Grandparent Caregivers Health Issues and the Pediatric Visit

Grandparent Caregivers: Health Issues and the Pediatric Visit Amanda D. Soong, MD Assistant Professor of Pediatrics University of Alabama at Birmingham

Objectives § Identify key health issues for: w Grandparent Caregivers § Discuss ways for the pediatrician to assist in the evaluation of Grandparent’s health during a pediatric visit § Discuss resources available in the community for grandparents in need of medical evaluation

Definitions § For the purposes of this talk, Grandparent Caregivers are defined as grandparents that provide the majority of care for their grandchildren under the age of 18. § This may include grandparents with formal or informal custodial arrangements, or grandparents that provide childcare for working parents. § Also included are other older relatives that may have custody/provide care.

The Issue § According to 2011 American Community Survey Estimates: w 2, 870, 639 Grandparents are primary caregivers to one or more grandchildren. § Some estimate that in the inner city, 30 -50% of children are in the care of grandparents.

Grandparent Health § Grandparents who care for grandchildren often neglect their own health for a myriad of reasons § We may be the only health care providers a grandparent sees if they have been overlooking their own health in the process of caring for their grandchild.

At Well Child Checks…. . § You should already be asking about the Family Medical History during your well child checks. § When dealing with grandparents, ask specifically about their health instead of just asking what runs in the family.

At Well Child Checks. . § After asking about the child’s medications, ask about other medications in the home and how the medications are stored. § This may offer you more insight into the grandparent’s health, and also provide invaluable information in the case of an ingestion of an unknown substance.

Health of Grandparent Caregivers § Multiple studies have examined the health of Grandparent Caregivers. § Almost all of the studies have concluded that Grandparent Caregivers have worse health than their peers not raising children.

Health of Grandparent Caregivers § Besides worsening of adult illnesses like DM 2, hypertension and arthritis, grandparent caregivers may face other challenges. § Multiple studies have documented that grandparent caregivers have greater difficulty than their non-caregiving peers with performing activities of daily living such as performing day to day tasks, climbing a flight of stairs, and moving around the house.

Health of Grandparent Caregivers § The caregivers are also more likely to report depression than their non-caregiving peers. § Depression is known to have a significant impact on overall health.

Health of Grandparent Caregivers § Your interaction with the grandparent caregiver can also give you valuable insight into their health. § Observe how well the caregivers seems able to walk when going in or out of the exam room. § Do they appear to have hearing or sight issues?

Health of Grandparent Caregivers § While talking with the caregiver, do they appear forgetful or confused? § As the child’s pediatrician you should consider if you feel as if the child would be safe with the caregiver. § If you have concerns for the safety of the child, social work should be contacted.

Dementia or Cognitive Impairment § There is a continuum that exists between mild cognitive impairment and dementia. § Early dementia may also be difficult to differentiate from just a disorganized or overwhelmed caregiver.

Signs of Dementia § Cognitive Changes: w New forgetfulness, increasing trouble understanding written and spoken communication, work finding difficulty, disorientation. § Psychiatric Symptoms: w Withdrawal or apathy, depression, suspiciousness, anxiety, paranoia, hallucinations § Personality Changes: w Excessive friendliness, flirting; frustration, disinterest, explosive outbursts.

Signs of Dementia § Problem behaviors: w Wandering, agitation, noisiness, restlessness § Changes in day-to-day Functioning: w Trouble driving, getting lost; neglecting self care or chores, trouble shopping, cooking and paying bills.

Diagnosis § There are 3 main categories to think of in the continuum of dementia. w Age Related Cognitive Decline- memory loss without other cognitive issues. Within normal limits given a person’s age. w Mild Cognitive Impairment- patient with some cognitive impairment, but not to the degree found in dementia. w Dementia- according to the DSM-IV, cognitive impairment to the degree that social or occupational function is reduced, with the functional impairment representing a decrease in the patient’s normal ability.

What should you do if you suspect a caregiver has dementia or signs of cognitive decline? § If during the visit you are concerned by what you observe, ask the child if they are old enough, if they have noted any changes. w Are there any other relatives you could talk to? § You could ask the grandparent open ended questions like, “Do you find you have more trouble doing X than you used to? ” If they say yes, probe further. § If you are concerned for the child’s safety, social services and DHR should be contacted.

Identifying dementia § As stated before, you may be the only contact with a medical professional for the grandparent caregiver. § If you suspect dementia, there is an easy, quick screen you could perform in the clinic to help guide your decision making called the Mini-Cog exam, or clock drawing test. § http: //www. alz. org/documents_custom/minicog. pdf

The Mini-Cog § The test consist of 3 steps: w 1) Instruct the caregiver to listen carefully to and remember 3 unrelated words and then repeat the words back. w 2) Have the caregiver draw a clock face, and once the face is drawn, ask them to add clock hands to read a specific time like 10: 20. You can repeat instructions, but give no other instructions. This is called the Clock Drawing Test (CDT) w 3) Ask the patient to repeat back the 3 words previously presented.

Scoring the Mini-Cog § Give 1 point for each recalled word at the end (1 -3 points) § A score of 0 is a positive screen for dementia. § A score of 1 or 2 with an abnormal CDT indicates a positive screen. § A score of 1 or 2 with a normal CDT is a negative screen. § A score of 3 indicates a negative screen.

The Mini-Cog § As with any screen, further evaluation is needed for a positive screen. § If concerns persist despite a normal screen, further evaluation is also warranted.

Health Resources for Grandparent Caregivers § Be aware of resources for geriatric patients in your community. If concerns regarding cognitive impairment arise, a physician specializing in Geriatric Medicine may be able to assess the patient and offer recommendations.

Social Support § Studies have indicated that Grandparent Caregivers can benefit from taking part in support groups with their peers. § Information regarding groups in your area may be found at: http: //www. aarp. org/relationships/friendsfamily/grandfacts-sheets/

Conclusions § Remember to ask about who is the primary caregiver in the home. § Always ask about family history, but in the case of a grandparent caregiver, try to get a complete history and assess their access to care. § Consider screening for dementia if indicated. § Encourage the caregiver to seek medical care. § Advise caregivers of available community support groups.

Sources § Minkler, M, Driver, D, et al. Community Interventions To Support Grandparent Caregivers. The Gerontologist, 33( 6). 807 -811. § Kelley, S. , Whitley, D. Psychological Distress in Grandmother Kinship Care Providers: The Role of Resources, Social Support, and Physical Health. Child Abuse & Neglect. 24(3) 311321. § Minkler, M. , Fuller-Thomson, E. The Health of Grandparents Raising Grandchildren: Results of a National Study. American Journal of Public Health. 89(9) 1384 -1388. § Clinical Toolbox for Geriatric Carehttp: //www. hospitalmedicine. org/geriresource/toolbox/mini_cog. htm § Grandfacts: A State Fact Sheet for Grandparents and Other Relatives Raising Children. AARP. Alabama, August 2007 § Santacruz, Karen, and D. Swagerty. Early Diagnosis of Dementia; American Family Physician. Vol 63, No 4; pages 703 -713. § Personal communication with Dr. Marsha Crowther, Associate Professor of Psychology at the University of Alabama