One of the many challenges older adults face as they age and inevitably start to fail to cope with daily living is how and where to get help to maintain functional independence. I’ve been navigating this challenge personally with several declining family members in the past year, and I’ve become acutely aware of the difficulties aging can bring up and the stresses it can bring to family and friends.
I was having a conversation the other day with two adult siblings who came into the office with their mom. She has worsening dementia and was failing at daily living at home. Like so many seniors, she is fiercely independent, not wanting to ask for help or burden her family. Yet, inevitably, she got to a point where she is figuratively “crashing and burning” – losing weight, unable to get out and shop, getting weak and falling, which prompted a recent hospitalization.
One adult child was from out of town and took a leave from work along with the other sibling to come and “give Mom a hand.” They quickly discovered her needs are far greater than they have the time or resources to provide and were wondering where to turn. I talk to patients regularly who are unsure what their options are, what Medicaid and Medicare might cover if acute care is needed and what information they need to decide about if and when to move out of the home to a place with more resources and care.
As a person’s agility, energy and sometimes health naturally diminishes, it’s extremely important to plan for safety and care – and make that plan well ahead of time before an emergency or hospitalization. Planning and taking advantage of resources can also lighten the load on younger family members, particularly daughters who are often providing care for parents while working and caring for their own families.
So often we are uncomfortable with these difficult conversations because it’s a reminder of our own mortality. We hope that when our time comes, we can quietly and painlessly go to sleep and never wake up, but the reality for most is a gradual and progressive loss of function and independence. We must remember no one escapes, so having honest and open conversations is not only essential but also can be a bonding experience with our loved ones.
Home safety first
One of 4 people age 65 and older falls each year. Falls can lead to broken hips or other injuries, and that’s a major trigger for older adults to need to move to a skilled nursing facility or require hospitalization. Encouraging walking and exercise and getting regular eye exams are the first lines of defense. Some medications can increase the risk of falling; a conversation with your provider can determine if it’s appropriate to reduce them. Easy changes can reduce the risk of falls:
• Review the home for trip hazards like loose carpets, cords and cracks in pavement.
• Install stability or grab bars in the shower and near the toilet.
• Increase lighting, including nightlights on the path to the bathroom.
• Make sure there are handrails on both sides of hallways and on stairs and ideally limit living to a single floor to avoid stairs.
• Using devices like single prong or quad canes, front- or four-wheeled walkers and wheelchairs can be a huge help with safety at home.
Help around the home
Sometimes Mom and Dad just need a little extra help, whether it’s meal delivery to the rescue or hiring in-home help for simple household tasks and basic care. These services can be vital in maintaining independence in one’s home. Cost can vary and are typically paid out-of-pocket, from cleaning to nonmedical needs like bathing. With any level of care or services, check ahead of time directly with your Medicare plan, Medicaid and insurance, such as long-term care insurance, to see what is covered and what isn’t.
• Get parents set up for grocery delivery, especially helpful if a senior is no longer driving.
• Use restaurant and meal delivery services for prepared meals. It’s a little more expensive but easy and convenient.
• Many drugstores, and even pet supply stores, deliver, and many health plans provide mail order delivery of medications.
• Get help with household tasks like meal preparation, laundry and errands or with care assistance, for example, help with bathing or dressing or assistance with getting to doctor’s appointments. There are companies that offer hourly help for household tasks and offer personal care and semi-skilled medical care. Search online for “senior home care services” to find large national providers and local agencies, or find helpers locally. But wherever you hire, check references and vet candidates thoroughly.
• Reaching your toes to trim toenails becomes challenging as you age, especially with declining vision and arthritic hands. Some home care workers will help trim nails. Podiatrists and local nail salons also do senior pedicures. If there are issues like painful bunions, ingrown nails or blisters, which can impair mobility, seniors might need a podiatrist consult.
There does often come a time when more skilled care is needed. Regular in-home visits, care after hospitalization and temporary care facilities such as skilled nursing facilities are all options. Understanding health care coverage for this kind of care can be complex. I find that many seniors and their caretakers are unsure what costs they are facing and what Medicaid, Medicare or long-term care insurance (if you have it) might cover in different care situations.
But you can prepare yourself by knowing the financial realities. Talk with your plan providers about out-of-pocket expenses, waiting periods and what’s covered for short term-care, long-term care and other needs.
When it’s time to move
Deciding to move out of your home is a big step, and, like any move, it’s easier when it’s planned. Have a conversation, ideally way ahead of time, about what types of living arrangements are available, what they cost and a timeline. Here’s a brief rundown of types of senior living:
• Over 55 communities and continuous care retirement communities: Often include several levels of housing so an older adult can transition in the same community as needed from an independent apartment to assisted living or memory care.
• Assisted living: Residents get assistance with daily activities like meals, errands and managing medications. There are often recreational and social opportunities.
• Nursing homes: Provide daily living help plus limited medical treatments and skilled nursing, including rehabilitation. Nursing home staff usually serve a larger number of residents and can only provide limited one-on-one care.
• Adult family homes: Usually have a small number of residents, often just three to six, and can give one-on-one support to people struggling with managing the activities of daily living like bathing, dressing, meals, transfers, etc. or those coping with dementia. This is usually nonskilled or sometimes semi-skilled care but not full nursing care.
Talk it over with family
Have conversations together honestly and openly before it is a crisis with an urgent need for decisions. Complex factors like independence, pride and comfort go into care decisions, including end-of-life care and advanced directives. Your primary care physician can often facilitate a family care conference to review the medical aspects of care.
Ask one another questions about wants and realities like budget, time available for family care and what the local community support options are. Remember this process takes time. Having these conversations can provide a tremendous sense of relief for children and parents and allow parents to age gracefully in place.
Dr. Jeff Markin is a family medicine physician practicing at Kaiser Permanente’s Veradale Medical Center.
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