Alzheimer’s Care Ensures Enough Warmth for the Patients
The cruel grasp of Alzheimer’s disease has captured millions of helpless senior citizens around the world. It is a disease that gradually worsens along with the deterioration of the brain. The saddest part is that there is no proven cure for this disease. There is no other way than to provide extensive care and support to the affected people, suffering from this disease. There are many options to avail the required Alzheimer’s care facility. One can hire professionals to treat the patients at home, go for long-term care and avail nursing home facilities.
It is not tough to understand that family members of those elderly people suffering from Alzheimer’s disease go through an emotionally turbulent time. It is quit heart-wrenching for the relatives and family members to witness the slow and steady journey of the patients towards death. As the condition deteriorates the fragile persons urgently need extensive medical care facility at home. However, sometimes, due to certain constraints at home the patient is required to be sent to a long-term care center.
Although there is no effective solution to tackle Alzheimer’s disease, providing proper care to the patients is the ideal step to ensure their peace. However, such cares are fraught with concerns and worries. The near and dear ones of the patients always want to avail the best possible treatment and care for their beloved elders. But it is not a cakewalk. Since it is a complicated disease and affects the nervous systems of the affected, due attention should be given to ensure warmth for the patients. It includes lots of thinking and planning to avail quality service in this regard.
Since the cruel clasp of Alzheimer takes its toll upon the brain of the affected, the behavior of the patient becomes topsy-turvy. Moreover, the logical thinking capability and the memory power are severely affected due to this illness. The nursing homes are well-equipped to optimize the fight against this disease and provide affectionate care to the patients as much as possible. Medical centers like nursing home cannot cure this illness but they can slow down the wrath of Alzheimer. The caregivers are well-trained to serve their best in such well-equipped centers.
Alzheimer progresses through several stages. In the very early phase, the patient begins to lose his grasps over memory power. But as the disease worsens, several other ailments crop up. The affected person begins to suffer from perplexity. Even the near and dear ones around him seem to him as unknown persons. Moreover, such patients gradually lose their controlling power over performing simple basic tasks such as reading, writing and speaking. Special care is required in such situations to keep the patient cheerful enough.
Home health care facilities turn out to be the favorite option of many households to counter Alzheimer. The family members want to remain beside the patient during his/her last days. So, they take this decision. However, Alzheimer’s care can be provided at home if the family consists of several able-bodied members who can give a substantial time to look after the elderly patient. Otherwise it is better to send him/her to professional medical centers.
Alzheimer’s Disease – A Carer’s Guide
There are various definitions of Alzheimer ‘s disease including:
- “The slow onset of memory loss leading to a gradual progression to a loss of judgement and changes in behaviour and temperament.”
- “A living death”
- “The global impairment of higher functions, including memory, the capacity to solve problems of day to day living, the performance of learned percepto-motor skills (for example tasks like washing, dressing and eating), and the control of emotional reactions in the absence of gross clouding of consciousness.”
Memory Loss
Memory loss occurs in all cases of Alzheimer’s disease. The most recent memories are the first to be affected, the things we’ve done in the last few hours or days. Later, as the disease progresses, the past memory also deteriorates.
The fact that memory loss is such an important feature of Alzheimer’s, the testing of a person’s memory is an easy and cheap method of diagnosing the condition. Questions asked should be extremely basic, for example:
- What day is it today?
- How old are you?
- Where are we now?
- What year is it?
- What month?
- Count backwards from 20 to 1.
These questions will test a person’s short term memory, and also orientation; disorientation being another problem experienced by Alzheimer’s suffers.
Disorientation
Disorientation, or not knowing who or where you are, is closely connected to memory loss. Typically, an Alzheimer’s sufferer will forget birthdays, become unsure of what day it is, and even forgets their own name. You can understand why Alzheimer’s has been called ‘a living death’.
Because it is the short-term memory that goes first, suffers who go out alone have often returned to a house they lived in years ago, thinking they have come home.
Disorientation inside the home can become a problem too but not until the disease is in its later stages. It is important that nothing is moved or changed in the home to preserve continuity. If their environment and routine remains unchanged, an Alzheimer’s sufferer will remain more content and confident; change the environment however and their confusion and disorientation becomes readily apparent. This is why treatment at home rather than in hospital is preferred and transfer to hospital should be a last resort.
Personality Change
One of the cruellest aspects of Alzheimer’s disease is the change in personality many people experience. Often, the general behaviour and personality of Alzheimers suffers in the later stages will be in complete contrast to their usual behaviour they exhibited in earlier life.
Mood swings, from being ecstatically happy to extremely sad, verbal and sometimes physical aggression, and extreme anxiety and nervousness often affect the Alzheimers sufferer and, of course, the carer who can help best by offering continuous reassurance and patience.
Personal Hygiene
Personal hygiene often becomes a major issue with the sufferer forgetting to wash and bathe. Body odour, and stained and soiled clothing and hands can be a cause of great stress and result in a cruel loss of dignity.
Communication
During the early stages understanding simple speech remains unaffected, but finding the correct words can be a problem and the Alzheimers sufferer will often leave sentences unfinished. The taking of messages particularly over the telephone can be difficult and this is often one of the first signs of dementia.
As the disease worsens communication will become more difficult as comprehension skills decrease. Eventually their whole speech can become gibberish until eventually the Alzheimer sufferer will cease to talk altogether and will withdraw into his or her small world.
Sleep
Although the amount of sleep required by an Alzheimers sufferer is unlikely to change, their sleep cycle may do. So, instead of wanting to sleep at night and be awake during the day, this could become reversed. This isn’t a problem of itself except for the carer who will have his or her nights disrupted.
The carer is advised to keep the patient active and awake during the day as much as possible, even though it is tempting to seize an opportunity to do some chores and enjoy some peace and quiet should the sufferer fall asleep. A warm drink at bedtime may help, although any problems with incontinence should be considered. Ensure there are no other reasons for the restless nights, such as joint pain or night cramps. In the event the latter are a problem, administer mild painkillers. In the worst case scenario, many people use a night sitting service to ensure the sufferer is closely supervised while the carer gets a few nights of undisturbed sleep.
Malnutrition
Eating and drinking can be a problem with Alzheimer suffers. More accurately the lack of food and drink and the resulting malnutrition is the problem.
A sufferer may develop an irrational fear of the food you are providing, or they may simply forget or refuse to eat. Two likely causes of the latter are ill-fitting dentures, especially if the sufferer has lost weight; and constipation. A well balanced diet with plenty of roughage and a high fluid intake will help prevent constipation.
General Advice For Carers
It is difficult to judge who has the worse time, the Alzheimers sufferer or the carer. In the early stages of the disease it is probably the sufferer, in the latter stages it is undoubtedly the carer.
Help minimise disorientation by not moving anything in the home. To do so will make their confusion worse.
Admit an Alzheimers suffer to hospital as a last resort. Once you do so disorientation and confusion will increase markedly.
Do not let a sufferer out alone, they may have difficulty finding the way back home.
Do all you can to help the sufferer maintain dignity.
- A warm drink or a tot of their favourite alcoholic drink may aid sleep at night.
- Try to keep the patient active and awake during the day.
- Keep a cold drink nearby to remind the sufferer to take fluids.
- Keep disruption to routine to a minimum to prolong the Alzheimers sufferer’s independence as long as possible.
Closely supervise medication. It is very easy for the Alzheimers sufferer to forget they have taken their medication, and take it repeatedly. Alzheimer’s disease is progressive and incurable, although there are drugs that can slow the progression. It is one of the saddest diseases in that it is difficult to care for or regularly visit someone who no longer knows your name or recognises you.
Insite Tools for Alzheimer’s Caregivers
Having spent my career as a Medical Social Worker and Elder Abuse Investigator it seems natural for me to share some insight for those family members and caregivers working with victims of Alzheimer’s disease.
I will not take a Physiological and Psychological approach for delivering information. I will leave that to Physicians and Therapists. What I would like to share is some practical information that has proven helpful to my clients and their families and caregivers.
First of all, I will say that being with a loved one or patient with Alzheimer’s type dementia is difficult if not heartbreaking. Seeing a person often familiar or most dear in an abyss of memory loss takes determination and strength. The greatest barrier to appropriate care is accepting the relationship must change and must become flexible. It is the burden of the caregiver to initiate these changes in order to provide safe and loving care.
The nature of this illness fluctuates and the direct caregiver would benefit from being able to do the same, emotionally and practically. Visualize the mind of the patient or loved one as a window. The window is often foggy, half open, closed or completely clear. There is no timetable that will report what is going on inside the window. The foggy window represents the normal goings on with the early or mid-stage person with Alzheimer’s. The half-open state is the obvious fluctuations between clarity and confusion. It is during this phase that most agitation, suspicion, aggression and fear are displayed. This is the most difficult time for the caregiver and the most emotionally painful for the person being cared for. The closed or end-stage is the most painful for the caregiver. The person behind the window is no longer home and often recognizes no one or nothing around him or her.
Activity in the affected brain is erratic and therefore there are often periods of clarity, comprehension with appropriate behaviors and responses. Knowing how to respond to these changes can reduce the burden of care, increase the safety of the cared for and bring some peace of mind and acceptance for the caregiver.
Why Alzheimer’s Patients Need Expert Care
Alzheimer’s Disease is a degenerative brain disorder that affects mostly ageing people (65 years of age on the average). Every retirement community or senior living Dallas and other areas in the United States have built has one or more patients afflicted with Alzheimer’s. People who have Alzheimer’s suffer from confusion, dementia, disorientation and as the disease progresses, long-term memory loss. The need to take care of these patients is a must. The disease is irreversible but certain medication should be given to patients whose condition has become worse.
One dilemma of Alzheimer’s to both the patient and his family is emotional stress. Since the patient eventually suffers from irritability, memory loss and behavioral problems, the family can be subjected to frustration and stress. What most families of people with AD do is to send them to retirement homes or senior living Plano and other areas offer. This way, patients are given proper care—both medically and emotionally—as well as the attention that they need as the disease progresses.
It can be very painful for family members to see their senior members suffer from the effects of Alzheimer’s, especially with the fact that it leads to death. In the long run, patients will suffer from malnutrition, poor hygiene and health deterioration. With this, the need to seek professional help and guidance is greatly considered.
Eventually, the nurturing and care that each member of the family can give to the patient become conditional due to emotional stress, frustration and the patient’s increased demand for attention. With retired homes or communities, both the senior and his family are given the opportunity for acceptance and healing through caregiving. As the disease progresses, the patient’s need for attention also greatly increases.
Some retirement communities and senior living have employed professionals that have proper experience in behavior, cognition, emotion, and stimulus problems. They can conduct psychosocial therapies for AD patients, as well as monitor the patient’s condition as it progresses.
Apart from increased interaction with other seniors, patients with AD who live in retirement communities have more opportunities for different recreational activities. Although these activities cannot cure the disease, they help lessen disturbances and calm patients. Symptoms of AD may appear to be common in every patient, but no two cases are exactly the same. Every patient has different issues to be addressed.
What’s The Difference Between Alzheimer’s and Dementia?
“What’s the difference between dementia and Alzheimer’s?” It’s a common question, and doctors are some of the best at confusing us. Physicians seem to prefer the word “dementia,” possibly because Alzheimer’s has become such a loaded word. “Dementia” somehow sounds less frightening to many people, and now even the experts have started using the words interchangeably.
They aren’t interchangeable. Alzheimer’s Disease and dementia are two very different things.
Dementia is a symptom. Pain is a symptom, and many different injuries and illnesses can cause pain. When you go to the doctor because you hurt, you won’t be satisfied if the doctor diagnoses “pain” and sends you home. You want to know what is causing the pain, and how to treat it.
“Dementia” simply means the symptom of a deterioration of intellectual abilities resulting from an unspecified disease or disorder of the brain.
Alzheimer’s Disease is one disease/disorder that causes dementia. Many other illnesses or “syndromes” can also cause dementia. Parkinson’s Disease can cause dementia. A stroke can cause dementia. Even dehydration can cause dementia.
Many of the things that can cause dementia are treatable, even potentially curable.
If you have taken your elder to the doctor and received a diagnosis of “dementia” you haven’t received a diagnosis at all. Unless you know what is causing the dementia you can’t begin to treat it’s root cause.
If your physician has diagnosed “dementia” it’s time for a second opinion. You are probably dealing either with a physician who is not comfortable with the truth, or one who doesn’t know how (or doesn’t want to bother) to differentiate between all the possible causes of dementia. Either way, a skilled geriatrician or a neurologist who is comfortable with seniors would be a good place to start.
Tags:Alzheimer; at home care, Elder care, Home Care, home health care, in home care
The cruel grasp of Alzheimer’s disease has captured millions of helpless senior citizens around the world. It is a disease that gradually worsens along with the deterioration of the brain. The saddest part is that there is no proven cure for this disease. There is no other way than to provide extensive care and support to the affected people, suffering from this disease. There are many options to avail the required Alzheimer’s care facility. One can hire professionals to treat the patients at home, go for long-term care and avail nursing home facilities.
It is not tough to understand that family members of those elderly people suffering from Alzheimer’s disease go through an emotionally turbulent time. It is quit heart-wrenching for the relatives and family members to witness the slow and steady journey of the patients towards death. As the condition deteriorates the fragile persons urgently need extensive medical care facility at home. However, sometimes, due to certain constraints at home the patient is required to be sent to a long-term care center.
Although there is no effective solution to tackle Alzheimer’s disease, providing proper care to the patients is the ideal step to ensure their peace. However, such cares are fraught with concerns and worries. The near and dear ones of the patients always want to avail the best possible treatment and care for their beloved elders. But it is not a cakewalk. Since it is a complicated disease and affects the nervous systems of the affected, due attention should be given to ensure warmth for the patients. It includes lots of thinking and planning to avail quality service in this regard.
Since the cruel clasp of Alzheimer takes its toll upon the brain of the affected, the behavior of the patient becomes topsy-turvy. Moreover, the logical thinking capability and the memory power are severely affected due to this illness. The nursing homes are well-equipped to optimize the fight against this disease and provide affectionate care to the patients as much as possible. Medical centers like nursing home cannot cure this illness but they can slow down the wrath of Alzheimer. The caregivers are well-trained to serve their best in such well-equipped centers.
Alzheimer progresses through several stages. In the very early phase, the patient begins to lose his grasps over memory power. But as the disease worsens, several other ailments crop up. The affected person begins to suffer from perplexity. Even the near and dear ones around him seem to him as unknown persons. Moreover, such patients gradually lose their controlling power over performing simple basic tasks such as reading, writing and speaking. Special care is required in such situations to keep the patient cheerful enough.
Home health care facilities turn out to be the favorite option of many households to counter Alzheimer. The family members want to remain beside the patient during his/her last days. So, they take this decision. However, Alzheimer’s care can be provided at home if the family consists of several able-bodied members who can give a substantial time to look after the elderly patient. Otherwise it is better to send him/her to professional medical centers.
Alzheimer’s Disease – A Carer’s Guide
There are various definitions of Alzheimer ‘s disease including:
- “The slow onset of memory loss leading to a gradual progression to a loss of judgement and changes in behaviour and temperament.”
- “A living death”
- “The global impairment of higher functions, including memory, the capacity to solve problems of day to day living, the performance of learned percepto-motor skills (for example tasks like washing, dressing and eating), and the control of emotional reactions in the absence of gross clouding of consciousness.”
Memory Loss
Memory loss occurs in all cases of Alzheimer’s disease. The most recent memories are the first to be affected, the things we’ve done in the last few hours or days. Later, as the disease progresses, the past memory also deteriorates.
The fact that memory loss is such an important feature of Alzheimer’s, the testing of a person’s memory is an easy and cheap method of diagnosing the condition. Questions asked should be extremely basic, for example:
- What day is it today?
- How old are you?
- Where are we now?
- What year is it?
- What month?
- Count backwards from 20 to 1.
These questions will test a person’s short term memory, and also orientation; disorientation being another problem experienced by Alzheimer’s suffers.
Disorientation
Disorientation, or not knowing who or where you are, is closely connected to memory loss. Typically, an Alzheimer’s sufferer will forget birthdays, become unsure of what day it is, and even forgets their own name. You can understand why Alzheimer’s has been called ‘a living death’.
Because it is the short-term memory that goes first, suffers who go out alone have often returned to a house they lived in years ago, thinking they have come home.
Disorientation inside the home can become a problem too but not until the disease is in its later stages. It is important that nothing is moved or changed in the home to preserve continuity. If their environment and routine remains unchanged, an Alzheimer’s sufferer will remain more content and confident; change the environment however and their confusion and disorientation becomes readily apparent. This is why treatment at home rather than in hospital is preferred and transfer to hospital should be a last resort.
Personality Change
One of the cruellest aspects of Alzheimer’s disease is the change in personality many people experience. Often, the general behaviour and personality of Alzheimers suffers in the later stages will be in complete contrast to their usual behaviour they exhibited in earlier life.
Mood swings, from being ecstatically happy to extremely sad, verbal and sometimes physical aggression, and extreme anxiety and nervousness often affect the Alzheimers sufferer and, of course, the carer who can help best by offering continuous reassurance and patience.
Personal Hygiene
Personal hygiene often becomes a major issue with the sufferer forgetting to wash and bathe. Body odour, and stained and soiled clothing and hands can be a cause of great stress and result in a cruel loss of dignity.
Communication
During the early stages understanding simple speech remains unaffected, but finding the correct words can be a problem and the Alzheimers sufferer will often leave sentences unfinished. The taking of messages particularly over the telephone can be difficult and this is often one of the first signs of dementia.
As the disease worsens communication will become more difficult as comprehension skills decrease. Eventually their whole speech can become gibberish until eventually the Alzheimer sufferer will cease to talk altogether and will withdraw into his or her small world.
Sleep
Although the amount of sleep required by an Alzheimers sufferer is unlikely to change, their sleep cycle may do. So, instead of wanting to sleep at night and be awake during the day, this could become reversed. This isn’t a problem of itself except for the carer who will have his or her nights disrupted.
The carer is advised to keep the patient active and awake during the day as much as possible, even though it is tempting to seize an opportunity to do some chores and enjoy some peace and quiet should the sufferer fall asleep. A warm drink at bedtime may help, although any problems with incontinence should be considered. Ensure there are no other reasons for the restless nights, such as joint pain or night cramps. In the event the latter are a problem, administer mild painkillers. In the worst case scenario, many people use a night sitting service to ensure the sufferer is closely supervised while the carer gets a few nights of undisturbed sleep.
Malnutrition
Eating and drinking can be a problem with Alzheimer suffers. More accurately the lack of food and drink and the resulting malnutrition is the problem.
A sufferer may develop an irrational fear of the food you are providing, or they may simply forget or refuse to eat. Two likely causes of the latter are ill-fitting dentures, especially if the sufferer has lost weight; and constipation. A well balanced diet with plenty of roughage and a high fluid intake will help prevent constipation.
General Advice For Carers
It is difficult to judge who has the worse time, the Alzheimers sufferer or the carer. In the early stages of the disease it is probably the sufferer, in the latter stages it is undoubtedly the carer.
Help minimise disorientation by not moving anything in the home. To do so will make their confusion worse.
Admit an Alzheimers suffer to hospital as a last resort. Once you do so disorientation and confusion will increase markedly.
Do not let a sufferer out alone, they may have difficulty finding the way back home.
Do all you can to help the sufferer maintain dignity.
- A warm drink or a tot of their favourite alcoholic drink may aid sleep at night.
- Try to keep the patient active and awake during the day.
- Keep a cold drink nearby to remind the sufferer to take fluids.
- Keep disruption to routine to a minimum to prolong the Alzheimers sufferer’s independence as long as possible.
Closely supervise medication. It is very easy for the Alzheimers sufferer to forget they have taken their medication, and take it repeatedly. Alzheimer’s disease is progressive and incurable, although there are drugs that can slow the progression. It is one of the saddest diseases in that it is difficult to care for or regularly visit someone who no longer knows your name or recognises you.
Insite Tools for Alzheimer’s Caregivers
Having spent my career as a Medical Social Worker and Elder Abuse Investigator it seems natural for me to share some insight for those family members and caregivers working with victims of Alzheimer’s disease.
I will not take a Physiological and Psychological approach for delivering information. I will leave that to Physicians and Therapists. What I would like to share is some practical information that has proven helpful to my clients and their families and caregivers.
First of all, I will say that being with a loved one or patient with Alzheimer’s type dementia is difficult if not heartbreaking. Seeing a person often familiar or most dear in an abyss of memory loss takes determination and strength. The greatest barrier to appropriate care is accepting the relationship must change and must become flexible. It is the burden of the caregiver to initiate these changes in order to provide safe and loving care.
The nature of this illness fluctuates and the direct caregiver would benefit from being able to do the same, emotionally and practically. Visualize the mind of the patient or loved one as a window. The window is often foggy, half open, closed or completely clear. There is no timetable that will report what is going on inside the window. The foggy window represents the normal goings on with the early or mid-stage person with Alzheimer’s. The half-open state is the obvious fluctuations between clarity and confusion. It is during this phase that most agitation, suspicion, aggression and fear are displayed. This is the most difficult time for the caregiver and the most emotionally painful for the person being cared for. The closed or end-stage is the most painful for the caregiver. The person behind the window is no longer home and often recognizes no one or nothing around him or her.
Activity in the affected brain is erratic and therefore there are often periods of clarity, comprehension with appropriate behaviors and responses. Knowing how to respond to these changes can reduce the burden of care, increase the safety of the cared for and bring some peace of mind and acceptance for the caregiver.
Why Alzheimer’s Patients Need Expert Care
Alzheimer’s Disease is a degenerative brain disorder that affects mostly ageing people (65 years of age on the average). Every retirement community or senior living Dallas and other areas in the United States have built has one or more patients afflicted with Alzheimer’s. People who have Alzheimer’s suffer from confusion, dementia, disorientation and as the disease progresses, long-term memory loss. The need to take care of these patients is a must. The disease is irreversible but certain medication should be given to patients whose condition has become worse.
One dilemma of Alzheimer’s to both the patient and his family is emotional stress. Since the patient eventually suffers from irritability, memory loss and behavioral problems, the family can be subjected to frustration and stress. What most families of people with AD do is to send them to retirement homes or senior living Plano and other areas offer. This way, patients are given proper care—both medically and emotionally—as well as the attention that they need as the disease progresses.
It can be very painful for family members to see their senior members suffer from the effects of Alzheimer’s, especially with the fact that it leads to death. In the long run, patients will suffer from malnutrition, poor hygiene and health deterioration. With this, the need to seek professional help and guidance is greatly considered.
Eventually, the nurturing and care that each member of the family can give to the patient become conditional due to emotional stress, frustration and the patient’s increased demand for attention. With retired homes or communities, both the senior and his family are given the opportunity for acceptance and healing through caregiving. As the disease progresses, the patient’s need for attention also greatly increases.
Some retirement communities and senior living have employed professionals that have proper experience in behavior, cognition, emotion, and stimulus problems. They can conduct psychosocial therapies for AD patients, as well as monitor the patient’s condition as it progresses.
Apart from increased interaction with other seniors, patients with AD who live in retirement communities have more opportunities for different recreational activities. Although these activities cannot cure the disease, they help lessen disturbances and calm patients. Symptoms of AD may appear to be common in every patient, but no two cases are exactly the same. Every patient has different issues to be addressed.
What’s The Difference Between Alzheimer’s and Dementia?
“What’s the difference between dementia and Alzheimer’s?” It’s a common question, and doctors are some of the best at confusing us. Physicians seem to prefer the word “dementia,” possibly because Alzheimer’s has become such a loaded word. “Dementia” somehow sounds less frightening to many people, and now even the experts have started using the words interchangeably.
They aren’t interchangeable. Alzheimer’s Disease and dementia are two very different things.
Dementia is a symptom. Pain is a symptom, and many different injuries and illnesses can cause pain. When you go to the doctor because you hurt, you won’t be satisfied if the doctor diagnoses “pain” and sends you home. You want to know what is causing the pain, and how to treat it.
“Dementia” simply means the symptom of a deterioration of intellectual abilities resulting from an unspecified disease or disorder of the brain.
Alzheimer’s Disease is one disease/disorder that causes dementia. Many other illnesses or “syndromes” can also cause dementia. Parkinson’s Disease can cause dementia. A stroke can cause dementia. Even dehydration can cause dementia.
Many of the things that can cause dementia are treatable, even potentially curable.
If you have taken your elder to the doctor and received a diagnosis of “dementia” you haven’t received a diagnosis at all. Unless you know what is causing the dementia you can’t begin to treat it’s root cause.
If your physician has diagnosed “dementia” it’s time for a second opinion. You are probably dealing either with a physician who is not comfortable with the truth, or one who doesn’t know how (or doesn’t want to bother) to differentiate between all the possible causes of dementia. Either way, a skilled geriatrician or a neurologist who is comfortable with seniors would be a good place to start.
Tags:Alzheimer; at home care, Elder care, Home Care, home health care, in home care