How to stay — when to leave: Seniors, and crucial decisions to make

The adult children are concerned about their mom in her house alone. She has cognitive impairment and the bills are not getting paid. They want her to leave, but no one can agree on where she should go, and she’s adamant that she’s not going anywhere. 

Variations on this theme occur every day. It’s a dilemma no one wants, but it’s becoming more and more common. Most seniors want to remain in their homes as they age — a term now often called aging in place. But as the consequences of aging become more apparent, without proper planning, it can become more difficult.

According to the National Institute of Aging, the best time to think about aging in place is before the person needs a lot of care. This is a conundrum, because most people don’t want to think about these things, and often don’t, until it’s too late and becomes a crisis.

After all, who thinks about staircases before they have a fall?  Who worries about kitchen appliances before they leave the stove on? Adult children are often reluctant to broach the subject. It’s difficult for everyone to accept that aging leads to changes no one wants.

While there are actually more choices today than ever before (serving an ever-growing senior population), not surprisingly, the best options go to those who can pay for them. There are beautiful facilities resembling country clubs, but most people can’t afford the price tag.

And the vast majority choose to stay at home for as long as they can. In fact, a survey by AARP of 2,826 American adults found that 75% of seniors prefer to remain at home. But of that group, only 15% had started to consider the necessary changes to their homes and the support they might need.

Healthline.com, a useful resource, suggests that people can successfully age in place with adequate healthcare, housekeeping services, company, transportation, safety, and social and physical activities. The specifics of each aspect are detailed on the site.

A senior care advisor might be an excellent resource to advise the senior and their families to help assess the needs and then navigate the process. They can simplify the process by helping to ask the right questions, find resources, and then plow through potentially complicated paperwork.

A senior advisor must be compassionate and understanding of the client’s wants, but also must assess if those wants are unreasonable. Should there be family disputes, a good senior advisor can mediate with all parties to find the best solution in this very imperfect world.

Specialized construction companies now make homes more accessible with ramps, widened doorways and reconfigured bathrooms, as needed. For low-income people, a grant known as the Section 504 Repair program is available in rural areas such as Shelter Island.  Their website is: rd.usda.gov/browse-state.

At some point household help will most likely be needed — at first to help with chores, but as the senior’s condition deteriorates, more and more hours will be required. Full-time, in-home care is expensive, with the numbers increasing as you go from companion care, to personal care, to medical care. 

Companion care may be someone coming in a few hours a day to do shopping, and helping with meal preparation and household tasks. A non-medical home health aid can assist with the activities of daily living (known as ADL’s) such as bathing, dressing, walking, toileting, and eating. Some people who perform this function have no credentials other than experience.

Others may be licensed practical nurses (LPN), which does not require a college degree but does require some nursing training. They are generally more expensive than those without the credential.

Care from a registered nurse may include wound dressing, intravenous therapy, administering medication, monitoring the general health of the patient, pain control, and other health support. Obviously, this is more expensive, but still allows the senior to be in familiar and comfortable surroundings. Whatever the credentials of the caregiver, it needs to be a good “fit” where the senior feels cared for.

So, what if the decision is made to leave the home? Unlike days of old, most older adults do not live near their children and grandchildren, so a decision to move closer can be a well-thought-out solution.

Obviously “mother-in-law” style living arrangements can be mutually gratifying, but those have become more uncommon. Seniors often choose to sell their house and move to a condo or apartment requiring less upkeep.

A recent Wall Street Journal article discusses things to consider when making a decision about one’s final home. Real estate economist Ken Johnson recommends that one should spend no more than 4% of retirement savings per year. He says to add in Social Security and other cash flow and that should cover the budget, including housing costs. And most importantly, be mindful of maintenance costs, especially for seniors who may not be handy themselves. Even with new homes, things go wrong. 

The decision to move to “senior housing” can be overwhelming and once again, getting ahead of a crisis is the key, because once the emergency occurs, options become limited. A senior living community for many people is the best way to age optimally and ensure quality health care. In addition, they may provide recreation facilities, housekeeping services, continuing educational opportunities, transportation assistance, and medical care. 

But there are various levels of housing and it can become confusing. Independent living focuses on the social needs of residents — dining hall meals and recreational opportunities. Assisted living communities support people with ADL needs.

According to Harvard Hebrew Senior Life, assisted living typically follows a rental model. There are three meals a day and one to two hours of assisted personal care. In independent care, most residents pay an entrance fee when they move in and additional monthly fees to cover maintenance, housekeeping, security, meals, and programming.

Communities that have both independent and assisted living allow for residents to move when it becomes necessary without looking for an entirely new arrangement.

Some facilities even have a memory unit and skilled nursing care, should that be needed. It’s actually one-stop shopping for end-of life care. Nursing care is a complex topic and a subject for another article.

Unfortunately, these facilities are expensive. Seniors often pay for them with the sale of their home or with accumulated wealth, should they have that luxury. 

According to a recent Forbes Magazine article, more than 15 million older adults are “economically insecure” (earning $27,180 or less per year for a single person in 2022). Clearly, this limits the options. The U.S. Department of Housing and Urban Development (HUD) offers affordable subsidized units for older adults in need.

Ted Gottlieb, a founder of the Senior Learning Institute in St. Louis, says that subsidized rents are usually based on 30% of your income. However, availability of these apartments is problematic, and there are often long waiting lists. He suggests speaking to a local HUD representative. And because of those long waiting lists, the preparation should be done before, and not when it is needed.  HUD’s website, hud.gov, supplies a lot of information along with the opportunity to talk to a housing counselor.

Often families and the senior themselves are so focused on the mechanics of the move that the psychological ramifications become secondary. According to the National Institutes of Health, “relocation stress” is a significant risk factor for anxiety and depression.

These mental health issues can add to the decline in overall well-being.  There is also a link to cognitive impairment when the senior is depressed or anxious.  A life transition, such as this kind of move, can cause great emotional turmoil. It is normal to grieve for one’s past life, and knowing that this is the last move leads to an acknowledgment of decline and mortality.

Counseling can be helpful. But should the symptoms persist, there might be a more complicated depression, particularly if the move is not perceived as satisfactory. Seniors tend to be under-medicated for depression, so a full psychiatric assessment should be arranged if the symptoms persist and medication should be prescribed if indicated.

But sometimes a move leads to new beginnings — new friends, new activities, and the security that one is being cared for and safe. The last phase of a senior’s life can be a joyous affirmation of a life well-lived, with the final chapter adding the exclamation mark.

Nancy Green is a retired social worker and a member of the Shelter Island Health and Wellness Alliance. How to stay — when to leave: Seniors, and crucial decisions to make