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Mom (age 90) is in skilled nursing (Medicaid). She is pretty lucid (diagnosed with mild dementia but since the diagnosis she has improved) however most of the people around her are a lot less so. She complains that there are few people around her who are capable of conversation, so she is bored. She doesn't like the nh activities (bingo etc). She's in a wheel chair but can walk, though unsteady, with a walker. She wants to go home but I live far away. She has had several falls, the last a broken hip. NH staff say she needs 24/7 care. We can't afford that and I don't think Medicaid will give it. I have warned her of risks of returning home but she is determined. I don't feel I have a right to dictate where she lives but I want her to be safe. On the other hand, quality of life is a factor. She is getting EXCELLENT nh care (great staff) but it isn't her home. I don't know what to do -- let her return home with the maximum care we can get from Medicaid or can afford out of pocket or have her stay in the nh where she feels isolated. It's a real dilemma for me. My fear is that if she returns home and can't handle it or has an accident she will lose her place in the nh and the alternative nursing homes will be poor.

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Trevor, my mantra is this. As adult children of elderly parents, we can't make them happy (you carry happy around with you, no one can supply it from the outside, longterm). We CAN help to keep them safe. We shouldn't remake our lives so they can maintain an illusion of "independence ". Of course one wishes the privacy, personalization and freedom of living in one's own home. But as with school aged children some processes (education, eldercare) are done more economically en masse.

In your shoes, my real question would be, does your mom actually have dementia. That's progressive, and she would be well advised to stay put.
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Trevor one thing jumps out at me. Mom is in a wheelchair but can walk with a walker, She has fallen several times once with serious injury. Sorry it just can't happen. She won't be happy at home she will be lonely and scared. She is in a good place and skilled people who see her and others like her every day say she would not be safe at home. The only way it could possibly work is with you living with her and hiring other caregivers. I promise you you can't even carry a cup of coffee from the kitchen to your chair with a walker. Can she even get up out of a chair with her walker to go to the bathroom. Are you prepared to get up in the middle of the night and clean up the stream of diarrea from her bedroom to the bathroom. Wash her up and change the bed and do the laundry. The dementia or lack of is only a small part of the problem. Getting her declared totally competent is not going to improve her other disabilities. Living in you would have to be gone for a good part of the day to work and take multiple days off for Drs appointments etc. Of course you feel guilty and she really does want to go home but job one is keep her safe.
There are probably volunteers who would visit maybe take her out for a meal or a drive in the country, push her outside to sit in the sun. Does she have hobbies she used to enjoy. perhaps she knitted sweaters well maybe she can knit squares that can be made into blankets for the homeless. There are many hobbies that can be miniturized as we get older. Can she still see to read. If not how about books on tape of if the TV is limited CDs of current or old movies. Did she love horses? Well someone could take to a local horse show. Whether she stays or goes home she is going to have to become content with being 90 years old. So loose the guilt Trevor and do what is best for her.
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Trevor, this is a real dilemma and I have no easy answers for you. First, you say her dementia has "improved". Does she really have dementia, or was she suffering from temporary disorientation in the hospital after her surgery? I would look into that and get her mental status clarified, because, while you may see some temporary improvements in a dementia patient, once they are in a stable environment, moving them often causes a rapid decline. So, if your mother has dementia and you move her "home", she may say "this isn't my home". She may be talking about her childhood home, or the home she had when she was first married.

Is there any possibility of moving her closer to where you live, so that you could visit more frequently ?

Talk to the staff about whether assisted living would be enough care for her. Could she sell her house and fund that?

But I would get her dementia status clarified first.
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Trevor, that's a tough decision especially since your Mother feels she can manage on her own at home. That's the problem, denial by our elders.

And please note once an elder gets into their 90's, every year of life is like 10 years. I've seen that with my parents. My Dad always says they will manage. This year for the first time Dad realizes he can't do the yard work, nor the house maintenance.... he wants me to do it, sorry Dad, that ship sailed a few years ago because I had aged, too. My calendar doesn't shop going forward.

I know you are grateful you found a nursing home that has so many positive things going for it. And that you know if Mom moves out, she might not be available to move back in and has to go elsewhere. The tough part is convincing her. Thinking ahead, does this nursing home take Medicaid?

As for her mind, I know after I had surgery, I had brain fog for quite some time.... eventually it cleared up, but it came back after I had a serious fall and sustained a bad injury. The pain kept interrupting my train of thought :P Maybe that is what your Mom is experiencing.
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Dementia is progressive but so too is physical frailty, especially once you pass a certain tipping point. I can't help feeling that if your mother were to return home and then be forced by another serious injury to go back round the revolving door of fall, hospital, rehab, NH it would just add a sense of failure and "fault" to the resentment she already feels at losing her independence.

And if I were put to bed at half past six in the evening I'd be pretty bloody resentful too. What are they thinking???

It's an incredibly difficult decision, but - I hope this is a comfort - from your description of your mother's mental state it is, you are correct, actually hers to make. What you can get very stern with her about is the self-defeating stupidity of ignoring medical advice and discharging herself against recommendation. That will be a very useful delaying tactic until you can do a bit more research and get all of her options down on paper, with prices and pros and cons as FF suggested. Best of luck, please update.
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Trevor, these kinds of dilemmas aren't like those that exist in work, which usually have more finite variables. I was thinking of that the other day in trying to analyze why some caregiving situations are so problematic, in part because there are no easy answers. Sometimes it's a gut feeling, sometimes a best guess, factoring in the issues discussed in the various posts here.

Can you quantify those factors? If so it would make the analysis easier.

There is a program called PACE (http://www.medicare.gov/your-medicare-costs/help-paying-costs/pace/pace.html), which as I understand it helps people to stay at home (or as described on the Medicare site "in the community") as opposed to going to a facility.

I've had it bookmarked but never thoroughly investigated it. It might help narrow down the variables in your analysis.

As to the issue of falls, my personal opinion is that someone can fall anywhere, including in a facility. The question is how quickly can someone get assistance - if your mother were to fall in the middle of the night, what would alert the staff?

During my mother's rehab, her roommate fell. The attention needed was provided when my sister (a nurse) called out "PATIENT DOWN in room ....". Then staff came running.

Had we not been there, who knows how long this woman would have laid on the floor? She wasn't screaming.

It may be that one of the solutions is for your mother to return home, until and unless such time as any dementia changes her ability to live alone. If that occurs, your decision will be easier.

If quality of life is the issue (and it is a major one), will she have a better quality of life at home in her own surroundings or at a nursing home where she doesn't want to stay? And it is HER life so she does have a right to participate in the decision making process.

It also depends on your own situation and plans for your future.

Don't push or chide yourself for being unable to resolve this dilemma; it's probably one of the most challenging ones you'll face. It would probably be easier to go back to work where the dilemmas are more analytical and solvable.
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Trevor only you and mom can make this decision. These are my thoughts. If you were able to provide 24/7 care for mom (whether yourself or paid help) take her home. However from what you have already said you are not in a financial position for the caregiver to be you and there is no money to hire help. Honestly, i dont think you have any option but to keep mom where she is. Medicaid doesnt help to pay for in home services in my state. Not sure where you are but you can check that out. Hiring home care aids is not easy nor quick. If there are problems with the help you will not be 15 mins away. Personally, i would leave mom where you know she is safe, clean and fed. Can you bring a few things from her home? Her favorite chair, some pictures, wreath for her door? Putting some personal items in the room could help. I gave my uncle a pretty candy dish and each time i came i would bring new candy. Good luck
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I would suggest that you take your mom for a complete neuropsych workup which will greatly clarify her ability to live at home with help.

Does your mother have good social connections at home? My mother kept saying she didn't want to go to a facility because she would miss talking to her neighbors. But in reality, she never talked to the neighbors anymore, the ones she'd been friendly with had died. She only really talked to the mailman.
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I agree with Blannie on trying to help your mother integrate more into the facility's social life, beyond that of the bingo games. Talk to the activities staff and see if they'll take her to music and craft therapies. If there's a pet therapy service, find out which one, contact them and ask to be sure to visit your mother.

Bring a few things from home, but not so many that it appears she is going to be there for the rest of her life.

Bring a CD player (not an iPad) if she's used to one and can operate it. Otherwise bring a radio and mark her favorite channels. Music is a great soothing therapy.

I don't know if this would exist or not, but there might be some church groups or children's groups that visit people in rehab centers. You might try calling the United Way helpline, 211, to ask about things like visiting Samaritans.

If you do decide to bring her back to her home, I would get as much oversight as I could - life alert monitor, lock box for first responders on the outside of the house, internal surveillance so that you can monitor her from afar.

If she's friendly with the neighbors, ask that one or another bring her mail, call or check on her during the day. If she's a churchgoer, contact someone in the relief group or something similar and arrange for visits.

I would also ask her regular treating physician to script for home care - nursing, PT, OT and a home health aide. Add grab bars, remove trip hazards and do whatever you have to to upgrade the safety situation.

Get Meals on Wheels as well.

Good luck; these situations are always so tough - neither option is that desirable for one reason or the other.
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Thanks for all these thoughtful comments. It helps to know that people are interested. I am trying to find out what the state will offer in terms of in-home care. In talking to a neighbor on Medicaid, it seems home aides are available. There is a local volunteer service that will shop for her, get her prescriptions and take her to the doctor (I also think there is a government sponsored transport service). Meals-on-Wheels are available and I understand an aide can come to help with a bath. Organizing all these and other help services would be essential but the risk of a fall remains. She has already fallen four times. The last was the most serious. We had a useful chat today. She wants to go home but she is aware of the risks. She wavers in her thinking. The thought of spending years in the NH upsets her but she also worries about falling at home (there is no absolute guarantee that she couldn't fall in the NH of course. She said that she had seen two such incidents there). Unfortunately she is right that there aren't a lot of people where she is who are conversant but because she is shy, it is all the harder. I tried to get her involved in church. There is one very close by. We went one Sunday and the people were very nice but I can't get her to go back. Does she know more people at home? Probably yes and a few who don't live in the neighborhood would stop by more often. Where she is now is a good distance from home and not easy for friends to get to. It's a very difficult situation. In reality she doesn't accept her age.
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