What follows is a
questionaire to help caregivers determine if their loved one is able to
manage living alone.
Safety Concerns
- Has your loved-one had accidents because of weakness,
dizziness, or the inability to get around? ___ Yes/No
- Has use of the stove, oven, or appliances become a
problem because of forgetfulness? ___ Yes/No
- Are there stairs or conditions in the home that are a
hazard? ___ Yes/No
- Does your loved-one refuse to use adequate safety
devices such as railings or a walker? ___ Yes/No
- Has your loved-one lost interest in living or
expressed a desire to die? ___ Yes/No
Nutritional Needs
- Is your loved-one unable or unwilling to prepare
meals? ___ Yes/No
- Is there a demonstrated nutritional problem such as
weight loss, illness, or anemia? ___ Yes/No
- Does your loved-one eat only inappropriate foods that
will not supply nutritional needs? ___ Yes/No
- Does your loved-one forget to eat? ___
Yes/No
Personal Hygiene
- Is your loved-one unable or unwilling to get to the
toilet when necessary? ___ Yes/No
- Is your loved-one unable to change clothing or bed
linens as necessary to remain clean and dry? ___ Yes/No
Health and Safety Concerns
- Would your home require modifications to provide an
adequate environment for your loved-one, such as heating, plumbing, or
an accessible bathroom? ___ Yes/No
- Would you need to modify your home to make it a safe
environment? ___ Yes/No
- Does your loved-one require nursing services that are
too difficult or demanding for you physically, such as turning or
lifting? ___ Yes/No
- Does your loved-one regularly disturb the sleep of
others by callingout, needing care, or wandering at night?
___ Yes/No
- Is your relative likely to wander away from the house
if left alone? ___ Yes/No
- Does your relative create safety hazards for others in
the family because of forgetfulness or carelessness? ___
Yes/No
Time and Energy
- Does your loved-one need someone to care for him/her
at all times? ___ Yes/No
- Must clothing or bed linens be changed and laundered
so frequently that care becomes an excessive demand? ___
Yes/No
- Do you have responsibilities for care of others family
members, that result in split loyalties or emotional
overload? ___ Yes/No
Family Considerations
- Does your loved-one interfere with the running of the
household? ___ Yes/No
- Has the loss of privacy become a problem for the adult
members of the household? ___ Yes/No
- Is there excessive conflict with younger adults and
teenagers because of this loved-one? ___ Yes/No
Scoring
More than one yes in each category would strongly indicate the need to
begin considering the potential for placement. Alzheimer's
Services, however, recognizes that each famly's resources, needs and
capacities differ. Not every late stage patient must be placed in
a nursing home. In-home care options are increasing and may delay
or prevent need for placement.
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