Stages of Dementia

Seven Stages of Dementia | Symptoms & Progression

Health professionals sometimes discuss dementia in “stages,” which refers to how far a person’s dementia has progressed. Defining a person’s disease stage helps physicians determine the best treatment approach and aids communication between health providers and caregivers. Sometimes the stage is simply referred to as “early stage”, “middle stage” or “late-stage” dementia, but often a more exact stage is assigned, based on a person’s symptoms.  This article discusses three scales that use stages.

 

1) Global Deterioration Scale for Assessment of Primary Degenerative Dementia (GDS)

The most common scale is often referred to simply as GDS or by its more formal name the Reisberg Scale. The GDS divides the disease process into seven stages based on the amount of cognitive decline. This test is most relevant for people who have Alzheimer’s disease, since some other types of dementia (i.e. frontotemporal dementia) do not always include memory loss.

Diagnosis Stage Signs and Symptoms
No Dementia Stage 1:
No Cognitive Decline
In this stage the person functions normally, has no memory loss, and is mentally healthy. People with NO dementia would be considered to be in Stage 1.
No Dementia Stage 2:
Very Mild Cognitive Decline
This stage is used to describe normal forgetfulness associated with aging; for example, forgetfulness of names and where familiar objects were left. Symptoms are not evident to loved ones or the physician.
No Dementia Stage 3:
Mild Cognitive Decline
This stage includes increased forgetfulness, slight difficulty concentrating, decreased work performance. People may get lost more often or have difficulty finding the right words. At this stage, a person’s loved ones will begin to notice a cognitive decline. Average duration: 7 years before onset of dementia
Early-stage Stage 4:
Moderate Cognitive Decline
This stage includes difficulty concentrating, decreased memory of recent events, and difficulties managing finances or traveling alone to new locations. People have trouble completing complex tasks efficiently or accurately and may be in denial about their symptoms. They may also start withdrawing from family or friends, because socialization becomes difficult. At this stage a physician can detect clear cognitive problems during a patient interview and exam. Average duration: 2 years
Mid-Stage Stage 5:
Moderately Severe Cognitive Decline
People in this stage have major memory deficiencies and need some assistance to complete their daily activities (dressing, bathing, preparing meals). Memory loss is more prominent and may include major relevant aspects of current lives; for example, people may not remember their address or phone number and may not know the time or day or where they are. Average duration: 1.5 years
Mid-Stage Stage 6:
Severe Cognitive Decline (Middle Dementia)
People in Stage 6 require extensive assistance to carry out daily activities. They start to forget names of close family members and have little memory of recent events. Many people can remember only some details of earlier life. They also have difficulty counting down from 10 and finishing tasks. Incontinence (loss of bladder or bowel control) is a problem in this stage. Ability to speak declines. Personality changes, such as delusions (believing something to be true that is not), compulsions (repeating a simple behavior, such as cleaning), or anxiety and agitation may occur. Average duration: 2.5 years
Late-Stage Stage 7:
Very Severe Cognitive Decline (Late Dementia)
People in this stage have essentially no ability to speak or communicate. They require assistance with most activities (e.g., using the toilet, eating). They often lose psychomotor skills, for example, the ability to walk. Average duration: 2.5 years

(Reisberg, et al., 1982; DeLeon and Reisberg, 1999)

 

2) Functional Assessment Staging (FAST)

The second scale is called the Functional Assessment Staging Test or by the acronym FAST. FAST also employs a seven-stage system based on level of functioning and daily activities.  However, FAST focuses more on an individual’s level of functioning and activities of daily living versus cognitive decline. Note: A person may be at a different stage cognitively (GDS stage) and functionally (FAST stage).

Functional Assessment Staging (FAST)
Stage 1 — Normal adult
No functional decline
Stage 2 — Normal older adult
Personal awareness of some functional decline.
Stage 3 — Early Alzheimer’s disease
Noticeable deficits in demanding job situations.
Stage 4 — Mild Alzheimer’s
Requires assistance in complicated tasks such as handling finances, planning parties, etc.
Stage 5 — Moderate Alzheimer’s
Requires assistance in choosing proper attire.
Stage 6 — Moderately severe Alzheimer’s
Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.
Stage 7 — Severe Alzheimer’s
Speech ability declines to about a half-dozen intelligible words. Progressive loss of abilities to walk, sit up, smile, and hold head up. (Reisberg, et al., 1988)

 

3) Clinical Dementia Rating (CDR)

The Clinical Dementia Rating (CDR) scale uses a five-stage system based on cognitive (thinking) abilities and the individual’s ability to function. This scale is more commonly used in dementia research and less so as a communication tool between medical professionals and patients and their families. This is the most widely used staging system in dementia research. Here, the person with suspected dementia is evaluated by a health professional in six areas: memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care and one of five possible stages is assigned.

Clinical Dementia Rating (CDR) Scale
CDR-0 — No dementia
CDR-0.5 — Mild
Memory problems are slight but consistent; some difficulties with time and problem solving; daily life slightly impaired
CDR-1 Mild
Memory loss moderate, especially for recent events, and interferes with daily activities. Moderate difficulty with solving problems; cannot function independently at community affairs; difficulty with daily activities and hobbies, especially complex ones.
CDR-2 — Moderate
More profound memory loss, only retaining highly learned material; disoriented with respect to time and place; lacking good judgment and difficulty handling problems; little or no independent function at home; can only do simple chores and has few interests.
CDR-3 — Severe
Severe memory loss; not oriented with respect to time or place; no judgment or problem solving abilities; cannot participate in community affairs outside the home; requires help with all tasks of daily living and requires help with most personal care. Often incontinent.

View References

de Leon MJ and Reisberg B. An Atlas of Alzheimer’s Disease. The Encyclopedia of Visual Medicine Series. Parthenon Publishing, Carnforth, 1999. Available at: http://www.alzinfo.org/clinical-stages-of-alzheimers

Reisberg B et al. The Global Deterioration Scale for Assessment of Primary Degenerative Dementia. American Journal of Psychiatry. 1982;139(9):1136-1139.

 

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In the Know….

Assisted living is one of the fastest growing areas of health care, as many who are in need of long-term care are seeking out the aesthetically pleasing, homelike environment of assisted living rather than the institutional skilled nursing environment.

The problem

There are a number of people who are living in assisted living facilities (ALFs) who have some degree of dementia—and too often, the difficult problem is that these residents are not identified or treated appropriately.

According to the 2016 Alzheimer’s Facts & Figures [PDF] report by the Alzheimer’s Association, 42% of residents in assisted living have some form of dementia or cognitive impairment, and that number is increasing every day.

Yet only 58% of those facilities provide a memory care program.

The solutions

These facts and our own experience and observations indicate that environments are often ill-prepared to care for this population. We believe that the root of the care management problem is in the resident admission and ongoing assessment process.

In many ALFs, the resident assessment performed by the facility is very lean and is often more like a questionnaire of needs than a professional assessment of needs. A physician assessment is usually performed prior to admission, but often this does not adequately identify the cognitive status and the specific associated functional limitations or abilities of the client. Many people move to an ALF in Allen level 4, and we know that in Allen level 4, persons will have IADL and then ADL needs. However, we also know that these individuals are not good self-reporters of needs.

In our experience, a facility may have half of its residents performing in Allen level 4, and this is the level in which we have witnessed the greatest discrepancy in what is delivered versus what is actually needed. We know the problem is associated with the often relatively intact verbal skills fooling the assessor. It will then take time for the facility to realize that Mrs. Smith is having some problems, and by then the problems may have led to a serious issue such as a fall or depression leading to hospitalization.

The key for success is rooted in enhancing the facility assessment process. This should be done in two ways:

  1. Improved resident assessment performed by the facility. The facility must identify a team member within the environment who can perform a comprehensive evaluation of needs. The evaluation is usually performed by the Director of Nursing or other lead nurse. The evaluation should include a cognitive assessment such as the FAST, GDS, MMSE, and/or SLUMS. In addition, the assessment should look at other areas that impact function such as physical limitations and sensory loss. The assessor will then make a determination of the level of assist the resident may require. This will help eliminate the trial-and-error getting-to-know-you process that typically ensues after admission.
  2. A professional therapy assessment. Many ALFs use home health as the only source of therapy involvement. Most often, the delivery of service involves coming in AFTER the resident has had a medical issue and/or hospitalization. This doesn’t solve our need for a proactive therapy assessment to help identify the care needs and necessary approaches for a complex client. We recommend an ALF partner with a therapy organization who can bill Medicare Part B and is trained in the Allen theory. We suggest the therapy team be on site five days per week and truly become a part of the ALF team. When a resident is admitted who has an Alzheimer’s or related dementia diagnosis, the therapist can perform an evaluation, including the Allen cognitive assessment, identify the person’s best ability to function, and create a plan to maximize and maintain the person’s function and safety.

Another essential element for success is dementia care training for all facility staff. Over 30 states in the US now require some amount of specialized dementia training for facility staff of an ALF that markets caring for persons with dementia. We believe it is absolutely essential that staff are prepared with a quality dementia training program to help them understand the complexities of the disease and approaches that work.

 

Summary

In our opinion, many assisted living facilities do not know the complexity of the clients that they’re serving. Many are oblivious to the pervasiveness of dementia and the relationship of dementia to poor outcomes and high liability. This is a golden environment for therapists to be a part of as we infuse a high degree of sophisticated medical and dementia assessment/care knowledge that will help the residents and the facility succeed. We believe that ALFs can be a wonderful alternative to skilled nursing facilities or to remaining at home. However, these environments must begin to provide the expertise needed to serve persons with dementia.

Fun Facts

Have A Happy Thanksgiving!

Did You Know… 

Although Thanksgiving was celebrated by the early settlers to the country in 1621, it wasn’t an official holiday until 200 years later. When Abe Lincoln declared Thanksgiving a national holiday in 1863, it was thanks to the tireless efforts of a magazine editor named Sarah Josepha Hale. Her other claim to fame? She also wrote the nursery rhyme, “Mary had a Little Lamb.”

91% of Americans eat turkey on Thanksgiving. Californians consume the most turkey in the U.S. on Thanksgiving Day!

The First Thanksgiving lasted for three days.

20% of cranberries eaten are eaten on Thanksgiving.

Pumpkin pie didn’t become a staple until the second Thanksgiving.

According to the American Pie Council (yes, there is one), the flavor of pie you like will describe your personality.

If you love…………………………………. You are likely to describe yourself as…
Apple Pie:                                    Independent, realistic and compassionate
Pecan Pie:                                    Thoughtful and analytical
Chocolate Pie:                              Loving
Pumpkin Pie:                              Funny and independent

Happy Thanksgiving!!!!!!!

Hey Buddy, Come Here

We all have that one resident-the one who touches the caregiver’s life in way that can not be explained. This is the case with a gentleman we nicknamed “Pop”; who moved into the facility in late October.  Dementia had taken control of his thoughts causing him to need total care. One thing Pop could do very well was….talk. The man loved to talk!

Let me share a little background to help you know the man we all loved and understand the power of interaction between caregiver and patient.

Pop spent his entire life working as a Game Warden  – he loved the outdoors which made his job the perfect fit for his life. His side hobby was rebuilding classic cars and tinkering with his own 97 short-bed Ford Ranger.  Pop believed in stretching his dollar as far as it could be stretched and then some, so much so, people would say “he is so tight, he squeaks when he walks”  If a new fuel pump was $69.99 at one store, he would travel 25 miles to save eight cents!

As Pop aged, he needed a little help with pulling transmissions, starters and other such big jobs . When seeking someone to help him out, he would call around and ask ” Hey Buddy, how much would you charge to help me for about two hours today?”  If Pop thought the price was too high, he would reply,” Let me think on it get back to you.” He would then proceed down his list, calling each- “Hey Buddy, how much would you charge to help me for about two hours today?”.  He would then say, “Let me get back to you……”.

Sadly, Pop began to show signs of dementia shortly after his retirement. He and his wife , Sarah, lived alone in a very rural area, with their sons living in a distant city.  Sarah did the best she could, managing the house,  finances, grocery shopping, lawn care and every other task associated with every-day life.  The day finally came for her to reach out to her children for assistance; describing herself as ‘worn out, worn down and exhausted”.  Within hours, Sarah and Pop were in the car, headed to the city to stay with their oldest son, Jerry.

Once everyone was settled in, Jerry saw a side of his father he had never seen before -a man who was aggressive when Sarah tried to help him shower and “get him cleaned up” as she called it.  Jerry realized that the family was not equipped to handle Pop, for fear of him hurting Sarah  due to the progression of the disease process.  It was at that point, Pop moved into the facility and a new chapter for everyone involved would be written.

Oh how the staff loved Pop! He would call out, “Hey Buddy, come here. How much would you charge to put this started in? ”      “Hey Buddy, come here, let me talk to you for a minute. How much are we looking at for the muffler and the tailpipe?”    The staff, including myself would name our price which varied greatly- some would say $200 cash, others would say $15.00,- whatever the price was Pop would reply: “I have to think on it. When do I have to let you know?

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

Maya Angelou

Twenty minutes would pass, Pop would call out again- repeating the same as before. Again the staff would reply with their prices, leaving Pop to think on it each and every time.  Like clockwork, every day, every 15-20 minutes or so ( unless he was napping), Pop was always bidding out his labor needs. The days he wanted to go in great detail about his automotive concerns, the staff would sit down with him and talk “car parts” with him, until he dozed off.

Then came Thursday. As I walked past Pop, he called out…“Hey Buddy, come here, I want to ask you something. How much would you charge to put a starter in a pickup truck? ”  Without hesitation, I gave him a price of $650 to which he replied, “Let me think about that. Is that for parts and everything? I just have to think on it..”       The rest of the day, Pop dozed on and off, didn’t eat much for dinner and just seemed “not right”. The nurses assessed him finding his overall vitals being within normal limits, no issues noted. As the evening wore on, Pop declined further causing the nurses to send him out to the hospital.

Friday morning, Jerry came to my office. I could tell by his facial expression, this was not going to be good.      “ Dad’s not going to make it. He is in heart failure, kidney failure and a whole list of other things that the doc says aren’t good. We will be lucky if he makes it through the weekend. I appreciate everything you and your staff have done to give his life meaning and purpose.”        We talked about the great life Pop had lived, about his cars and farm…….we just talked.  I asked hos Sarah was holding up under the present circumstance and of course the answer was not good.

Later that day, I stopped by the hospital to check in on the family and on Pop. Sarah was beyond devastation; but there she sat, holding Pop’s hand as the tears rolled down her cheeks. Pop laid perfectly still in the bed, eyes closed.      When the time came for me to slip out, I leaned over to Pop, and said….” Hey Pop, I am going to drop that price I gave you on the starter job. Going to drop it down to $5, everything included.”   His eyes opened and he softly mumbled something……… The family was in shock at his reaction as was I.  Just as quickly as he opened his eyes, he closed them again.     Saturday morning, Pop passed away.

memories

The reason I chose to write about Pop was this: Those working in health care field need to know that those under their care, responsive or not, confused or not- every encounter matters.    The nursing assistant that sat with Pop and rebuilt the engine for $50 dollars didn’t know how to change oil in her own car, but carried the conversation with him and gave him a sense of purpose. The nurse who would seek Pop out to make conversation about cars- gave  Pop and opportunity to be the man he was.

Health care workers have hard jobs. Yet, be it known that the work they do matters.  If I could say one thing to any health care provider regardless of rank or file, it would be : What you do and say to every patient MATTERS. Your kindness and compassion may go unnoticed, but as evidenced by Pop, it is remembered by the patient.  Dementia, Alzheimer’s,  strokes- whatever the diagnosis a patient may have-  you touch their life when you take the time just to listen and have a conversation. Many people would have thought Pop was just a confused man who was stuck in the past- but he wasn’t. The diagnosis is not the identity of  any person- the time spent with the resident will reveal who they really are. Find the time to know your patient and be present in their lives. 

Pop, my staff and I will never forget you. You mattered to us and thank you for allowing us to matter to you.   I have to go for now Pop, but I will carry your memory always.

Hey buddy, come here………………….

                                                 memory

 

 

 

 

 

 

 

 

 

 

 

The Old Oak Tree

The other night as I was trying to fall asleep, my mind began to wander. Without warning, memories of my childhood home surged like never before. I am not sure if I had fallen asleep leaving my subconscious to have a hay-day, or rather, in my slumber something triggered me to think of days and places long ago. The next morning, the images of places and things from the 1970’s and 1980’s were both crystal clear and extremely vivid.

You see, my father was a Southern Baptist minister in the deep south. We moved quite a bit, covering almost every Southern State- going wherever a new preacher was needed (and voted in).  Being a young child, maybe 6 or 7 ,  I can recall moving to a small town in Alabama, which excited my siblings and I because the new Parsonage had more bedrooms and the church had a small jungle gym playground. It was an exciting time for us!

After we had been there for a while, my brothers discovered a huge, sky-high- tall Oak tree that had so many limbs, which made it very desirable for us kids to climb. Naturally my brothers could climb like monkeys and would swing off its branches- jumping to the ground from what I thought was “way t0o high to be doing that”. Our mother would yell from the screened in porch,” Boys stop doing that before you break your neck. Are you watching your sisters? Boys????”  They would reply, “Yes maa’m, they are here somewhere.”  ( The” somewhere” part was whispered only loud enough to be heard by God because they surely would not tell our mother the truth.)

god-is-watching

So, to make the truth more promising, one of my brilliant minded brothers made a decision. ” Okay, since we have to watch you, you have to come up the tree with us and do what we do so mom doesn’t make us stop doing it because we have to watch you. If you are doing it too, then we are watching you do it.”              Sure, that makes all the sense in the world- maybe to a 7 year old girl.  My sister who was older and so much more mature, made her own plans to go inside and “go to her room“- which was cool back then.  Off she went while I studied the giant, bark filled, super big and round, mountain top style tree.  Could I, a small little kid climb such a tree without breaking my neck which my mother had already predicted ?    I watched the boys climb higher and higher and higher eventually losing sight of them amongst the leaves and branches.  Only one brother waited patiently for my ascension into the heavens- my twin, Michael.

“Come on Jess…..just come on. It’s just a tree. Trees are fun!” . I caved under the pressure and started my upward journey.  We climbed higher and higher, leaving the ground further behind us. Without thinking about it, I glanced down….wayyyyy down.            Without warning, my little heart skipped a beat.  Suddenly, I froze.  Like ” froze froze” in mid air, close to where God lives,……wayyyyy up there.

Then it happened. Snapping branches. The sound of something falling heavily through the rustling leaves.  Swoooosh.  It had happened j just like mom said- he was gonna break his neck.            I looked down to see my older brother Wayne, laying flat on his back.          Laughing. Hysterically.         THEN….     I heard my mother’s voice.

“Daniel Wayne!!!!!! You better get up from that ground! Those are school clothes. The rest of you get down from that tree and get to your chores.   NOW.”

My brothers, swinging like monkeys, flew past…grabbing from branch to branch, jumping to the ground.   Then silence.  Dead silence.              ” Hey! Wait for me!……hellloooooo….wait for me!!!”    Silence.    The ground was so far away. The closest branch was at least 5 miles away. I clung to the tree as if it were our wedding dance….yelling for my brothers………climb-a-tree

 

I can recall the event of that day like it was yesterday, even though it has been well over 45 years ago.    Memories are for the making, almost certain never to be forgotten, regardless of advanced age, or the disease process.

Dementia may cause some to forget when they had their last meal or even how to feed themselves, but some things are not forgotten.  I have sat with residents and listened to their stories…..so what if they think the event is happening in the present instead of 45 years ago?  Have we ever considered that when a resident is looking  for a parent, believing they are still alive, that maybe it is a memory that sparked the thought?  Have we given attention to when a resident is constantly “trying to catch the bus”, that maybe they rode the bus to work, made friends along the way  and are missing that experience?          Not every misplaced memory or life timeline is “confusion”.   

 We as health care professionals  lack the art of true listening. We consider the ramblings of the dementia patient as “agitation” and “cure” it with medication to “reduce anxiety.”   Take Betty for instance. Betty stays in my office all day long, shuffling my papers, hitting buttons on the copier and inserting herself into conversations.  If I leave my coffee unattended for a split second, she drinks it.     It can be very challenging to maintain my sense of calmness when she moves a certain document or jumbles the 50 pages that were in order when they printed on the copier.      But here’s the deal.  Betty was/is a licensed therapist; a former educator, and an ordained minister.  When guest arrive in my office, Betty is no longer a dementia patient- she is there for them; to offer her services as a counselor.   All of Betty’s memories are of the good she has done over the past 70 years.  For me to discount her who rob her of the very memories that she is bringing back to life. She may have forgotten who she is, where she lived, or may not even know that she is a dementia facility.  But she is not forgotten who she is.

We all need to listen a little closer to people and not call it “confusion”. We should listen and maybe, just maybe, we can catch a glimpse of the person- the real person who raised a family, had a career, took vacations, traveled abroad and lived their life the same we live our today.   See the person, not the disease or disorder. Listen to their stories because their stories are their memories being retold.           

memories

How did the old Oak tree story end, you ask? Well, my dad just happened to walking from the church and heard my panic and fearful screams.   I can still see him, standing below the tree, looking up and asking…”Sweety, how did you get up there?   Hang on honey, I’m coming up to get you.  There  is nothing to be afraid of as long as you hang on” .

Once he had safely extracted me and we were safely on the ground, he knelt down and said…” Jessi, remember this day. Never follow the leader when you know you aren’t ready to follow. Don’t climb trees if you can’t get down.  Always remember that.”.

Forty five years later, I remember. Forty five years from now, if I am in a nursing home yelling out…..”Help me down”….”Get me out of this treeeeeeeeee”…. don’t medicate me, let me enjoying my memory.

 

 

 

 

Understanding When It’s When

Dementia robs people of so much….their memories,their lives and relationships. Some days it is difficult to sit behind my desk and talk with loved ones about the progression of the disease process. I listen to their words, but can clearly see the heart that has been broken……The question everyone asks is,” how will I know when it’s time?” I always have to and ask for clarification …”when what?”  This is where things become very sticky…..

” When do know when it’s time; I mean how long can a person live with dementia? When do they stop swallowing? I read that dementia causes people to forget how to eat and I guess they forget to swallow? Is that true?  If it is, when do you decide to put a feeding tube in? How long can a person live if they don’t eat?  I guess what I am asking is, when is when?

Such  loaded questions. How does anyone really know how to answer? We can recite the scientific data that we know, explain the process of death and dying and lecture for hours on dementia….but to answer when is when?   When does one decide to stop treating with antibiotics, IV fluids and or place a feeding tube?        One person defined the choice by saying ” It is a matter of quantity vs quality. ”     In some ways, I agree with the  statement, but every situation is unique to itself.          I do not think we should define ” quality of life” based on a disease process. Some dementia patients have the best time in the state of mind they are in. They laugh, sing, dance, and are content with the world dementia has created.   I have also seen a 103 year old woman perform the ” jitterbug” on the dance floor!  So, I do not think we can define life by ” quantity vs quality.”   elderly

What I do think helps to determine ” when is when” could be the individuals physical state…I would not propose placing a feeding tube or prolonging life in a person who is feeble, fragile and failing. It is not about their age, diagnosis or mental sharpness but rather, about the whole person and the state of their body. Modern technology and advances in the medical field has allowed us to ” live forever” with mechanical machines, devices and gadgets.  Ventilators, life support machines and other devices can keep any of us alive…..but where is the defining line to unplug them and allow nature to take its natural course?         In these situations we wait for a medical doctor to walk in and say ” this person is brain-dead and is only alive because of the machines.”  At that moment, all hope is gone, lost and it’s over.   That is the true determining factor….all hope is gone.

  If only it were as simple with dementia. We do not know what the patient can and does understand, nor do we know what their awareness of themselves or others really is either.    Hence the quandary.

The best advice I can give anyone is simply to always follow your heart and let the decisions made reflect what your heart feels.  Dementia has robbed so much from the victim’s family; the last thing needed  is to feel guilty about the decisions made  at the end of life.

I have a family member that tells me weekly how much money he has in the bank and how many months he can afford to continue paying for his wife’s care. His question to me is, “What if my wife out-lives the money?”   I explain the Medicaid system and other state and federal assistance programs to him to which he offers another problem .

” You see Jessi, I can’t get public assistance because I still have money in CDs, IRA’s and a few stocks. I won’t qualify for help from the agencies.  You see, I can’t spend every dime I have on Bessie because I still have to live after she is gone. I’m not talking a lot of money, maybe a little over $100,000 dollars, but too much to get Medicaid.  I’m only 73 and I am hoping I have set aside enough for myself.  Before Bessie got dementia, we have over $300,000. Now we barely have a little over $130,000.   See my problem ? “

Hmmm. I do see the problem, but I do not know the answer or how to solve it.  My standard answer is simply, “Let’s just take one day at a time and cross each bridge as we come to the crossing.”                    nc_longest_footbridge_1_sk_141001_12x5_1600 I know such a loose comment offers no comfort, but I really don’t know what else to say. Should I encourage him to continue spending what money he has so he will qualify for financial assistance ?  Should I encourage him to take his wife home so he can save money, knowing he is not able to provide the constant care she needs ?  Should I offer to have hospice evaluate his wife, or place her on palliative care which would decrease medical bills, aggressive treatments and eliminate costly medications?       I just don’t know.

There  are so many factors to the loaded question as to “when is when”.  Maybe the best answer is……”Let’s cross each bridge as we come to the crossing……..or maybe “Let’s go through the tunnel when we come to it”….at least there is hope in the light at the end of the tunnel.

Thoughts?tunnel

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