HOW TO TAKE CARE OF AGING PARENTS Elder care is a lot easier if you talk to your parents early on, plan way ahead, and get help from a big and growing network of resources.
By Brian O'Reilly REPORTER ASSOCIATE Rosalind Klein Berlin

(FORTUNE Magazine) – T'S SUNDAY NIGHT. Time to make the weekly how're-you-doing phone call to your mother living alone back in Omaha. But when she finally answers, something is wrong. Her speech is labored and slurred, and she is talking about things that make no sense. You, friend, won't be at the office tomorrow; you'll be on the first plane to Omaha. Your mother -- the exuberant bon vivant who was going to outlive you all -- has suddenly gotten old. And you have just landed a second career: caregiver to an elderly parent. What will it be like? Don't even try to predict. A thousand variables will determine what burdens elder care has in store for you, including the illnesses that befall your parents, how far away they live, and how much money you and they have. Nothing can make the decline of a proud patriarch or a once lively mother the least bit pleasant. But ignoring the inevitable and refusing to think about it could vastly increase the emotional, medical, and financial problems you and your parents will face. If you can pull your family together, talk frankly about options before a crisis develops, and get in touch early with the network of service and information providers designed to assist the elderly, you can make your job easier. A few common misunderstandings about elder care are best dispelled early. First, it is not child care -- treating an ailing adult like a child is demeaning and unnecessary. Second, do not assume that moving your parents permanently into your home is the best solution; they may not want to live with you, either. Third, you probably don't need to put them in a nursing home, but if you do, you may be stunned to discover that Medicare, which spares no expense to cure every medical problem, will not pay for extended nursing home care. Chances are, your parents won't need much outside help before they are in their late 70s or early 80s. But the odds that you will wind up taking care of an older relative are good and growing. A 65-year-old male can expect to live to be 80, a female to 84. The fastest-growing segment of the population is the over-85 crowd. Relatively few of them -- only about one in four -- can live alone without difficulty, says Eileen Crimmins, a demographer at the University of Southern California. According to a Conference Board study, about 25% of the working-age population describe themselves as responsible for the care of an elder. They spend an average of ten hours a week at the task. Unlike child care, elder care isn't necessarily ''women's work.'' One employee counseling service reports that males make only 10% of the calls concerning child care problems, but 40% of the calls about problems with elderly parents. Executives are as likely as blue-collar workers to wind up responsible for the care of aging parents. When Eric Mayer's mother had a stroke that left her partially paralyzed, Mayer, managing director of a Beverly Hills firm that oversees a $6.5 billion real estate portfolio, spent most of the next six weeks arranging her care. ''It completely changes your life,'' says Mayer. ''Taking care of someone is not the kind of thing you delegate to your staff.'' About half the time, an elderly person becomes incapacitated suddenly, going from independent to infirm because of an event such as a stroke or a broken hip, says Michael Creedon, a gerontologist in Vienna, Virginia. Even when parents decline slowly, their transition from frail-but-independent to needing help often comes as a jolt: A cop lifts Dad's driver's license after some confusion on the highway; now he can't shop for food anymore. Mom's arthritis becomes so uncomfortable she can no longer button her blouse. They get depressed or confused and fail to pay utility bills, and a neighbor calls you to say their lights have been off all week. Raising the subject of old age with your parents is often exquisitely difficult. But J. B. Hancock, head of a video production company in Arlington, Virginia, discovered a good opening line: ''I just went over my will and estate plan with my attorney,'' she told her elderly parents, who live in Florida. ''It made me wonder if you folks need any help with your plans or want to talk things over.'' The hope is that your parents will be relieved if you bring up the subject -- it indicates you don't plan to abandon them when they get old. If they balk at the topic, back off and try again in a few months. The consequences of not planning can be severe. When a crisis hits, you won't have the information you need or the authority to act on your parent's behalf. As a result, you could spend weeks or months lining up the services you need. It is best to involve your whole family in any discussion of care -- not just your brothers and sisters, but their spouses as well. And don't load everything onto the eldest daughter who happens to live nearby. Michael Creedon tells of one woman who announced her plans to retire, only to discover that her brothers and sisters then decided she should spend the rest of her . life taking care of their parents. Says Creedon: ''She went right on working.'' If you have a family that cannot discuss the weather without fighting, bring in a minister or other trusty outsider to act as referee. A FAMILY MEETING is a good time to learn some important basics, such as your parents' Social Security and Medicare identification numbers, their doctors' names, and as much of their medical history as they think you need to make intelligent decisions with them. Ask if you might meet their neighbors and exchange phone numbers for use in emergencies. Inquire, very gently, about their income, insurance, and other financial resources. Under which rhododendron have they buried their safe deposit box keys, wills, and other papers? Parents should give power of attorney to someone to make legal, financial, and medical decisions if they are incapacitated and cannot decide for themselves; a will, which disperses assets after death, does not accomplish that. Afraid your parents will think you plan to fleece them if they put you in charge? Point out that most states forbid self-serving asset transfers by caretakers. Also find out what kind of medical heroics they want and encourage them to fill out a living will. Now to the big question: Where should they live? While they are healthy and can afford it, staying in their own home is usually best. Anne Brophy Putney, community affairs director for WOGL, a CBS-owned radio station in Philadelphia, realized during a visit earlier this year that her 87-year-old mother in Palo Alto, California, was growing more fragile. Through a company- sponsored elder care program, she learned of a Palo Alto firm, Older Adults Care Management, that could evaluate her mother's needs and provide help. ''We decided not to move her now,'' says Putney. ''She's lived in her home for 40 years. The camellias are blooming, the freesias are out, and the fruit trees are laden with oranges. And she's the neighborhood candy lady who's been giving treats to the neighborhood children for more than 20 years. We decided she'd be happiest at home.'' The firm helped Putney find two women who take turns as her mother's live-in caregivers. If either parent is likely to want or need an alternative form of housing, start planning early. Attractive places are hard to find, and waiting lists may be long. In Memphis, where the Methodist Church sponsors several well-run, federally subsidized apartment buildings for seniors, Jerry Corlew, one of the directors, says there is a waiting list of 1,400 for the 400 apartments. Depending on the location, the wait ranges from three months to three years. The lesson: Get on several lists early. Parents should also know that if they wait until they are sick to move to new housing, they will limit their options significantly. King's Row, an apartment complex that provides meals, housekeeping, and social activities for the elderly in Middletown, New Jersey, requires residents to be -- and to remain -- ''continent, mobile, and oriented to time and space,'' says manager Bonnie Coffino. An oldster who remembers $90 mortgage payments will be stunned at the cost too. King's Row, though neat and pleasant, isn't much fancier than a good motel, but studio apartments cost $1,864 a month. ''You can't live here on Social Security alone,'' Coffino warns. ELDERS whose medical or family history makes them worry about a stroke, Alzheimer's, or any long period of incapacity might want to look at a so- called continuing-care facility. This is one of the fastest-growing new forms of senior housing. It combines apartments for those able to live independently, an ''assisted care'' section for people who have trouble dressing or using the bathroom, and a nursing home for those needing full-time care. Continuing-care facilities vary in important ways. Some, like Applewood Estates in Freehold, New Jersey, require a big entry fee up front -- between $90,000 and $140,000, depending on the size and type of apartment. Monthly rent and fees for a couple come to another $1,700. However, the rent does not go up if one of them needs to move to the nursing home. The facilities appear similar at Bedford Court, a continuing-care facility run by Marriott in Silver Spring, Maryland. But the finances are much different. Bedford's up-front fee of $7,000 is refundable, with interest, if a tenant leaves; the nursing home, on the other hand, costs $40,000 a year. Last year Jack Whitwell, a retired Princeton professor, and his wife, Blanche, moved to Applewood. She had fully recovered from a serious illness, but both feared a recurrence might mean moving her to a nursing home. ''We were paying a lot for our house and for nursing home insurance, and determined that a continuing-care facility would cost about the same,'' says Whitwell. Your parents must be in good health to enter a continuing-care home. Applewood asks to see their medical records and reviews their finances to make sure they can afford the place, says marketing director Jack Titus. Study the track record of the operator of any home you're considering, and have a lawyer familiar with elder care issues review any contracts. Some homes have gone bankrupt, often meaning that residents lost their up-front fee. Should you plan to move your parents into your own home? Most expert opinion counsels against it. They get cut off from their friends, lose autonomy, and often bicker with their children. ''There is no kitchen big enough for two women,'' argues Rose Dobrof, head of the Brookdale Center on Aging at Hunter College in New York City. Dobrof says her father-in-law made her promise, on her wedding day, that she would never put him in a nursing home. When he could no longer live independently, she felt obliged to move him into her house. He missed his home and friends of 50 years, and his last years were difficult for everyone. ''I should never have been pressured to make that promise,'' she says. Parents sometimes won't admit they can no longer manage by themselves. A mother may hide from the children that her husband has Alzheimer's, or that an expensive new prescription means they can't afford groceries. The result: When the kids go home to visit, they are often aghast at the problems they discover. Agencies that work with caregivers report a spike in the number of desperate phone calls right after Christmas, when all those offspring returning to the family homestead have discovered their parents' lives in disarray. Suddenly or gradually, ready or probably not, you understand just how hard a time your parents are having as they try to cope unassisted. Diane Piktialis, who heads the elder care referral program for Work/Family Directions, a Boston firm that advises employees at dozens of large corporations, identifies the following signs of trouble: forgetfulness, mood swings, weight loss, lack of grooming, and unpaid bills. Your job is to help your parents keep safe and independent for as long as possible. A surprising number of services are designed to assist you. If an accident or illness already has your parent in the hospital, contact the social services director there. Virtually every hospital has one, though your doctor may not think to tell you. A good social services person will evaluate a patient's needs for assistance after discharge and arrange his care -- even place him in a nursing home. The hospital should not pressure you into taking home a relative you can't handle. If, after discharge, your parent still needs help from medical professionals, doctors can prescribe an array of services. Cedars Sinai Hospital in Los Angeles, for example, has a small mock village, complete with shops, curbs, kitchens, and teller machines, to help stroke and accident victims regain skills. Occupational therapists can teach an impaired person how to brush his teeth again or cook, and devise solutions to other problems by using such props as oversize buttons and grab bars for bathtubs. Medicare will sometimes pay for such services -- but usually only for a few weeks. IF YOUR PARENT'S PROBLEMS develop more gradually, there are other avenues of assistance. Large corporations often have elder care resources for employees that include literature, videotapes, and seminars on topics ranging from guilt to finances. You can also call on your local government for help. The department responsible is often listed under the Area Agency on Aging. Don't worry, it's not welfare; many elder care services are available regardless of how affluent the recipient is. One man in Santa Monica, California, uses the town's elder care ambulance to get his mother to the doctor because her stretcher won't fit in his limousine. In most cases the town or county contracts with local nonprofit groups to provide care. A confederation of 350 churches handles virtually all the organized elder care in Memphis. Sister Mary Simon, a Catholic nun, runs the Monmouth County, New Jersey, office on aging. ''Call us early,'' she suggests. ''Ninety percent of the time, people wait until they are exhausted from elder care before they seek help. Often it's the people who tried to do too much and get to the end of their rope who wind up abusing their parents.'' Nearly all area agencies will send a trained social worker to evaluate your parent's problems and to help arrange services. Most agencies provide transportation for shopping and medical visits, day care centers where otherwise isolated seniors can socialize with peers, and daily home delivery of a hot meal. The last is particularly useful, because the volunteers are trained to look for signs of trouble and report back if the person fails to answer the door. For frail elderly who cannot afford to pay, some agencies will provide homemakers to help with grooming and housekeeping a few hours a week. Waiting lists for free services are often long, but sometimes just a little money will go a long way: Memphis oldsters who pay $3.75 a day can be put on the ''upscale'' Meals on Wheels route without delay. For families who can afford it, one of the most useful new services for elder care is the private geriatric care manager. These are typically social workers and nurses who arrange and supervise most of the help an elderly person needs. They are particularly useful if parents live far away from children, or if relations between the generations are strained. New York City case manager Edith Bayme hires, inspects, and fires in-home care aides for clients; pays bills; arranges placement in nursing homes; and even made daily visits to a dying woman whose kids couldn't get to her bedside. Robert Giese, chief executive of a computer sales and service company in Rochester, New York, hired geriatric care manager Marianne Ewig three years ago after his mother in Milwaukee was found unconscious in a diabetic coma. When she recovered, Ewig noticed a hearing problem and had it diagnosed and treated. Giese says Ewig then realized that his mother was depressed. She arranged for Louise Giese to see a psychiatrist and set up visits between her and other lonely seniors. Once the depression was controlled, Mrs. Giese was emotionally prepared to move to an apartment complex for the elderly that Ewig found. PRIVATE CARE managers aren't cheap. Ewig charges $65 an hour. Mary-Ellen Siegel, a private geriatric social worker, says the going rate in New York City is $75 to $100 an hour; the bill for a typical case requiring two visits monthly and phone calls to the parent and children could be $250. How do you find the right person? The National Association of Private Geriatric Care Managers in Tucson, Arizona, offers lists of experienced professionals by region. Local organizations that work with the elderly can also make suggestions. Keep in mind that states don't license elder care managers. Are you a failure as a son or daughter if you have to send Mom to a nursing home? No. For many older people, especially those requiring 24-hour care, a home eventually becomes the best choice. Alzheimer's victims may start wandering the streets at night or leave the stove burning for hours. In other cases a caregiver may be unable to lift the still-at-home parent out of bed. If your parents pressure you to promise never to send them to a nursing home, don't humor them or lie. Assure them that they will be involved in the decision, that it will happen only if it is absolutely necessary, and that it won't be a surprise. ) EVALUATE nursing homes carefully. The lady at the front desk will have a big smile, but the care your mother really gets comes down to the low-wage aide, often an immigrant, who hoists her out of bed and changes her diaper. Inquire about staff turnover, training and wages, the ratio of nurses to patients, and the visiting hours, which should be almost unlimited. Many states perform regular inspections of nursing homes; you can get copies of the evaluations from local agencies for the aging. There are several kinds of nursing home care, and the differences are important. Medicare, ''Medigap,'' and most private health insurance policies pay a limited amount for ''skilled nursing home care,'' which requires the services of doctors, nurses, and rehabilitation experts. They do not cover nursing home costs if the patient there can get by with relatively unskilled custodial care. The probability that a woman will enter a nursing home at some point in her life is 1 in 2; for men it is 1 in 3. Many patients stay only a few weeks to recover following hospitalization. But the risk of a long stay -- one year or more -- is 1 in 7 for men and 1 in 3 for women. The homes cost a bundle -- an average of $30,000 a year in 1990, and as much as $50,000 in large cities. Since the median household net worth for people over 65 is $73,500, and the average annual income for senior males is $14,000, according to the American Association of Retired Persons, a long stay will bankrupt many families. Daniel Fish, a New York attorney specializing in law for the elderly, sees the problem up close. ''The phone call I get a lot is from the spouse or children of an elderly person about to be released from the hospital. They've just been told he has to go to a nursing home and that Medicare won't pay. They are hysterical and desperate.'' What happens? When the family gets poor enough, a welfare program, Medicaid, will pick up the cost. Rules vary by state, but a single or widowed person can have only about $2,000 in assets to qualify for Medicaid. Depending on the state, a spouse can retain between $13,700 and $68,700 in assets -- hardly enough to live off the income. There is an escape: A person anticipating a long nursing home stay can transfer all his assets to his children or to an irrevocable trust, and thus qualify for Medicaid. The hitch is that the transfer must usually be made 2 1/ 2 years before Medicaid begins. It is perfectly legal, says Fish, who arranges many asset transfers. / Proponents of transfers view them as ethically akin to shrewd tax-avoidance maneuvers. Opponents say transfers, especially when orchestrated by greedy relatives who don't want to ''waste'' their inheritance on Dad's nursing home care, take money away from the truly needy. Once the money has been given away, the parents cannot get it back even if the children are spending it on themselves. Also, good nursing homes usually charge more than Medicaid pays. A person relying solely on Medicaid may have to settle for a shabbier setting. Many good homes, however, will let people who came in paying the full private rate remain once they must use Medicaid. For families who have made some advance preparations, elder care should not be a crushing burden. It may be a disruptive surprise, but professionals in the field have observed that most children -- even harried baby-boomers struggling with young children and midlife crises -- assume their responsibilities willingly and without resentment. The caregivers who suffer most are those who try to do too much alone. They should realize they will do themselves and their parents a greater service by seeking help. When your turn comes, be conscientious. Remember, your own children will be watching. And someday you may be on the receiving end of elder care.

CHART: NOT AVAILABLE CREDIT: FORTUNE CHART/SOURCE: ANDRUS GERONTOLOGY CENTER, UNIVERSITY OF SOUTHERN CALIFORNIA CAPTION: WHICH PROBLEMS HIT AT WHICH AGE Most people in their 70s are healthy enough to live independently; by their 80s, however, many need help. About 42% of 70-year-olds live to be 85. But only one-quarter of 85-year-olds are in good health.