Aging in Place – Lessons Learned from an Occupational Therapist

Intended Audience

Background

According to the CDC, the average life expectancy in the United States is 78 years. Interestingly, the average life expectancy of other countries such in Canada and Europe surpasses that of the US. Nonetheless, older adults are not only living longer but living longer in their homes. Therefore, aging in place will be an important topic to address, especially with COVID-19 leading to increased older adult social isolation and occupational deprivation.

Stages of aging
The stages of aging

Existing Resources

The AOTA has a few, but not many resources for PDF’s on their website on the topic of aging in place. While it is likely that OT practitioners find these resources, it is very unlikely that clients and patients lookup in this information themselves. Many older adults do not even know what occupational therapists do, right? Therefore, it is up to OT practitioners to disseminate this information to patients and their family members. Oftentimes, it is too late – and an older adult has either had a fall, a stroke, or other medical complications that lead to their hospitalization and a nightmare of a discharge planning for the team and family members involved. All of this can be avoidable. We will discuss this later on in the post.

Lack of OT Aging in Place Content

In fact, a google search for “aging in place” returned about 386,000,000 results on Google, but is this a lot? Also, why is occupational therapy not one of the top search results with the broad search term of “aging in place”. Only when I type in “aging in place occupational therapy” does 11,400,000 results come up on Google. 11400000/386000000 = only about 3% of the search results! That’s it. Although this is only a broad example and not focused on the research in the literature, this is what the general public will do – a Google search. I am not saying that other sources are not reliable for information, but they do not provide the occupational therapist’s perspective. OTs are very much appropriate to address aging in place with older adults and their family members.

Occupational therapists need to step up our game and not only talk about aging in place, but getting online content from the OT perspective to patients and their family members.

The Trend

A good way to gauge interest, trend, and popularity of a topic is to look at Google Trends. I did a google trend search for “aging in place” expecting a gradual increase in the trend leading up to 2020. The results were surprising.

Google Trend for Aging in Place
Google Trends results for “aging in place”

To my surprise, interest overtime for “aging in place” has been quite stable. There may be many reasons for this – I do not know why.

Aging is Not Popular

Overall, the topic of aging in society is likely not popular. For Americans, aging is often not talked about. How often do you hear about the topic of older adults aging in place at home, hanging out at an Assisted Living Facility, or socializing at a nursing home? Popular shows that do show these environments often portray the stereotypical older adult in a wheelchair sleeping or playing Bingo and not appearing to be having any fun. The advertisements that do come to mind related to aging are medication advertisements to treat a variety of medical disorders. What does come in the top searches related to “aging” according to Google is:

  1. anti-aging
  2. aging cream
  3. skin aging
  4. anti-aging cream
Aging cream
A woman puts on anti-aging cream.

Society puts in a lot of effort into hiding the fact that we are aging physically. And it appears to be a good money maker too. No matter how hard we may try to hide aging physically on the outside, physiologically…our physical and mental ability is declining.

Discharge Planning Nightmare

Earlier in my career, I worked as an EMT and experienced the head and tail ends of a patient’s medical journey through the healthcare system. I responded to calls of older adults who have fallen or injured themselves in their homes, outside their homes, or in the community. On the opposite end, I have discharged and assisted in the transport of older adults from various medical facilities back to their homes. Many of these calls were very sketchy.

If this was my grandfather or grandmother, I would not want to leave them in this situation in this environment.

Thankfully, these calls were rare and our crew took the necessary precautions and either notified family members, social workers, or the appropriate avenues of reporting. As healthcare workers we can see why we do this, but for the general public, why is this important? These older adults could injure themselves and end up right back in the hospital. We call this readmission. Readmissions lead to increased healthcare costs and pose a high burden on the overall healthcare system – when it could be prevented…right?

cluttered home
A cluttered home with unsafe living conditions.

Healthcare System is Trying it’s Best

So who is responsible? In general, we all play a role in preventing and managing aging in place. A good analogy is Coronavirus and COVID-19. The general public is starting to understand their role in this pandemic. The general public should follow recommendations from experts to shelter in place, social distance, and wear masks. This helps to prevent and contain the spread of COVID-19. Meanwhile, front line workers such as nurses, doctors, and therapists work directly with people diagnosed with COVID-19. If not for the general public’s efforts, the hospital and healthcare system would be overwhelmed and be unable to care for everyone diagnosed with COVID-19. This is not just a theory or fake news. China, Italy, and New York are examples of what could happen at its worse. But I digress. We all have a role to play in managing aging in place just like with COVID-19.

Older adult with financial burden

Nurses, Doctors, Dieticians, Therapists, Assistants, Dentists – you name it, if we are in the healthcare field, we are all trying our best and advocating for healthy habits of eating right, exercise, taking medications, getting enough sleep, managing stress and your mental health, etc… However, everyone’s background and case are different. Some people do not believe in Western medicine. Some don’t see the doctor. Some do not have health insurance. Some may have health insurance but are unable to afford their medication. This post is not an answer to the pros and cons of the current American healthcare system. In fact, the topic of aging in the place itself is very broad.

Consequences of Not Addressing Aging in Place

However, I participate in discharge planning every day that I work and my team encounters the same problems way more than we should. Oftentimes, these issues go unnoticed until our healthcare team unravels the complicated medical and socio-economic issues. While I am not saying this is not our responsibility, and it is, many of these issues could be lessened to lower the burden of (1) stress, (2) finances, and (3) time, while maximizing the independence of older adults that they deserve.

The worse case scenarios result in older adults dying, living a really short life span after discharge, or getting readmitted to the hospital.

 

Many of these problems can be prevented – with early planning and execution of these plans. This post is not influenced to sell a product, get you to buy life insurance, or do anything like that. Sure, my job as an occupational therapist can be demanding physically when I help older adults in rehab get better. This I can handle.

The biggest stress and mental toll on me as an occupational therapist is the discharge planning and the discharge plans that fall apart.

Example of Discharge Planning Nightmares

  • Patient is safe to go home and is independent with self care (ADLs), but requires some help with grocery shopping, medications, cleaning, etc., but there is no family member or friend to provide this assistance. They have limited resources to hire help. Patient ends up going to a skilled nursing facility and declines in function.
  • Patient unexpectantly has a stroke and now requires 24/7 supervision. Family members have to work or live remotely and are unable to provide even any supervision, let alone 24/7. Patient ends up going to a skilled nursing facility and loses the independence they would have had with living at home.
  • Patient lived alone and had no family or friends. They do well physically with PT and can walk with low risk of falling, but have cognitive deficits of safety awareness, memory, insight, planning, and problem-solving. Team recommends intermittent supervision with a home discharge, but no one is available to provide such supervision. Patient has no financial resources. Patient may discharge home with home health and supportive services, but these services eventually get discontinued. Patient fails to thrive and their health declines.
  • Patient has lost the mental capacity to make healthcare decisions. There is no designated decision-maker, power of attorney, etc. Family issues arise as family members argue about making healthcare decisions collectively. Ethical issues appear as some family members have financial motives for the patient’s outcome, e.g. patient’s financial estate.
  • Patient is an older adult, e.g. in their 80’s and are full code. Health care team resuscitates the patient, but they now have a poor quality of life. Family members are faced with providing 24/7 care for the older adult, placing them at a facility, or the older adult’s health rapidly deteriorates – meanwhile they may face depression, pain, and suffering.
Senior couple disagreement
A senior couple in disagreement about future plans.

While I do not work directly with the end of life and hospice care, my wife is a nurse and I also hear stories about the difficult discharge plans associated with patients who are in the ICU. Family members are faced with very stressful and difficult decisions that could literally turn their world upside down. Why can we not prevent these things from happening? The topics I will cover are from the serious to the less in hopes of covering all the bases from my experience working as an occupational therapist in a rehab hospital. Let’s start with the most serious.

Recommendations

Why can we not prevent these things from happening? The topics I will cover are from the serious to the less in hopes of covering all the bases from my experience working as an occupational therapist in a rehab hospital. Let’s start with the most serious.

DNR and POLST Forms

If you are approaching older age or your family member is, discuss and document your wishes. DNR stands for “do not resuscitate”. POLST stands for Physician Orders for Life-Sustaining Treatment (POLST). What do you want to happen to you in case of a medical emergency? Do you want CPR aka resuscitation? If you are unable to eat, would you want to sustain your life by feeding tube? The form is pretty self-explanatory. Adult adults: familiarize yourself with the POLST and start thinking about what you would want to be done to you in case of an emergency. Family members: start the conversation with your mom, your dad, your grandma – earlier rather than too late.

POLST Form
Example of a POLST form highlighting the important key areas in case of a medical emergency.

Many ethical issues happen because this issue is not addressed. For example, older adults may wish to not be resuscitated, but family members want everything in their power to prevent death. No POLST was filled out. Patient gets resuscitated. Meanwhile, the patient’s wishes are not followed because they were not addressed before, they suffer in pain or depression, and family members carry the burden of caring for the older adult for an extended amount of time. Many states do not allow for euthanasia. What if one family member does not want euthanasia while the others do? See where I am getting at here?

Power of Attorney – Medical & Financial

According to Investopedia,

  • Power of attorney allows one person to give legal authority to another person to act on his or her behalf.
  • A financial power of attorney authorizes an individual to make financial decisions, while a medical power of attorney allows for someone to make medical decisions.
  • Financial and medical powers of attorney should be separate documents and can be designated to the same person or to two different individuals.

Designate the power attorney, both medical and financial. Oftentimes, this will be your spouse. Otherwise, this responsibility often falls on the children. But what happens if there are multiple children? How can they decide when they all feel like they should be involved?Do not let this responsibility fall on your children during dire times if and when you become hospitalized. Sometimes, it may be a good idea for a third party to be involved if your children would likely have a quarrel. There may also be financial issues that arise if you have an estate to leave behind.

Your Wishes – Hiring a Professional

Disclaimer: I am not a lawyer or specialized in this area of managing estates, living wills, power of attorney, POLST, etc. Consult with a professional who deals with such issues and take care of this early on rather than later. If you are nearing retirement, it may be a good time to address this now. We are in a Pandemic. You probably have no excuse not to do this rather than re-binge-watching a Netflix show. This not only plans for your future, but can also give you peace of mind knowing that your wishes will be respected regarding your health, your personal assets are protected and will be rightfully distributed, and your family members are not left with the stress in managing your health and finances if and when you become incapacitated.

Finances

Senior Care Costs
Costs of Daily, Weekly & Yearly Care Cost. Source: https://www.payingforseniorcare.com/costs

Aging in place and end of life care are not cheap. Older adults and family members are often caught off guard when they see the costs associated with care for higher functioning older adults. This cost is likely expected to increase along with inflation. Of course, everyone’s financial situation is different. Some are barely making ends meet, others may be well off – depending at which stage of life you are in. If you are young – start planning and saving now. Set aside some money and consider investing it as opposed to putting it in a saving account subject to low-interest rate and it eroding away due to inflation. Start investing in a retirement account such as 401k or IRA as early as possible.

Long-Term Care Insurance

Depending on your age, you should consider long-term care insurance. Medicare and Medicaid do not cover everything. For example, Medicare does not cover the cost of a shower chair or bench to place in your shower. Family members often have to pay for this expense themselves. Long-term care insurance can help to cover the costs mentioned before and can help you to age in place in your home.

Long-term care insurance is an insurance product, sold in the United States, United Kingdom and Canada that helps pay for the costs associated with long-term care. Long-term care insurance covers care generally not covered by health insurance, Medicare, or Medicaid.

When should you purchase long-term care insurance? Purchasing long-term care insurance too early may not be a good idea as it can be expensive and even increase over-time, leading to expended funds if you do not utilize the benefits because you are healthy. You may be better off investing this money instead. Dave Ramsey (not affiliated with OTDUDE.com) has an excellent article on long-term care insurance.

Dave suggests waiting until age 60 to buy long-term care insurance because the likelihood of you filing a claim before that age is slim. Statistically, 89% of LTC claims are filed for people over age 70.6.

On the other hand, waiting too long to get long-term care insurance – when you have multiple health issues, may result in higher premiums or even denial. Timing is everything, and it may never be too late to look into long-term care insurance.

Caregivers

Family Support

Do you live alone? This is not necessarily a bad thing. However, do you live far from your children or family members? Do your children live in another state? Are they estranged? Although life is dynamic and people may be moving, changing jobs, etc. Talk about what you want to happen. Would you be fine with moving in with your children and vice-versa temporarily or permanently? Do not leave it up to the social workers and case managers to address this when you become incapacitated. More than likely, your children will be holding jobs, have their own family and personal responsibilities, etc. In my experience, many older adults do not want to burden their children with their care. You should discuss this with your children so that you are on the same page or to get on the same page.

What if you have no family members or relatives?

Neighbors

Believe it or not, there are often discharge plans where neighbors are the ones who may check-in on older adults, help them with groceries, take them to appointments, etc. Therefore, where you live makes a big difference in your future and your care.

In writing this article, I currently have an older adult patient who has been having their neighbor assist with groceries, driving, etc. However, they are expected to require additional assistance (showers, toileting, cooking) upon discharge. We do not expect neighbors to be available to provide this level of assistance for the patient. You can imagine how difficult this discharge may be.

IHSS

IHSS stands for in-home supportive services.

You may qualify if you:

  • Are 65 years of age, disabled or blind.
  • Have a functional impairment and are at risk for out of home care placement.
  • Have a need for IHSS services in order to remain safely at home.
  • Physically reside in the United States.
  • Have a Medi-Cal eligibility determination.

“An In-Home Supportive Services (IHSSprovider is someone who gets paid to provide services to a person who receives in-home supportive services under the IHSS Program.” In fact, a family may qualify to become your IHSS provider and get paid to do so. The money earned is not a lot relatively speaking, but this allows a family member to provide caregiving with some financial assistance.

Where You Live Matters

The more rural, the fewer the services. It’s that simple. Home health, therapists, doctors, nurses – everything involved in healthcare available to you will be more limited the more rural place you live. Bigger cities have better services. Therefore, if you live in a rural area, you can expect to face these barriers when you require additional resources after a hospitalization. It is an unfortunate reality. The worst-case scenario is that you will not be able to discharge back your home safely. So if you do not wish to go to a nursing home, but age in place, consider moving to a more populated location that has more services to allow you to age in place.

Your Neighbors (Again)

We discussed how neighbors can be a valuable resource for aging in place. However, if you live in a really rural location where your nearest neighbor may be miles away, your discharge plan could result in you not going back home safely and again – having to go to a facility such as a nursing home.

Home Environment

The multi-level home

If you can live in a home with no stairs, then do it. Or if you have stairs, we recommend at least a place that has communal elevators (that will be maintained by the facility and not your own elevator which is expensive to maintain). One of my regrets currently is purchasing a home that (1) has stairs and (2) has no shower downstairs. Ask a physical therapist, and they will likely tell you the same thing. Too many times do we have older adults who have multi-level homes and are unable to sleep in their bedroom, do their laundry, or have a wet shower because they are all upstairs. Stairs also pose high fall risks for older adults.

Ok, what about stair chairs and lifts inside the home? In my experience, the stair chairs that are installed in homes to go upstairs are non-operational, become dangerous to use, or pose a danger in the event of a blackout. I live in Sonoma County in California and the recent wildfire has resulted in the power utility company shutting down the power to prevent the spread of wildfires. How will you use your stair chair or elevator in such an event? The more simple and less dependent you are on technology and external factors that are outside of your control the better!

Home Modifications

We mentioned stairs and multi-level homes first because they are basically fixed and not easily changed. This should be addressed first. If you are buying your first home, try to buy a single-story, if not the very least one with a shower downstairs.

Home modifications come secondary and can even be installed in a short moment’s notice – if you have the financial and physical help to do it. Occupational therapists are trained to evaluate your home and make recommendations for modifications so that you can safely age in place. Some modifications include (but are not limited to):

  • Installation of grab bars in the bathroom and entryways.
  • Removal of clutter that pose hazards, throw rugs, etc.
  • Improving lighting, reducing glare, etc.
  • Installation of environmental controls to prevent burns in the shower.
  • Recommending assistive technology such as water sprinklers, automatic lights, etc.

Talk to your occupational therapist about home modifications so that you can safely age in place. This may be an ongoing process as you age and require additional assistance. Technology is constantly advancing to aide with aging in place and decreasing in price.

Driving

Many Americans, including women, associate driving with their independence and freedom. Older adults may face suspension of their license following a hospitalization or a permanent loss of driving.

As an occupational therapist, I am faced with the challenge of addressing the loss of driving with many older adults. Occupational therapists have an ethical responsibility to ensure the safety of the public due to car accidents potentially leading to loss of life and property. Occupational therapists may specialize in driving as a Certified Driver Rehabilitation Specialist (CDRS) to assess your off-road and on-road ability to drive. You can find a CDRS specialist from the AOTA database.

There are many alternatives to driving and the activities involved with driving. There are non-emergent medical transport services, basically an Uber for medical needs such as driving you to your appointments. Meals-on-wheels can help to deliver food. There’s public transportation. Many resources exist that your occupational therapist and social/case manager can provide you with to allow you to age in place if your license gets suspended or revoked.

What to Be Cautious of

Life Alert and Similar Systems

While these systems are great themselves, the main barrier to their use is cost. Many older adults lack the finances to be able to afford such systems.

The Life Alert In-Home system with Help Button cost is $69.95 per month with a one-time fee of $96.00, while the Life Alert system with Mobile and Help Button cost is $89.85 per month with a one-time fee of $198.00.

Better alternatives exist and more affordable at about $20/month. Be sure to read the fine print as some require signing a contract for a certain amount of years.

However, if you can afford to pay the subscription cost, Lifealert / emergency call systems can very well save your life.

Apple Watch

The Apple Watch is a good device overall, but it may not be the right fit for some people. It comes with a heart rate detection and fall detection, but its biggest weakness is its battery life. Older adults will likely not remember to charge the device every other day. A dead Apple Watch is a useless Apple Watch. Unless you opt for the cellular model, the regular model requires being in close proximity to an Apple iPhone – another limitation, having to buy into the expensive Apple hardware ecosystem. The screen is also very small and hard to read for individuals with low vision and difficulty with fine motor skills. You are better off getting a more dedicated device for the job.

Independence Checklist

The following is a checklist of common activities and occupations to consider for an older adult to be independent. Individuals can fall on a spectrum from most dependent (needing significant caregiver assistance) to most independent (can live alone, no caregivers needed). Not all older adults participate in everything in the checklist, this is individually based.

ADLs

Activities of daily living. Considered the most basic but essential.

Feeding and Eating

Toileting

Grooming and hygiene

Dressing

Showering

IADLs

Instrumental activities of daily living.

Communication Tool Use

Meal Preparation

Emergencies and Safety Management

Medication Management

Cleaning

Laundry

Shopping

Financial Management

Driving & Community mobility

Pet Care

Assessments Tools

Allen Cognitive Level Screen

0 – Coma: A zero indicates that you are unable to respond and are comatose.

1 – Awareness: A score ranging from 1.0 to 1.8 indicates that cognition and awareness is extremely impaired. Total care 24 hours a day is necessary.

2 – Large Body Movements: A score between 2.0 and 2.8 means that some mobility is present, but 24-hour care is needed to prevent wandering and to assist with all activities of daily living, such as bathing, eating, and hygiene.

3 – Manual Actions: Scores of between 3.0 and 3.8 reflect the need for supervision and assistance with activities of daily living. Providing cues, such as handing a toothbrush to you, will often trigger the result of brushing teeth.

4 – Familiar Activity: Routines are very beneficial if you score between a 4.0 and 4.8. Safety issues and problem-solving are often a challenge; however, at the higher ranges in level 4, you may be able to live alone with a plan in place of what to do (such as calling a loved one) if an unexpected situation develops during the day.

5 – Learning New Activity: A score between 5.0 and 5.8 indicates that although there may be some mild cognitive impairment, you are often capable of learning new things and functioning quite well. If you are at the lower range of this level, you may benefit from weekly checks from a loved one or from other community support services. Those who score in the upper range are likely to function very independently and be able to perform a job well.

6 – Planning New Activity: A score of 6.0 is the highest score of Allen’s cognitive levels and reflects intact cognition. Specifically, your executive functioning ability allows you to make decisions using good judgment and complex thought processes to plan ahead for the future.


Sources:

https://www.verywellhealth.com/what-is-the-allen-cognitive-level-screen-4129962

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