She will not admit that anything is amiss. Sometimes her clothing smells of mildew, too. When she visited us recently, she would pee all over the toilet seat. She insists that she is just fine, she lives in a huge house that she refuses to leave, and she still drives. She also refuses to get a medical alert device. What should I do? Write a letter to her doctor?

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Do you have the financial and medical POAs set up? That would be an important thing to get done right now. Other than that, you can talk to her about going to assisted living. As long as she is not deemed incompetent, though, you can't force her to do it. You'll just have to wait for something to happen or for her to be willing to do it.

Would she allow a maid to come into her home to help keep it clean? Even a warm house shouldn't be mildewed. It sounds like she isn't keeping it clean enough. It is hard to figure out what to do. As long as they're legally competent, we can't force anything onto them. We just have to wait for an opening.
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As we age the body does what it needs to do to keep the core warm. This means that extremities like fingers, hands, toes, feet get cold. This may be why the heat is up. Or if it is summer she keeps the AC off.  (Or it could be she is "saving money" not running the AC.  Was the house cold in the winter?)
Get a dehumidifier that will remove moisture from the air so that mildew, mold will not continue.
If you see any you must have it removed or you can do it if it is not an overwhelming problem.
The presence of mold can cause medical problems so use that method to talk to her about this.
We need to take care of this now before it gets worse, if the problem continues you will not be able to live her because it will be dangerous for you health.

This is your might be best if some of this comes from her Son if he is able.
The note you want to write to her Doctor might also bear more weight if it came from her Son but if he can not a letter from you might give him a bit of insight.
Does she have someone that is designated POA for Health and Financial?
If not and she will not do that you will have 2 courses of action.
Do nothing until a "catastrophic" event forces action.
See a lawyer, go to court, declare her incompetent and assume Guardianship.
Neither is a great way to enter into this "care-giving" role
At that point you must decide will she live with you or go into Assisted Living.

That is a whole 'nuther discussion.
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When I noticed a smell of mildew in our home, I also noticed water along the wall in our garage. I called a plumber, and he discovered a leak under the house. It might not be a bad idea to have someone check your MIL's home. I agree with having someone come in and "help" her clean. Urine around the toilet is also a health hazard. A little honesty might be called for here. But, not from you. It should come from her children. When it came to the point that my FIL had to go to a facility for his own safety, his children had an "intervention" with my MIL and we, as the spouses, weren't even there.
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If she won't run an air conditioner to lower the humidity then a dehumidifier in the basement is an option, they can be rigged up with a hose running to the drain so it doesn't have to be emptied. I would also get her a raised toilet set and grab bars by the toilet and in the bath, actually it would probably be a good idea to go through the whole house with an eye to improving accessibility, insist it is necessary if she wants to remain in her home. I like the idea of a cleaning service too, many will come in bi weekly or even monthly if she won't agree to someone every week. It also gets he used to having someone come into the home so she may be more amenable when the time comes for outside caregivers.
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Older people do not have the greatest circulation--they generally keep their homes set at a temperature that is considerably higher--also they don't move around as much. It's 103 degrees here, my mother's home is about 80-85 and she's fine. Also probably wearing a sweater.
This, combined with the 3 aerosol deodorizers that go off "automatically" and several open jars of "room freshener" PLUS 2 cockatiels in a cage that hasn't been cleaned in 6 months, wet depends in the trash at all times--make for a pungent visit. Mother may also not do the laundry correctly and there may also be the smell of mildew. She had a pipe leaking for months before she noticed it (somebody else noticed it, actually). Mildew needs constant moisture.

A good cleaning never hurt anyone--and the mildew can actually ruin structures, so you need to address that.

I would LOVE for mother to allow ANYONE to clean for her. Most of her apt is so hoarded you just cannot GET to the places to clean. She recently refused ANY type of in home care, so she is doing for herself. She says her 17 yo granddaughter gets paid to clean, but she cleans like a 17 yo--badly.

A service that will do top to bottom twice a month would be best. Find the source of the mildew smell and remediate that and you should be OK.

As this is your MIL, the suggestions should come from somebody who is NOT an in law. Unless you have a fabulous relationship with her. Good luck.
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Ah Denial,
My personal favorite! Followed by outright ignoring any suggestions you try to make things better. I'm fine! I don't need (fill in the blanks) What smell? Nothing is wrong! I did not! Arrrrrggghhh. The never ending battle of wills when you try to help them out. Even letters from doctors can be ignored unless you have been named as the one "legally responsible" for her health, well being. My Mom is stubborn, always has been but she has become WORSE! I just don't have the energy to argue on every score anymore. Wish I had a magic answer for you but everyday I am the crocodile's dentist.
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Do you live in the same town or nearby? Start by writing her doctor or offering to go to an appointment with her, but getting things in place - POA, etc. is also extremely important. Does she have a diagnosis that involves memory loss? Can you try to coordinate a "benefits check" with the county? It will get someone in her house & perhaps if safety recommendations come from them it will help? (The toilet thing - I got my mom a "frame" that gives her handrails to grab onto with sitting down/getting up - because she was wrestling with the toilet everytime she sat down to go. These are the types of things she needs to be evaluated for - for her safety...You might need to play hard-ball - if she wants to stay in her home, she has to be safe and follow recommendations.) Contact Senior Services with the county to discuss/see if you can't come up with a game plan? If the house smells musty - could there be a water/plumbing issue that's gone unchecked? Sitting/breathing in that environment is a health risk, so someone needs to get into that house and check things out. Sometimes advice coming from a third party will be heeded more than family members.
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Oh, of course heat kills mildew, but a source of continual dampness + heat creates the perfect storm in some under the sink, under a bathtub, behind a washer.

Could just be mom isn't completely drying her clothing or she's letting it sit too long in the washer before drying it. My daughter lived in Houston and if you left wet laundry for more than a few hours, it would begin to mildew. The smell cannot be removed w/o a re-wash. I notice Mother is getting "sloppy" with her laundry (the ONE task she still can do) and forgets to put vinegar in her final rinse. All her clothes smell strongly of urine. So she sprays on more cologne.

And there is that "old person smell" which thankfully, neither of my lovely grandmothers got--but it's a combination of fusty old furniture, urine, dirty dishes, an unclean kitchen. personal hygiene slipping and unopened windows.
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OkieGranny. I'm kind of in the same place. My mom is 79. Drove today. Only drives once a month. A year ago drive to her job every day. She loved to work. She is with it in some areas. Totally not in others. Takes aricept. Bathes / dresses/ takes meds as prescribed but failed the memory test. Guess we are in the grey area
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Um, you are sure that the odour you've noticed is mildew, are you?

Have you noticed any problems with the fabric of the house apart from the odour?
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