Depression and the Elderly

 

If you work with the elderly for very long you soon realize that one of the major challenges in that work is recognizing and treating depression.

 

One of the ongoing challenges presented by depression is that to many people the symptoms of depression are often very similar to dementia.  For this reason alone, if you are caring for an elderly person who seems to be suffering from dementia, it is critical to have that individual also examined by a qualified medical professional to check whether the symptoms being presented are actually a result of depression.  The elder in your care may also be suffering from both as well.

 

In an earlier post, I noted the sadness that is associated with growing older.  Sadness is not the same thing as depression, but may be a symptom of it.  As we journey through life, we will almost inevitably find ourselves in situations that make us sad, and that is even more the case with the elderly.  Our bodies start to fall apart, we experience more pain, and we can’t move around with the same agility we once took for granted.  Our children move away and become focused on their own lives, their spouses, and their children.  We find ourselves searching for meaning in our lives beyond the roles of parent and grandparent, waiting patiently for some opportunity to be involved in the lives of our families.  These adjustments in our place in the world often bring on sadness.

 

Being aware of the difference between the sadness described above and the far greater threat of full-on depression is critical.  Depression in the young might produce more symptoms that appear to be sadness:  emotional fragility and weeping.  In the elderly, depression may manifest itself in physical symptoms (more pain and difficulty moving) and withdrawing from activities with friends and family.

 

Add to this, recent studies show that depression is only diagnosed in a small fraction of the elderly suffering from it, in part because they are loath to seek help due to the stigma attached to mental illness in general and depression in particular.  Even in these supposedly more modern times, we still tend to view with moral blame and sanctimony illnesses affecting the brain where we would be more supportive and caring if the illness affected, say, the pancreas, liver or heart.

 

When it comes to treatment, that which works with younger individuals may not be so effective with the elderly.  Mental health professionals skilled in treating the elderly need to be consulted.  Depression, left untreated, also can affect the progress of other diseases that require treatment.  It may take a number of visits and intervention by a coordinated team of professionals to sort out what the symptoms present, their effect on other diseases and conditions, and the appropriate regime of treatment to address the complexity of the situation.


Don’t let depression deprive the elderly of the joy of their remaining years of life – make sure they get the diagnosis and treatment they need and deserve.

 

The mysteries of social security...

I often marvel at how little people know about Social Security and the benefits that are available to individuals and couples upon reaching age 66, the current retirement age.  To say Social Security is complicated is to state the obvious.  It is, like many government programs, a system that was set up in a bygone age when few women worked (in comparison to men), so the system has built-in biases that are a detriment, particularly to widows.

 

A recent article in the New York Times highlights these biases very well and is a plea for updating Social Security to better serve widows.  It seems this is unlikely as there is a large segment in Congress, not supported by the citizenry in general, to do away with Social Security so this is not a good time for reworking the system.

 

The article is available at http://www.nytimes.com/2015/09/12/your-money/for-widows-social-security-system-can-provide-rude-shocks.html?_r=0.  It is worth a read, as it also contains a wealth of information about Social Security in general.  The article also mentions a recent book entitled “Get What’s Yours: The Secrets to Maxing Out Your Social Security.”  It’s available from Amazon for around $10 and is worth the price as it is a great guide to making sure you don’t leave thousands of dollars behind due to ignorance and the complexity of the system.

 

If you are approaching retirement age, or are caring for others who have reached that point in life, do yourself and those you serve a favor by educating yourself about Social Security.

 

The sadness of growing older...

 

 

I took a walk with a friend not too long ago and during our conversation she mentioned an incident with her married daughter.  She had gone to watch her grandson play a Little League baseball game.  The game was rained out – not something that happens often in Southern California!  With the game cut short, my friend related that her daughter began to berate her for not paying more attention to her grandson.  “You hardly ever come to his games!”  The conversation went downhill from there.  My friend was left very saddened by the exchange with her daughter.  She found it hard to defend herself because “getting into it” with her daughter just means she sees even less of her.  She observed to me that she would love to attend more of her grandson’s games, but her daughter never has provided the schedule of games even though she has requested the schedule many times.  My friend then went on to say that she texts her daughter from time to time and never hears back from her.  My friend has stopped calling her daughter because she never picks up the phone, apparently doesn’t listen to the voice mail messages she leaves, and doesn’t call back in any event.

 

I pointed out that her daughter is a busy woman with a job, a family, a husband, all demanding her attention and devotion.   My friend acknowledges all of that, but the inattention, however justified, still hurts.

 

The same friend recently went on vacation with her extended family.  She described an incident in which her sister-in-law asked my friend’s children, in her presence, what their plans were for the holidays.  My friend was devastated!  It wasn’t the question that hurt; it was the fact that the exchange occurred in a way which made it clear that her input was irrelevant.  “Input from me was not required.  The ‘adults’ will decide the agenda and I, as an old person, will be expected to go along with whatever is decided.  I’m not included in the ‘adults’ category anymore; I’m just old (67) and so no longer thought of as having any input in these matters.”

 

I met another friend who just celebrated her 47th wedding anniversary.  She and her husband went out to dinner and a show, and had a good time.  But, she didn’t receive a letter, card, email or text message from any of their children wishing them a happy anniversary.  Her comment:  “Well, you know, the younger generation just doesn’t do that kind of thing anymore.  .  .  I understand, but it still hurts!”

 

I can remember my mother-in-law complaining of waiting around her apartment for her grandson or granddaughter to show up.  The grandchildren had said they would come by.  Even though she had other things she wanted to do out in the community, she stayed at home waiting.  The grandchildren, by contrast had spoken casually, and didn’t think it was really so important to come by at a set time or even to show up at all if there was something else that came up that made the visit less urgent or attractive.  So my mother-in-law sat at home, waiting, sad, and alone.  She understood, but it still hurt.

 

If you visit retirement communities, assisted living facilities, nursing homes, and other places where older folks live and/or are warehoused, those old people exhibit lots of emotional states; boredom, anxiety, depression, but the one that stands out most for me is just plain old sadness.  It’s the sadness of those hundreds or thousands of small hurts that others dish out to them without though or intention.

 

This month I celebrated reaching the age when I am covered by Medicare saving me hundreds of dollars a month in medical insurance premiums.  But, I also then passed a threshold at which I am on the road to being old.  I’m still alive, still a vibrant person not willing to be put on the shelf.  I have work to do, places to go, meetings to attend, and decisions to make in the course of my life and work.  I’m very optimistic by nature and have a full life.  The small and casual hurts are just beginning, but I can feel them.  I tell myself that I need to build my own life with my own friends and not let the hurts accumulate, but those small cuts still keep coming despite my best efforts.


George Bernard Shaw is credited (by some) with the observation that “Youth is wasted on the young.”  There is no getting around the fact that the truth of this observation is itself not generally appreciated by the young, and so on.  But, we are all entitled to dignity, kindness and respect, and that includes the elderly.

The Conversation...

The Conversation

I recently read an article in the New York Times by Alexandra Butler entitled “Experts on Aging, Dying as They Lived.”  It is one in a great series in The Opinionator section of the Times called The End.

In the article Ms. Butler described her parents’ efforts to be prepared for end of life, including making sure all their documents were in order expressing their wishes regarding medical treatment and things of that nature.

She described her reaction to her parents’ efforts to involve her in their process this way:  “As a teenager I hated these discussions. I probably told them to stop torturing me and to stop being so morbid. They were reassuring me about scenarios that I did not want to think about. I could not have known how grateful I would be now.”

As a fiduciary, I often see the consequences of the failure of individuals to prepare for the end of life and to involve their families in the process that should accompany such decisions.  Having your house in order as you approach old age and, eventually, the end of your life is probably one of the greatest gifts one can give to the next several generations.

I also speak to many people who express much the same sentiments when the elders in their lives attempt to engage them in the conversation about aging, death, and the preparation needed to make those events dignified and comfortable.

Ms. Butler ended her meditation on the death of her parents with a moving and thoughtful insight.  “Our deaths are the last message we leave for those we love. How my parents died — in comfort — was the way they cared for me after they were gone. I was not ready to lose them in my 20s, but they had prepared and so I was protected.”

When we visit a lawyer and prepare our estate plans, it is essential to engage the rest of the family in that process, even when they view it as morbid.  A few examples of the importance of those conversations illustrate the importance of having these discussions.

I have found that parents are often clueless about their children.  First, they tend to believe they all get along and there are no stresses or conflicts among their children.  Second, there is a belief that their children innately share the same values and beliefs they do.  These beliefs and assumption are not necessarily true and the consequences when they turn out not to be true can be catastrophic.

If a family never has conversations about their end of life decisions, they will never discover what all too often becomes clear after the death of the older generation.  Decisions are left in the hands of people who don’t agree with the dying wishes expressed in an Advance Healthcare Directive.  Among all your children, which one’s views on end of life decisions is closest to your own?  How do they feel about letting nature take its course rather than engaging in all manner of traumatic and ultimately useless heroic efforts to save life at the expense of the value of living?  The fact is, you will not know whether your wishes will be zealously championed by your chosen representatives if you have not discussed with those representatives what it is you want, and how they feel about that.

In the case of trusts and wills, many parents, believing their children all “get along so well,” name them all as co-trustees or co-executors of their estates.  If the children do not get along well, then forcing them to get along when the crisis of your death occurs is a prescription for disaster.  Every past slight or grievance gets dragged back into the decision making process and things begin to fall apart.  Once relations are strained, every action is scrutinized for a hint of bad faith dealing, fraud, or mismanagement.  All of the worst aspects of putting decisions into the hands of a committee are magnified by the lack of agreement among the family-committee members.  Better to have extended discussions with the whole family where the unpleasant and harmful dynamics of the family are revealed.

If you are experiencing difficulty having the conversation in your family, check out the program and resources available at http://theconversationproject.org/.

Don’t wait; have the conversation with your family and give them the gift of peace, love and fond memories rather than a legacy of hurt and strife.

Family trouble...

Sibling Trouble

 

If you want to be a professional fiduciary, and in particular are interested in taking on the role of conservator, you might be interested in the May 29 article in the New York Times entitled “Strengthening Troubled Sibling Bonds to Deal With an Aging Parent.”  You can read the article at http://www.nytimes.com/2015/05/30/your-money/strengthening-troubled-sibling-bonds-to-deal-with-an-aging-parent.html.

 

Conflict among family members regarding their aging parent or relative is very common and something you will encounter in a wide variety of situations as your practice grows.  The son or daughter in whose home the elderly person is living often resents the perceived lack of support from their siblings.  The non-custodial siblings, in turn, sometimes come to believe the custodial sibling is taking financial advantage of the elder, relying on their income rather than their own earnings.  These feelings often have little to do with the actual occurrences taking place and more to do with long nursed grievances and slights going back to childhood (“Mom always liked you best!”).  

 

In these kinds of situations you will often hear a variation on the exclamation/explanation, “It’s the principle of the thing.”  The family combatants then “lawyer up” and bring legal actions against one another alleging all manner of abuse, financial chicanery, and deception.  In this kind of situation, there is very little thought to the cost verses the benefits of legal action.  I often hear the family combatants in these cases saying they want “justice” more than anything.  Justice usually means some form of criminal penalty – something they will certainly not get in probate court.

 

Professional fiduciaries are not brought into these situations until a court, in exasperation, decides that none of the warring siblings can be the conservator or trustee and appoints an independent professional fiduciary.  If you are appointed in such a case, make sure your attorney is well versed in the ways of the local court and probate bar and is thick skinned.  Make sure your own skin is also nice and thick!

 

Some thoughts about Lawyers...

Lawyers

 

If you want to be a professional fiduciary, you will spend a lot of time with lawyers.  Lawyers are a much maligned profession as seen by the popularity of lawyer jokes and other jibes by comedians and others who make points at their expense.  But if you work in a field where lawyers play a multitude of important roles, you will come to view them as your allies and friends, even when you don’t always agree with what they are doing.

 

The lawyers who practice probate law in each county are usual a fairly small group, most of whom know one another well, have worked together and in opposition to one another, usually with minimal rancor or trouble.  Even in the larger counties like Los Angeles, the lawyers who show up in probate court day after day form a small community with many of the attributes you would expect in any small, tightly knit community.

 

When you are interacting with lawyers, keep in mind that not all is wonderful in their world.  May I suggest you read the article that appeared in the New York Times on May 12, 2015, with the headline “Lawyers With Lowest Pay Report More Happiness.”  You can read the article at http://well.blogs.nytimes.com/2015/05/12/lawyers-with-lowest-pay-report-more-happiness/?_r=0.  The article notes that “Struggles with mental health have long plagued the legal profession.”  Lawyers are significantly more prone to depressions, substance abuse problems, and suicide than the general public and many other professions.  Their lives are filled with the stress and strife, deadlines, demanding judges, objecting and critical colleagues and opponents, and stressed out clients.  In many ways, when viewed from that perspective, it is no wonder that lawyers are particularly susceptible to stress-related problems.  So next time you meet a lawyer making your life miserable, keep in mind that his or hers may be even more miserable than he or she is making yours now.

 

Many of the stress-inducing aspects of the practice of law are also prevalent in being a professional fiduciary, so watch those lawyers and remember to monitor yourself for those same issues.

 

As a fiduciary, you can’t do the job without a lawyer.  Your own lawyer is there to protect you and he or she will likely become your friend as well.  The lawyers for other parties to probate proceedings will also be your friends in many circumstances.  When everyone is misbehaving and acting irrationally, the only people who can bring some semblance of order to the situation are the lawyers.  You may not always agree with them, but generally they are at least rational and pragmatic, both extremely useful attributes when embroiled in a contested or contentious probate matter.

 

So who are the lawyers you will encounter in a probate setting?  There is your lawyer.  In guardianships and conservatorships, the court will most likely appoint a lawyer to represent the ward (the minor in the guardianship proceeding) or the conservatee.  If you act as a trustee, you will often interact with the lawyers who represent various beneficiaries of the trust and third parties with an interest in the administration of the trust, such as creditors of the individual who established the trust or creditors of the beneficiaries.  In a probate case where a person has died leaving an estate to be probated, the heirs may hire lawyers to represent them.  Creditors of the deceased person may also hire lawyers to represent their interests in the estate.  Finally, there may be other, outside, lawyers who represent individuals or entities bringing legal actions against the various types of estates you may be handling.  In those circumstances, you may then need to hire litigation counsel (lawyers) to defend or settle legal actions against the estate for which you are responsible as a fiduciary.  First, and most important, is your lawyer.  The lawyer who represents you is there to guide you in the law applicable to the tasks you undertake and to protect you in your fiduciary role.


Look for later posts that discuss in more detail the roles each of these lawyers play and suggest ways to view what they do.  They are often exasperating and infuriating.  But before you allow them to raise your blood pressure to dangerous levels, take a moment to understand their viewpoint and it will help you work productively with them to resolve matters to the benefit of the estates for which you are responsible.

Beginnings...

"From time to time, it is my intention to write posts here about my experiences and observations as a licensed professional fiduciary, teacher and observer of the world of probate.  My intention at the outset is to write about two main topics.  First I want to write about being a fiduciary in a variety of settings.  Second, I intend to write about the challenges faced by the elderly, including the many ways in which they are abused as they begin to lose the capacity to manage their own lives and must depend on the good will, honesty, and care of others. 

The word “fiduciary” comes from the same root at fidelity.  A fiduciary is a person who acts for the benefit of another.  A fiduciary steps into the shoes of another and does for that other person what they no longer can do for themselves – a form of surrogate.  As such, a fiduciary must look out for the interests of the others to whom they owe a fiduciary duty even if that is incompatible with or contrary to the fiduciary’s own interests.

In California, fiduciaries act in three main types of situations; conservatorships or guardianships, trust administration, or decedent’s estate administration.  The laws governing all of these roles are found primarily in the Probate Code and are overseen by the probate judges of the Superior Court in each California County.

A conservatorship is a court proceeding in which the court has made a finding that an individual lacks capacity to manage his or her personal life and/or finances.  In that situation, the court appoints a “conservator” to manage the affairs of the “conservatee,” the individual found to lack capacity.  The conservator of the person is appointed by the court to manage the personal affairs of the conservatee.  This role often includes, for example, finding appropriate caregivers to help the conservatee continue to live at home, and making all the necessary arrangements to make that possible.  Depending on the level of incapacity of the conservatee, as determined by the court, the conservator of the person might also be responsible for making medical decisions for the conservatee.  The conservator of the estate is the person appointed by the court to manage the conservatee’s assets and day to day finances.  In many cases, the conservator of the person and estate is the same individual, but in some cases these two rolls are divided between different individuals who must then work together for the benefit of the conservatee.  Guardianships, in California, are concerned with the care of minors.  The guardian of the estate would be responsible for managing the assets and finances of the minor and the guardian of the person would be responsible for the personal care of the minor.  As with a conservatorship, the guardian is appointed by the court and mustaccount to the court periodically regarding their efforts on behalf of the minor or “ward.”

The person responsible for administering a trust, is called the “trustee,” and owes a fiduciary duty of utmost good faith, trustworthiness and fidelity toward the beneficiaries of the trust being administered.  The job of the trustee is to carry out the instructions of the person who established the trust as stated in the trust and any amendments to it.  In many instances, trusts are not supervised by the courts.  In that situation, the trustee carries out the instructions of the trust, providing information and accountings to the beneficiaries showing that he or she is abiding by the terms of the trust.  A trust, and the trustee, might become subject to court supervision if, for example, there was a great deal of conflict among the beneficiaries such that judicial supervision was advisable.  Some trusts are established by court order and are then usually subject to court supervision from their inception.

When someone makes reference a “probate case” they are usually referring to the administration of a court case whose purpose is to gather and distribute the estate of a person who has died in accordance with the instructions contained in their will, if they had one, or in accordance with rules established in the Probate Code where a person dies without a will.

Each of the roles assumed by licensed professional fiduciary described here are potentially complicated and controversial, requiring a high degree of knowledge and experience to fulfill.  In many cases, a professional fiduciary becomes involved in these proceedings when family members or others are unable to manage the levels of complexity and discretion required in being a fiduciary.

My intention in future blog posts is to write about events and observations that illustrate aspects of the job of being a fiduciary.  Before becoming a fiduciary, I thought, as I suspect many do, that probate was a dull and uninteresting area of the law.  My experience of the world of probate is that it is anything but dull and/or boring!  Probate cases are where you see the whole range of human nature.  Probate is involved with major upheavals in the lives of families and individuals.  These proceedings involve births and deaths, the management of assets and money in times of crisis, and elderly people declining

in body and mind and the struggles to deal with the transfer of responsibility that often accompanies those changes.  In those moments of crisis, fiduciaries see individuals at their best and also at their worst, but always challenging and interesting.

More later... stay tuned."