For the most part, senior care communities enjoy the trust of the families and residents they serve. The nursing assistants generally provide warm personal care. Nurse managers are professional and compassionate and help families sort through a wide array of problems over a long span of time.

Sometimes though, painful disagreements can arise over the progression of care needs of the resident, which tends to mean that the cost of care will increase. And so … difficult questions can arise as to whether care decisions are based upon commerce or compassion. This seems especially true when the issue is related to memory loss and cognitive impairment and the assessment of safety.

We dislike the word “dementia.” It is a very poor and pejorative descriptor of the people we meet that are in varying stages of a progressive brain disorder that slowly robs them of the ability to function.

Exactly when does a loved one become “demented?” We say this because even in the later stages of the disease, the essence and charm of that person can be very intact.

It is the earlier stages of cognitive impairment that create differing perspectives over care needs and safety. This is because there is no definitive marker to say, “This person is now impaired so that safety is a concern.”

There can be many signs, but safety can become a real issue even relatively early in the disease. Then the question is unsafe to do what? Unsafe to live alone? Unsafe to drive? Unsafe to use a gas stove or microwave? Unsafe to be left alone for a few hours?

There can be obvious danger signs. For example, wandering. One local gentleman, a formerly brilliant professor, wandered away from his home and was gone for hours. He was finally found at 1 a.m. by a police manhunt, when a dog found him up to his knees in water in a wooded marsh. His brain disease and behavior posed an obvious hazard that everyone could agree upon.

But when did he cross that line from having cognitive impairment and being relatively safe, to now wandering into a swamp? Were there red flags before that incident, or was that the first?

If you are interested in the early process of cognitive impairment, a fascinating aspect is self-appraisal. Now, you don’t have to be cognitively impaired to have a limited ability for self-appraisal. After all, we all have our blind spots at any age. But when it comes to cognitive impairment, there is a certain river that gets crossed, in which a person really has no idea that their ability to function in the world is severely impaired.

Steve had a recent conversation with a woman who is very emotionally present in the immediate moment, and who responds appropriately and meaningfully in those moments. But within minutes, there is no memory of the conversation. That conversation had to do with her understanding her level of impairment. At each moment in the conversation, she related appropriately and intelligently.

Then less than five minutes later, the conversation went right back to the beginning as though it had never occurred. By her reckoning, she was perfectly fine, and perfectly safe, and sure, maybe she’d forget a couple of things, but doesn’t everybody? This person had clearly lost the ability for self-appraisal, and therefore must rely upon the guidance from family members and/or professionals.

What this acute short-term memory loss creates is the inability to hold onto a new understanding, or an agreement, a rule of thumb, or safety considerations and risks. And this is where administrators start worrying about safety, comfort and risk reduction — not just for the individual, but also for the other residents of the care community, and not just for the care community, but also with needed consideration for our public perception, and also to the regulatory requirements of the Department of Health and Human Services.

After all, it is one thing if someone wanders from his own home into a marsh. Can you imagine how you would perceive it differently if that same person wandered away from a care community and suffered an injury?

Now… for a family member communicating with their parent or spouse, the fact that their loved one is very emotionally present can create an illusion of competence that is not really there. Or even if they see the acute memory loss, it may not weigh as heavily on their appraisal of safety and risk reduction. In these disagreements, doubt and mistrust may enter the conversation, because an inescapable fact in the relationship of care communities and residents is cost and commerce.

Is the nurse manager making an assessment that is driven by a profit motive? Or conversely, is the family resistant to an assessment of higher care needs because they are trying to conserve funds? These types of questions can create an unfortunate distrust.

Obviously we can’t speak for the whole profession, or all consumers. We feel that by far, the broader experience is that most professionals have integrity and can be trusted to not exaggerate care needs motivated by profit.

An administrator has many considerations, but profiteering off an individual is generally not one. The emotional minefield for a family watching the disintegration of the thought processes of a loved one is hard enough.

Managers do not want to taint the trust of a family relationship with profit driven decisions. By far, most managers treat family relationships with the guidance of the Golden Rule. Any manager with half a brain knows that he could easily one day be the person who is cognitively impaired. Statistically, some of us certainly will.

We also feel that most consumers are operating in good faith with the people that they contract with to provide care for their vulnerable loved ones. We always hope that when there is a disagreement about care needs, the conversations can occur with mutual respect and consideration for each other’s perspectives, and that the best solutions are found for the most important person in the discussion … the person who must, by definition, rely upon the integrity, humanity and compassion of the professionals and their families who are guiding them through the difficult waters of cognitive impairment.

Jill Wallace is the owner and director of Elm Street Assisted Living in Topsham. Steve Raymond is director of community outreach at the Lincoln Home in Newcastle, and the producer and host of the television show “Spotlight on Seniors.”

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