Evelyn and Gloria are two devoted daughters of an 88-year-old woman still living in her two-bedroom apartment. A widow for 15 years, Ruth managed her affairs quite well until three years previously when the sisters and their brother in Edmonton, noticed some loss of her usual fastidiousness in her grooming and in her apartment. They assisted Ruth by arranging a weekly visit by a cleaning lady, who begrudgingly Ruth accepted. Gradually Ruth's mental abilities declined, with increasing forgetfulness. She could not do her banking or pay her bills. Evelyn and Gloria both worked and had families of their own. They split up the tasks and managed to get everything done. They arranged for a geriatric assessment that confirmed their worst fears, Ruth had evidence of dementia, probably of the Alzheimer type. She had other previously defined medical problems, including high blood pressure (hypertension) and type 2 diabetes, which required numerous daily medications.

After the diagnosis of dementia was established, she received a medication used in such conditions. The daughters understood that such drugs although not curative might result in some benefit and might decrease the progression of the disease. There were a few months of cognitive and behavioral improvement but these were transient. Ruth agreed to join an Alzheimer's day program and enjoyed attending three times a week. But on the other days she was home alone other than when visiting family. Her daughters became increasingly concerned about her well-being and safety.

Ruth refused to have anyone in the house with her during her weekdays and weekends at home. Evelyn and Gloria were increasing concerned because despite their devoted supervision and visits, they could not fill all the days and nights. They worried about whether Ruth might fall; leave the stove on or the sink running. Ruth phoned her daughters regularly, often about the same concern two or three times in an hour.

They came to my office for advice, Ruth accompanied by Evelyn and Gloria. From the point of view of medical treatments, things were about as good as one could hope for. But the daughters observed that Ruth often forgot her medications. The dosette pill dispenser they carefully filled was not always emptied of the correct pills. Phone calls during the day to remind her to take her pills, which originally worked, were no longer effective.

They sought my advice. Evelyn felt that maybe a retirement home with some assisted living was necessary but Gloria was reluctant and Ruth would have none of it. Gloria asked me to recommend to Ruth that she have someone in the apartment a few hours every day, including weekends. Ruth adamantly declined, saying, " I'm fine"- a common response in people with dementia. Neither daughter wanted to "force" their mother into a decision, but felt compelled to do something. Ruth listened carefully to their concerns in our discussion, while denying she had any problems. Eventually with some cajoling, Ruth agreed to "try it out" on my "medical order" for three months, having someone come every day and weekends, and "promised" to continue with that plan until the next visit when we would review the situation.

Three months later she came to the office and agreed that the arrangement, although not exactly to her liking was working, much to the relief of Evelyn and Gloria. They both recognized that future plans were necessary as Ruth's condition was sure to decline. The improved situation was temporary and eventually it might not be possible for Ruth to stay safely at home- but that would be another chapter.

Michael Gordon, MD, FRCPC, Medical Program Director, Palliative Care Baycrest Geriatric Health Care System. Co-Author with Bart Mindszenthy of Parenting Your Parents: Support Strategies for Meeting the Challenges of Aging in the Family (2nd edition), Dundurn Press

Reprinted from the Canadian Jewish News