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Episode 64: The Six- to-Eighteen-Month Window You're Missing
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In this episode, I reveal the quiet six to eighteen month window that often comes before a caregiving crisis, and why so many families miss it. I walk you through the subtle warning signs that signal something is changing, how to tell the difference between normal aging and meaningful decline, and the four critical steps to take before an emergency forces difficult decisions. You'll learn how early preparation can preserve your parent's independence, reduce family stress, and give everyone more options. Recognizing this window may be one of the most important things you can do for your aging parent and for yourself.
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Transcript
00:00:01
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The male had been stacking up for four months before anyone noticed. She was a retired school teacher, 81, sharp on the phone with her daughters, which is what mattered because they lived three states away and the phone was how they kept track.
00:00:14
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She drove herself to her appointments. She paid her bills on time, which had been her own quiet pride for over 40 years. Then her daughter flew in for a long weekend in February and found three unopened bank statements, a power bill marked final notice, and a Christmas card from her sister that had never been opened.
00:00:36
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Because by the time it arrived, her mother had quietly stopped opening things. Nothing was on fire. That isn't what made it so disconcerting.
00:00:46
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The fridge had milk. The plants were watered. The house was fine. The mail was the only thing that did not match the woman she had spoken with on the phone three days earlier.
00:01:00
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Six months later, that mother was in the emergency room with an infection that had become sepsis.
00:01:09
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She never went home again. There is a window before almost every caregiving crisis. It opens about six to 18 months before the fall, the hospitalization, the moment everything changes.
00:01:22
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Most families don't know it exists until it closed. Today I'm going to teach you how to see it.
00:01:32
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Welcome to the Aging Parent po Playbook. I'm Dr. Barbara Sparacino, triple board certified psychiatrist in adult and geriatric psychiatry. and addiction medicine, a coach and a daughter.
00:01:49
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If there is one episode of this show I wish I could hand to every adult child in America, it just might be this one, because most families come to me in a crisis.
00:02:00
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The parent fell, the parent was hospitalized, the diagnosis landed, the family had no plan, and now they are scrambling, exhausted, making enormous decisions under the worst possible conditions.
00:02:14
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But in almost every one of those stories, there was a window, a quiet stretch of months before the crisis, when the signs were there and the family either did not see them or saw them and told themselves,
00:02:29
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it was nothing. Today's episode is about that window, what it looks like, the eight signs you you are in it, and most importantly, what families who get it right actually do when they're inside Part one, what the quiet window is.
00:02:50
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So let me define it for you because once you can name a thing, you can act on it. The quiet window is the period, usually six to 18 months between the first real changes in your parents functioning and the triggering or activating event that forces everything into the open.
00:03:07
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These are the fall, the sepsis, the car accident, the afternoon, the bank calls. And here's why the window is so hard to see. The changes inside are unremarkable, unspectacular.
00:03:20
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Nothing in the window looks like an emergency because nothing in the window is an emergency yet. Your mother is still your mother. She greets you at the door with the same smile. She asks about the kids. The conversation runs on rails it has run on for over 40 years.
00:03:36
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And those rails hold because long practice social routines are the very last thing to go. What changes first is everything that does not run on rails.
00:03:47
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The novel tasks, the initiating, the keeping up, the mail, the bills, the hobby she has chosen to start. And those changes are exactly the ones that are invisible from a weekly phone call.
00:04:00
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And easy to explain away on a weekend visit. I want you to think of it as two separate systems. System one is the performative system. right It's the one the conversation, the hosting, the recipes she has made 400 times, the social graces.
00:04:17
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That system is deeply entrenched, grooved, and it runs beautifully late into cognitive change. System two, however, is the management management system, the noticing system, the initiating, the planning, the keeping track.
00:04:32
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That system is fragile and it fails first. and it fails silently because nobody applauds you for opening the mail. So your visits, which mostly sample System 1, keep coming back reassuring while the System 2 is quietly going down behind the scenes.
00:04:49
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The window lives entirely in System 2, which means seeing the window requires deliberately looking at System 2, the counter, the fridge, the checkbook, the calendar.
00:05:01
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So families do what loving families do. They believe the explanation. the holidays threw her off. He has always hated paperwork. Everyone forgets a word sometimes.
00:05:13
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And each explanation is plausible. Except 18 months of plausible explanations later, they are standing in a hospital hallway. I am not telling you this to frighten you. I am telling you this because the window is also the opportunity.
00:05:28
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The families who act inside it have time. options and a parent who can still participate in every decision the families who miss it have none of those things same love different timing so part two the eight signs you are in the window here are the eight signs as i go through them please do not panic match your parent to the list one sign once means very little what you are listening for is a pattern
00:06:00
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and change from baseline. Three or more of these persisting over about three months, and you should assume you are in the window. Sign one, mail is piling up.
00:06:11
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Unopened envelopes are one of the most reliable early markers I know because opening mail requires initiating, deciding, and acting every single day. When that quiet system breaks down, it shows up on the kitchen counter.
00:06:26
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Sign two, Bills paid late or paid twice, especially in a parent who is always very precise about money. You are not looking for poverty. You're looking for a change in a 40 year pattern.
00:06:39
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Sign three, they stopped doing the one thing they used to enjoy. Garden goes a little while, the book club go gets skipped, the golf club stays in the garage.
00:06:51
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Nobody announces a decision. The thing just quietly stops because initiating it became harder than just not doing it. Sign four, forgetting words and sentences.
00:07:03
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New word finding difficulty, circling around an ordinary word. The thing, you know, the thing you start with. Occasional in all of us, a new pattern in your parent is data.
00:07:17
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s Sign five, repeating questions they just asked. Not retelling an old story, we all do that. Asking the same question twice in like 10 minutes about without any awareness of the repeat.
00:07:30
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Sign six, expired food in the fridge. Shopping happens because shopping is routine, but tracking what's in the fridge, rotating it, noticing what has turned, that's executive function and the fridge tells on it.
00:07:44
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Sign seven, New dents on the car that nobody can explain, small ones, mailbox height, parking lot height, right? Driving is one of the most cognitively demanding things your parent does.
00:07:57
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And the bumper often knows before the family does. Cyanate. The calls change. Your parent calls you more often, sometimes about the same things, or less often because initiating the call got harder.
00:08:14
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The direction matters less than the difference. You're always comparing against their baseline, not against some random standard. Three or more, three months different from baseline.
00:08:27
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That is the screening test. Look, this is not diagnostic. It is a signal that the window is open and the clock inside is running. And just as important, what does not count?
00:08:39
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But let me protect you from the other failure mode because I do not want you turning your 75-year-old mother's every misplayed word was place more into a crisis. There is normal aging and it has a profile and it's not in the window.
00:08:55
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Slower recall that arrives late as normal. Your father blanks on an actor's name at dinner and texts you about it at 10 o'clock at night, triumphant. I got it That's normal aging.
00:09:07
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The retrieval system got slower, but it still works. What is not normal is the never coming back or him not remembering that he was trying to remember. Misplacing things in reasonable places is normal.
00:09:19
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Glasses on the bookshelf, keys in the coat pocket. What's not normal is things turning up in unreasonable places. The keys in the freezer, the wallet in the pantry,
00:09:30
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or the misplacing curdling into accusation. Someone took my checkbook. Because the brain that cannot track an object will sometimes write a story about it instead.
00:09:43
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Needing more time is normal. Doing the taxes more slowly but accurately is aging. Doing them quickly and wrong or quietly handling handing them to someone else after 50 proud years is data.
00:09:56
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And one bad day is just a bad day. Look, it could be poor sleep, a head cold, a new medication, grief. All of these can produce a frightening afternoon and a perfectly intact brain.
00:10:07
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That is exactly why the rule has three pack parts. Pattern, not moment. Months, not days. And change from their baseline, not deviation from perfection.
00:10:20
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Your mother was never organized? The messy counter means nothing. Your mother ran a classroom of 30 children with military position for years? The messy counter is a flare going up.
00:10:32
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Part three, why families miss the window, including smart, loving, capable families. If the signs are knowable, why do families miss them?
00:10:44
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Three reasons, and I want you to check yourself against each one honestly. Reason one, the phone hides it. Long practice conversation is preserved late into cognitive change.
00:10:56
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Your mother can sound completely intact for 20 minutes on the phone while the mail piles up behind her. If most of your contact is by phone, you are monitoring the strongest remaining system and missing all the others.
00:11:11
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This is why an occasional unhurried visit where you quietly notice the mail, the fridge, the car, the calendar is worth 50 phone calls. Reason two, believing them is easier.
00:11:25
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When your father waved it off and says he has been meaning to get to it, believing him costs nothing today. now believing him opens a door you are afraid to walk through.
00:11:36
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So families choose, often without knowing they are actually choosing, the comfortable explanation. I don't judge anyone for this. I have done it. It's human.
00:11:47
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But name it for what it is. It's a choice and it has a price. And the price is paid later, often with interest. Reason three, nobody is assembling the picture.
00:12:00
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You saw the dance, your sister saw the late bill, your brother noticed dad repeating himself at Thanksgiving. Each of you saw one puzzle piece and decided one piece was nothing.
00:12:11
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Nobody put the pieces on the same table. This is why I tell families, when something pings your radar, say it out loud to your siblings, even if it feels small.
00:12:23
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I don't know if this is anything, but is one of the most important sentences in family caregiving. Say it. Invite your siblings to say it. The picture only appears when the pieces meet.
00:12:36
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When your sibling says you are overreacting, you know, and because I know exactly what happens next and half your family's, g let me arm it for it. You will say the small thing out loud and a sibling will say, you're overreacting. Mom's fine.
00:12:52
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I just talked to her Sunday. Don't argue. Arguing about conclusions is is a swamp. Instead, do two things. First, translate your worry into observations the same way you would for a doctor.
00:13:06
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Not I think something is wrong with mom, but there were 11 unopened envelopes on the counter. The electric bill was marked final notice. And she asked me twice in one visit when I was leaving.
00:13:21
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Observations are very hard to argue with. Conclusions are easy to argue with. Stay in observations. Second, don't ask them to agree.
00:13:32
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Ask them to look. You might be right. Do me a favor. Next time you visit, check the mail pile and look in the fridge and and tell me what you see. You have just converted a skeptic into a second data collector.
00:13:45
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If they see it too, you have an ally. If they genuinely look and see nothing, that is also real information and you should weigh it. And remember what we said about the phone.
00:13:56
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I just talked to her Sunday is the performance system reporting. It is sincere. it is also exactly how the window stays hidden. Gently invite them past the phone.
00:14:11
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Now part four, what to do inside the window. I think this is the part that matters most. You have run the screen. You suspect you are in the window. What do the families who get it right actually do?
00:14:24
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Well, there's four moves and in this order, if you can. Move one, get a medical baseline. Call your parents physician, share specifically what you have observed and when it started.
00:14:37
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Ask for a thorough evaluation, including a cognitive screening, screening a full medication review, hearing and vision, thyroid, B12, and a mood check. A meaningful share of what looks like early dementia in the window is something else.
00:14:53
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medication side effects, um depression, untreated hearing loss, sleep apnea, thyroid. And some of this is reversible. You don't know what you're dealing with until someone looks and everything else you plan depends on the answer.
00:15:11
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And a word again on how to deliver your observations because it changes what the doctor does with them. Again, mom scenes off lately is almost unusable clinically. I don't know what means.
00:15:23
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But if you say since March, she has asked the same question twice in a conversation, at least once a week. There are about two months of unopened mail and she stopped going to her Thursday books club, which she had attended for nine years is a clinical picture.
00:15:37
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specific behaviors, rough dates compared to baseline. And if you cannot attend the appointment, send exactly that in writing to the office beforehand.
00:15:48
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And know this, privacy law limits what the doctor can tell you without authorization, but it has never limited what the doctor can hear. You can always provide information, use that.
00:16:02
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And the question I get every time I teach this, But what if my parent refuses the evaluation? First, don't lead with the word that frightens them. Nobody wants a dementia test, right?
00:16:14
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Almost everybody will accept a regular checkup. And while we're there, let's make sure nothing simple is going on, right? Your hearing, your thyroid, your medications, because some of this could be very fixable.
00:16:29
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That sentence is true and hopeful. And it works for far more, far more often and what and better than the scary version. Second, anchor it in something your parent really wants already wants, like keeping the driver's license, and staying at home.
00:16:46
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the best way to keep what you want is to keep The best way to keep what you want to keep is to have a clean bill of health on file. And third, if they still refuse, go ahead and call the doctor's office yourself, report what you're seeing, and ask them to raise it at the next routine visit as their own idea.
00:17:03
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we do this all the time. It is one of the quiet kindnesses of primary care and your parent never needs to know the suggestion came from you. Move two, do the legal work now.
00:17:14
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If you have been with with me the last few weeks, you know this one. The window is almost by definition the time when your parent still has capacity. durable power of attorney, financial and healthcare, care healthcare care proxy, advanced directive, HIPAA authorization, while your parent can still sit across from an attorney as the author of their own decisions.
00:17:38
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Episodes 61 and 62 walk you through the conversation. If you skip them, this is your reason to go back. Move three, align the family. One conversation.
00:17:52
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all the siblings before the crisis assigns the roles for you. Who is a point person for medical? Who handles the money? Who can give time? Who can give dollars? Who can give neither and needs to say so honestly?
00:18:05
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This conversation is awkward in the window, but it is brutal in the ICU. Pick awkward. Let me give you the shape of that meeting because align the family sounds nice and lands nowhere with an agenda, right? So 45 minutes, video call is fine, and four items only.
00:18:24
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Item one, the shared picture. Everybody says what they have observed with the rule that nothing is too small to mention. This is where the puzzle pieces finally meet on one table.
00:18:37
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Item two, what mom and dad have said they want as best everyone knows. Not what we think is best, what they have said. Item three, the role draft.
00:18:51
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Who is medical point person? Who is money point person? Who is a backup? One name per job because committees do not answer the phone at two o'clock in the morning. And item four, the honest inventory.
00:19:04
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Each person says plainly what they can contribute, time, money, proximity. or honestly very little right now. The sibling who says, I can't do much, but I can do the finances from here and I can pay for a cleaning service is worth 10 siblings who vaguely promise to help more.
00:19:21
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End the meeting by scheduling the next one. Alignment is not an event, it is a standing appointment.
00:19:30
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Number move four, walk the house and widen the world. the practical layer, right? Grab bars, lighting, rug, stairs, the bathroom. And just as important, gently push pushed back against the shrinking world.
00:19:45
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Make sure they stay engaged, drive them to the book club, restart the standing Sunday call grandkids. An engaged brain and a connected life are not just for quality of life, they are protective.
00:19:57
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The window is small. The window is when small supports is still align as kindness instead of surrender. Four moves, a baseline, the documents, the family meeting, the house.
00:20:10
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None of them requires a crisis. All of them require the window. And that is the whole point of seeing the window.
00:20:19
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So
00:20:22
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I want to share a bit about how, about the time I noticed the window in someone I love. Because I want you to hear that even with my training,
00:20:35
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even after years of teaching this exact material, the window is hard to see from inside family.
00:20:44
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So it was my grandfather and um
00:20:50
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he was a wonderful man, a very intelligent, very educated man, a very well-spoken man. um And he had been living independently, um and mean, his whole life, right? ever the bed and living with my grandmother, who was also a teacher. there my My grandpa was an accountant, later became a teacher when he came to this country, and my grandmother was a kindergarten teacher.
00:21:17
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And they were both highly educated, very active, very engaged, travel. um And so my grandfather started slowing down, and he went from driving everywhere to then using a motorized scooter.
00:21:33
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to go because he would go to the supermarket every day to the market every day and engage there and he had a fall and whatnot and he and i would visit my grandfather every weekend my mother would go on saturday no i would go on saturday and my grand my mother would go on sunday and um And I remember, well, at this point we had already moved him into our, my mom's home because he had had some decline. And at that point I had just thought it was functional, like physical decline, cause he was nineteen in his nineties. And I decided to do a MOCA, the mont Montreal Cognitive Assessment. It's a screening exam to see how someone is doing.
00:22:23
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And it's out of a score of 30 and he scored a 15, which is moderate. And i was very shocked because like like I said, I was already i was already a geriatric psychiatrist. I was still young in my career, but I was still very well trained and very well informed.
00:22:43
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And yet I hadn't really seen it with my own grandpa. And i hadn't, it was it was so different when it's your your own loved one.
00:22:57
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And it's really important to be able to recognize that because
00:23:16
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we have to,
00:23:20
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ask specific questions. We have to look at specific things. It's not always going to smack us right outside the face. right And so I want you to think about you know that
00:23:44
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if it can happen to me, it can happen to anyone. And I want to normalize that because I don't want folks feeling bad. i We're all doing the best we can. and But again, what you're not looking for, you won't see, right? If you don't think...
00:24:00
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and And here's what that experience taught me and what I want to leave you with. Love does not make you see the window. Love on its own often makes you look away from it.
00:24:12
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Seeing it is a skill. And now you have it.
00:24:18
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Now here's the whole episode in one minute. There is a quiet window six to 18 months before most caregiving crises. It hides because the changes are unspectacular and the social rails still hold.
00:24:32
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Aid signs, mail piling up, later double bills, a dropped hobby, word finding difficulty, repeated questions, expired food, unexplained dents, and change in the calls.
00:24:46
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Three or more over three months, different from baseline, means you are in it. And remember, it doesn't count. Slow recall that arrives late, classes on the bookshelf, right?
00:24:58
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Needing more time, but getting it right. Pattern, not a moment. Baseline, not perfection. Families miss it because the phone hides it, the leaving is easier, and nobody assembles the pieces. So visit unhurried, say the small things out loud and put the pieces on one table.
00:25:18
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while When you're inside the window, there's four moves, medical baseline first, legal documents second, family alignment third, and help the house and the shrinking world fourth.
00:25:33
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The families I meet in the ICU are not failing families. They are families who walked out of every visit just a little behind. Don't be a year behind. Use the window.
00:25:45
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And if you are heading into appointments and records and discharge summaries, I made you my free medical dictionary. 50 of the most common medical terms in your parents chart. So you can be the advocate in the room instead of the person Googling in the parking lot.
00:26:09
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go to the Instagram um for this post for, for this episode and for anyone and comment dictionary and I'll send it right over.
00:26:38
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Next week, we pivot to you, the caregiver. The episode is called the 10-minute pity party and why you're not allowed more. I am a psychiatrist and I'm going to tell you to feel sorry for yourself on purpose with a timer.
00:26:52
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It is one of the most useful frameworks I have ever used in my practice and it might be the permission slip you have been waiting for. Until then, take care of your parents and take care of you.
00:27:06
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I'll see you next week.