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I'm am 18 years old and have been taking care of my 80 year old grandmother for about 2 months now. Her husband has been deceased for 14 years now. My grandmothers daughter (aka my mother), passed away in 2008 and her son (my "uncle") doesn't want to have anything to do with my grandmother or my family and is just waiting for her to die. My father and grandmother have never gotten along, so it isn't a choice for my dad to help me take charge. I am alone on my own with this situation I about about to speak about so any help is appreciated. Two years ago, my grandmother had a very bad leg infection that cause her to fall and had to be rushed to the ER. My father, my younger sister, and I have been left to take care of her dog on top of our own cat and dog, which wasn't a big ordeal for a few months. She was then transferred to a nursing home/rehab center for care while she got surgeries on her leg. She was then diagnosed with a cancerous brain tumor and had to go through tons of chemo. She beat the Cancer and the leg infection, and was then told she needed surgery for cataracts is her eyes (that hasn't happened yet). I did not know about any of these things, because my uncle did not keep my updated because he himself could careless about her and wasn't there to support her. After many calls and pleas for me to help her get out and back home, the nursing home finally was able to get her discharged and healthy enough after a year and a half. I drove her home, went grocery shopping, cleaned her house, cared for her until the home care nurses and aids were able to start visiting her a few times a week. She got weaker and weaker, was barely able to go to the bathroom alone, refused to eat food that she asked me to get for her, and couldn't make it to the phone in time when the aids called to let them know they were coming, so they didn't show up. Multiple times I let the home care know the door was unlocked and they were able to get in. She would always end up on the ground because she was too weak to walk, and I would always have to throw out my muscles trying to help her up (I don't want to admit it but I'm a frail, 110lb female and she weighs 175lb, and cannot lift her like that on my own). One fall last month I needed to call an ambulance, and they admitted her to the hospital. She was discharged and sent home and was fine, but things started to progressively get worse. She wasn't taking her medicine on her own, she wasn't washing herself, and refused help from the aids when the call but insisted I came over to do everything for her. I did when she needed it, but its honestly starting to wear me out a lot. Just this week, she fell again and called an ambulance, but apparently refused to go to the hospital when they came. I haven't heard from her all week, she usually calls me every day, so I decided to stop at her house. I found her on the floor, again, crying for me to help her up. I refused, propped her head up, and called an ambulance, and she was takes to the hospital. The house was a complete wreck, nothing like I had seen from her before, feces were covering the bathroom, and trails of it were on the floor from her crawling. She hasn't been taking her important medication, or antipsychotics. She is a threat to herself but refuses to go to a nursing home. She is not in the right state of mind, and says and does irrational things half of the time. I am afraid for her and her health. I don't want her to live the way she is living. It is also starting to kill me. I lost my job, I can't go back to college, I'm getting physically sick, I'm getting panic attacks, and I am developing extreme insomnia. I have issues of my own such as severe clinical depression and have been trying to battle it for 5 years and finally got to work with a psyciatrist last October. This situation is hindering my ability to get better mentally and is making me hurt mentally and physically. She is in the hospital right now and I believe this is the best chance for me to talk to someone there about this whole mess of a situation. I wish I would have never taken her out of the home. I cannot provide adequate care for her, and I feel bad about that. I want her to be well cared for 24hrs like she needs. I am basically her primary caregiver other than help from her aids/nurse/physical therapist that she sees a few times a week. I am alone, and have no advice from any one else. Any input would be highly appreciated. I'm just worried I wont be able to get her into a nursing home because she continuously screams about the "misery" at the last one and how she will never go back. That is the best option for her, she cannot care for herself even with the help of us, and she needs 24hr care. I need all of the help I can get.

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All the previous posters have great ideas and suggestions! All the best! Some background from my grandmas cycle of "Fall at home, Break bones, Go to ER, Rehab at Rehab facility, Discharge to home...and repeat." I am not sure if you are having/had meetings with the rehab staff on a regular basis; definitely request a discharge meeting with the PT,OT, SW, Rehab Coordinator, and have your Grandma present. What I heard everytime was: "Your grandma has reached a point where no further treatment will make her better. She is at a plateau point where Medicare and her current insurance will not cover any further expenses here. We have to discharge her." At that point is where I requested all those at the meeting to advise me of what other alternatives are available instead of her going home to fall once again. They all agreed that she shouldn't be at home...there was just nothing they seemed they could do about it...or had the knowledge to share with me on what the solution was beside repeating the cycle. Once I even asked for a Medicare review (Rehab facility did not like that at all!). I also found that I could keep her in her same room there, and even get the staff to fib to her about her needing to stay a bit longer...its just very expensive to do so of course. Each time I would lean on the SW for guidance...and finally took it upon myself to research, locate, and tour LTC facilities that would take Medicaid (because eventually my grandma would financially qualify), read up on Medicaid, how to qualify mentally/physically & financially, what tricky diagnosis words and phrases I needed to ensure were in her record "cognitively declined" "mentally disabled". Really leaned on her primary care doctor and contacted DOA and all of the resources they had. Read as much as I could on this site and took down notes from all the posters who had knowledge and advice to share. Took pictures and recorded video of all the issues dementia was causing: bruising, wounds, overcooking, leaving the stove on, lashing out with anger and hitting, wandering down the street, etc....and then promptly showed the pictures and played the videos to anyone who thought for a split instant that grandma was okay to be on her own at home for any length of time. I know I was being discriminated against due to my young looking face and the fact that I was 2 generations removed from my grandma...no doubt you are likely feeling the same way...and for us, we definitely have to do more. Continued best, I am proof there is light at the end of the tunnel and things work out.
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What VStefans said. Write it out and rehearse it.
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The phrase we kept repeating was "unsafe discharge". My sister camped out at the hospital at 6AM to catch the doctor and one of us was there all day. When he did rounds, she outlined every symptom we knew of and pushed for assessments and evaluations. The doc was the one who got the ball rolling, OT, PT, cardio. On a side note, you are one impressive lady, with strength, intelligence and compassion.
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OK. Here's the script. Tell the social worker - "look, GM calls me daily stating that she is discharged and ready to go home and I should pick her up. And she says you can't reach me but here we are talking daily. She does not know what day of the week it is. She is confused and she obviously has significant dementia, and I cannot take care of her at home even though that's what she wants and expects. I am 18, an adult, and not stupid, and I need accurate information and a realistic alternative plan for her."

If you get more BS answers, then the next thing you say is "You're not listening."
Pause and repeat "You're not listening." Social workers pride themselves on listening skills so this should stop her cold from rambling on with more BS. You tell her firmly, "The discharge plan to send her home with me as her caregiver will not work. She cannot stay at home alone - we both know that, and I cannot and will not stay there 24 x7 with her." Rinse and repeat. Demand to talk with her supervisor. Demand to talk with the physician. If they try to blow you off, you tell them you will call the ombudsman and the office of long term care.

Is it possible the SW is inexperienced or dense enough not to realize that GM has dementia??? Otherwise, This. Makes. No. Sense.
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Grr - Jessica, I expect some well-meaning fat-head is feeding your grandmother bromides about going home "mañana" and she, poor innocent soul, is taking them literally.

Can you get an assessment lined up ready with her GP/PCP for when she's discharged, if the SW is still harping on the 'temporary' theme?
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Jessica, I hope so too. I have my fingers crossed for you - along with a lot of prayers that you will get some help. It seems the key is the evaluation and for now, you aren't getting cooperation from the facility or social worker. If all else fails and protective services doesn't come through, maybe finding a good geriatric psychiatrist who will evaluate her and make the right decision which will give you the legal authority to move her even if it is against her will. Family doctors just don't want the responsibility of taking away someone's independence unless the person is certifiably over the top. Keep us posted!
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Jessica, I am hoping and praying that they can see how disoriented grandma is and they get her to a safe place with 24 hour care. You are so young!! So many things ahead of you!
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* and physical therapist for a period of time.
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Update: My grandmother keeps calling me telling me she is discharged and needs picked up. She is also saying nobody can get in touch with me and that the social worker hasn't spoken with me and can't get ahold of me either. I've spoken to the social worker, three times now, and once yesterday. The social worker again stated they won't be doing testing on her, and I mentioned protective services yet that didn't seem to matter to her at all (as I expected). She did say my grandmother isn't quite done with her treatment and they still did not have a discharge date for her. This was yesterday, and my grandma called me today saying she can go home. I'll believe that when the social worker calls me, since my grandmother thinks it's Sunday and still believes she's at the hospital. So no real progress, just an update about what the social worker said, which is everything I already heard. I guess I will be relying on protective services once she is home. I'm praying they send her home with the in home nurses
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Jessica,

I am writing to give moral support and to tell you not to feel guilty. I am a 70 yr old retired RN, who is responsible (from far away) for both my parents. My Dad is already placed in a facility due to his dementia getting so bad. He is 93. Mom is at home and now with caregivers and is 89. Her dementia is getting worse. Here are a few things that others have had to teach me...the RN who has been a caregiver all through my career...

1.Caregiving with a relative is NOT about giving them everything they want. It IS all about keeping them in a safe situation first of all.

2. When the person needing help is up and down at night; falls a lot; has problems with being incontinent; has dementia or is argumentative, violent or uncooperative....think about this....in a care facility, or a hospital, nursing home or such...the caregivers are 'on duty' for 8 hours or 12 hours. NO ONE does it for 24 hours/7 days a week with people who need that kind of assistance....so no family, without the skills and training even, should be expected to do it 24/7 in the home! You don't do this 'just because someone is family' Many caregivers who take on this 24/7 stuff end up dying long before their time, from the stress of it all.

3. It is MUCH better for your grandmother, and anyone else's family member in need, to have a loving family member come visit them, AS FAMILY....than to have them over stress, short tempered, too tired to even talk and potentially resentful of the responsibility.... and let STAFF do the physical care needed. Your grandmother is going to appreciate you coming to visit, and bringing a little treat or gift and just being able to sit and talk about her, and gather her family history while she is alive, to get her talk of her childhood and pleasant memories of her life.... that is a 'gift' you can give to her in lieu of just 'caring for her' at home, until all this crises happens again. Commiserate with her about how you agree it's tough getting old, but stick to the line of 'the doctor wants her to be where she is until she is stronger'....and 'put the blame elsewhere' while you are there as her friendly loving granddaughter....the bright spot in her day! Move towards, just being her friend.... That is the kind of 'care' she needs from you!! Your life needs to move forward. YOU are your grandmother's legacy....and if she could see and feel more clearly, she would want you to go about your life....your future and for you to BE her legacy too! I do hope this helps you! It took me a LONG time of dealing with a difficult Mom to come to this understanding myself......
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Jessica, we all know you would never leave your grandmother there to take a taxi and that it was a rhetorical question. But, that might be what they would do for anyone who didn't have a ride, especially when they have determined the patient is "competent". I hope they will re-consider evaluating her for both your sakes. They are doing her no favor. Some hospitals - when you are discharged, they are done with you unless you connect with the right person! You are doing a great job and will get results soon. We all wish that for you.
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Jessica i am feeling you..... i too am a single caregiver for my 67 yo mother. My 2 brothers dont help me either. My mom recently was admitted to the hospital for chronic pain and unable to move on her own. The hospital told me i had to take her home. I cried all night and all day. I too could not finish my college class because of this. I understand giving up everything because this is the right thing to do though it is overwhelming.... i cried to the doctors and social worker here at the hospital that im unable to give her that care. Like you im small built and my mom too but picking up dead weight caused me some aches. The hospital is now putting her in short term rehab.
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I was told transportation would be provided on discharge day and the cost added to the invoice. The main thing I learned is that the rehab (Medicare) only covers until the person gets to a plateau. Then it is up to the care recipient and team to investigate whether the person goes back home or other living arrangements are made via private pay and/or a combo of that and VA, Medicaid, LTC insurance, what have you. Obviously with the person indicating there is nothing wrong with them and you not having POA that puts you in a tough spot. She'll end up at home, and hopefully before anything happens to her, the DOA evaluates her accordingly and based on the evaluation takes some action. Or at least you'll know what steps you have to do on behalf of your grandmothers safety. Sounds great on having the appointment to evaluate her. They will be able (if they are good and spend even just a little bit of time with the interview) see what is really going on...and really what you have been going through as well. I believe it will ultimately come down to the tough decision by her doctor and these professionals that have evaluated her to make the decision to begin the approval process for LTC somewhere. There is a resistance to removing someone from their home, especially when the person does not want to go. Having POA for me, made it easier no doubt. Within the DOA, you may find resources for elder law free services combined with local university law departments willing to do the the POA at little or no cost. The trick is then to get your grandmother to sign such a document. Feel free to play those messages left by your grandmother to the interviewers. Also, If you have a smartphone or camera, start taking pictures and recording as much video of your grandmother's issues, time in rehab, doctor's offices. That has helped in so many ways letting anyone and everyone know what the true conditions and needs of grandma really are. Continued best!
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Jessica you'll want to check this with the discharge planner at the care facility - may turn out to be Ms Helpless, but let's hope not - but the routine should include an OT evaluation of your grandmother's home and how exactly she is going to manage when she gets there. If/when that evaluation takes place, you need to be there while making it crystal that you are not your grandmother's primary caregiver and you do not have any responsibility for her. So you shouldn't be driven to the point of having to refuse to take her: support will, technically anyway, need to be put in place before she can be discharged. Unless they somehow come to the perverse conclusion that she's managing just fine… But that's why you need to be there: to point out the hazards and pitfalls and sites of previous incidents.

The thinking you hate her thing - my daughter would say "aw, poor li'l Granny!!!" She's not necessarily playing victim, she's probably struggling to work out what's changed. Send her a jolly card saying you're rushed off your feet but love her loads and you'll see her soon (((hugs))) - that kind of thing. You need to break that close association in her (and others') mind between loving your grandmother and being held wrongly and grotesquely responsible for her wellbeing.
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Let me also mention that I wouldn't actually leave my grandmother there unless I knew for sure that she wouldn't be leaving. I would never let her take a taxi or a bus in the mental state she is in, let alone the fact that she can barely walk 10 feet without getting tired.
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Wow, I don't know but I'm guessing that they would call a taxi to take her home if you are not there to drive her.
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Update: I just got off of the phone with my local area agency on aging protective services, and the man I spoke to was the kindest and most helpful person I have encountered during this entire time. I told him all of the circumstances and my concerns, and he told me for legal reasons, they cannot go in to see a person while they are still in a facility, but if/when my grandmother gets out and back home (which will probably happen, realistically), they can send their team out to evaluate the home and my grandmother almost immediately. He said that situations like these are very hard, because even though I can see that she is deteriorating mentally, none of us can do anything if she passes the evaluations they give. it's just a process of waiting a matter of time until she fails the test and someone else has to make decisions for her, which he said is a very unfortunate situation in the case where the elder refused to go somewhere. He mentioned a POA (which I know all about but my grandmother doesn't have one, as I asked her). I also told him about how the home she is in now won't do testing on her because she's not long term care, and he agreed that it is ridiculous. He recommended I mentioned how I spoke to protective services next time I speak with the social worker there, and that might give them a little push to evaluate my grandmother. Although I know most of what he told me already, it was a huge lift off of my shoulders knowing that if my grandma goes home, they can be in her house almost immediately to evaluate everything. It was great to finally talk to someone who I felt actually understood where I was coming from with everything. But still the problem stays where basically unless my grandmother fails these tests, or agrees to go, I cannot do anything. I'm beginning to accept that this may be a long term process if that's the case. I still have not spoken to my grandmother, reason being I do not want to continue to enable her to rely on me for every little thing, that she should be able to do if she's capable of living alone. But she doesn't see that due to her confusion, and she is playing victim saying that it's because I "hate her". This is all expected. Nothing she says or does is a surprise to me anymore. Wednesday, as told to for more info, I will be calling the (unhelpful) social worker at the home/rehab place she's staying. I will be letting her know that I did speak with protective services and they highly recommended that my grandmother gets evaluated prior to the decision to discharge her. I also have a pretty far fetched idea, and a question for all of you guys. What would happen if I refused to take her home? If when the day comes along that the social worker says "this is the discharge day" and I simply refuse to do so? I know that may sound a little insensitive to some, but I am willing to try anything at this point as my grandmother IS NOT SAFE AT HOME. I will continue to update and seek all of your input. I couldn't thank you all enough.
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All the best on Monday and this week Jessica. Remember, if you don't get the answer you think is correct with one person, just call back...or like someone else posted, ask to speak to a supervisor. With your due diligence, you will eventually talk to someone who knows what you are going through and can provide the help you need. It still works for me...even last week to verify POA status with a financial institution. Oh, and I thought of someone else you may want to join you on team grandma; the health insurance company your grandmother currently has will likely have a nurse specializing in geriatrics that travels around to document and keep track of the current status of its members. It seems totally separate from the primary care physician and any person they may send out as well. My grandma has United Healthcare...and that was one of the first places I called, after I saw a postcard in her stack of mail with the other overdue bills asking " Are you caring for an older adult? You don't have to do it alone. We are here to help." My grandma exclaimed when she saw me read it. "I 'don't need that, that's for old people!" They sent a nurse out to the house within the week: evaluated the house & living conditions (good), evaluated how she moves to the bathroom from the couch, around the kitchen (okay), and gave her a mini-mental test (cognitively disabled). So even though she could show time/boat with almost everything...she could not do well at all with the mini-mental test. After getting a copy of all the documentation from UHC's nurse evaluation, I took it right into the Primary care doctor's office and had a copy put in her file. I also keep a copy myself and refer to it when anyone wants to know how I know that grandma meets any requirements for assistance. "Well, you don't have to take my word for it, I can share the past few years results of her mini-mental tests for you that were performed by her healthcare's traveling nurse trained in geriatrics." To this day they do a yearly mini-mental test even in the ALF; Proving the continual decline as expected...and importantly its documented for me to share with all doubters.
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Dear JessicaJ54, Save all those voicemails as evidence.
I'm not sure psychosis and neurosis are applicable terms for ALZ, dementia and cognitive loss. Best to check for clarity's sake and so you come across as bright as you are. I am in awe of your fortuitousness. Wherever you go to college should give you big scholarships. Warm regards, Pat
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Seconded - you're going about everything the right way. Let us know how you get on on Monday, won't you? Best of luck.
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AmyGrace, you took the words right out of my mouth. My grandmother is extremely good at acting "normal" around people other than me, especially when they suggest help or that she goes to AL or a nursing home. She often deceives people about everything, just so she can go back home. These people she encounters do not know her like I do, and cannot see that she is delusional now. They just assume she's fine because she passed a simple mental evaluation of a few questions. It's ridiculous to me that they can ask a person 20 questions and ask them what year it is, and come to the conclusion that they're mentally stable. I was actually just talking to my therapist about this yesterday. I have known my grandmother my entire life, and this person she is now is just a shell of what she used to be since her mind and body have been failing her, unfortunately. I would not be surprised if she doesn't remember calling me so many times, because somebody in their right mind would not leave a person 40 voicemails in a weeks time.
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Jessica - are you sure you are not 30? You are mature, capable and wise beyond your years! You will do well in whatever path you choose for your life. That was wise of you to call and report her self abuse and neglect. I hope that someone there can help you move this process along.

I understand the frustration you must feel about the professionals not helping you. Three years ago I begged Mom's doctor to say she was not capable of living in Independent Living - she wouldn't do it, and wrote an Rx for Aricept (in 2 days Mom either took it all or threw it out - because it disappeared and she said she was finished with it) I had to beg to get her to diagnose her this fall, and then she threw out the Alzheimers without testing, just from a few questions she asked. The IL wouldn't renew her lease so we could finally move her to AL. She refuses help, shutting down about showers, a walker, etc so they leave her alone except for helping with hearing aids and making sure she gets 2 meals a day. She was writing paranoid little notes on every scrap of paper - and no one said a word about it. Between my sister and me, we have probably received 100 phone calls, half of which she says "I can't hear" and hangs up. Repeated calls to the AL, they say she is "fine", has a friend, goes to dinner, etc. They say they don't understand why we insisted on Mom getting an antidepressant. Hello - Mom has been depressed, paranoid and obsessive for years - then she started to get angry and a little physical. They think she is ok because they don't know her. As long as she doesn't wander, smell or go crazy, she is "normal". Maybe they are all like that in AL and it is normal?
One thing which could be what you are experiencing: people with dementia often can "fake it" and act normal around others. Mom has done that for years. She shows her true paranoid, confused, irrational self to her family and often takes it out on us. (She doesn't even remember calling me 5 times the other day.)Chances are your grandmother doesn't remember either. Each time is the first time she thinks.

Your grandmother may be doing a great job of fooling caregivers. I'm disappointed in caregivers because they do what they have to do, but they work in shifts and don't really "know" the person or bother to "know" them - you are right.
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And yes, I know they are both very related to each other. But my point is that I don't believe they should be ruling out possible (and obvious) dementia, when all they did was a simple mental evaluation, and not an in depth test of her total mental state or a full neurology type test.
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(Correction on my previous post: 38 voicemails in the past 8 days since she was admitted to the hospital). She is showing so many signs of dementia (anger, delusions, irrational) yet they are all completely oblivious at the rehab because she is "psychologically" ok. And if I have not mentioned, she was mentally evaluated, but not neurologically for dementia.. Which are obviously two different things. Psychosis is different from neurosis.
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Update: Thank you l for your prompt responses, I really do appreciate all of the input. I completely understand that my grandmother is not going to reason with me because of the state she is in, and I will be holding off on expressing my concerns for her directly to her. Instead all of my concerns are going to be targeted at the professionals, because that is obviously the best thing I can do. I woke up to three more voicemails by 8 AM this morning from her (which makes that 38 voicemails total since , and I could not fall back asleep so I got up and called my local Area Agency on Aging to report my grandmothers cases of self-neglect and dementia. The woman on the phone was helpful, and told me she would forward my case to the appropriate person. I am going to have to call back on Monday, during regular business hours, to get further advice and options, as the woman I spoke to only records cases and doesn't directly deal with them. So Monday morning I will be calling back and speaking with another person regarding my case. I am also planning on going in to the nursing home/rehab center she is at, possibly without visiting my grandmother, and asking to speak to the supervisor, if there is one, and letting them know the extreme extent of this situation. And I agree VS, I think it's absolutely ridiculous that they will not do dementia testing on her simply because she is short term. How the heck are they supposed to admit people to long-term care in situations like these for people who cannot rationally decide things on their own if they will not do testing? They are failing me, and even more so are failing my grandmother.
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Jessica - heed all of the above, but also, be aware that your grandmother has dementia. You can try to reason with her, but the truth is, you can't reason with someone with dementia when it gets that bad. She will never admit she needs to be in Assisted Living. My mother still doesn't and she isn't quite as far along as your grandmother. While she is in the hospital you might want to get the help of the professional staff to certify she is incompetent so you can get a POA to move her without her permission. If all else fails, get in touch with your local, county and state representatives (find that on line). Sometimes politicians can clear a lot of red tape for you. You are doing great!
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Yup, I agree with VS. Jessica, your grandmother does need to be made to face up to the reality of this situation - but not right now. From your description of how she is at the moment, her team (her team, note, NOT YOU) has a lot of work to do to get her mentally and medically stabilised. Then the discussion can move ahead to where she should be living, and with what support.

So for the time being, treat your grandmother as though she were an innocent babe with no control over her own plans and save the discussion about her living needs for the professionals who are supposed to be taking care of her. If her social worker is being a wet rag, take it up with the staff at the hospital and get them to impress on the social worker that her client does not currently have the mental capacity to make decisions. Once that's established (it isn't necessarily permanent), the social worker can provide support and services for your grandmother without her consent, although she should continue to be consulted.

I am glad you are keeping your distance. You are doing a sterling job for your grandmother without getting walked all over. Brilliant stuff, well done.
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Jessica, though most social workers are awesome people who take on difficult situations and deal with them better than anyone could imagine, yours is a lemon.
A competent one would not suggest a person whose primary caregiver is 18 years old and can't stay full time with her, plus has already had multiple falls and is disoriented could go home without 24/7 supervision.

I don't think your chances of getting grandma to be reasonable and voluntarily agree not to try to go home again are all that good. She pretty obviously has dementia and/or delirium. There is not one single valid reason that she cannot have a mental status exam documented for her while in short-term subacute rehab and not one single valid reason that any physician would find her competent and able to return home on her own. If the social worker feels that making such a determination on her own is outside her scope of practice, so be it, but she could tell you where to turn and how to get there from here. Does she have a supervisor? Would the hospital SW potentially be of more help? Do you have a contact in Adult Protective Services or Medicaid office as suggested above?
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Follow Babalou's lead. Talk to Local Department on Aging. Try to get your grandmother's primary care physician to diagnois your grandmother with dementia/Alzheimer/cognitively declined. Get a signed hard copy for yourself to show anyone and everyone who even question your grandmothers state of mind. The symptoms your grandmother is showing is of her in an altered state of reality. And unfortunately those in this state do not understand reasoning anymore. All the best in trying to still reason with her...hoping for that moment of clarity you might see in her...but it will not last. My grandmother fell a few times and it was the same situation as yours: hospital, rehab with Medicare covering, reached a plateau state but "she didn't want to be put in a home". I asked for help, but applying for medicaid or a medicaid program was just not mentioned or talked about for some reason... so back at home to fall once again. Finally I talked straight with the facilities themselves and found they have Medicaid (long term care) specialists who helped me through the whole process and alternatives. Currently my grandmother is at a CBRF and part of her funding comes from a county sponsored program that uses Medicaid dollars. They take all her SS and pension and leave $40. But the important thing is she is covered. Co-pays, Rx, Doctors visits, everything. And I can sleep better now knowing that there are professionals keeping an eye on her. NO! They cannot provide the same care that a family member with the caregiver gene can provide...but she is safe and I can get back to living my life. I did some private pay until the program kicked in...and that sounds like something you'd have to do since your grandmother has funds. For the case that it seems you are having a difficult time with the current social worker, ask for a second opinion; ask the doctor to refer you to someone else to try. In my case I knew I had to ask for referrals for other doctors since my grandmother's doctor mentioned that "I was doing a great job, and he looked forward to hearing more about things I was doing...as he was going to have to deal with his parents and in-laws very soon." Great to hear...but not what I wanted to hear. Now my grandma sees a few different doctors...because I truly believe it takes a village. Another thing I did was just threaten to leave my grandmother at the doctors office. (Now, I really wouldn't do that of course) But that gets results. A doctor, social worker, geriatric nurse, neurologist, when in their right mind will not tell someone with dementia where to catch the bus, or call a cab for them. Though I imagine it happens. Continued best to you!
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A visit to grandma's home must be made prior to her being released if she is going to live on her own. An ot needs to go there to evaluate if it's a safe place for grandma to live alone with no help. Inform the social worker that you are going back to school out of town for the semester that starts May 15. Grandma will be without help.

Call your local area agency on aging and talk to them. I would also call the discharge folks at the hospital and tell them how grandma is being treated in rehab. If she ends up back in the hospital for the same condition, Medicare will not pay. It's in the interest of the hospital to get this sorted out.
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