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

2. Objectives  Identify key health issues for:  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

3. 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.

4. The Issue  According to 2011 American Community Survey Estimates:  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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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?

12. 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.

13. 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.

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

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

16. Diagnosis  There are 3 main categories to think of in the continuum of dementia.  Age Related Cognitive Decline- memory loss without other cognitive issues. Within normal limits given a person’s age.  Mild Cognitive Impairment- patient with some cognitive impairment, but not to the degree found in dementia.  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.

17. 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.  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.

18. 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

19. The Mini-Cog  The test consist of 3 steps:  1) Instruct the caregiver to listen carefully to and remember 3 unrelated words and then repeat the words back.  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)  3) Ask the patient to repeat back the 3 words previously presented.

20. 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.

21. 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.

22. 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.

23. 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/friends- family/grandfacts-sheets/http://www.aarp.org/relationships/friends- family/grandfacts-sheets/

24. 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.

25. 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) 311- 321.  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 Care- http://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. Vol63, No 4; pages 703-713.  Personal communication with Dr. Marsha Crowther, Associate Professor of Psychology at the University of Alabama