Kristen Mauk

Background

Hypothyroidism results from lack of sufficient thyroid hormone being produced by the thyroid gland. Older adults may have subclinical hypothyroidism, in which the TSH (thyroid-stimulating hormone) is elevated and the T4 (thyroxine or thyroid hormone) is normal; 4.3–9.5% of the general population has this problem (Woolever & Beutler, 2007). In this condition, the body is trying to stimulate production of more thyroid hormone. Some older adults with this condition will progress to have primary or overt hypothyroidism. This is when the TSH is elevated and T4 is decreased. Hashimoto’s disease is the most common cause and represents 90% of all patients with hypothyroidism (American Association of Clinical Endocrinologists [AACE], 2005; Woolever & Beutler, 2007), though certain pituitary disorders, medications, and other hormonal imbalances may be causal factors.

Warning Signs

Older adults may present an atypical picture, but the most common presenting complaints are fatigue and weakness.

Diagnosis

Diagnosis should include a thorough history and physical. Bradycardia and heart failure are often associated factors. Lab tests should include thyroid and thyroid antibody levels (common to Hashimoto’s), and lipids, because hyperlipidemia is also associated with this disorder.

Treatment

Treatment centers on returning the thyroid ¬hormone level to normal. This is done through oral thyroid replacement medication, usually L-thyroxine. In older adults with coexisting cardiovascular disease, starting with the usual doses may exacerbate angina and worsen the underlying heart disease, so it is important to start low and go slow. Titration should be done cautiously, with close monitoring of the older adult’s response to the medication. The does should be adjusted on 6- week intervals until normal levels of thyroid hormone are achieved. Once the TSH is within normal limits, then checking the TSH should be done every 6 to 12 months to monitor effectiveness and blood levels, because hyperthyroidism is a side effect of this therapy and can have serious implications on the older person’s health.

Patients need to learn the importance of taking thyroid medication at the same time each day without missing doses. Sometimes older adults have other problems associated with hypothyroidism, such as bowel dysfunction and depression. Any signs of complicating factors should be reported to the physician, and doctors’ appointments for monitoring should be religiously kept. Strategies for managing fatigue and weakness should also be addressed, because some lifestyle modifications may need to be made as treatment is initiated.

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L.
Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Sudbury, MA: Jones and Bartlett Publishers. Used with permission.

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According to the CDC, nearly 800,000 persons in the United States have a stroke each year. This is about one every 4 minutes, resulting in over 130,000 deaths annually. Stroke is simply defined as an interruption to the blood supply to the brain and is caused by a clot or hemorrhage. It can be a devastating problem for survivors, resulting in changes in mobility, cognition, speech, swallowing, bowel and bladder, self-care, and general functioning to varying degrees.  Some people recover completely after a stroke, but others experience lifelong challenges.

The good news is that there is hope and quality of life after stroke. In my research with stroke survivors, I discovered 6 phases that survivors reported as they made the journey through rehabilitation towards recovery. These steps can be used to see where a person is in the recovery process, help us understand how they may be feeling, and help guide the way we interact with them.

Agonizing:  In this first phase of the process, stroke survivors are in shock over what has happened to them. They can’t believe it, and may even deny the warning signs of stroke. The important task during this time is survival from the stroke itself.  Call 911 if you see the warning signs of facial droop, arm weakness, or speech difficulties.

Fantasizing:  In the second phase of the stroke process, the survivor may believe that the symptoms will all go away. Life will return to normal, and there is a sense of the problem being unreal. Time takes on a different meaning. The way to help is to gently help them recognize reality, and without taking away hope for recovery.

Realizing: This is the most important phase that signals a turn in the recovery process. This is when the survivor realizes that he/she may not fully recover from the effects of the stroke and that there is work to be done to rehabilitate and reclaim life. Common feelings during this phase of realizing are anger and depression. The way to help is to encourage the person to actively engage in rehabilitation. The real work of recovery is just beginning.

Blending: These last 3 phases in the process of stroke recovery may be occurring at much the same time. This is where the real work of adaptation to life after stroke begins. The survivor begins to blend his “old life” before stroke with his new life as a stroke survivor. He/she may start to engage in former activities even if it requires adaptations to be made. He/she will be actively engaged in therapy and finding new ways to do things. The way to help is to promote education. This is a time when survivors are most ready to learn how to adjust to life after stroke. Listen to your rehab nurses, therapists, and physician. Be active in the recovery process.

Framing: During this phase, the individual wants to know what caused the stroke. Whereas in the Agonizing phase they were asking “why me?”, now they need to the answer to “what was the cause?”  Stroke can be a recurring disorder, so to stop a subsequent stroke, it is important to know the cause. Interestingly, if the physician has not given the survivor a cause for the first stroke, patients often make up a cause that may not be accurate. Help the survivor to learn from the health care provider what the cause of his/her own stroke was. Then steps can be taken to control those risk factors.

Owning:  In this final phase of stroke recovery, the survivor has achieved positive adaptation to the stroke event and aftermath. The survivor has accomplished the needed grief work over the losses resulting from the stroke. He/she has realized that the effects may not go away and has made positive adjustments to his/her life in order to go on. Survivors in this phase have blended their old life with the new life after stroke and feel better about their quality of life. While they still may revisit the emotions of the prior phases at times, they have accepted life as a survivor of stroke and made good adjustments to any changes that resulted. They feel that they have a more positive outlook on life. At this point, survivors can use their experience to help others cope with life after stroke.

For more information about stroke recovery, visit www.seniorcarecentral.net and view Dr. Mauk’s model for stroke recovery.

We have all heard of the “sandwich generation” – those middle-aged adults who are still caring for their own children and also an aging parent. Well, here is an emerging trend that I will call the Triple Decker Sandwich generation: Baby Boomers who help care for aging parents, who still have children at home of their own, and who find themselves also taking on full time care of their small grandchildren. Yes, that is a sandwich of an entirely different kind. That is a Triple Decker.

Pew Social Trends (2013) revealed that many adults in their 30s and 40s were caring for ailing older parents and also providing some type of financial support for grown children. This resulted in reports from the sandwich generation in feeling in a hurry, rushed, and not having enough time for all of their expected duties. Now, add to those statistics another emerging trend: grandparents caring for grandchildren. I am not referring to the occasional or even regular hour babysitting or childcare that loving grandparents provide. Instead, this is the 24/7 responsibility for grandchildren who live with them, or whom they have adopted. The 2015 Profile of Older Americans from the Agency on Aging found that “in 2014, about 554,579 grandparents aged 65 or more had the primary responsibility for their grandchildren who lived with them”. Now, please note that this is only those grandparents aged 65 an over. What about all the others in their 50s and early 60s doing the same? I imagine that each person reading this can think of at least one or two grandparents who are raising small grandchildren. The implications of this on the health of aging persons is enormous. So, here are some tips to survive the Triple Decker Sandwich generation.

Pace yourself

If you have this many people in your life to care for, you must pace yourself. Avoid the temptation to give 100% all the time. It isn’t possible. Something in your life will suffer – and often this is your own health. Think of this task of caring for multiple generations as running a marathon. Develop skills, train, get into a good rhythm that you can maintain for the long haul.

Set priorities

You might have been able to juggle 4 kids and a job when you were in your late 20s or early 30s, but maybe now you are in your 50s with aging parents, teenagers, and a grandbaby to care for. Flexibility is a key to success. You just can’t do everything the same way if you are caring for small children again. Decide what is most important. Set reasonable and attainable goals. Make small goals for each day and celebrate those accomplishments.

Accept help

Even if you were used to being able to do it all yourself when you were younger, the amount of care that a Triple Decker generation person takes on requires some help at times. Let your adult children watch that baby to give you a break. Let the teens in the house help with the childcare. It is a good time for them to learn these skills for when they are parents. Tag team with your spouse to share the burden if you have a little one in the home. Church friends are happy to help if you need a night out.

Take time to rejuvenate

Being part of a Triple Decker sandwich is tough. Take time to rejuvenate to avoid burnout. You can’t care for anyone if you become ill or incapacitated yourself. For each person, renewal comes in different forms. For men, this might mean playing a sport or watching games on TV without interruption, or having a quiet private place in the house that is off limits from the noise of the household. For moms, this might be shopping alone or getting a manicure or pedicure. Sometimes talking on the phone, or meeting with friends for lunch provides a needed break. Know what you personally need to recharge and refocus and then allow yourself this (without guilt) on a regular basis. You may not be able to change your circumstances, but you can change how you deal with them.

Don’t expect too much

Chances are, if you find yourself in the Triple Decker mode, you are aging yourself. You can remember how you balanced work, life, kids, and higher education by yourself years ago. Now you wonder how you did it all. Well, you were 20 or 30 years younger then, so cut yourself some slack. Be sure to get enough sleep. Take breaks as needed. Exercise and eat right. Cut out the unnecessary things you did before to fill time and focus on those priorities that you set, without neglecting your own health.

Triple Decker Sandwich persons are tough and resilient. Congratulate yourself that you have been able to make it all work and care for your many loved ones. You sacrifice many things such as an easy and comfortable retirement and the ability to travel. But, you have given a great gift to those you love by sharing your care for them. In the end when you reflect back on your life accomplishments, you might very well find that this was one of the greatest.

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A Profile of Older Americans (2012) revealed that over 480,000 grandparents had primary parenting responsibility for their grandchildren who lived with them.  AARP cited that over 2.5 million grandparents are helping with the responsibility of raising their grandchildren, and 7.8 million children live in homes owned by their grandparents. These statistics represent a growing trend in American culture.

I have several friends who have raised or are raising their grandchildren in their own home. Some have formally adopted their grandchildren. Others share parenting responsibilities with one or both parents. All of them share the common feeling that this is a blessing, not a burden, but that raising grandchildren in later life does have its challenges.

Whatever the circumstances that brought grandchildren into the home of their grandparents to be raised, it can come as a shock to the older adults who find themselves in this situation.

Here are some beginning considerations to raising your grandchildren in your own home.

Impact of aging

Older adults who are assuming primary responsibility for children should “cut themselves some slack”. Don’t feel that you have to do everything as if you were a first-time parent in your 20’s. Remember that you may be parenting, but your body knows that you are still a grandparent. You may have to limit the children’s activities because keeping up with the driving and multiple schedules is too difficult. The good news is that many grandparents in this situation are retired, so both Grandma and Grandpa can help with the kids. This teamwork might not have been possible with your own children because one or both of you were working, but now you can share the duties such as driving kids to school or sports practices, helping with homework, and taking them to doctor appointments. If the children are school age, allow yourself extra time to rest and relax during the day so that after school you have the energy required for these new-again activities with the grandkids. If needed, enlist the help of other family members or friends to help by giving you a break on occasion.  Keep in mind that maintaining your own health is especially important if you have young ones depending on you.

Expenses and Education

Many older adults are on a fixed income and may not have planned to care for grandchildren. Your financial plan for retirement might need an overhaul with additional family members in the household. Several organizations have worked cooperatively to compile resources for grandparents in this situation. National and state fact sheets have been developed to link grandparents with key resources in their area. You can find out about resources available to help you at http://www.aarp.org/relationships/friends-family/grandfacts-sheets/ .These helpful fact sheets list local programs, public benefits, key state laws, and contact information for national resources. There may be funding or tax breaks to help with living or educational expenses.

Records and immunizations

It’s important to keep important documents together in one safe place. This includes birth certificates, legal papers, report cards, baptismal papers etc… Keeping a log or journal of important events is also a good strategy, especially when caring for multiple children. There are a number of immunizations for children today that were not available or required when you parented your own children. Immunizations are often free at your county health department, but can be very expensive at the doctor’s office. The health department can tell you what your child needs and when, and will help you by providing an immunization record that will need to be kept up for school. The CDC has a helpful chart of recommended immunizations for birth to 6 years that can be found at http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf  A summary of vaccinations for birth to age 18 can be found at http://www.immunize.org/catg.d/p2010.pdf

Enjoy your Grand Family

Despite the obvious challenges of raising grandchildren in your older years, most grandparents describe the many joys that come with this new adventure. Grandparents share a special bond with their grandchildren, and when sharing a home together, that bond can be strengthened. Grandparents can share the wisdom of their experience with this younger generation and have the opportunity to shape their lives for the better. If you are new to this second round of parenting, AARP offers a helpful guide with tips to GrandFamilies, as they call them. These can be found at Grandparents Raising Grandchildren: A Growing Trend

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