental status exam or the MOCA to start. If your parent tests 25 or below, then that would warrant intensive investigation. Perhaps a referral to a geriatric psychiatrist or neurologist to do a further in-depth evaluation of their thinking skills. This will assess whether they have developing dementia or more importantly are they capable of managing their own affairs. Are they capable of living independently and if not to what degree of support do they need. Go to your physicians and ask them for these exams.

None of us like to step on our parent's toes. No one wants to be in a position where we are accused of robbing them of their independence or dignity that we are taking over in some way. Yet is really important for all of us as loving family members to step up and do our best. Observing our older loved ones. Noting changes that may be going on. Recognizing that those red flags. Making sure we address them. So we keep our loved ones as happy and as healthy as possible. That is our best way of supporting them. This is good work that we all are involved in. We are all trying to do the right thing.



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