1. Til Death Do Us Part- Care Management for Aging Couples Helene Bergman, LMSW, MA Geriatric Care Manager Elder Care Alternatives, NYC Presented at New England Chapter NAPGCM Geriatric Care Management: The Complexities of Caring April 4, 2005

2. Workshop Objectives: 1) Identify issues unique to Care Management (and care- giving) for an elderly couple when both individuals are physically and/or cognitively impaired. 2) Identify and understand the family dynamics that exist when both parents (or loved ones) require substantial care. 3) Create a Care Plan to address the functional needs of each individual and the emotional needs of the couple.

3. Primary Issue Self Determination Autonomy vs. Protection

4. Hypothesis: A Care Management Protocol for an infirmed elderly couple significantly differs from that designed for a single elder. *How *Significance of Issue

5. Meet Three Elderly Couples Mr. & Mrs. G Mr. & Mrs. D Mr. & Mrs. P

6. Married over 50 years. History of dysfunctional marriage w/alcoholism She (S) 75 w/borderline personality disorder, OCD and dementia (AD w/Korsakoff syndrome) and paraphasia; violent and aggressive; under IBW; hypersexual; beautiful He (J) 80 w/post stroke (HTN, s/prostate Ca)– memory loss, disoriented to time, mild paranoia, depression w/psychosis; passive aggressive- narcissistic, controlling and manipulative; tight- fisted

7. *Neglect of Medical Issues- no medication compliance *Home environment- chaos and clutter *Family System- Closed boundaries w/distrust; sons w/sibling issues; emotional closeness; functional distance *Social withdrawal-no friends, no neighbors, no activity *Safety factor-crises w/violence, police, hospitalizations *No advance directives; no LTC plan *Assets- about a million.

8. What are the similarities among these elderly couples? 1. A couple with a long term marriage and a commitment to be together. 2. Two elderly clients with direct care needs and diminished cognitive capacity (dementia or depression) to make decisions on their own behalf. 3.One elder with more medical needs and the spouse with more advanced dementia. 4.A couple known to either a hospital, nursing home or community agency. 5.Recent history of chronic crises. 6.Co-dependency of the elders to maintain status quo and sabotage a Care Plan. 7.Adult children who are aware of the crisis but feel impotent to make change. Strong Denial and Resistance! 8.Adult children who are suffering the emotional loss of two parents at once.

9. The Differential Assessment The Marital Relationship Barriers to Care (Environmental/Human) Risk Factors (Safety, Security, Medical) Legal Issues Financial Issues Home Care Home Environment Family Dynamics Social Support Change Factor

10. Care Plan Options Maintain the couple at home with adequate supports Relocate the couple to a supportive environment with adequate supports Separate the couple and relocate each to an appropriate environment with adequate supports

11. What happened to? Mr. & Mrs. G Mr. & Mrs. D Mr. & Mrs. P