On March 5, 2003, Shirley Burak's life changed when she was taking out the trash.

On her way back into her McKeesport home, Shirley slipped on an icy surface and fell.

Shirley, 73, had broken her upper femur, an injury requiring three pins to be put in her leg. While the fall was traumatic, it forced Shirley to do something she had been avoiding her entire life: Go to the doctor.

When she was hospitalized, doctors found that Shirley also suffered from a thyroid problem and emphysema. It didn't end there.

During her hospital stay, Shirley fell from her bed, breaking her wrist. Almost immediately after leaving the hospital, she had a mini-stroke, prompting balance and coordination problems.

"It had been coming on, but she didn't tell anybody," says her son and caregiver, Timothy Burak, 46. "It was very stressful. I was not prepared for anything. She was doing really well up to that point."

By May, Burak insisted his mother move into his Lawrenceville apartment. Since then, Shirley, now 77, has dealt with osteoporosis and two stress fractures in her spine. Burak and his sister helped her sell her duplex.

Now, Burak has developed a routine. He gets up at about 5:30 a.m. every day, puts something in the crockpot, then makes his way to work at Elan Financial Services in Station Square.

While he's gone, Shirley watches C-SPAN, reads the newspaper and does a few crossword puzzles. Sometimes a family member or friend stops by for a visit.

But for the most part, Burak is Shirley's lifeline.

"At first, I wasn't emotionally prepared and you have that shock," he says.

While caring for a loved one can be rewarding, caregivers need to pay special attention to themselves as well.

The National Alliance for Caregiving, based out of Bethesda, Md., reports "in the population as a whole, 9 percent of people report their health as only fair or poor. Yet, 17 percent of all caregivers report their health as fair or poor, with 35 percent of those doing the most intense caregiving saying they have fair or poor health."

In addition, 34 percent of those with only fair or poor health said that caregiving had made their health worse.

Dr. Susanne Hartmann, medical director of geriatric medicine at UPMC St. Margaret in Aspinwall, attributes much of this stress to a lack of preparation on the part of the caregiver.

"They risk moving the focus from themselves to their parent," she says. "Caregivers report high rates of depression, decreased life satisfaction and other health problems. It can cause strains between the parent and the child and the caregivers and their own family."

The best way to avoid being taken off guard when taking on a caregiver role is early diagnosis, says Hartmann, though it can be particularly difficult when the diagnosis is dementia.

"In the mild or moderate stages, caregivers tend to think their parent is lying or just trying to irritate them," she says. "Their mother or father is not the mother or father they remember from five or 10 years ago."

No matter the diagnosis, Hartmann says the best defense against stress is education, which enables the caregiver to develop realistic expectations about their loved one's illness.

Paula Tchirkow, president of Allegheny Geriatric Consultants in Carnegie, connects the high likelihood of caregiver burnout to the emotional experience of watching a loved one's health decline.

"It's very heartbreaking to see your parent deteriorate, especially if it's related to Alzheimer's disease," she says. "Caregivers don't get enough rest; some never even go out to the grocery store."

It also causes stress within the family when one person ends up doing all the work, as is most frequently the case, Tchirkow says. National Alliance for Caregiving and AARP report that the typical caregiver is a 46-year-old woman caring for her mother.

And often, family is not the only thing on caregivers' minds. NAC reports that 59 percent of caregivers also work.

UPMC Institute on Aging reports that the Family and Medical Leave Act allows employees to take unpaid leave from their jobs for up to 12 weeks within a 12-month period for a specified family or medical condition.

However, how much time one can take varies with how long he or she's been employed.

Export resident and school nurse Janice Walter, whose father, Stuart, is a resident of Arden Courts in Monroeville, says she did not have enough accrued hours at the time of her father's illness to qualify for the time off.

"I kept calling off sick saying it was a family emergency, but then I was informed I couldn't do that any more," she says.

Luckily, her husband, Dan, made arrangements to get Stuart to his doctor's appointments. Janice Walter still took him, however, during school vacation days, which left little time for an actual vacation.

Caregivers tend to take on almost all the responsibility themselves, not allowing others to offer help.

"Especially if they've had experience with care facilities, they feel they can do the better job and are really unwilling to trust someone with their loved one," Hartmann says. "This is when they need emotional support. Getting involved in support groups and other types of counseling can help them get to know other people in their similar situation."

Sometimes, the caregiver simply doesn't know what help is available to them.

"Most people who aren't in the profession don't know about all the services," says Jordan Golin, director of older adult and clinical services for Jewish Family and Children Service. The service is one branch of AgeWell Pittsburgh, a Squirrel Hill-based organization devoted to providing resources for a multitude of aging issues.

"We all try not to spend a lot of time thinking about aging. The changes come gradually, but the awareness is very sudden. Then you're forced to make a decision without a lot of research."

These situations also often require the adult children to discuss topics with their parents that would otherwise go avoided, such as mortality and finances.

To ease this process, AgeWell Pittsburgh offers a series called "Get Ready, Get Set, Talk," to open the discussion.

"It's emotionally-laden," says Pearl Averbach, AgeWell Pittsburgh geriatric care manager.

"Even if the caregivers are not a direct family member, they care intensely about the person and they're sincerely determined to change things for the better. This lets you put the emotional component aside and be proactive versus reactive."

To find help with everyday issues, Tchirkow recommends contacting the loved one's church to see if there are volunteers who offer home visits or trips to the doctor or grocery store. She also encourages caregivers to keep up with their own health issues and keep scheduling all the necessary tests, such as mammograms.

"If you go into it with that attitude, it will be easier," she says. "You must get regular respite. Maybe your loved one follows you around the house and you get no privacy. You can pay someone to come in once a week so you can go to lunch with friends or to the library to sit and relax."

However, Tchirkow cautions caregivers not to expect their loved one to be happy with the idea of bringing in outside help.

"Across the board, they're reluctant at first," she says. "They hear a social worker is coming and they get very leery.

"But I'm there to ensure their independence -- that is always my goal. There is also a lack of insight. They don't think they have a problem."

Through his mother's many hospital stays and the occasional use of a caregiver, Burak was introduced to the classic caregiver center at UPMC St. Margaret, a network of doctors, social workers and psychologists.

One of the hardest parts of the process, he says, has been realizing his mother is not invincible.

But the situation has made Burak understand he needs to pay attention to his own health. He now gets physicals every five years and he makes it a point to de-stress through his hobby of photography.

After a life of traveling domestically and internationally for work with nuclear power plants, he's OK being a bit of a homebody to care for his mother.

"I've traveled around for work. I've seen the big things," he says. "This is her time."

Caregivers can seek help from respite care, adult day care and adult sitting services when they need time to regroup and address their own needs.

However, when 24-hour care becomes a necessity, a more formal arrangement is required.

See the last part of Gateway Newspapers' series next week for advice from experts on when and how to find a care facility.

Get caring support

In the Pittsburgh area, several agencies are devoted to easing the burden on people who find themselves caring for a loved one.

• The Allegheny County Agency on Aging offers caregiver support programs.

The programs are designed to reduce caregiver stress and burdens by offering benefits and resource counseling, caregiver training and education, access to support groups and financial reimbursement for caregiving-related supplies and services. Call the SeniorLine at 412-350-5460.

• UPMC St. Margaret, Aspinwall, offers an Alzheimer's support group that meets the third Monday of every month. Details: 412-784-5313.

• AgeWell Pittsburgh, Squirrel Hill, offers a one-stop resource that links older adults, their family members, friends and caregivers to solutions for issues related to aging.

Services include geriatric assessment, adult day services, in-home caregiver services, assisted living, nursing, outpatient rehabilitation or other residential care options and many others. Details: 412-422-0400.

• Westmoreland County Agency on Aging participates in the state's Family Caregiver Support Program.

Participating people must live in the same home or apartment, be related and consist of at least the care receiver (who must be 60 or older and/or have a diagnosis of chronic dementia) and the caregiver. The care receiver must also be functionally dependent on others to meet daily needs.

Depending on their annual income, family caregivers can receive up to $400 a month to help purchase services such as respite care, adult day care, homemaker services and more; or to purchase caregiving supplies.

In addition, eligible families may receive a one-time grant of up to $2,000 to help pay for home adaptations and services. For more information, see caregiverpa.psu.edu/index.html.

Avoid caregiver burnout

The following are tips from the American Geriatrics Society's Foundation for Health and Aging to stay healthy while caring for another:

• Get information: Learn as much as you can about your older loved one's health problems and needs and how these can change over time.

Learning about options for care that your loved one may need in the future -- such as help from a home aide, or assisted living or nursing home care -- can help you feel more secure about your loved one's future.

• Ask family, friends and neighbors for assistance: Ask if a neighbor can take your mother to the grocery store once a week or your sibling could help make meals on weekends.

Try not to criticize if others don't care for your loved one exactly the way you would.

• Take care of yourself: Eating well, exercising and taking time to relax are key to avoiding burnout. If you take care of yourself, you'll be able to take better care of your family member.

• Help your loved one help himself or herself: Doing something as simple as putting a special, no-slip seat in the shower or bath, installing grab bars near the bed and moving kitchen supplies to lower shelves can make it possible for an older relative to keep doing certain things independently.

• Talk about it: Talking about your experiences and feelings can make caregiving less stressful. Joining a caregiver support group in your area will give you a chance to share your thoughts, feelings and information with others in similar circumstances.

• Contact organizations that assist caregivers: A wide array of programs, agencies, organizations and individuals can help you manage the challenges of caring for an older relative.