Today, learn from Kumar what “aging in place” actually means, the pros and cons of aging in the home, and how to determine when it’s time to get a caregiver or move into an assisted living facility.
We're talking today about aging in place, which I think we all have a different idea of what that means for all of us. What does it actually mean from a medical perspective to a doctor like you? What does it mean to age in place?
Kumar:Aging in place to me really means that one is able to stay in their home for as long as possible as they get older, as they develop more health conditions, maybe become more dependent on others. They're still able to not just be in their home, but really thrive in that familiar situation for them rather than move to a more institutional setting, which may always be there, but they're really keeping their roots.
Jason:You hear a lot of people, whether they're seniors or or not, the desire to age in place. What are some of the reasons that you hear when you're talking to a geriatric patient and they're reaching a point where they may have to make a decision? What do you hear about why they want to age in place?
Kumar:We both heard the expression home is where the heart is and it's a place that's familiar. It might be a place where they raised their families. It's a central point for many social connections and their lives have been there and it's a big deal to move from that to another setting and then also have that be an institutional or congregate setting where they may not have the same privacy, they may not have the same space and they certainly may not have the same familiarity and so it makes perfect sense to me which some of them want to stay in their homes for as long as possible.
Jason:So I think, you know, a few years ago, it was almost considered antiquated. It was sort of thought of, at least in popular culture it was thought of as, Oh, they're stuck in their ways, they're stubborn, they want to age in place--it was just emotional reasons and emotional being discounted for why they wanted to age in place. It sounds like you're saying though that it's legitimate, that it's not just about some stubborn or sentimental person who wants to do it. There are actual benefits to staying in your home.
Kumar:Yeah. And if I asked you where would you want to be as you age, you'd probably say in my home as opposed to, you know, in a facility. And so no, I think it just makes perfect sense. And the other thing which I think has really fueled this movement is like many things in modern medicine, it's expensive. And so care in a facility is expensive to a patient, it might be expensive to their family, and expensive to the government. And over time there've been a number of studies and programs have shown that allowing people to stay in their home, but with additional supports where appropriate cannot just make the person happier because they're at home, but it can be cheaper and their health outcomes could be better. And so, you know, I think there's a number of reasons for why it makes total sense, where it's feasible.
Jason:Talk a little more about those health outcomes. The cheaper makes sense. I think we all know there can be concerns about hospitals being very expensive and certainly no fun to be in. But what are some of the medical benefits for staying at home?
Kumar:R ight. I think the biggest one is probably the way that it affects people's mental health. We've seen cases myself, clinically, know people seeing the data t hat when someone moves from one environment where they're familiar, their roots are to another, it's a big change. And sometimes people can get depressed or they feel socially isolated, which is also, you know, very distressing to people. And so for many people staying at home truly is where t hey're happiest. The other thing I think in staying at home is, you avoid some of the, it's a technical term in medicine, but nosocomial problems o r facility associated problems and complications and infections. So in a facility where you're with many people, it increases the likelihood of, let's say i f one person gets the flu, other people getting the flu, or complications. It's unfamiliar, so might be more likely to fall at night or get confused, especially if you have cognitive impairment or other medical conditions that predispose you to getting confused.
Jason:Dementia.
Kumar:Dementia. Exactly. And so, you know, while I can't say there's a huge database on outcomes at home versus in a facility, it just makes common sense to me that if you can be at home, and again, the big IF here though is home and thriving. It shouldn't be home and unsupported, which could be more dangerous than being in a facility. So if you, to your point have dementia and there's no caregiver in the picture, there's no other supports in the picture and you're confused and you're managing your own medications and you know, you have to cook for yourself and you know, you might screw up the meds or you might get burned while cooking or leave the stove on. These are common things for someone with dementia in certain cases. And so really it's about being at home, but having the right supports while you're there to make it work.
Jason:So let's say I'm an adult child and my dad-- it's getting a little harder, but he wants to stay at home. He knows he can't keep living completely independently with no additional support in his house, but he doesn't want to move into an assisted living facility. What are the things, you know, and I'm not even, I don't live with him, but I'm worried about him. I want him to have that kind of support. I want him to be able to stay at home and thrive as long as physically possible. What are the things that I could do to help him extend his time at home?
Kumar:Well, I think the first thing is to actually have a conversation with him. Try and understand why he wants to stay at home, try to understand what his health needs are at home, what are the challenges to staying at home. And then there are actually some uncomfortable but really important conversations: trying to understand the finances. And sometimes parents, especially if there are financial issues, they don't want their kids to know because they don't want to upset their kids. In many cases, their kids have their own kids and their own lives and parents are parents. They don't want to be a burden on their children in many cases. But I think it's a really important conversation because it gives you a sense of the context and what may or may not be feasible and it helps focus that session. So I think that's step number one, have a real open discussion. And I'm not saying that's an easy open discussion, but I think you have to start there because if you don't know the situation, it's hard to understand what the next steps are. But let's say you've had that discussion and you have a sense of why your dad, in your example, wants to stay at home. I think now you figured out why he wants to stay at home and a little bit about what his needs are. As he's aging, I would say there are groups that need to be talked about it, what I call self care needs. These are things like does your dad need help with dressing or bathing or going to the bathroom or eating or moving within his home? Usually at this point people are pretty far progressed in terms of what we call their functional needs are developing, their self care is becoming difficult on their own. In that case, you might need custodial care or someone who can be there 24/7 and you know, that could be challenging financially, but I think that's helpful to understand that, right? Someone needs to be there, but if someone isn't as far progressed in their functional needs, let's say they just need help not caring for themselves with those sort of basic activities, but just managing an independent household. So those are things like managing finances, cooking, cleaning, doing the laundry, managing their transportation, shopping, things like that. Well, you might not need someone around 24/7, you might just need a homemaker who comes in a few days a week or even just a couple hours a day who can cook and you know, bring in new groceries. That can be less challenging. There could still be financial costs associated there, but that's a difference. And then in addition to understanding those needs, we can do a lot in our homes to sort of fit them for the needs that are going to develop over time. So usually as people age and they develop and also potential mobility problems. So we can think about how is my dad, as in your example, getting in and out of the home? Do I need to install a ramp or are there stairs there? And if you know, if your dad is going to have trouble going up the stairs, maybe you see if you can just work it out on the bottom floor. Right? Is there a bathroom there? Can you get food there? And so I think that's important. There are other things that people don't really think about but are important. So as we age, we might get more wobbly when we walk in, maybe in the kitchen, all the food that your dad accesses is on a high shelf. And so he needs to like get on a chair, you know, so there are little things you can do, let's move it to a lower shelf, so just less likely to fall. How's the lighting, you know, are there throw rugs on the ground that slip when he steps on them? In the bathroom, can we put some grab bars, which are these bars you install literally in the wall so while he's taking a shower or doing whatever he's doing there, he's not going to fall, he'll h ave something to hold o nto or a chair in the bathtub or you know, around the toilet. Is there a raised toilet seat that lets him get on and off the commode more easily. Right? So there's, I think trying to address those functional needs, trying to fit the home to make it make sense.
Jason:Falls, is that the big concern that as a geriatrician, is that the one that you worry about the most in terms of somebody who's not quite as agile as they used to be?
Kumar:Yeah, falls are a big concern. I don't know if I would tell you it's the most, it's one, but it's very important and I think there's a role there with falls, not just sort of making the home more friendly from a fall perspective. So some of the things I've just talked about, getting rid of throw rugs, making sure the lighting is really good, making sure that maybe there's a commode what's called a bedside commode next to the bed, so you know your loved one doesn't have to go in the dark to the bathroom and back and forth because you know, a man with prostate issues might go to the bathroom three, four or five times a night. Each of those is an opportunity to fall if it's dark, if there are wires and cords that are running across the floor. So I think falls are an important issue, but I think there's a side there where you can work with someone's doctor to really impact that in a positive way. Many people are on a lot of medications and some of those medications can increase the risk of falls, so really going through that list to your doctor and saying, is this all unnecessary? Do I really need this medication or which among these meds might be making me feel a little wobbly or a little tired or any of those things that could result in falls. Then the last thing I think that's really important that you can work on with your doctor is can I get a mobility aid? A cane, a walker, things like that, that can really make a patient who's wobbly and at risk for falling a lot more stable as they walk. I think those mobility aids are often under used in older adults. In addition to the mobility aid, sometimes physical therapy and exercises can really increase strength in the legs, increase balance, and just lower the overall risk of falling.
Jason:Those are great tips. I want to shift gears a little bit to the cost of all of this. I don't doubt that, you know, staying at home is often cheaper than going into an assisted living facility, but who pays for that? They like, so if I, if you mentioned having somebody who come in to either help with the laundry or cook or clean or even more fundamental things like help me get dressed or bathe, is that covered under Medicare or private insurance or Medicare Advantage plans? Or is that really just out of pocket?
Kumar:It's often out of pocket. So Medicare will pay for what's called a home health aide who will come in a few hours a day, but in the context of what's called a"home care episode." So let's say someone was hospitalized and discharged and now they have home health for 60 days where there's a nurse coming in or a physical therapist. During those episodes, Medicare will pay for some limited, you know, supports like what we just mentioned, Medicare does not pay for 24/7 supports. And the reason is it could be$20 an hour to have a home health aide that's$480 a day, a day, and you can understand why these resources are really hard to come by and it's hard to afford this, which is why in many cases people leave their jobs to be with their loved one because it's cheaper to do that than to keep working and then have a$480 per day bill. In general, these sorts of supports are not routine recovery. Now Medicaid, that's different than Medicare-- so just for clarity, Medicare's the health insurance predominant for older adults, Medicaid is predominantly for adults but also for children of lower financial means that could be older, could be a pregnant woman and there tends to be more of these sort of benefits. But again it's still hard to come by
Jason:if you're low income and a senior and you qualify for both Medicaid and Medicare, there might be a little bit more flexible from a government funding perspective. Worth checking out. How do you know when it really is time to leave your home. Even if you've got, let's say you've got all these supports, how do you know when it's time? And I, and I guess I asked that question maybe from two perspectives, both from the perspective of the senior who's probably going to be holding out hope til the very, very end versus say an adult child who is seeing things in his maybe you know, see things slightly differently and might just be more worried, you know, that tend to be maybe a little bit more concerned about the parent and the parent's like, I'm fine, I'm fine. How do both of those perspectives, what are some of the signs that, okay, even with help, it's time to think about moving into an assisted living facility?
Kumar:I think when it's unsafe it is, it may be time. So that's when, even if someone has supports in the home, you're finding cases where people are just, they're just falling too often. And when they fall, it's hard to get picked up because let's say, you know, there's a patient that weighs 220 pounds who's 80 year old man and his son or daughter weighs 140 pounds and he falls, it's really hard to pick someone up, right? And oftentimes there, what happens is people call ambulance, they call 911 for some team to come in and you know, bring grandpa off the ground. And so oftentimes people might not have the resources at home to provide the care that's necessary. So I think safety is an issue. I think the other thing is there's a real thing called caregiver stress or caregiver burden, which is taking care of someone sometimes 24/7. It's really stressful because you know, a daughter or son will have their own lives. They'll have to pay their own bills, they have children, they may not be able to work because they're taking care of a loved one. And I think the reality is in many cases people, they just don't have the time or energy because especially with certain conditions, let's say dementia as an example, is dementia progresses to moderate levels or severe levels, you might have to watch someone 24/7, right? And so, you know, I have small children and, one of them's a two year old and I have to watch her a lot because she's going to do what two year olds do. Right. And she's going everywhere, jumping up on things, climbing things, but doesn't always know that she should or shouldn't be doing that. And you know, just like that I think is dementia progresses, they're at risk for a lot of things. Falls, wandering, going in and out of the house, going into the kitchen and turning off the stove, leaving the faucet on in the bathroom...Really unsafe situations. And so I think for many people it reaches a breaking point.
Jason:So I'm thinking of my uncle Fred who's 96 years old, mentally as fit as a fiddle, losing his eyesight, so he is more likely to trip on things. But he is of the generation where, you know, going into any kind of nursing home as you would call it, is the equivalent of, of going to jail. Like he, it is the last thing in the world he would want to do. We've taken them on tours of these beautiful places that look frankly much more like hotels these days than what I think the institutional warehousing that he might've been used to. And he's just not interested. He's living, he's living with his 90 year old brother and they're making do and he is just dead set in his ways there. I can't imagine a scenario where I could convince him that it would be time to look at going into any kind of assisted living facility. So with that, how do you talk to patients or how do you help adult children talk to their parents or in this case uncle Fred? What are the kinds of things that you can say when you really do feel convinced? Uh, is it, you know, an adult child, mom, dad or uncle Fred need to go in some place cause it's just not safe for them anymore. What resonates? What are the things that you've heard that can really get them to understand your concerns and really hear you that it may be time to seriously consider moving into a different place.
Kumar:It's not easy. Clearly I think your example shows that it's not, a 96 year old and a ninety year old living together, just sort of hacking it and maybe making it work but not the best situation. I think it comes back to first understanding why this person wants to stay at home and really understanding what their health goals are. So I'm going to make up health goals for your uncle, right? But if his health goal really is to be as functional and maybe live as long as possible, that may or may not be his goal, but if it is, you know, if you can convince him that a nursing home will actually help him get there because the supervision will actually prevent potential complications, he might, you know, that might be good, right? If his goal may be to, if he's very social and he's actually gonna meet more people within a nursing home than at home, that might help convince him. But this isn't an easy conversation for sure. And you know, I think to your point that some of them might look more like the hotels of today is rather than the jails of yesteryear, I think maybe it's baby steps here, right? And so maybe bringing him out to one of these, you know, hotel like facilities might shock him, might change his mind. The other thing is in this example, there's two people living together and maybe they've been living together for awhile. Maybe there's a congregate decision here. So maybe you know, your uncle is scared that they're going to get broken up, right? Either because only one will go to the nursing home or they'll go to different ones. And so maybe there's an opportunity for them to go to the same place, get rooms right next to each other and essentially maintain that relationship. Even though it's going to be in a different setting, but I think these are all specific conversations because it's not easy.