Dr. Sandra Timmermann

One of the hardest decisions for adult children of aging parents to make is what to do when it becomes obvious that Mom or Dad are having difficulty living at home without assistance. And all too often, any suggestions about getting a home health aid to come into the home or about moving into assisted living or other supportive environments are met with resistance. And parents often don’t reveal their financial status to their children.

It’s understandable. Looking at things from our parents’ point of view, they are adults who have lived long lives with independence and dignity. Now their children are acting like their parents, and they feel vulnerable and are experiencing a loss of control over their lives. However, from the children’s point of view, their parents appear to be at risk. They can see problems that are not going away and could get worse. There are many scenarios that most of us our familiar with. Mom is becoming more forgetful and leaves food in the oven without realizing it. Dad is losing his vision and has fallen a few times. Dad died and Mom is now living alone and lonely. Ultimately it is our parents’ decision about what to do as they age but in so many cases a crisis occurs and the children end up being responsible for making decisions for them. That’s when we wish that we had had “the conversation” before things took a turn for the worse. We also wish that they had purchased long-term care protection as choices are limited if money is an issue.

Care setting: How to choose

If we sense that its time for a discussion about whether to move or not, or in the worst case, if we realize that immediate action is needed, what are the options? Here are a few pointers to help you or your clients as they weigh the pros and cons of each choice.

Most older people want to “age in place” in their own homes. As more and more public and private community services become available, this choice becomes more viable when a parent needs care. It is possible to plan ahead before care needs arise by retrofitting the house (building a bedroom and bath downstairs, for example) and exploring outside resources in advance of emergencies. Problems arise when the home is not architecturally suitable, the property needs maintenance, there is limited transportation and family members live far away.

• Pros: Familiar surroundings, already-established networks in the community, emotional ties.
• Cons: Unsuitable housing/neighborhood, potential social isolation, all services need to be brought in, home care costs can be high, limited supervision.

These communities are appropriate for people over age 55 who can live independently and are in generally good health. They often offer a range of housing types, and most have clubhouses. They appeal to those who are looking to downsize, who want less maintenance and who seek opportunities for social engagement with others in their age category. While home health and other services can be arranged, residents are living on their own just as they did in their original dwelling. It works for those who are independent and want a simpler life, but a move to a 55+ community would not be the best choice for someone needing care and assistance.

• Pros: More appropriate, age-friendly housing, opportunity for social connections, good for those who are independent.
• Cons: No services, health care or meals onsite.

Assisted living is a viable option for those who need some help with activities of daily living or assistance with personal care (for example help getting dressed, bathing or taking medications), but are still able to function fairly well on their own. These residences generally offer apartment-style living with meals, housekeeping, transportation and activities. Many have separate memory care wings for people with dementia. Many assisted living facilities permit residents to hire approved private-pay aides (at the residents’ expense) to provide higher levels of care and continue to remain in their apartments. There are also smaller single family dwellings that provide “board and care” that offer fewer services but a more home-like environment.

• Pros: Supportive environment; personal care assistance included, some home-like qualities.
• Cons: Monthly charges are high, especially for extra hours of assistance; no skilled nursing; If care needs increase, may be required to move out.

These facilities are designed for those who are in the poorest health and unable to care for themselves. Residents receive assistance with activities of daily living and skilled nursing care is provided as needed, including monitoring and interventions. Doctors are on call or on staff and other professionals such as physical therapists and speech therapists provide services. Nursing homes often have special units for those with advanced dementia. When health and function deteriorate and remaining at home or in an assisted living facility is not viable, a nursing home is likely to be the last option.

• Pros: 24-hour care is provided for those who need it the most; families know their loved ones are in a safe environment.
• Cons: Institutionalized setting; costs are high; quality varies from facility to facility; difficult decision for families.

This alternative was not uncommon 50 years ago and may work for some families now. Knowing that mom or dad will receive the personal care, food and love they need is one of the pluses of this arrangement. Saving on the cost of care is another factor when compared to paying expensive monthly charges for assisted living or a nursing home. Many new homes are now being built with separate suite or apartment and universal design elements such as accessible doors, entryways and bathrooms. There are some potential problems that can arise, however. Much depends on the relationship between an adult child and his/her spouse and the parent as well as the suitability of housing.

• Pros: 24-hour care is provided for those who need it the most; families know their loved ones are in a safe environment.
• Cons: Institutionalized setting; costs are high; quality varies from facility to facility; difficult decision for families.

These communities are designed for people who plan ahead and have some level of wealth. If parents wait until their health or cognition have deteriorated, it’s too late to make this decision. A CCRC’s selling point is a “continuum of care” within the same complex. Residents must be able to live independently, pass a physical and cognitive screen and have adequate finances before they can buy into a CCRC. They start off by moving into independent living homes or apartments with amenities such as social, cultural and recreational activities. Meals are usually included and/or available on site. If their health declines, they can move to assisted living or, if needed, the nursing home. Usually a substantial upfront payment is requited and there are set monthly charges.

• Pros: Provides some certainty about basic long-term care services; environment is pleasant with amenities and social connections; can provide peace of mind for families.
• Cons: Significant amount of money lost if resident decides to move out; finances or management of CCRC could deteriorate; still may need supplemental monies to hire outside help in order to remain in independent living.

Making the difficult choice

These life decisions are difficult to make, and even more so if adult children find themselves making them on behalf of their parents and against their will. There are professionals in every community who can assist families make hard choices, but how much better it would be if parents and children talked about these issues well in advance of need. Discussions of finances go hand in hand with care planning because choices about future living arrangements are dependent on how much money is available to spend. Knowing that a parent is insured for long-term care takes a burden off both parent and child. Caregiving also can be a wake up call for children who see first hand the need to insure for their own long-term care risk.