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I'm looking for some advice by people who have faced similar challenges. My father who is in his mid-70s has cognitive impairment.

He recently had a serious accident resulting in a third degree burn. He was burning trash outside and accidentally lit his clothes on fire. For a brief period the fire was burning out of control. He was within 50 feet or so of a very large propane tank. Fortunately, he was able to control the fire before any huge disaster occurred. He had to have a skin graft and has been in recovery at a skilled nursing facility following a couple of weeks in the hospital.

Three years ago, he had a major stroke which left him with minor memory problems and some speech difficulties. After his surgery about 3 or so weeks ago, I noticed his memory and speech difficulties worsened significantly. He also had a few instances of paranoia, extreme anxiety, and recently, talking to himself.

The skilled nursing facility conducted some tests and based on the results, he has moderate cognitive impairment. Based on their assessment, he should not return to living on his own. He needs nearby 24-hour care, like the level of care available at an assisted living facility. I think some of his memory and problem solving issues may have been caused by pain medicines. I've seen some improvement, but his memory, speech and problem solving abilities are still quite impaired. He has multiple health issues, including diabetes for which he requires insulin.

He is expected to be released from the skilled nursing facility in about 2 weeks. He claims he can take care of himself at home and he is fine to drive. The skilled nursing facility says, and I agree, that he cannot. And, he lives about 2 hours away from me, his closest relative, and his home is filthy and he is living in the house without a certificate of occupancy. It is unfinished with no railings inside. The house is loaded with paper and garbage. There are numerous safety issues for a person with no cognitive impairment. His car isn't much better.

I know that I can take the path to have him declared legally incompetent, but am concerned that even if I do, I can't force him to go to an assisted living facility. I'm stuck and I have a family of my own with a very busy family and work schedule.

I don't have lots of time to run him around to various physicians who are going to confirm what the skilled nursing facility has already confirmed through testing and observation. And, I'm pretty sure he's just stonewalling. Other physicians in the past have said he shouldn't be living on his own. If the fire, which could have killed him or caused him to have to have his leg amputated, isn't enough of a warning, I don't know what is.

He can afford to live in an assisted living facility for about 10 years. Given his health conditions, it's unlikely he'll live that long and if he does, we can worry about it in 5 years or so.

Where do I go from here?

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Karen, just to clear up; my mom didn't come home from rehab early - she came home directly from the hospital, with arrangements having been made that she was going to have her rehab at home with me there; they didn't come inspect her home but think they may have, if they would have even let her do it that way by herself (well, with my dad) if I hadn't been going to be there; her home did have some issues but nowhere near that bad but I did have the carpets cleaned while she was in the hospital and I think there were some other things that were supposed to have been done that not even really sure realized didn't get done until later when things did get worse but we weren't quite at that point then like Pam is; wondering how things are going; seems like it's probably getting close to 2 weeks
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Pam, I had the same experience as Debdaughter. My mother came home from rehab early, against doctors orders (because that's how she is...don't get me started)! Even then, they would NOT release her until they came to inspect our home and made sure that she had help. Good luck!!!
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Tough time for him and you. I too agree that guardianship may be necessary; but i truly value the advice given to me about always respecting my care-receiver with choices. Living home alone is not a choice, but are there choices in addition to assisted living? Just sharing that this approach has resulted for me in positive cooperation and more gentle surrender with Mom and all care changes/decisions that arise. I too feel better in the end to have offered her a little extra dignity that is so challenged by Alz/Dem; not to mention that exercising my own creativity is good for me.
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on another group I'm on for something very different - but apparently many times these things dovetail - someone in a very similar situation said the facility their father was in required a home check before releasing him - might be something to check into
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With the healthcare proxy they can discuss his health with you and if they feel he is impaired which you already said they have stated, the Doctor can then activate your proxy and you will be given the authority to make decisions on his behalf.

Filing for guardianship is another route but involves filing in court, it is expensive, and I have a family member who has to go that route and it took her eight months to get a determination from the courts. This way is easier and faster.
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I would insist to the facility that he is in that he can NOT return home for safety reasons. If you do not have POA or healthcare proxy I would work immediately to get that into place. There are forms that the hospital has for healthcare proxy that they can have him sign and a POA can be downloaded from the Internet, but needs to be signed by a notary.

That should be done ASAP.
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how much does the nursing home know about all this?
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Zombie, that sure does suck. You should not have to live like that, and of course he should not live like that either. APS can be a catch-22 because as long as you are there doing everything, they will say he seems to be OK...some people have had to leave and call in a welfare check but it can be risky to leave someone like that alone. Well, if he won't go to the mountain - you could invite a health care or social service person in to see him instead; they would likely do the incapacity letters you need. And, you have an option of filing for a guardianship. I googled "starting guardianship proceedings when medical care refused" and the first hit is this one: resourcesforseniors/ssarchive/lawyerapril02.html which might be of help. Every state is different so I would put that in as a search term.
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He sounds like a proud man. et him keep that by asking him if he would consider living w/you,{maybe add an apartment?},because it would help YOU out?
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oh, Karen, I'm past that point but it was dad's eye doctor - ophthalmologist, somewhat any way, well, may have reported him even though he didn't have an ALZ diagnosis but dad's license ran out and he didn't realize it at the time but then he did and wanted to go get it renewed but then he'd forget about it so it just became a nonissue - so take it not that way with your dad...
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Debdaughter, I'm sorry, but I'm not sure. This was an ongoing conversation with my dad FOR YEARS. I'll admit that I've been to many lectures and seminars on the subject, and most recommended to have the dr. be the bad guy. I don't know if I was just unlucky or what, but my dr. wasn't much help. I've heard that it was a legal mandate, but drs. are only human and sometimes don't want (or don't have time) to get involved. Don't let that stop you! Keep trying. You can do it! Be brave!
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Yikes, so many people in the same boat. The system is so hard to maneuver. I recently found paperwork that I have DPOA but, since my father won't go anywhere and has refused to see any doctors in two years, I have no doctors that can declare him unfit to care for himself. He doesn't want help. He just wants to sit all day in his filthy clothes and rot. And, I'm supposed to just take care of everything else, and he'll be fine? I can't even make him get a hair cut even if I offer to drive. He doesn't have the desire to need or want anything. If I didn't feed him, he'd only eat breakfast biscuits. Life sucks.
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Karen, do you know - does that only apply to a neurologist?
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In San Diego, Elder Law provides free assistance for seniors at local senior centers. Please look into that! Perhaps there is some kind of free elder law in your area, too! They helped me with my parents. We had several discussions with my dad about his driving. It was very emotional and not very effective. Our family dr. didn't do or say much, but she did refer dad to a neurologist. Once we visited a neurologist and my dad got an ALZ diagnosis, the neurologist had to report him to DMV by law. Now it's off me. Dad isn't happy, but he can no longer blame me. DISCLAIMER: I work with seniors. Just because they don't have a license or keys may NOT prevent them from driving. Beware, they can be sneaky like teenagers!
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It's great he can afford the fees for assisted living. With his cognitive decline and paranoia he probably will not agree, what does his doctor say about his mental status? If you need to look at guardianship, you will need 2 physician's statements before the petition is sent to the court. Speak with an attorney after you speak with your father's doc. Good luck, I know it can be difficult but if he's not mentally capable of managing on his own, then you need to do what you can to keep him safe.
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An Elder Law attorney will be able to guide you through this process and advise you if your papers are in order and when to do what. They are expensive however. You might ask them for a referral to an Elder Care Manager. They are also expensive but not like an attorney and their outrageous fees.. Can he still pass his Driver License exam? My mom couldn't and even though they kept giving her the required 2 mos and it took about 5 trips to the DMV, at least I wasn't the one that took her driving privileges away. Your city government probably has a Department on Aging that would be able to give you good advice on what to do. It's a long hard road you're about to start. I wish I could tell you different but it's not. Educate yourself. You may want to call the Alzheimer's Association. They were invaluable to me and had good, local sound advice.
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yep, muzette, I ran into that with my dad; except, fortunately, ours was through the VA and he'd do almost anything for them
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Also I believe you can go to your local DMV and report that he is likely an unsafe driver. They may require him to come in for a driving test. If he can't pass, he will lose his license. That at least will prevent him from an accident that could hurt others. Unfortunately, from my recent research, the elderly can pretty much do what they want and you cannot force them to get help. My 87 year old father seems mentally sound in all respects, except he has been sitting and sleeping in a urine soaked bed and clothes for three weeks and doesn't seem to think that is a problem. Won't change clothes or clean himself. But every authority I have checked with so far says there is no legal way I can force him to get help, or even to allow help into the house. I had two professional caregivers ready to help me clean his bed and he would not let them in the house. Legally, I am out of luck until he is delirious or unconscious.
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Get the incapacity letters. Make oodles of copies. If you need guardianship go for it; if you can cajole convince or otherwise muddle through without it great. I needed only a few communications with the attorney with my parent's estate planning company, and one elder law consultation after I finally moved Mom to my state. I never did need the guardianship, just the letters that more or less "fully activated" the POA so I could do the more major things like sell a home and sign off on things. It's hard and its a steep learning curve. I wish you well!
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He cannot live alone. My mother choose to live alone in Massachusetts.That was a real problem for my husband and I b/c I had to move in with mother from my home in Maryland for a long term duration of time.
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You have recieved excellent advise another place to contact is your local codes Enforcement officer. it sounds as though the house may not be fit for human occupancy and Codes can deal with that. get moving fast before dad gets released. By the way you can refuse to pick him up.
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I am in a very simular situation now. For the past 5 years both parents have been living in their home with medication issues, unpaid bills, falls and the home is filthy and my mom is a boarder line hoarder. This past year there have been many trips to the ER and hospital/rehab stays. Most recently, my dad went to rehab and I tried to place him in the NH there permanatly then have my mom placed however he took a cab home.

A visiting home health nurse had reported them to an elder abuse hotline on a Fri which really got the ball rolling. On Mon, a social worker from the state called me so I filled her in on everything that has been happening. Note: I called the social worker from home health many times previously and nothing was done. My advise is to call the elder abuse hotline ASAP.

I consulted with an elder law attorney and she said that the medical POA's that my parents have states that I needed a letter from two Dr's stating that due to their impaired capacity they are unable to make healthcare decisions and that they are a danger to themselves and that the Dr invoked POA to me.

Within 1 week of the social worker being notified, my dad was back in the hospital. 3 days later, my mom fell and cut her head open resulting in her being in the same hospital at the same time.

My mom finally realized that they can not live independantly. Her Dr that was treating her in the hospital told her she needed rehab and needed to live in a NH afterwards. She was transferred there 2 days ago from the hospital. Meanwhile, dad is still in the hospital now with an infection due to loose hardware with a previous knee replacement. My dad will go to the NH to be with my mom when he is released here.

What I have learned from this experience is that if a parent doesn't want to go to a facility you can't make them unless you have a DPOA and have the required number of Dr's stating they are incompetent. Per my attorney's advise, check with the facility to see if they will take the DPOA as some of them may require guardianship however I did not find that to be the case with 3 that I called.

If they don't have a DPOA then you will need to file for guardianship. Luckly, I did not have to go this route. The state SW told me that the court will assign an attorney to my parents if they can't get one themselves. If they can not physically go to court the attorney will represent them. They judge will hear the evidence then assign gardianship. If you don't want to be their guardian, the court will assign one from the state however, they will place the parent any where they choose.

Best of luck to you. I understand what you are going thru.


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I did have this similar situation. The good news is that you have the evidence from the SNF regarding his cognitive assessment but you may have to get more, dependent up on the State and their guardianship process. My father was had a heart attack and was going to be released from hospital. As an OT, I recognized frontal lobe issues of grandiose behaviors, swearing (which he never did), and various other things, that my siblings did not. I asked for psychiatric placement for testing. This was not taken well by hospital staff who wanted him out but I insisted. He had anoxia (due to heart attack) and did have frontal lobe dysfunction and I went before a judge and got guardianship. The law favors the individual (as it should) and you need to have good documentation. The SNF probably had an OT or SLP do this documentation, and not a psychiatrist. So you need to seek this out as to what you need to go before a judge. Good luck.
If I had not done this, my dad would have gone home, drove and spent all his money on whatever as he was thinking he was on top of the world!!! Very hard!
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This is a drastic situation. When I read your headline I was going to tell you how to transition him by asking him about how he is experiencing getting through his day to help him recognize his impairment. However it appears his impairment is in an area of his brain probably the frontal cortex that cause him not to see his decline. I agree that guardianship should be sought through the courts but it could not hurt to higher a private care manager/ advocate in addition to seeking guardianship. A professional advocate/care manager will walk him and you through the process and will elviate some of the stress of the situation from you and your father. I would suggest a ver experienced RN care manager/ advocate who has access to a mental health professional in their group that understands his cognitive deficits. These professionals will know the system and have experience working people through the transition. You would pay these professionals out of your Dad's money and they can help you navigate the systems that will save money and get access to public programs and services.
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You are very lucky that he can afford ALF. My father cannot afford it. I had to take my father's car to stop him from driving. He broke his hip and while in the hospital I took the car. That sounds like something you can do right now. I was very matter of fact about it. I said I couldn't live with myself if he hurt someone (including/especially himself). I don't know where you live but in NYS your doctor can help with this and DMV.

Can you work with Adult Protective Services? The nursing home can say they cannot release him to his home because it is unsafe.

I have no experience with guardianship. But, it sounds like it might be necessary. Talk to a lawyer, I do know it is hard to get someone declared incompetent.

Try to be matter of fact and as unemotional as possible. There is no point in trying to appeal to him emotionally. My father didn't even care when I asked him if he would feel bad if he hurt someone's child (or his own grandchildren) because of his bad driving. He basically said it was his God given right to drive. That's when I knew I would stop at nothing to stop him from driving ever again!

Best wishes. It's not easy but you will get through it.
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You immediately pursue emergency Guardianship and get a court order to place him in ALF. Do not delay. You don't take him anywhere, the court evaluator will go to him and sort it out. No other way. Legal fees should be paid from his funds.
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