Making the decision to help an aging adult move into assisted living can be difficult. People give so much of their time and energy to caring for a loved one with dementia, Alzheimer's disease or many other age related issues, that when the time comes for someone else to care for your loved one, it can be painful and emotional.
Hollis D. Day, MD, Chief of Geriatrics at Boston Medical Center, discusses how to tell when it may be time to consider moving a loved one into assisted living if their health needs become too much to handle at home.
Hollis D. Day, MD
Hollis Day, MD, MS has been Chief of Geriatrics at Boston Medical Center since December 2015. Dr. Day joined BMC/BUSM from the University of Pittsburgh Medical Center (UPMC) where she specialized in geriatrics, and the University of Pittsburgh School of Medicine (UPSM) where she was advisory dean, associate professor of medicine and the medical director of the Advanced Clinical Education Center. Her clinical focus areas include dementia and delirium in geriatric patients, cognitive assessment in the primary care geriatric setting, and helping patients. She is a member of the American Geriatrics Society, the Society of General Internal Medicine, and the American College of Physicians, among other professional organizations. She holds a faculty appointment at Boston University School of Medicine (BUSM). She earned a bachelor’s degree in English from Johns Hopkins University, a master’s degree in anatomy from the University of Maryland, and her medical degree from the Medical College of Virginia. She completed her residency in internal medicine at the University of Pittsburgh Medical Center and fellowships in general internal medicine and geriatrics at the Hospital of the University of Pennsylvania.
Learn more about Hollis Day, MD
Melanie Cole (Host): Making the decision to help an aging adult move into assisted living can be difficult. People give so much of their time and energy to caring for their loved one with dementia or Alzheimer’s Disease or other age-related issues that when the time comes for someone else to care for your loved one; it can be very painful and emotional. My guest today is Dr. Hollis Day, she’s the chief of geriatrics at Boston Medical Center. Dr. Day let’s just start with red flags and the first signs as we all are looking for those signs when we have those aging relatives. What do you want us to be looking for that would signal that that discussion is coming down the line?
Hollis D Day, MD (Guest): Well, I think one of the very first things to think about is how is that person functioning in their current environment. When we think about this, we really want to try to keep people at home as much as possible, obviously, but there may come a time when that’s not really possible. So, we look to see how well are they doing things such as being able to do – take their own medications for example or how are they doing with cleaning, shopping, cooking, all those kinds of things. Often those things can be helped at home and that’s great, but then there comes a time when a person may not be able to do basic things such as maybe getting in and out of bed or getting in and out of a chair or getting around as easily. Maybe they are not able to bathe as easily. And certainly, things like being able to take their own medications or if they are really having trouble with cooking; that can be a real problem too because nutrition is a big issue. So, we start to look for things and if people aren’t able to really support themselves in their own environment, or their family isn’t able to support them in that environment, then we start to think about assisted living.
Melanie: Once we notice some of these things, and the medications are certainly an important factor as we can’t always keep track of every medication they take and every time that they are supposed to take it. But it can be scary for loved ones thinking that your elderly relatives are taking medications on their own and trying to keep track of them all. Who do we start the discussion with? Do we start the discussion with our loved one that we are considering assisted living, or do we talk to our siblings first or a spouse? Who do we start that discussion with?
Dr. Day: Well, I think everybody ultimately really needs to be involved. But often it can be very helpful for families to talk with a physician first so that they can be the ones to broach the subject. It can be very emotionally charged for families to start to raise these issues with a loved one because all of us want to really maintain our independence as much as possible. And then there are often family dynamics that come into this as well. So, I think it’s often better to have a physician raise this issue asking about how well someone is doing, their functional status and really corroborating that information with the family members. That way, it takes the pressure off of the family and the conversation really engages the healthcare professionals as well.
Melanie: What a great bit of advice and such an important point. Now, comes the time the physician can broach it, and everybody is getting involved, how do you start that discussion with your loved one and what if they are adamant and they won’t go and they are just absolutely not interested in hearing about it?
Dr. Day: Yeah, that can be a really tough conversation for everybody involved. And I think that that’s important to understand that this isn’t a single conversation. This is often a conversation that has to happen over time and in multiple venues both with family members and with healthcare professionals. So, one of the most important things is to always consider the older adult at the center of this.
What is it that is preventing them potentially from getting more care? Many people do not want to leave their homes. They know their home. They are comfortable there. They can make do there and don’t always recognize that they are needing more help and support in that setting. Sometimes, this comes in the context of someone have some cognitive impairment and therefore don’t have the best judgment and are unable to really explain to themselves that things are not going all that well. And that’s when a family member often has to step in and sometimes even make decisions for the older adult.
But if an older adult is able to make decisions for themselves, it is really important for them to explain to the family and to the healthcare professional what is that they think they can and cannot do. And how do they react when they are presented with examples of where things have not gone that well. Often if people are losing their ability to judge their ability to care for themselves or their thought process around that, that’s also a sign of cognitive impairment and requires some different measures.
Now if someone is really adamant about not going, that can be very, very tricky. If a patient has cognitive impairment, that may require that the family actually ultimately gets a durable power of attorney. On the other hand, if a patient has that capacity to make that decision, unfortunately, there is no way to force them into any other kind of living situation that they don’t want to be in.
Melanie: How do we go about looking for a place Dr. Day? What are we looking for?
Dr. Day: Well, first of all, it’s important to understand, that assisted living is not a medical facility. There may be a nurse on the premises, but there is not a doctor on the premises. And often, these are semi- independent types of facilities that just provide more support around things such as cleaning, shopping, providing meals, perhaps with bathing etc. Now every assisted living is different. And when families are looking or a patient is looking at a facility; it’s really important to see what the actual belief system is that the facility has. And what I mean by that is do they believe in helping the older adults to preserve their independence and what do they do around that? What kinds of housing are there? So, for example, is it a small apartment, is it a suite, is it a shared room which is sometimes the case actually for assisted living.
It is also important to note that these are not regulated in the same capacity that nursing homes are. So, there’s a lot of variation in assisted living. One of the big things to ask are what are the activities that your assisted living provides or what kind of services do they provide. It’s also equally important in this case, to understand what are the finances of it. Most assisted living is private pay. They are required to take Medicaid at some point, but they only are required to have a certain number of Medicaid beds and unfortunately, if someone gets to the point where their finances require them just to have Medicaid, if they haven’t given a heads up to the facility; the facility depending on the contract, can actually ask the patient to leave. So, it’s really important for patients and families to understand the finances, what the activity levels are and what their sort of personal beliefs are around keeping residents independent as possible before they enter a healthcare system.
Melanie: And you mentioned advanced directives and living wills, these things come into play Dr. Day especially if somebody is suffering from dementia or other age-related memory issues. So, do we include that in this discussion as far as when they do go into an assisted living, that everybody is on the same page and they all understand what any kind of treatment would entail?
Dr. Day: So, I think it’s very important to understand that advanced directives and a healthcare proxy are not exactly the same thing. A healthcare proxy is a legal document that gives someone else, usually a family member, but whoever the patient may have initially designated; the ability to make healthcare decisions for a patient or an older adult if they are unable to do so themselves. And they may be unable to do this due to dementia or they may be unable to do this because of other healthcare needs. So, it’s important to understand that that under the circumstances is usually the type of document and decision making we are talking about.
Advance directives just as an aside is more about what people would want in the setting of for example a terminal illness or a critical illness where they would not be able to speak for themselves. It absolutely - healthcare proxies come into play when someone has been deemed to have dementia. If they cannot make a decision for themselves, then they absolutely need to have someone else be able to make that decision for them, but it actually has to be legally documented that this is a healthcare proxy who really is able to make that decision for them. If that’s the case; then the healthcare proxy can decide that someone could go potentially to an assisted living. It’s also important to understand that different assisted livings may or may not have a memory care unit which is specific for patients with dementia. Often patients with rather advanced dementia. It also needs to be clear to a family that not all memory care units are created equal. Some people can say that they have a memory care unit, but do not necessarily have clear expertise in dealing with elders that have dementia. So, it’s really, really important that a family explores that. What the expertise is that’s available, what the layout of the environment is like, and how they manage behaviors for people who have dementia before they would put someone in that type of assisted living.
Melanie: As we wrap up, Dr. Day, I’d like you to give your best advice obviously for when do we consider assisted living for our loved ones, but for caregiver advice because it can be overwhelming and emotional and guilt feeling. It can create all of these feelings for the caregiver as well. So, what would you like them to know about caring for themselves and these feelings of guilt even considering our topic today?
Dr. Day: So, I think these are great points and it is really emotional for caregivers to have to put a loved one into a facility. Many people say I should be able to take care of my parent or my spouse at home, but it is equally important to understand that the caregiver’s health is incredibly important and that if the caregiver’s health is impacted, then the person themselves, the patient or the older adult also would be deeply impacted if they didn’t have the support of the caregiver any longer. I think one of the important things to understand is that all of these feelings about placing someone in an assisted living or ultimately perhaps a long-term care facility, are very normal. And I think sometimes people need help processing that with either a chaplain or a spiritual guide or perhaps some type of therapist in addition to other family members or friends who have gone through the same experience. It’s also really helpful to get advice on different facilities, either looking at the compare.gov some have it for long-term care facilities, not as much for assisted living but can talk to a social worker perhaps or again, to friends and family and find out what their experience has been with a particular facility.
Lastly, it’s really important to have a set of questions such as the ones that we have talked about to ask a facility or each facility that you visit. It is very important to visit a facility to know that you are comfortable putting a loved one there and then in the end, it’s also important to understand that if you need to change, you can change facilities but I think it’s very important for caregivers to realize that this can be a very stressful time for everyone involved and that the more support and help that you have; it’s very important for you to put that into play.
Melanie: Thank you so much. It’s such important information especially for people of a certain age who may be caring for their own young children and for their aging parents. Thank you again, for joining us Dr. Day. This is Boston Med Talks with Boston Medical Center. For more information you can go to www.bmc.org, that’s www.bmc.org. This is Melanie Cole. Thanks so much for listening.