Support Brain Research With Your Donated Stock

Donating long-term appreciated securities to BSN benefits families affected by neurological disorders and potentially you as well! Gifts of long-term appreciated securities may have tax advantages that could maximize your gift and reduce your taxes.

Potential benefits of donating stock may include:

  • Reducing federal and state tax on the capital gain;
  • Receiving an income tax deduction (federal and most states) for the full-market value of the gift if you itemize deductions on your tax return and have held the assets one year or longer;
  • Making a larger gift at a lower original cost to you.

Please contact BSN at +1 650-814-0848 with any questions about donating stock. Please send email to [email protected].

Prefer to make a traditional contribution via credit card? Click here to donate.

Multiple System Atrophy and Cognition Webinar – Recording, Resources + Notes

Brain Support Network and Stanford University co-hosted a webinar last Monday, November 12th about Multiple System Atrophy (MSA) and cognition.

———————–

RECORDING

The webinar recording can be found here —

https://youtu.be/hr0TCWqBgUY

———————–

SURVEY

If you listen to the webinar recording, please take LESS THAN TWO MINUTES to answer six questions on our survey.  See:

https://www.surveymonkey.com/r/W23K9RW

———————–

FUTURE WEBINARS ON MSA

To be alerted to future webinars on MSA, join Brain Support Network’s MSA email list –
www.brainsupportnetwork.org/join

———————–

RESOURCES

For additional information on the topics addressed during the webinar, see:

Multiple system atrophy (including our list of Top Resources from around the world) – www.brainsupportnetwork.org/msa

Brain donation to support MSA researchwww.brainsupportnetwork.org/brain-donation

Lewy body dementia – www.brainsupportnetwork.org/lbd

Parkinson’s Disease (PD) – parkinsons.stanford.edu

Orthostatic hypotension –
parkinsons.stanford.edu/orthostatic_hypotension.html

Cognition in PD – parkinsons.stanford.edu/cognition.html

Psychosis in PD – parkinsons.stanford.edu/psychosis.html

Make an appointment with Dr. Poston or other movement disorder specialists at Stanford – Call 650-723-6469

———————–

SUMMARY

Our terrific volunteer, Denise Dagan, wrote a summary of the webinar:

Movement disorders specialist Kathleen Poston, MD discussed the diagnostic criteria for MSA with special attention on recent research showing memory and cognition problems can occur in MSA patients.

Here are some points Dr. Poston covered in this talk:

* Symptoms of MSA (now unofficially includes cognitive impairment).

* How to approach treatment of cognitive impairment based on how suddenly symptoms appear.

* How to identify if cognitive symptoms are associated with dopamine medications.

* Outline of six cognitive domains.

* In all variants of MSA executive cognition is affected, typically later in the disease process.

* The other five cognitive domains are affected to greater and lesser degrees, depending on the variant of MSA in question.

* Definition of psychosis.

* When sudden onset or worsening of hallucinations may occur, and how to treat them.

* When a diagnosis of MSA, Parkinson’s or Lewy body dementia (LBD) should be made — based on what symptoms present and the timing of those symptoms.

———————–

NOTES

Our terrific volunteer, Denise Dagan, took notes from the webinar.

Webinar
Multiple System Atrophy and Cognition

Speaker:  Kathleen Poston, MD, movement disorders specialist, Stanford University
Host: Candy Welch, former MSA caregiver, Brain Support Network

November 12, 2018

This webinar will address these topics:
• What are normal cognitive problems in multiple system atrophy (MSA)?
• Can “cognitive impairment” be part of MSA?
• Can “dementia” be part of MSA?
• Are there MSA symptoms that can mimic dementia?
• When should a diagnosis of “Lewy body dementia” be given?  Does it make a difference?
• What’s the treatment?

DR. POSTON’S PRESENTATION

Diagnostic Criteria for Multiple System Atrophy (MSA)
From: the Second Consensus Statement on the Diagnosis of MSA (Gilman, et. al., Neurology 2008)
Every person has early, significant autonomic dysfunction (blood pressure fluctuations, urinary frequency or incontinence, constipation, sweating, sexual dysfunction, etc.) PLUS
* Parkinsonism (slowness, stiffness, muscle rigidity) = MSA-P
OR
* Ataxia (poor coordination) = MSA-C

Autonomic Systems (reiterated) =
• Blood pressure and heart rate fluctuations (orthostatic hypotension)
• Urinary difficulty and incontinence
• Obstructive Sleep Apnea and/or RBD
• Difficulty with sexual functioning

Parkinsonism =
• Bradykinesia (slow movement)
• Rigidity (stiffness in the muscles)
• Tremor (rhythmic shaking)
• Balance and walking problems

Cerebellar Symptoms =
• Ataxia (poor coordination)
• Can be either with limb movement or with the trunk and neck movements
• Speech problems
• Swallowing problems

Traditionally the diagnosis of ‘dementia’ has been considered a red flag that the diagnosis is not MSA.  However, it has recently been recognized that memory and cognition problems can happen in patients with MSA
2008 currently being considered for revision.

Motor versus Non-Motor Symptoms:
Classic Motor Symptoms =
• Ataxia
• Bradykinesia, Tremor, Rigidity

Mixed Motor/Non-Motor Symptoms =
• Hypophonia (soft speech) and Dysarthria (difficult or unclear articulation of speech)
• Gait and Balance Problems

Non-Motor Symptoms =
• Mild Cognitive Impairment and Dementia (rarely dementia)
• Psychosis (hallucinations and delusions)
• Sleep disorders (RBD and OSA)
• Depression/Apathy, Anxiety, Fatigue
• Constipation, Orthostatic hypotension, Urinary frequency, urgency, incontinence

Types of Cognitive Impairment:
1. Sudden
2. Intermittent (off and on)
3. Slowly progressive

1. Sudden Change in Cognition
* Most common reason for a sudden onset or change in symptoms, including cognition, is general medical illness or other medications
– Infection (such as a UTI or a cold/flu – elderly & those with neurodegenerative disorder may not run a fever or feel pain urinating)
– Medications (for pain, urinary frequency)
– Physical stress (constipation, poor sleep, travel, new physical environment)
– Emotional stress (anxiety)
– Being in the hospital (all of the above)

How to treat a Sudden Change
* Deal with the underlying cause (prior slide)
* Reduce or stop certain medications:
– Artane (any other anticholinergics)
– Amantadine
– Dopamine agonists
– Sinemet CR (carbidopa/levodopa CR)
– Comtan (entacapone)

2. Intermittent Cognitive Impairment
* Sometimes called fluctuations in cognition
* Can be associated with level of alertness throughout the day
– Determine whether cognitive impairment is related to dopamine medication by keeping a daily diary of medication dosages and times, symptom timing and duration, and meals.

Scenario 1: Non-motor symptom improves with dopamine
7:00a – Take 1, 25/100 Sinemet (carbidopa/levodopa)
9:00a – Symptom A starts
10:00a – Take 1, 25/100 Sinemet : Symptom A continues
10:30a – Symptom A ends
12:00p – Symptom A starts again
1:00p – Take 1, 25/100 Sinemet ; Symptom A continues
1:30p – Symptom A ends

Scenario 2: Non-motor symptom worsens with dopamine
7:00a – Take 1, 25/100 Sinemet
7:30a – Symptom A starts
8:00a – Symptom A ends
10:00a – Take 1, 25/100 Sinemet
10:30a – Symptom A starts
11:00a – Symptom A ends
1:00p – Take 1, 25/100 Sinemet
1:30p – Symptom A starts
2:00p – Symptom A ends

Scenario 3: Non-motor symptom is independent of dopamine, but related to meals.  This happens especially in orthostatic hypotension (fluctuating blood pressure).  Cognition can be reduced by low blood pressure.  A home blood pressure monitor can help determine if this is the situation.
7:00a – Take 1, 25/100 Sinemet
7:30a – Symptom A starts (Breakfast)
8:30a – Symptom A ends
10:00a – Take 1, 25/100 Sinemet
12:00p – Symptom A starts (Lunch)
1:00p – Take 1, 25/100 Sinemet
2:00p – Symptom A ends

3. Slowly progressive change in Cognition
* More likely to be part of the disease process

Cognitive Domains:
Each controlled by different parts of the brain.  Different parts of the brain are affected by pathology of different neurodegenerative disorders.
* Memory
* Processing speed
* Attention and working memory
* Executive function
* Visuospatial function
* Language

Memory:
* Example: On your way out the door your spouse asks you:  “Can you pick up some milk while you are at the store?”
* The process of memory includes:
– Encoding = storing information properly
– Maintenance = keeping it in storage long enough to be useful
– Retrieval = recalling the information when it is needed

Processing Speed:
Time it takes to absorb new information and come up with a response.

Attention and Working Memory
Example: A friend tells you a 10 digit phone number – you keep it in your mind for about 30 seconds while you look for a pen and paper to write it down or enter it into contacts on your phone.

Executive Function:
* The cognitive processes that dictate flexible and dynamic adjustment of performance in response to a changing environment.
* Examples:
– Planning/organizing
– Complex or novel problem-solving
– Shifting attention, keeping track of, or alternating from 1 task to another
– Not being susceptible to distractions
– Generating fluent sequence of thought or words
– Learning the rules of a new task (example: programming new DVR) without direction or explicit cueing

Visuospatial Function:
[Slide showing 4 complex geometric drawings and various trapezoids, rectangles and parallelograms in the center of each.]
Given an isolated parallelogram, an impaired subject would have difficulty finding a parallelogram of the same shape within the complex geometric drawings.
* Causes problems with parking the car or clipping corners when driving
* Causes problems with directions somewhere that is not familiar and getting turned around

Language:
* Names of objects and people
* Problems can be simple:  ‘Tip of the tongue’
* Problems can be more severe:  You can’t remember the name of something you use regularly.

What is dementia?
* Comment: Alzheimer’s is the most commonly diagnosed type of dementia, but not the only one – by far.
* A person who can no longer do an activity of daily living because of a cognitive impairment has dementia.
* Examples:
– Can no longer pay the bills correctly
– Gets lost when driving
– Cannot shop for groceries

[Slide showing study results, “Cognitive Impairment in MSA: A Position statement by the Neuropsychology Task Force of the MDS Multiple System Atrophy (MODIMSA) Study Group,” Stankovic, et. al., Movement Disorders, vol. 29, no. 7, 2014.]

Autopsy verified diagnosis.
Table 1. Impaired cognitive functions in:
MSA (multiple system atrophy)
MSA-P (multiple system atrophy, parkinsonian variant)
MSA-C (multiple system atrophy, cerebellar variant)

MSA P+C
Often impaired:  Executive cognition
Sometimes impaired: Attention and working memory, spontaneous recall (immediate & delayed), recognition, visuospatial functions

MSA-P
Often impaired:  Executive cognition
Sometimes impaired: Attention and working memory, spontaneous immediate recall, visuospatial functions

MSA-C
Often impaired:  Executive cognition
Sometimes impaired: Attention and working memory, spontaneous delayed recall, recognition, visuospatial functions]

[Slide results from same study:]
* Prevalence of rates of cognitive impairment in autopsy confirmed MSA:
– 22% Mild Cognitive Impairment,
– 2% Moderate Cognitive Impairment,
– 0.5% Severe Cognitive Impairment
* 50% of those MSA patients with more than 8 years after diagnosis had some Cognitive Impairment
– Cognitive impairment seems to happen most frequently late in the disease process
* 14% of MSA patients had dementia in the last year before death
* 9% had well-formed visual hallucinations (one study)

[Slide showing study results, “Profile of Cognitive Impairment and Underlying Pathology in MSA,” Koga, et. al., Movement Disorders, vol. 32, no. 3, 2017.  Autopsy verified diagnosis.]

Table 2. Comparison of demographic and clinical features between 102 patients:
MSA-CI (multiple system atrophy with cognitive impairment) 33 patients
MSA-NC (multiple system atrophy without cognitive impairment) 69 patients

Data collected:
– Females with and without cognitive impairment
– Age at onset, in years
– Age at death, in years
– Disease duration
– Family history of dementia
– Family history of parkinsonism
– Having clinical diagnosis of MSA.  Only 70% accurately diagnosed.
– Clinical phenotype (both Parkinson’s and Cerebellar)
– Clinical symptoms of depression]

[Slide showing Characteristics of cognitive impairment in same 33 patients with MSA and cognitive impairment.  11 of the 33 had other pathologies that may have contributed to cognitive impairment, in addition to MSA pathology.]

What is meant by ‘psychosis’?
* Illusions – Misinterpretations of real stimuli. Can be unformed, such as a sense of presence or a fleeting false impression.  Example: see a jacket on a chair and misinterpret that it is a cat.
* Hallucinations – Spontaneous, fully formed. Most often visual, but can be auditory, tactile, olfactory (smell), or gustatory (taste).  Example: seeing there is a cat when there is not a cat.  With insight the person knows the hallucinations are not real.  Without insight they cannot know the hallucinations are not real; at this point, consider medication intervention.
* Delusions – False thinking. Can be paranoia.  Also, consider medication intervention.

Motor Symptoms – Sometimes Improved by dopamine medications
BUT
Hallucinations – Can be worsened by dopamine medications

Sudden Onset or Worsening of Hallucinations (Same as any worsening symptoms, including cognition.)
* Most common reason for a sudden onset or change in symptoms is general medical illness or other medications
– Infection (such as a UTI or a cold/flu)
– Medications (for pain, urinary frequency)
– Physical stress (constipation, poor sleep, travel, new physical environment)
– Emotional stress (anxiety)
– Being in the hospital (all of the above)

How to treat a Sudden Change
1. Deal with the underlying cause (prior slide)
2. Reduce or stop certain medications:
* Artane (any other anticholinergics)
* Amantadine
* Dopamine agonists
* Sinemet CR (carbidopa/levodopa CR)
* Comtan (entacapone)

What is the difference between MSA, Parkinson’s disease and Lewy body Dementia (LBD)?
Clinically:
Cognition = Memory and Hallucinations AND
Motor = Ataxia, Bradykinesia, Rigidity and Tremor WORSEN OVER TIME

Pathologically (only visible at autopsy):
[Slide showing Lewy body Pathology (image) in Both PD & LBD
Glial Cytoplasmic Inclusion Pathology (image) in MSA
Both Lewy Bodies and GCIs are make of up of the protein a-synuclein]

As is currently defined, all 3 would have autonomic dysfunction:
* The Diagnosis of PD with cognitive impairment or Dementia should be made when memory problems develops within the context of established PD.
* The Diagnosis of LBD is appropriate when the diagnosis of Dementia precedes or coincides within 1 year of the development of motor symptoms (parkinsonism).
* The Diagnosis of MSA is appropriate when the there is primary Autonomic Dysfunction, along with either parkinsonism or ataxia (with, or without memory problems).

Please take a 20 question online survey about MSA diagnosis and symptoms!!!
http://med.stanford.edu/poston-lab/msa-survey.html

QUESTION AND ANSWER
Lots of questions were received in advance.

Q. When will the diagnostic criteria be updated?
A. It is in the works.  So, probably the next year and a half.

Q. Why aren’t MDs able to determine if someone has MSA or LBD?
A. Even though in pathology the Lewy Bodies look different from the GCIs, there is no way to image them through an MRI, etc.

Q. Are there any specific assessments or screenings that you recommend for evaluating and monitoring an MSA patient’s cognitive status?
A. The screening a doctor would do during an office visit.  The Montreal Cognitive Assessment covers all the cognitive domains.  The problem is that is it fast (30 questions) so not detailed.  A neuropsychological battery, 2-3 hours of testing requires a PhD, clinical psychologist, to administer.

Q. Connection between NPH (normal pressure hydrocephalus) and MSA.
A. NPH can cause spaces in the brain to enlarge and press against other areas of the brain affecting urinary, cognition and gait.  The symptoms manifest differently from MSA and can be seen in an MRI.  That is one way to identify those with NPH and exclude MSA.

Q. What is sleep’s role in cognition?
A. A bad night sleep affects processing speed, executive function so address sleep apnea, have a nap, monitor blood pressure and minimize BP fluctuation to maximize cognitive function.

Q. How are executive functions affected in MSA?
A. This can come across as difficulty with multi-tasking because that requires a very high level of cognitive function.  Figuring out what to do in the right order is required.  When someone has trouble making a to-do list, there are some executive function issues.

Q. What is fatigue’s role in cognition?
A. Fatigue is very involved in blood pressure.  There is a lot of fatigue fundamental to each of these disorders.  Fatigue gets some improvement with napping or resting where blood pressure and dementia does not.

Q. How common are hallucinations in MSA?  Can there be hallucinations without Lewy body dementia?
A. Yes, recent studies have convinced clinicians.  That wasn’t known 10 years ago and Dr. Postonhas seen it in her clinic.

Q. How does dementia in MSA differ from Lewy body dementia?  Parkinson’s disease dementia?
A. It can be pretty darned similar.  The dementia, particularly the executive function issues, which is why the neuropsychological testing doesn’t differentiate between these.

Q. How does the cognitive impairment in MSA differ from that seen in Progressive supranuclear palsy (PSP)?
A. Patients with PSP can have a lot of executive function difficulty as well, but they often have poor judgement, even though they know their balance is terrible.  This can happen in other neurodegenerative disorders, but is more common in PSP,

Q. My husband is now very susceptible to TV ads and asks me to order products we do not need.  Is this executive function impairment?
A. Impulsivity can be part of the underlying disorder but can be made worse with dopamine agonists (Requip, Mirapex, Nupro patch).

Q. My husband is slow to respond, slow to make decisions, and has “on-and-off” periods.  Is this dementia?
A. It depends on the degree to which the on/off periods and indecision interfere with ability to complete activities of daily living.  On/off could be from medications or blood pressure fluctuations, so its hard to tell.

Q. Could MSA-related cognitive impairment be mistaken for vascular-related mild cognitive impairment?
A. The only study addressing that is the one showed where 4-5 had vascular disease found at autopsy that could have contributed to cognitive impairment.  It is impossible to tease out how much each contributes how much to cognitive impairment.

Q. How can you tell the difference between orthostatic hypotension and cognitive impairment?
A. The most common place you see this is when blood pressure stops and processing speed slows so much the person cannot answer questions. Blood pressure should be done during these episodes.  The tilt table test during cognitive testing can reveal whether the person has cognitive changes associated with blood pressure changes.

Q. In our local support group, people with MSA are taking Alzheimer’s medications such as Aricept and Exelon.  Does this mean they have dementia?  Lewy body dementia?
A. As far as medications to treat cognition, Alzheimer’s is the only disease FDA approved to treat.  Aricept, Exelon and Namenda are the most common.  These are not FDA approved for any other cognitive impairments.  The best data is behind Aricept and Exelon for Alzheimer’s and LBD.  They do help a little bit, but they can help for other cognitive and memory issues.

Q. How is the care of a person with MSA different from someone with dementia?  Or different from someone with other
neurological diseases (such as PSP or CBD)?
A. Longitudinal studies show the care of any two patients with MSA is completely different.  Care must be specifically tailored to each person.  One may have severe urinary issues and another not.  This is true of all the neurodegenerative disorders.

Q. If someone with MSA has cognitive issues, is his/her prognosis (survival time) any different?
A. Chance of having cognitive problems is most likely if they live 8+ years after diagnosis.  Once someone has a diagnosis of Parkinson’s disease with dementia their prognosis is shortened.

Q. How can medications affect cognition?
Q. If opiates can affect cognition and cause hallucinations, what kind of pain reliever can I give to my mother with pain?
A. Anything that treats pain dulls all neurons in the brain, blocking the sensation of pain.  Therefore simultaneously slows cognition, worsens hallucinations, etc.  Start with over the counter pain killers.  If you have to go to prescriptions discuss with doctor about what to try and start with lowest dose possible.

Q. Can cognitive problems be prevented in MSA?
A. We don’t understand what causes cognitive problems so we don’t have a way of preventing them.

Q. How can caregivers respond to someone with MSA and cognitive problems?
A. It is difficult because patients can get frustrated.  Patients do improve with a certain amount of cueing, reminding, etc.  Unfortunately, spouses call this nagging.  Try to know what the problem is by getting neuropsychologist testing and refer back to the test or have the doctor tell him/her what they have difficulty with.

Q.Do people with MSA not live long enough for dementia to show up?
A. No.

Q. Can people with MSA *also* have Alzheimer’s disease?
A. Yes.

Q. Can people with MSA *also* have Lewy body dementia?
A. Yes, but very rare.

Q. When do we determine when the patient is unable to work because decisions are cloudy or cognition is impaired?
A. Depends on the job and flexibility the employer has to move employee into a different role and relationship between the two.  Most of the time once executive functioning is impacted, it is difficult to be employed because decisions are too hard.

Q. Once the patient is non verbal and unable to move on his/her own accord, is this considered a disability automatically?
A. In filling out disability paperwork people qualify long before someone is nonverbal or unable to move.

Driving
Q. When do we determine when the patient is unable to drive because cognition is impaired?
A. This varies by state.  In CA if someone has dementia the physician is required by law to report them to the DMV for evaluation.  Occupational therapists can do an assessment, even with a driving simulator, to see what concerns might be, especially visuospatial changes.

Q. Importance of brain donation to MSA research.
A. Critical.  Without autopsy diagnosis confirmation we would still be guessing.  Before research based on brain donations we used to think MSA was 3 different disorders.  We can only continue research into MSA and other neurodegenerative disorders with continued access to brain tissue donated for research purposes.

“Are you a healthy caregiver” – 10 question test

Here’s a 10-question test for caregivers to determine if they are
injuring their own health.

The authors say: “On average, it takes family caregivers four years
to reach out and ask for help. Don’t be part of those statistics. Ask
for the help you want and need. You will be a healthier caregiver and
the person receiving care will be better cared for.”

Robin

—————————————————————

www.familycaregiversbc.ca/caregiving-parents/are-you-a-healthy-caregiver/

Are you a healthy caregiver?
July 19, 2018
Family Caregivers of British Columbia

Many caregivers understand the importance of caring for themselves
and, yet, in another breath, say things like, “I feel overwhelmed,”
“I’m stressed out,” “I’m too busy to eat, let alone find time to stay
healthy,” and “There are so many things to do, how do I make time for
myself?”

Start by checking in with yourself. Respond to the statements below to
recognize the positive steps you are already taking to ensure you stay
healthy, and to identify areas where you might consider action to help
keep you resilient.

1. I am satisfied with my overall personal health.

Yes No

2. I have the skills and information I need to give the required care.

Yes No

3. I maintain regular contact with family and friends and make time
to spend with them.

Yes No

4. I can ask for help and accept help when it is offered. I know I
don’t have to, and can’t, do this alone.

Yes No

5. I can communicate effectively with the person I am caring for, as
well as with others involved in their care.

Yes No

6. I am aware of community resources available to help support me in
my caregiver role.

Yes No

7. I am aware of caregiver support groups (locally or online) and/or
have a supportive network where I can share my challenges and
successes.

Yes No

8. I make use of respite options available and take breaks away from
my caregiving responsibilities.

Yes No

9. I have gathered information about the progression of my care
recipient’s disease, so I know what to expect and can prepare in
advance as best I can.

Yes No

10. I know how to navigate the healthcare system and who to ask if,
and when, I need help.

Yes No

****************

Give yourself one point for every “Yes” answer.

8-10 Points
You are already taking several important actions to take care of
yourself and make sure caregiving is sustainable for you. Look closely
at any statements where you answered “No,” and consider whether
accessing more resources would be helpful for you.

5-7 Points
You understand the importance of self-care, but you’re not always able
to take action to support yourself. Consider any barriers you have to
self-care and ask yourself whether these are external (you don’t know
about the resources that exist to help you) or internal (you have
trouble asking for and receiving support). Sharing the care is
essential to finding enough time and energy for yourself. Choose one
statement where you responded “No” to work on this week.

Fewer than 5 Points
Without contributing to your own well-being, caregiving quickly
becomes overwhelming and unsustainable. Use this list of 10 statements
as a guide to creating a self-care plan; start with learning more
about the caregiver support resources available to guide you. It will
be important for you to identify resources you’re not currently using
in your social circle, such as family, friends, acquaintances and
neighbours, to share the care and create some much-needed space for
addressing your own well-being.

On average, it takes family caregivers four years to reach out and ask
for help. Don’t be part of those statistics. Ask for the help you want
and need. You will be a healthier caregiver and the person receiving
care will be better cared for.

 

“Aikido communication – Align, agree, redirect, and resolve” – notes

Caregiver Teleconnection, a service of WellMed Charitable Foundation,
hosts periodic conference calls on caregiving topics.  Last week, the
topic was “Aikido communication – Align, agree, redirect, and
resolve.”  The speaker was a gerontologist with the Texas Extension
Service, Andy Crocker.

With Aikido, one listens for areas of agreement or common ground and
uses “I” messages, which are particularly effective when emotions run
high.  With “I” messages, rather than “You” messages, caregivers can
de-escalate potentially confrontational situations between themselves
and family members or healthcare providers.  This approach is also
useful in de-escalating situations between caregivers and care
recipients, even if the care recipient has cognitive impairment.

The conference recording (audio only) is available here:

https://soundcloud.com/caregiverteleconnection/finding-common-ground-aikido-communication-with-andy-crocker-91018

Brain Support Network uber-volunteer Denise Dagan listened to the
conference call and shared her notes below.

To sign up for email announcements about these conference calls, check out:

http://caregiversos.org/caregiver-teleconnection/

Check out the many examples.  This approach is definitely worth trying.

Robin

————————————————————

Notes by Denise Dagan, Brain Support Network volunteer

Finding Common Ground: Aikido Communication
Speaker:  Andy Crocker, Gerontologist, University of Texas Extension Service

Caregiver Teleconnection
September 10, 2018

Communication is a process or cycle.  When I speak, you respond based
on your individual interpretation of what I said (based on your
experience).  Your sensory perception, health, patience, etc. impacts
your response to my comment(s).

The process begins with how I choose to phrase what I say.  “I”
messages increase the chances of being heard with a positive tone.
“You” messages are confrontational and may result in conflict.

Example:  Conversation between siblings (Andy and Katie) caring for their Mom.

Andy: “You need to help around the house.”  The tone is accusing Katie
of not doing enough around the house and may result in conflict.

Andy: “I need help around the house.”  The tone is stating his need
for help around the house and is not accusing or blaming.

Another example:

Andy: “You made me so angry!”  Blaming Katie for Andy’s anger.

Andy: “I feel angry that you…”  Blaming Betsy’s action for Andy’s
anger.  One level removed is less confrontational.

Sometimes, it is best to make an appointment to speak about something
and actually plan what you will say to get your message across with a
level head.
* Take out “You” messages in the plan for how to communicate your
message or your ask.
* Keep out irrelevant factors from your history together from the discussion.
* Never say, “You always…,” or “You never.…”
* Be sure to express your appreciation for assistance others provide
in your caregiving so they feel appreciated.

Aikido Communication

Tenets / 4 Steps:

Align – find the other person’s perspective.  See the situation from
in the other person’s shoes.
* How would I feel if I were in their shoes
* What does this person need form me?  Praise, appreciation, control?
– Ask: Give me an example of something I can do?  If I could do one
thing to help you, what would that be?
– Rather than saying, “What do you want from me?!” or “What am I
supposed to be doing?!”

Agree – identify issue and concerns with common ground (goals, needs,
feelings) to get on the same page
* I share your concern about…,  I agree we need to do something about…,

Redirect – move to productivity
We both want to do what’s best for…

Resolve –
I think we should explore…,  I think…would be helpful for…

Sometimes, you have to agree that there is no resolution or solution
to the problem at hand.  That, in itself, is progress.

Aikido can be used in communicating with a person who has cognitive
impairment or dementia, where higher order functioning is not present.

Example: Grandson caring for grandfather with dementia who was a
Marine Colonel.  Every morning he rises at 4am and get the day
started.  You can’t tell him he’s no longer a Marine and has no place
to go because being a Marine is his experience of the world.  You must
align, agree, redirect and resolve to understand his motivation for
what he’s doing.  To help him maintain his dignity, activity,
independence as much as possible without adding fuel to verbal or
physical conflict.

* Align – he believes he is a Marine so you must cooperate with what
you can do at home within his ‘world’.  You cannot keep him in bed
longer.

* Agree – you know he always started with shaving, dressing,
breakfast, exercise – all things you can assist him with that align
with his belief that he is a Marine and are things he can do
productively at home.

* Redirect – ask for his help around the house today and direct his
attention to KP duty / cleaning up breakfast. You know he always
shaved twice daily, so be sure to include that activity to the daily
schedule.

* Resolve – In dealing with someone who has dementia, resolution is
that grandpa sleeps through the night and accepting that he rises as
4am, obtaining grandpa’s cooperation, calm demeanor, emotional calm
throughout the day.  Recognizing that what works one day may not work
the next day – just give your initial inclination / plan a try and see
how effective it is.

Aikido Communication is one more tool in your toolbox to help get
through your day, along with:
* Mindfulness & relaxation techniques
* Respite resources
* Caregiving or Home maintenance assistance (volunteer friends/family
or hired help)

Question and Answer

Q. Aikido is like Naomi Feil Validation.

A. Both her method and Aikido have the same understanding of how to
understand and manage someone with dementia, but Validation is less
useful for direct communication.  We can be assertive without being
aggressive or confrontational.  Using the “I” messages to identify how
you feel and what you need and suggest what needs to be done without
the conversation devolving.  It is not easy because it does not come
naturally to us, but it is effective.

Q. I found I always did what my father told me, but now that he has
dementia I find I am the one who needs to tell him what to do and how
to do it to keep him healthy and safe.  There is a big disconnect when
your eyes see your father, but your mind tells you he is not the same
man he was.  The disconnect is painful and challenging.

A. Good future topics are role loss or role change.  There is a good
amount of loss and grief when the person you used to look to for
direction and advice is no longer available to you because of their
cognitive changes.  At the same time, you need to take charge and do
what’s necessary to look after him.

A. There are family members surrounding the primary caregiver and care
recipient who are all struggling with grief before the care
recipient’s death (anticipatory grief).  There is grief with the loss
of each of the care recipient’s abilities.  Often there is a family
member who doesn’t want to help or visit because they don’t want to
see the care recipient in ’that’ state.  That’s anticipatory grief.
Sometimes, it is helpful to identify it as grief in a conversation
with them to try to help them work through their grief and garner
their help in caring until the person actually does pass away.  They
may be adamant that they don’t want to see their family member in
’that’ state.  It is sad but you must respect that avoidance is their
way of dealing with their grief.

“3 Legal Documents Caregivers Need to Manage a Senior’s Healthcare”

This short article is about the three documents — HIPAA authorization, medical power-of-attorney, and advance health care directive — caregivers should make sure they have if they are managing the care of a senior.  Although this article is directly to adult children caregivers, this advice applies to all caregivers, even spouse caregivers.  We have met many spouse caregivers over the years who do not have these documents either.

See AgingCare for the article:

www.agingcare.com/Articles/legal-documents-to-make-healthcare-decisions-for-your-parent-146623.htm

3 Legal Documents Caregivers Need to Manage a Senior’s Healthcare
Marlo Sollitto
Updated May 3, 2018
AgingCare

 

 

‘It can be isolating’: How caregivers handle the stress and find support

This short article from the Chicago Tribune is about how isolating and
stressful caregiving is.

Some people may recognize the name Denise Brown, who lives in the
Chicago area. She started the website caregiving.com as a result of
her experience caring for her elderly parents.

Denise Brown offers five suggestions for caregivers in the article:

* “If you are struggling, it’s not because you are failing. It’s
because what you’re doing is really hard.”

* If you need help and aren’t sure where to start, reach out to your
doctor, local area agency on aging, a disease-specific
organization…, a social service agency like United Way, or your
employer’s Employee Assistance Program.

* If the doctor you contact can’t offer suggestions, nudge him or her
to create a list of resources.

* Find ways to relax.

* Make self-care a priority. “We have a tendency to think that we’re
not doing enough,” she said. “I think it’s important for us to sit
still for a few minutes every day and know that we are doing enough —
that our work and our caring and our love is enough.”

Here’s a link to the article:

www.chicagotribune.com/lifestyles/sc-fam-caregiving-support-0911-story.html

Definitely worth reading….

Robin

 

“Dementia Spouse Caregivers’ Relationship Closeness” – Dissertation Excerpts

This is a doctoral dissertation from 2017 on the impact of the
relationship for a spouse caring for a husband or wife with dementia.
Though dementia caregiving is the focus of this dissertation, I think
the document applies to caregiver spouses where the care-recipient
does NOT have dementia.

The document is 280 pages so I didn’t read it all but skipped around.
Despite the fact that the language is scholarly, many of the pages are
worth reading.

I’ve provided two long excerpts below. The second excerpt includes
this sentence: “It is also known that a spouse’s vows, vigilance,
worry and tireless caregiving result in incredible morbidity.” I
think this refers to the caregiver’s morbidity. The dissertation’s
author indicates that “caregivers would be in better states of health
and wellness if clinicians were aware of the [couple’s] ability to
communicate…”

Here are the two excerpts I found the most interesting:

(From page 55 and 56, using the page numbers of the dissertation)

Couplehood. Lobo Prabhu et al. (2005) skillfully depicted the
relationship of husbands and wives… When dementia was introduced,
the fragile balance was thrown into chaos. The authors constructed a
framework to explain why couples stayed together and offered practice
implications to enable spouses to continue caregiving with sound
support. They reported that couples retained togetherness, despite
dementia, when the basis of stable marriage included concepts of:
1. quid pro quo (an equal exchange or substitution),
2. values of commitment (respect, pride, and accomplishment despite sacrifice),
3. holding on to the familiar (vs. letting go and abandonment),
4. rupture vs. repair of marital bond (what is the minimal
gratification the caregiver requires to sustain the relationship? will
a smile or eye recognition suffice?),
5. mastery of separation (decisional capacity and choice migrates from
care-recipient to caregiver),
6. spirituality (altruism and prayer),
7. changes in sexuality (loss of shared togetherness) and
8. emotional support (social connections, family support, and kin-care).

(From page 80 of the dissertation)

Regrettably, the couple’s “together life biography” and pre-dementia
relationship closeness are greatly underestimated in clinical practice
(Davies & Gregory, 2007). Pre-dementia relationship closeness and
current relationship closeness colors the way a spouse caregiver makes
decisions and renders effective and nurturing care, or not. It
triggers advocacy or ambivalence. It is also known that a spouse’s
vows, vigilance, worry and tireless caregiving result in incredible
morbidity. Moreover, empiric literature has shown relationships
characterized by kindness, respect, and warmth, or less criticism,
conflict, and family dysfunction are associated with better caregiver
and care-recipient morbidity and caregiving outcomes. Additionally,
the care-recipient behavior is a significant controlling factor for
the caregiver’s reciprocal emotions, relationship, burden, and
depression. Therefore, caregivers would be in better states of health
and wellness if clinicians were aware of the dyad’s ability to
communicate, the efficacy of their interactions, the strengths, and
weaknesses activated by dementia disease and the vulnerabilities now
present in the dementia dyad’s life together experience.

Here’s a link to the full document, in case you’d like to check out
more of the dissertation:

https://opencommons.uconn.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=7648&context=dissertations

Heart and Soul: A Phenomenology of Dementia Spouse Caregivers’
Relationship Closeness
by Elena Schjavland, PhD
University of Connecticut, 2017

Thanks to an online friend who is an FTD caregiver for sharing this
dissertation with me.

Let me know if you find other parts that resonate with you,
Robin

Sept 2018, Speakers at Parkinson’s Support Group Meetings, Northern CA

In September 2018, some Parkinson’s support group meetings in Northern and Central California have guest speakers that may be of interest to those in the Brain Support Network community:


Lodi

Tuesday, 9/4, 10am-noon  (meeting on 1st Tuesday in Sept)
Guest Speaker:  Shelly Azevedo, myofunctional specialist
Topics:  Facial, speech, and swallowing issues in PD
RSVP?:  No.


San Andreas (Calaveras County)
Tuesday, 9/4, 10am-noon (speaker usually begins at 10:30am)
Guest Speaker:  Kenneth Renwick, MD
Topic:  Medical marijuana for those with PD
RSVP?:  No.


Roseville
Tuesday, 9/4, 1:30-3pm
Guest Speaker:  Ability Tools representative
Topics:  Selecting the right scooter and other services regarding
assistive technology, mobility, and medical equipment
RSVP?:  No.


Soquel (Santa Cruz County)
Wednesday, 9/5, 2-3:30pm
Guest Speakers:  Miriam Tutman and Holly Blue Hawkins
Topics:  Tricks and tips of healthcare and setting up affordable
care at home
RSVP?:  No.


San Jose/Willow Glen
Friday, 9/7, 10am-noon  (speaker begins about 10:15am)
Guest Speaker:  Kathleen Poston, MD, movement disorder specialist,
Stanford University
Topic:  Fatigue, drowsiness, and depression in PD
RSVP?:  No.


Auburn
Tuesday, 9/11, 11:30am (lunch meeting)
Guest Speaker:  Stephanie Watson, Sierra Senior Placement
Services
Topic:  Types of assistance, places, and cost
RSVP?:  No.


Palo Alto YOPD (Young Onset PD)/Stanford
Tuesday, 9/11, 6:30-8pm
Guest Speaker:  Robert Magbanua, Mark Green Sports Center,
Union City
Topic:  Rock Steady Boxing
RSVP?:  Yes, if this is your first time attending.  Please email group
leader John Mamin, [email protected]


Menlo Park/Little House
Wednesday, 9/12, 2-3:30pm
Guest Speaker:  Carrolee Barlow, MD, CEO, The Parkinson’s
Institute, Sunnyvale
Topic:  Causes, treatment, and latest research in treating PD
RSVP?:  No.


Stockton
Thursday, 9/13, 1:30-3pm
Guest Speaker #1:  Karen Fabreo-Hittle, PT, physical therapist,
O’Connor Woods, Stockton
Topic #1:  Successful transferring
Guest Speaker #2:  Anna Lissa Garcia, OT, occupational
therapist, O’Connor Woods, Stockton
Topic #2:  How speech therapy can help with swallowing, speech
volume, and articulation
RSVP?:  No.


Walnut Creek (Mt. Diablo)
Saturday, 9/15, 10am-noon  (speakers begin at 10:45am)
Guest Speaker #1:  Carol Fisher, RYT, yoga therapist
Topic #1:  Meditation and yoga
Guest Speaker #2:  Elaine Welch, CEO, Mobility Matters
Topic #2:  Transportation issues for seniors and disabled
RSVP?:  No.


Lincoln
Tuesday, 9/18, 10-11am
Guest Speaker:  Cate McGregor, nurse educator, Coalition for
Compassionate Care of California
Topic:  Importance of POLST
RSVP?:  No.



Merced
Thursday, 9/20, 10am-noon
Guest Speakers:  Claire Osborne, OT, occupational therapist,
and Judy Chi, PT, physical therapist
Topic:  LSVT BIG and LOUD programs
RSVP?:  Yes, preferred.  Contact Elina Lopez, Amie’s Senior Care,
[email protected], 209-384-3300.

 

For meeting location and other details, see the Stanford Parkinson’s Outreach website.

 

“Guardianship 101” – Webinar Notes

On August 9th, the Alzheimer’s Foundation of America (alzfdn.org) hosted a webinar on guardianship by Britt Burner, Esq., who specializes in wills, trusts and estates in New York state.

For adults who have been injured in an accident, suffer from an incapacitating physical illness or psychological disorder, or have some other condition that prevents them from caring for themselves, a legal arrangement called guardianship, or conservatorship, places the individual under the supervision of a guardian, or custodian, for their protection and care.

There are two main types of guardianship: guardianship of the person and guardianship of the estate or property. This webinar focused on situations in which a guardianship may be necessary, how to avoid a guardianship proceeding, and the impact that moving between states can have on an individual that has been subject to a guardianship proceeding.

You can find the webinar recording here:

alzfdn.org/webinar-archives/

Brain Support Network volunteer Denise Dagan listened to the webinar and shared her notes.

Robin

==============================

Notes by Denise Dagan, Brain Support Network Volunteer

Guardianship 101
Speaker: Britt Burner, Esq.

Alzheimer’s Foundation of America
August 10, 2018

What is guardianship or a conservatorship?

  • Based on local state law
  • Incapacity vs diminished capacity
  • Unable to make decisions for self and unable to understand the consequences of this inability in
    — Personal needs (health)
    — Property management
  • In NY, not a medical standard; factual determination
    — Medical records are not usually admissible (everyone still has HIPPA rights, so you may not have medical records)
    — Demonstration of determination is usually
  • Least restrictive alternative (person under guardianship is allowed to make decision which they are capable of, like last will & testamate, but not checkbook)

Roles:

  • Petitioner – person asking for guardianship on behalf of another
  • Cross-petitioner – another person who wants to be guardian when the petitioner ask guardianship be granted
  • AIP – alleged incapacitated person
  • Court evaluator – ‘the eyes and ears of the court,’ appointed by the court who does an investigation of the circumstances being claimed by the petitioner. May be a lawyer, but not always. Testifies to the court (in NY w/in28 days).
  • Counsel to AIP – hired by the court to represent the AIP. When guardianship is suspected to be needed, the Counsel to AIP is responsible for speaking the AIP’s wishes to the court, even if they don’t make any sense.
  • Other interested parties
  • Guardian of the person and guardian of the property (can both be appointed)

Who can commence a guardianship action?

  • Family member
  • Medical institution
  • Local municipality
  • APS investigations (Adult Protective Services)
  • An individual can request guardianship for themselves

Why does someone commence a guardianship action?

  • cognitive impairment
  • inability to balance a checkbook or make other financial decisions
  • check the mail/pay bills
  • coordinate care
  • vulnerability
    — Senior scams
    — Family member abuse
  • improper actions by appointed agents (inappropriate or untrustworthy people appointed power-of-attorney)
  • invalid documents (insufficient or incomplete powers-of-attorney in your advance directive)

Pros:

  • court oversight (to ensure those w/POA act in your own best interest)
  • orders from court on big decisions, i.e. sale of property, etc. (title company may question a POA’s actions, but not a court order)
  • third party institution recognition of authority (some banks don’t accept POA but not court orders)

Cons:

  • court oversight (can be a hindrance & delay when all parties are in agreement; annual accounting to the court can be costly & a hassle, especially when everyone is being honest)
    — reporting requirements
  • costs (court evaluator, accountants, bond – insurance on the estate, commissions to the guardian – not mandatory, lawyer’s fees, etc.) In NY the court decides on how much fees will be and who will pay them, usually the estate in question but sometimes the petitioner (especially if petition is unwarranted).
  • time
  • family disagreements
  • embarrassment

Examples of Powers: Guardian of Person

  • arranges medical care (usually specific court instructions to petition for major medical treatments, removal from life support)
  • consents for treatment
  • make sure ward is fed, housed, educated, entertained and supervised
  • may hire aides
  • if no guardian of property is appointed
    — arrange to be rep payee
    — initiate lawsuits
  • pay debts

Examples of Powers: Guardian of the Estate/Property (Conservator)

  • prudent investment of assets
  • management of bank accounts
  • maintain home
  • prepare tax returns
  • participate in operation or management of ward’s business (court orders will have very specific instructions for the guardian)
  • financially support dependents
  • establish and maintain fiduciary accounts (guardianship accounts cannot have checkbooks, debit cards so money is transferred into fiduciary accounts)
  • provide for cost of care (not arrange for it – Guardian of Person arranges for care)

Does a Guardianship last forever:

  • duration determined at hearing (can be temporary or permanent)
    (One example given was a situation where guardianship only lasted a year to move a woman into assisted living)
  • can petition court for termination (can be termination of guardianship or reassignment of the Guardian, themself)
  • can petition court for removal

How do you avoid a Guardianship?

  • power of attorney
  • health care proxy
    — Including power to make end of life decisions
  • MOLST form (POLST, in CA) – signed by individual and their doctor specifying what types of care the individual allows and disallows.

Guardians MAY NOT…

  • prohibit a ward from marrying
  • vote for the ward (but can assist)
  • Need court approval to consent to:
    — civil committment
    — electric shock treatment
    — dissolution of marriage

Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act (UAGPPJA)

  • all states (excepting 4)
  • goals
  • jurisdiction
    — transferring guardianship between states
    Example: A ward owning property in NY has a guardian appointed in NY but moved to one of the 4 states not covered by UAGPPJA, so they will have to start over and have a guardian appointed in that state. If they had moved to a state covered by UAGPPJA they could have filed a single form to extend that guardianship to the new state, as well as NY.

This really comes in handy when moving an elder between states and keep a single person as guardian. Also allows family to bring suit in the most convenient state if another family member ‘kidnaps’ an elder to another state.

Additional Resources to find legal advice near you:

  • American Bar Association
  • NAELA (National Academy of Elder Law Attorneys), naela.org
  • Local Bar Association

Question and Answer

Q. Are self initiated guardianships always granted by the court? Is this process easier than when initiated by someone else?

A. A self initiated guardianship is fairly rare. Most people who have the ability to say that they want a guardian have the capacity to sign a power of attorney, which is easier and cheaper. There is still a court evaluator appointed and a full investigation and report done. Of course, the proceeding is much easier than when multiple family members are arguing, but you still need to establish a strong need to the court.

Q. Can an APS employee request guardianship for a client?

A. If an APS employee is called to a home and feels guardianship is necessary, they will make a report to the NYC legal department and the city is the petitioner. The APS employee testifies for the city, but they are not the petitioner.

Q. Is the POA short form can be used for benefits and entitlement instead of guardianship?

A. Yes. One way to avoid guardianship is to have a valid, comprehensive POA in place. In NY the standard POA is 16-pages long and that’s the short form. As long as it has all the powers required it can be used in place of guardianship and can be a defense to a guardianship petition.

Q. Please give a few more examples of the need for guardianship.

A. What are the functions of day-to-day living and is there someone appointed to accomplish those tasks for you? If you are not able to bathe yourself and do not have the ability to know who to call for help or to make arrangements to hire in-home care and to pay them, you qualify as someone who would benefit from guardianship. It is the physical and cognitive incapacity combined that usually can be demonstrated to justify a guardianship petition. If you have one or the other you probably don’t require guardianship.

Q. How can a family member get a guardian changed if they do not feel they are doing a good job?

A. Each state is different, but basically you file a petition with the court asking for the guardian to be removed and why. The court will evaluate the situation and make a decision. In NY there are guardianship offices to help families file the paperwork properly.

Q. Does a guardian appointed in a will have the same powers as those appointed by a court?

A. The only time we appoint a guardian in a will is for a minor, if both parents become unable to care for the child, so no. Usually, a guardian for a minor has full authority, not restricted as for an adult.

Q. How would the court decide between siblings disagreeing about the care of a parent?

A. This happens quite a bit. In a case one daughter decided her sister was mistreating their mom. She petitioned the court to have herself appointed guardian to save mom from the sister who was guardian. She needed to prove to the court her mom could not make her own decisions or was under duress by the present guardian or that mom was in danger physical or financially by the present guardian or that the present guardianship was being misused.

Q. Are attorney fees awarded to the victor in this type of dispute?

A. If a petition is brought and guardianship is appointed, the fees are paid for out of the estate. However, if there is a contesting of the guardianship and it is found to be unfounded, the court has discretion to assign fees to the petitioner.

Q. How many times can a ward change guardians?

A. Guardians stay in place until they retire, move, die, are petitioned to be removed for cause, etc. They do not change frequently.

Q. The POA documents my parents signed are in case they are unable to take care of their own affairs, but we feel they need to be used now, but we still have to petition the banks, clinics, etc. How is this simpler?

A. If you have a checking account with a POA not on file with the bank the bank doesn’t know it exists, so you have to submit the POA and have it approved before the agent can act. That is still simpler than going through the courts.

Springing POA is a document that only comes into effect if a person is incapacitated which may require a medical professional put it into effect and needs the POA to act on their behalf.

Q. Is there a standard amount a guardian is paid? It that monthly or annually?

A. Annually is typical, but it is up to the court. The amount varies based on the value of the estate and whether the guardian accepts payment at all.

Q. What happens if the AIP is low income and cannot afford the guardian fees and the court says they must pay them?

A. In NYC there are community guardians for low income cases, but on Long Island they don’t have those. There is a preference for family members to be guardian, which is often free or minimal amounts. If the court appoints a lawyer to be guardian the court can also choose not to assign payment for that service. Courts try not to spread these guardianships around so it does not become a financial burden on the lawyers providing guardianship services.

Q. Caregivers of those with dementia struggle with putting a POA in place so that it is in effect when it is signed.

A. In NY, the affidavit of full effect says, this document is valid at the time it is signed and the person signing has capacity and cannot be revoked due to incapacity. The same as a durable power of attorney.

“How to Ask for Help and Actually Get It – People want to help you. You just have to ask.”

This recent New York Times article is about asking for help. Advice is always given to caregivers to have a specific list of ways that you’d like others to help you or your family member.

The author refers to Heidi Grant, a social psychologist and author of
the book “Reinforcements: How to Get People to Help You.” She
indicates that people want to help you, but you have to ask for help.
Ms. Grant says there are four crucial steps to asking:

* “First, make sure the person you want to ask realizes you need help.
Thanks to a phenomenon called inattentional blindness, we’re
programmed to have the ability to take in and process only so much
information, ignoring the rest.”

* “Second, and the other side of that coin, make clear that the person
you want to ask understands your desire for help — in other words, you
have to ask.”

* “Third, be specific with your request and make sure your helper
knows why you’re specifically asking him or her and not someone else
(or worse, asking a group).”

* “Last, make sure the person you’re asking has the time and resources
to help. We’re all busy, sure, but you probably don’t want to ask for
help from the co-worker who’s juggling five different projects, moving
apartments and prepping for a vacation.”

Here’s a link to the article:

www.nytimes.com/2018/08/20/smarter-living/how-to-ask-for-help-and-actually-get-it.html

How to Ask for Help and Actually Get It
People want to help you. You just have to ask.
The New York Times
Smarter Living
By Tim Herrera
Aug. 20, 2018