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Glad you were able to connect with the SW. Not sure where you are or what the rules are but I would imagine there's a Nurse Care Manager or someone similar to assist with planning and connecting you to resources.
Here in the US discharge planning starts on day of admission and identifying issues from the get go.
Yes some of the cognitive test are difficult one I absolutely would not be able to do is to count backwards by 7's.

Yes, they are talking about connecting us to whatever services she would need. They've already given her a bunch of pamphlets on home food delivery companies, for eg.

However, I still think she needs some kind of assisted living. Am investigating retirement homes where it's like your own apartment but they provide meals, assistance with bathing, housekeeping and laundry, etc. It's super expensive but I think if we sell the house, she can swing it for a few years maybe, and then at her age, I imagine we'd be looking at long term care for sure by then.

My mom is still in the hospital. It's been 8 weeks.

She was given permission on Nov 7 to half-weight bear on that leg. They have her walking a bit with a walker. Physio continues daily, and they are working on both arms and both legs.

She has had the moca dementia test, and I'm shocked to say she scored better than I thought she would although the result indicates mild cognitive impairment. They recommend at her score that she stops driving. She had already given up her license.

Ok, great, it's mild. But it's a score and I think we all know that a score doesn't tell an entire story. I still find her extremely repetitive, and extremely forgetful. I realize she doesn't have a lot going on right now so there's not much to tell me, but she tells me the exact same stories every time I'm there. One day she told me the same story twice within 2 hours. She argues with me about what's going on medically. For instance, I was there on the 7th when they took her for xrays on her leg, and the surgeon came up and gave her permission to half-weight bear. She argued with me yesterday that she hadn't seen him since she first came into the hospital. On the 14th, they took her for a chest xray because her feet are swelling a lot. She argued with me that she went for a chest xray, not a leg xray. Yes, mom, you had a chest xray on the 14th, you had a leg xray on the 7th ... They put her on Metamucil a few weeks ago, daily. She told me yesterday that she had it for the first time yesterday morning even though she's told me previously she's had it in the past few weeks. This is not someone who can keep her medication straight on her own.

I thought I had made some progress on the assisted living front. She seemed somewhat agreeable. I guess she's forgotten that, and is now saying she wants to try it at home. My brother and I were just saying to each other that it takes at least a staff of 4, that staff being me, my brother, his girlfriend, and mom's friend, to keep her in her house and just why does she think we're her staff? I commented to my brother that I'd like to visit mom, just visit mom and not have to work at her house. He said that's exactly how he feels. Mom has commented to me that perhaps she'll need a wheelchair when she goes home. Maybe she will but how exactly is that going to get her upstairs? How exactly is she going to get through her little goat paths of her hoard? Not a real logical thinker, that one.

Her next leg xray is the 28th. That one may lead to a move to the more intensive physio rehab still in the hospital. She told me yesterday that she thought when she fell she'd be in the ER for an hour, can't believe she's been in the hospital for 7 weeks (had to then tell her it's been 8).

I just don't know how to get through to her that she is not mentally capable despite her testing score or physically capable to live on her own. The hospital is still clear on their mandate to return her "to her community." No one seems to care when I tell them that her house needs to be condemned. They are so focused on all of the wonderful services that can help her stay in her home. They say I can't force her to go into assisted care. Yes, I have medical POA but I would have to hire an expensive, independent assessment person to have them declare her incapable to enforce it. I just want my mother to agree on her own.

One nurse at the hospital did advise trying to talk my mom into a trial run at assisted living. Put it to her as a couple of months further rehab/care after leaving the hospital. She said that then quite a few patients realize it's not a bad place to be, and come to love it. She said that a lot of patients are completely unrealistic about how much the nurses are doing for them in the hospital. And mom is completely unrealistic about how much my brother and I and her friend were doing for her at her house.

Put it to her as a couple of months further rehab/care after leaving the hospital. She said that then quite a few patients realize it's not a bad place to be, and come to love it. She said that a lot of patients are completely unrealistic about how much the nurses are doing for them in the hospital.

They just did that with my x-mil. She was doing so well at the facility that her family thought maybe she was good enough to return home.

It did not take to long to realize that she was doing so good at the facility BECAUSE there were folks there to help with everything (meals, meds, activities, care, etc).

Now she is back home and struggling (and lonely). However, the battle to get her to go back started all over again.

I know you are trying (and trying) to get everyone onboard because it does sounds like some sort of assisted care would be ideal for her. I am sending you good mojo on getting all that aligned for her.

Ten weeks in the hospital now. However, she was given permission to full weight bear on that leg, and today she was moved to the in-patient rehab area which offers more intense physio. Twice a day now. I'm told that they will likely give us a release date shortly, but that it will be in 2-3 weeks.

Meanwhile, the day that her latest room mate went home from the hospital was the day that I could finally just let loose and really make my case for a retirement home. I know that my brother did the same that night. And she has finally agreed to do it! I'm a little afraid she may feel like what evenkeel just said, that she may think she can go home after being out for a bit.

The snag ... I had no idea that she has to be assessed to even go into a retirement home. I know that a person has to be assessed for long term care, but this came as a surprise. Now I'm afraid she's right in the middle of these 2 situations. Doing not quite good enough for a retirement home where they want to help you a little and not too much, and not bad enough for long term care. Sigh.

I've been to visit one retirement home last week, going to another 2 this week. The one I'll be visiting this week offers different levels of care in the same place so it may be a good choice. A person can kind of transition along with the care that they require as time goes by, and that seems like a good idea.

The cost, though ... whoa! I am so grateful to her aunt that left her a little inheritance that will get mom through the first couple of years, and obviously her house needs to go. Obviously, it's either a total gut or a tear-down for someone. I just hope we can get a good price for her lot.

12 weeks in the hospital now, and she is set to be released on Thursday.

She is moving directly into a retirement home. I've got movers coming to her house tomorrow to pick up 2 dressers, her bed, 2 chairs, her TV. The retirement home is lovely. When I first walked into the rooms of different retirement homes, it was kind of depressing. They seemed so small. But then the tour person would take us into a room of another resident, and I was amazed at how much they managed to get comfortably into the rooms. I saw 2 rooms that had their bed, each had a loveseat and another occasional chair, small table, dressers, etc. It has really helped me to envision how to set up mom's room tomorrow. It has a little kitchenette, too, although hopefully she doesn't really need it. There is a medium sized fridge to keep some bottled water, juice, etc.

I've been picking up clothes and bringing them here to look over and launder because I don't know what is dirty and clean. I am being brutal in throwing out anything stained, in need of repair and donating anything that I think is too big for her (she's considerably smaller than she used to be). I am not going to have her wandering around the retirement home looking like a hobo. I'm tossing all underwear, all socks. Buying new.

I feel like a mom sending her kid off to camp. I'm worried that she won't leave her room to go to the dining hall to eat. They are going to come and get her for the first 3 days and walk her there so that she's well oriented on where to go. I went there last night and counted steps and compared the distance to how far I know she's walking in the hospital to get to physio. I know she walks 85 steps to get to physio although I think she usually is brought back in a wheelchair. I get it, physio takes a lot out of her. I counted about 65 steps to get from her room at the home to the dining hall so I know she can get there but she's going to have to do it 3 times a day and back. I just hope she can and will do it.

The halls at the home are extraordinarily wide and spacious and carpeted so in my mind, it really encourages walking. I'm going to go over for some of the activities that they offer since I can take part, too. I figure it will help to get her meeting more people and taking part. It's been a long time since I've played bingo and I think that chair yoga sounds kind of fun. That said, of course the home has to be experiencing a smattering of covid cases atm. Mom was not able to get her latest vaccine in the hospital. She asked for it, I was there. I'm going to have to get that arranged for her, and her flu shot. I hope she doesn't get covid - we kept her safe from it all the way through the pandemic. I can hear it now - I didn't get covid at my house! You move me in here and now I have covid ...

I've been losing sleep over this move and all of the work that I'm doing. She has no idea the mess she has dumped on my brother and me. BTW, he did call my h and moaned that he has too much stuff, and my h gave him quite a talking to about letting go of past interests and not keeping things you clearly don't use or need anymore. FWIW, he has been very helpful over at the house digging out the furniture I want to take to the home and moving it downstairs already so the movers don't have to go up into that hoard. He stripped her bed, took all of that laundry home and took care of it (or his girlfriend did - whatever, it's done.) I'm really not sure how he moved 2 dressers and a bed down the stairs all by himself but he did. He has visited her nearly every day in the hospital when I've only gone twice a week (45 minute drive for me).

I really can't wait until I can just visit my mom, and not have to deal with her house and her hoard.

It has felt like she was in the hospital forever!

I think she will really enjoy her new place once she gets use to it. Everyone I know that has been placed did a lot better because of the group activities, etc. Just that involvement helped them mentally-emotionally so much.

I've been picking up clothes and bringing them here to look over and launder because I don't know what is dirty and clean. I am being brutal in throwing out anything stained, in need of repair and donating anything that I think is too big for her (she's considerably smaller than she used to be). I am not going to have her wandering around the retirement home looking like a hobo. I'm tossing all underwear, all socks. Buying new.

Does this facility do her laundry or will you be doing that? I know in my area, it seems stuff is always getting 'lost'. I am not implying stolen by staff. I think it is more human error (labels/names fall off during the wash or someone with some short-term memory issues thinks it is their's etc).

As for size of clothes, my uncle has really gained since being in a home. I think it is because he is going for 'real' meals three times a day vs snacks. Whereas at home, he was depressed and not eating the best. So you may want to temporarily hang onto a few of her bigger sizes for a little while (just incase). My cousin was going crazy buying my uncle new clothes each month. He has now graduated to a 'stretchy-waist-type' wardrobe. But that is a good problem, the man was just a little twig prior.

Although you still have miles to go, this has to be a tremendous weight off of you. Just knowing she will be somewhere that has 24x7 eyes on her, etc.

I am hoping for a smooth transition for you all.

Sending positive thoughts your way. I may have said this before but many of us on this forum have dealt with similar things. I wish you peace and healing. I can’t imagine what this must be like for you.

Does this facility do her laundry or will you be doing that?

They do do her laundry! I'm so excited!

At this facility, each resident just has their own labelled basket. That basket is taken to the laundry, set in front of the machine they are using and put right back into the basket when done. It's not group laundry.

I'm just laundering the clothes I find in piles at her house because I don't know what is dirty / clean. Good thing I did because some was definitely very dirty. Big yuck.

She has gained 20 lbs in the hospital! So yes, I guess that keeping some of the bigger clothes is a good plan after all. That tells me that she wasn't eating well at home, which I suspected.

Thanks for the support. Sometimes it just feels good to type it out and send it off into the universe.

So mom got out of the hospital on Thursday, I took her for a little cruise around town, had to stop at her pharmacy to pick up some prescriptions (got her onto the blister pack service) and then to her retirement home. An occupational therapist showed up to check out the room to make sure she could access her dressers and that there were no apparent hazards. Another service sent over a riser commode to sit above her toilet and a safer walker. Her rolling walker was deemed unsafe for her because she uses it irresponsibly (she's not conscientious about the brakes). She did very poorly on a balance test before leaving the hospital, and is deemed very high risk for falling.

We determined that one of the chairs I took over there was extremely unsafe. It's been underneath a pile for the last 20 years so I thought it was in good condition. Which it is to look at. But it's a swivel rocker (didn't remember that) and it's very, very low to the ground. I could barely get out of it when I sat on it. So that has to be removed. The 2nd chair I took over there out of the 3 is also unsafe. Sigh.

She had a hard time getting from my car to the room. I think it was just more that she was overwhelmed. She's been getting to the dining hall and back all right, except she has missed one meal. Yesterday, my brother said he was there just after lunch and was asking her about it, and she talked about the bacon and eggs. He was confused and said wouldn't that have been breakfast? In talking it through, he determined it had been breakfast and she somehow skipped lunch. I was afraid of stuff like this happening.

My H and I were there on Saturday to bring over some more things for the room, and to hang some stuff. Making things more comfortable, etc. I had 2 really frustrating conversations with her. The first one was her telling me that she had asked my brother to bring over something that she had already asked me to bring over, and I just had brought it although she didn't know that yet. I got upset because she always asks 4 of us for the same things, and then 4 of us show up there with said item, and she doesn't need 4 of anything! She does not have the room to be hoarding there! I lost it a bit and was pretty firm in saying stop asking all of us for the same item! Just ask one of us! The 2nd one was that she showed me a word search puzzle that she was given in the hospital by the book cart lady. That lady saw she had like 7 word search books there and started bringing her photocopies of word search puzzles, like she needed more. Why does everyone feel the need to pile on more crap when they see that someone likes something and already has a bunch of that thing? For whatever reason, my mom would dutifully do the puzzles that the book lady gave her and then she would give them back when the book lady came back the next week. In the hospital, I said "mom, it's not an assignment! You don't need to return them. I'm sure she throws them away." I don't understand my mom thinking the woman wanted them back. So, she showed me a photocopied puzzle that the book lady gave her the other day and that puzzle relates to my job. I said hey, I'll take that and I'll photocopy and put it out on the lunchroom tables for my co-workers. Some of the people at my job like to do puzzles while they eat lunch and on their breaks. Mom hesitantly said well, ok, but she'd need it back. Why, I ask. Well, because it's not hers, she needs to return it to the book lady at the hospital. WTH? Who does she think is going to drive across town to return completed word search puzzles to the book lady at the hospital? My H literally said do you know how crazy you sound right now? It wasn't our finest moment, but we are so freaked out when she acts this way.

I told him when we left that we need to just re-frame with my mom, that we really need to just overlook how cuckoo she's being, just say ok, she's going to forget about it in a week anyway. But it's hard.

At home, I looked up a drug I saw there that I was not familiar with, and it's for occasional insomnia. It can cause confusion the following day so maybe this is why were are finding her more bananas on some days than others.

I just about fell over when she told me that she walked to the library in the retirement home which is just a bit down the hall from her room in a different direction from the dining hall. I was very pleasantly surprised to hear she did something that no one made her do. I was also very surprised to find her bed made (by her) on Saturday.

One problem we are having is the government services she qualifies for. Don't get me wrong, we're very happy that they exist and we do plan to use some of them. But for instance, a PSW showed up unexpectedly to help her shower on Friday and it was 20 minutes before she was due in the dining hall for dinner. I do think that shower help is something she should have, but I do not think it's reasonable to show up with no notice and expect her to get through that and be at dinner 20 minutes later - that is entirely too much for her at one time. That occupational therapist showed up with no notice, too. In a time when we're cautioning our seniors to be careful, to not let people into their homes, hang up when strangers call, don't fall for this, don't fall for that, etc. we've got services/strangers just showing up all willy-nilly wanting to come into her home. That's not right. That should be cleared through me so I can give her notice and the ok.

My H and I are going to join her for dinner at the retirement home on Xmas day. It's nice that we can join her for meals there. Apparently, it costs us $12 each. No biggie.

Sounds like you are having to face the difficult time of watching your mother's mental decline as it is in progress. Good that she has been placed in a care home! But it is sad nevertheless to lose our parents piece by piece like this.

When my father was declining for several years after his massive stroke and had stabilized for six months, the doctor told me that with his cerebrovascular dementia, we could expect to keep seeing him decline in his function, but in steps. In other words my father would hold onto what we were observing as his preserved abilities, but only for a while before there would be another step downwards. I didn't like hearing that news, but it proved to be exactly the case.

This time is for your family to heal the relationships with each other and strengthen your bonds before she goes.

It is a lot of changes for her BUT it is a lot of changes for your family as well. Please give yourself time to adjust to the new normal.

I lost it a bit and was pretty firm in saying stop asking all of us for the same item! Just ask one of us!

This might not be a request she is able to process. What can you do outside of her to elevate this? You are not going to be able to change her so how can you change what you can? Maybe your family keeps a group chat JUST for this type of stuff and each puts updates there. I.e., Mom asked for slippers with anti-slip bottoms; I am picking some up today. That way if someone else was also told the same request; they know it is covered, etc.

"mom, it's not an assignment! You don't need to return them. I'm sure she throws them away."

It is great your mom still has the capacity to do puzzles. Do not get bogged down in the details of it. If your mom feels responsible to this lady to do them and return them; so be it. If this keeps her engaged and doing them; that is a good thing. Like you said, the lady probably just quietly disposes of them. I am glad the facility is paying attention to what your mom enjoys right now and is catering to that. Those are good signs.

WTH? Who does she think is going to drive across town to return completed word search puzzles to the book lady at the hospital? My H literally said do you know how crazy you sound right now? It wasn't our finest moment, but we are so freaked out when she acts this way.

She is going through a lot of changes now and it is a lot for any brain to process, let alone someone who already is struggling. I would try to let anything go that sounds crazy to you because it is probably very real to her.

You know how her house was so you know somethings are just beyond what she mentally can do.

I understand this is so hard but you are doing great!

Thanks EvenKeel.

I wanted to set up a 3-way fb messenger situation with mom's friend and my brother, but they are not "friends" so not sure it's possible. It probably is, just haven't tried it yet. I don't think my brother is going to want to be her "friend" since her husband was his former boss and well you know ...

For the time being, I got a white board for her room so we can jot down what she needs and whoever is getting it can jot their name beside it. It's a start. We can jot her appts there and who is taking her as well.

My h and I were able to have Xmas dinner at the home with mom. It was nice. I went last Sunday afternoon to take her to a music thing in the lounge. They were just taking requests and playing the music the residents wanted. The lady running it came over and said hello to mom, asked her name since she's new, asked if she had any requests. Mom wasn't prepared as we didn't know what to expect so we just listened. After about the 2nd song, mom leans over to me and says "how long is this going on for?" in a not-so appreciative way. I just laughed and said "are you hoping I'll say forever?" But before long I noticed she was singing along and tapping, and I think that she did enjoy it.

Unfortunately, I got really sick 2 days after that, still am, and haven't been back. I've had to duck out of taking her to her hospital recheck on Thurs. She didn't get whatever I've got so that's good.

Thanks for the update, SackofSorry. It's tough. My mom passed from pancreatic cancer less than a month after I found out. I missed out on so much that people think is a burden.

When she's gone, you will be grateful for these moments. Or, you can think of those of us were denied these moments we wish we had.