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Aging Articles

What Is Assisted Living?

Assisted living is a term that is often used as though everyone understands it in the same way. But that’s not the case. Assisted living is just a generic term like hotel or automobile that covers a lot of options. Before getting into the specifics, here's a simple definition: Assisted living is a residence where groups of people share meals and other activities and where individuals can receive personal assistance to maintain their independence. People who choose assisted living typically would have difficulty living completely on their own but do not require constant medical attention. You can also think about assisted living as an intermediate step in long-term care. It’s in the middle of the spectrum of long-term care, which often goes from independent living to assisted living to nursing-home care. Independent living can be in your own home or the entry level of assisted living or in special housing for older people. About 70 percent of residents in assisted living come to the facility from their own house or apartment. In this section I cover a more formal definition of assisted living, what services are included, which health care options may be provided, and tips for finding a facility to provide a broader understanding of all that assisted living covers.

Interpreting industry and government language

Most definitions of assisted living come from industry or government sources and emphasize different aspects of this setting. It’s important to keep the source in mind when you gather information. For example, Argentum (formerly the Assisted Living Federation of America), a trade organization, says, “Assisted living is a housing and health care option that combines independence and personal care in a residential setting.” This is a good definition as far as it goes, but it doesn’t tell you what personal care means and what health care services are likely to be offered. The Eldercare Locator, a free service connected with the federal Administration for Community Living (ACL), has an even more specific definition: “Assisted-living facilities offer a housing alternative for older adults who may need help with dressing, bathing, eating, and toileting but do not require the intensive medical and nursing care provided in nursing homes.” This definition, while accurate, doesn’t include younger adults who may want or need the kinds of services available in assisted living. It also underestimates the importance of the social aspects of assisted living. Living with a congenial group of people with whom to share meals, activities, and conversation is a potential benefit, since social connections have been shown to improve health and well-being as well as to reduce medical costs. Keep in mind, though, that it is sometimes hard to make new friends in assisted living because residences experience a lot of turnover. Most people stay in assisted living for only 22 months, according to the 2010 National Survey of Residential Care Facilities. Nearly 60 percent move on to a nursing facility, a third die, and the rest move home or to another location. Note: The 2010 survey has not been updated and has been replaced by a survey with a different name — the National Survey of Long-Term Care Providers. The Centers for Disease Control and Prevention (CDC) website has several recent reports on aspects of assisted living. State governments, which license group residences, call assisted-living facilities by different names. Some examples of state licensing categories are residential care facilities for the elderly (California), residential facilities for groups (Nevada), and personal care homes and assisted-living facilities (Pennsylvania).

You may also come across the acronym ALF in your search. It is shorthand for assisted-living facility, not the character in the TV series popular in the 1980s. Similarly, ALP is an abbreviation for assisted-living program, not a mountain.

Owners of assisted-living facilities tend to shy away from that term in the name, preferring more appealing names like village, community, manor, or any phrase that evokes a secure and invigorating lifestyle. Your state’s name for assisted living is not as important as its licensing requirements and its monitoring activities. Some states have detailed standards about what counts as assisted living and what must be provided, as well as building and safety regulations. States may require training for staff, background criminal checks, and other safeguards. Regulations in other states are less definitive. The National Center for Assisted Living, a provider organization, has information about state offices and a state regulatory review. Another important publication is the National Center for Assisted Living’s “Guiding Principles for Assisted Living.” This guide offers a good check on the kinds of information that providers should be giving you as a prospective resident, including contracts, finances, and resident transfers. When you check out your state’s regulations, find out whether it has a bill of rights for assisted-living residents. Most states have such a document and generally require facilities to post it and give copies to residents. These documents may be lengthy. Some of the items include the right to privacy, to confidentiality of personal and medical information, to have private communications with a physician or attorney, to practice the religion of one’s choice, and to be given notice about transfers or fee increases. Some are negative rights, such as the right not to be coerced or required to perform work. However, not all the documents tell residents how to complain if they feel their rights have been violated. One way is to contact the state’s long-term care ombudsman, who is responsible for investigating complaints in nursing homes and assisted-care facilities. You can find the ombudsman in your area. Or you can contact the National Consumer Voice for Quality Long-Term Care.

What assisted living offers

All assisted-living facilities, however defined, offer three main components:

• Shelter: Residents are given a place to live, usually a private unit or apartment.
• Meals: Food is provided, although not necessarily three meals a day.
• Staff: The facility staff provide the assistance that comes with the name. In addition to managers and activity directors, most facilities have aides or attendants to help with bathing, dressing, getting around with a cane or walker, and other daily tasks.

When it comes to services provided by staff, you may frequently hear the term ADLs. It stands for activities of daily living, which are the actions people take for granted until they can’t do them by themselves anymore — dressing, bathing, going to the bathroom, and feeding themselves. ADLs have a companion term — IADLs, or instrumental activities of daily living — that includes tasks like making phone calls, managing money, managing medications, shopping, and cooking. People in assisted living may also need help with these responsibilities.

Assisted-living facilities may be located in cities and look like ordinary apartment buildings. Some are in suburban locations with lots of open space. There are fewer assisted-living sites in rural areas. Some assisted-living facilities are luxurious and provide a wide range of services and amenities. At the other end of the spectrum, some facilities have small staffs and offer limited assistance.

When you’re considering an assisted-living facility, be sure to ask about staffing: how many, training, special skills, and background checks. If the management seems evasive, probe further. The response will give you an idea of whether this is a place you want to consider further or avoid.

Assisted-living facilities may be large or small. About a third of all facilities are considered large (25 or more beds), but they have more than 80 percent of all assisted-living residents. About 82 percent of all facilities are run by for-profit organizations, some of which are national or regional chains. The rest are run by charitable or religious organizations or by state, city, or local governments. In general, larger facilities have more staff and can offer more activities. This benefit may be offset by frequent staff changes and a more impersonal management style. Your preferences about small-group living versus a large residence should be part of your decision. If you or your parent have always lived in a private house with few close neighbors, it may be difficult to adjust to large-group living, even if you have your own apartment. Or a new environment may be just what you are looking for. A CDC analysis comparing smaller and larger assisted-living facilities found that in 2016, in larger facilities, more residents were age 85 and older, and a higher percentage of people needed personal care assistance. Residents in smaller facilities were also more likely to be receiving Medicaid. The percentage of residents who had fallen in the previous 90 days increased with the bed size of the facilities.

Check out health care services

The health care services offered in assisted living vary considerably. Most common is assistance with administering medications. Some states require staff with specialized training to help with this task. Some assisted-living facilities have medical staff, usually a nurse, available 24/7 on-site; others have a part-time nurse or someone on call. Compared to practice 20 years ago, assisted-living facilities are now accepting people with more serious chronic conditions. The National Center for Health Statistics, a government agency, reported in 2010 that 82 percent of assisted-living facility residents had Alzheimer’s disease or dementia, high blood pressure, heart disease, or a combination of those conditions. Some assisted-living facilities have adapted to the greater health care and assistance needs of these residents, while others have not. The 2016 CDC survey described in the previous section found that among residents of smaller facilities (4–25 beds), the prevalence of Alzheimer’s disease and depression was higher, but the prevalence of cardiovascular disease was lower.

If you have a chronic condition that requires frequent monitoring and checkups, be sure to ask whether you can continue to see your own doctor or what alternatives will be available, especially if you’re moving to a new area.

Alzheimer’s disease and other types of dementia are conditions that require specific care and are a huge factor when making a long-term plan. A 2012 MetLife Mature Market Institute survey of long-term care costs found that about half of assisted-living facilities provided Alzheimer’s and dementia care, but 61 percent of them charged an additional fee. Sometimes the special units or programs within a facility are called memory care, perhaps to avoid the stigma of dementia. If memory care is important in your plan, be sure to ask about the staff qualifications and training, types of programs available, and opportunities for interaction with other residents. Also ask whether behavioral interventions are used instead of psychoactive drugs, which should generally be avoided. And care for people with dementia should be more than keeping them from wandering; it should include activities designed to stimulate their minds and keep them active.

More information on assisted-living facilities

Your goal is finding the right assisted-living situation, one that offers the right balance of independence and privacy with the kinds of assistance you need now and may need later. After you know more about assisted living, you can begin your fact-finding process. You can get information about specific assisted-living facilities from many sources. A lot of marketing information stresses the living aspect of assisted living and glosses over the assisted part. It’s hard to find out how friendly the staff is, whether management is responsive to concerns, and all the other quality-of-life questions that matter so much. You have to ask about and observe these aspects for yourself. But you can learn a lot from some basic resources, including the following:

• Eldercare Locator: This federal resource is a good place to start. It directs you to your nearest Agency on Aging for assistance. There is also a basic introduction to assisted living.
• State websites: State websites are important because you can generally find which assisted-living facilities have a lot of health and safety violations or don’t offer what you’re looking for. You can then eliminate these from consideration. Some states also have good consumer information, specific to that state, on their Office of Aging or Health and Human Services websites. Note, though, that these agencies have different names in different states.
• Your state’s long-term care ombudsman: This individual investigates complaints about assisted-living facilities and nursing homes. Check with that office, usually located in the State’s Office on Aging, to find any complaints about a specific facility and how they’ve been addressed.
• The Commission on Accreditation of Rehabilitation Facilities: This nonprofit organization lists continuing-care retirement communities that meet its survey standards about business practices, philosophy and physical environment, and some aspects of assisted living.
• Argentum (formerly the Assisted Living Federation of America): A membership organization of assisted-living providers, you can search for its state partners on its website.
• Internet sites: When you search on the Internet for “assisted living,” you can find ads for specific facilities as well as companies that offer to help you find a facility in your area. Sometimes these companies are endorsed by celebrities, which isn’t a guarantee of quality. Personal assistance from “care” or “family” advisers may be available. Facilities on these lists typically pay to be included, so not all options may be offered to you.
• Friends or relatives: People you know who are currently in or have lived in assisted-living facilities are a good resource for information on local facilities. Keep in mind, though, that one person’s good or bad experience may not convey the whole picture.
• Doctors and other health care professionals: Talk to doctors and nurses with experience in providing care to assisted-living facility residents.

Use more than one resource, because no single one is likely to have all the options. Be aware of the criteria for including the assisted-living facilities and the sponsorship of the list. And none of these resources can tell you what it’s really like to live there. You should address questions about quality of life in your visits to various facilities. I suggest some specific questions in the later section “Beyond the Brochure: What to Look For When You Visit.”

Aging Articles

Aging in Place Home Modifications

When you’ve completed a safety checklist on your home and made all the easy fixes and repairs, you may find that problem areas still exist for safely aging in place. Some problems may be unsafe conditions, but others may be barriers that make it difficult for you or your relative to move about freely and to enjoy the comforts of home that make him want to stay put in the first place. This article covers modifications that can be made to an aging person’s current home to allow him to continue his present living arrangement.

For more information on this topic, check out the AARP HomeFit Guide Downloads, Worksheets, and Resources.

Categorizing types of home modifications

Many houses and apartment buildings were constructed before universal design features were common or in some cases required by guidelines for remodeling and new construction under the Americans with Disabilities Act (ADA), passed in 1990. Ramps in public places, doors marked for wheelchair entrance, and buses with lifts and special seating for people with disabilities have become so common that they are scarcely noticed (unless of course you’re the person with a disability who needs these accommodations). Yet the need for similar accommodations in private homes is less visible although equally important. The Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) puts home modifications into three categories:

• Accessibility: Accessibility modifications allow a person in a wheelchair or with disabilities to move easily throughout a structure, such as with widened doorways, lowered countertops and sinks, grab bars in the tub or shower, and light switches and electrical outlets at waist height.
• Adaptability: Adaptability covers changes that can be made more quickly, without having to completely redesign the home or use different materials for essential fixtures.
• Universal design: These features are usually built into a home, including appliances, floor plans, and fixtures that are flexible, sturdy, reliable, and easy for all people to use.

These categories are important because they involve different levels of planning, implementation, and cost. For example, adapting a home is the least complicated type of modification. Grab bars and outdoor ramps are examples. Making a home accessible, however, may involve structural changes and complying with building code and ADA requirements. Universal design may come into play when you are completely remodeling a home or building a new space.

Checking out accessibility

General home safety issues (see the earlier section “Dealing with Two Major Hazards”) are important for all older people living on their own. But other specific features can make the home easy to use — or not — for people who have disabilities or are aging. Start in the kitchen and bathroom and think about the particular problems you or your parent may face in accessibility:

• Are cabinet knobs or pulls easy to use? Pulls are generally considered easier to use than knobs.
• Are stove controls easy to use and clearly marked?
• Are faucets easy to use? Universal design faucets have one lever, not two knobs to turn. This makes mixing hot and cold water easier.
• Can the oven and refrigerator doors be opened easily? Is the freezer easy to reach?
• Is the kitchen counter height and depth convenient? Most kitchen counters are too high for a person in a wheelchair.
• Is there room to move around the bathroom and a place to put towels and shampoo in easy reach?
• Is the shower faucet easy to use? Turning on the shower and getting the right temperature can be difficult. A new showerhead or faucets may be needed.
• Does the height of the toilet seat make getting up difficult? A raised seat may help.

In closets and storage spaces, check the following:

• Does the closet contain items that have just been put there to get them out of sight? Move them so that the closet is easier to access for coats, hats, umbrellas, and boots.
• Can items in the closet, like a coat on a hanger, be removed and replaced easily?
• Can the use of storage space be improved with closet shelf systems?

Doors and windows may need the following updates:

• Are the doors wide enough to accommodate a walker or wheelchair? The standard for a wheelchair is 36 inches. Most door openings are narrower.
• Are the doors and windows easy to open and close?
• Are the door locks sturdy and easy to operate?

Evaluate the electrical outlets and safety devices:

• Are electrical outlets easy to reach?
• Is the area around outlets free of clutter?
• Are the outlets properly grounded to prevent shock?
• Can you hear the doorbell in every room?
• Is the telephone readily available for emergencies? A land line may be more reliable in an emergency than a cellphone.
• Is there an alarm system? If so, is it easy to use? If not, consider whether one is needed.

The preceding information is only a partial list. The University of Southern California Leonard Davis School of Gerontology has an extensive resource list. Also see the AARP HomeFit Guide for a questionnaire to help you plan when you remodel. One part of the HomeFit guide has suggestions for remodeling for people with vision, strength, and mobility problems.

Some items that need correcting can be done by you or a friend or family member, but if you have determined that major changes are necessary — for example, widening doorways or replacing kitchen cabinets or appliances — you probably need to find a contractor to tackle the modifications. Head to the next section for advice on finding the right person for the job.

Remodeling is a messy and often frustrating experience. The first phase, demolition — even if it’s limited to one room or area — is unsettling. Delays are common. It may be a good idea to move your relative to another setting while the work is being done, especially if you expect a lot of dust, noise, and disruption.

Finding a contractor

How do you find a reliable and knowledgeable contractor? If you have already worked with a contractor and were pleased with the results, then you have a head start. Ask this person to go over the problem areas with you, suggest fixes, estimate the cost, and tell you how long it will take to do the work.

Most people with accessible homes have neither built their own houses nor undergone extensive remodeling. Ask for recommendations from friends or neighbors who have had similar work done. Check online referral sites for recommendations. Then ask a few contractors for estimates and for people to call for references. Some home builders work with certified aging-in-place specialists, a program developed in partnership with AARP. Visit the AARP's website for worksheets and more information.

Before hiring a contractor, check with the local Chamber of Commerce or other agency to see whether any complaints have been filed against the company. Make sure the contractor is licensed to perform the work and can obtain any building permits required. Finally, ask for a written agreement that stipulates a small down payment and schedule of payments, with the final payment to be made only when the work is completed and approved.

A frequent scam carried out against older people occurs when a “contractor” scans a neighborhood for a likely target and offers to do needed (or unneeded) repairs or home modifications. The person asks for a large down payment and either disappears or does only a token amount of work. If you’re thinking of home modifications for older relatives, be sure to warn them about this scam.

Attempting any major repairs, especially if they involve climbing ladders or using power tools, is dangerous. Some people want to save a few bucks by doing the jobs themselves, but they need to be reminded that the cost upfront is much less than the aftereffects of being injured.

If you or your relative lives in an apartment building or housing complex, you need to contact the management to make some changes, particularly in corridors and stairways and even within the apartment itself. Co-op or condo residents may be required to obtain approval from their governing board too.

Getting help paying for home modifications

Many home modifications, such as ramps and lighting replacements, are relatively inexpensive. But when you start widening doors and installing new kitchen equipment like a refrigerator with side-by-side doors, the costs add up. In the bathroom, installing a roll-in shower can be costly although important for someone who cannot move from wheelchair to tub. Eldercare Locator, a federal agency funded by the Administration for Aging (AoA), suggests these resources for financial assistance:

• Some funds for home repair may be available through Title III of the Older Americans Act. They are distributed through the local Area Agency on Aging (AAA). You can find your nearest AAA by calling Eldercare Locator at 800-677-1116 or going online. These funds are likely to be limited, however, and best suited for relatively small jobs.
• Rebuilding Together, Inc., a national volunteer organization dedicated to assisting low-income seniors, may be able to direct you to a local affiliate.
• Some types of home modification — those determined to be medically necessary — may be covered by Medicaid (for eligible low-income people), depending on the state you live in. For example, a roll-in bathtub or shower for a person in a wheelchair may be covered. A doctor’s order may be required, and some Medicaid programs limit eligibility to certain diagnoses or ages. Check with your state’s Medicaid office for details.
• If the home is mortgaged and has substantial equity, a home equity loan may be available from the bank. However, this loan will increase the mortgage payment.

Whether major improvements and their associated costs will substantially improve your or your relative’s safety and quality of life is a personal decision. You may decide that aging in place is not really feasible after all and that a move to assisted living or another setting is the best choice. If you do decide to stay, going through the important process of evaluating the home and making those small changes that can prevent accidents will make it much safer.

Aging Articles

2 Major Hazards of Aging in Place

Falls and burns aren’t the only sources of injury at home when you or a loved one is aging in place, but if you address them, you’ll likely prevent other kinds of injury as well. An important first step in deciding whether staying in the same home can work is taking a hard look at the home. Looking past a cherished home’s attractive features and focusing on its flaws and hazards can be hard to do. Having someone with fresh eyes with you as you survey the premises can be helpful, preferably someone with experience in home modification for older people, such as a physical or occupational therapist, a geriatric care manager, or a contractor who has done similar jobs.

If you’re trying to improve the home for a relative, be aware that older people often downplay concerns about safety and resist change. Be tactful but firm. Safety is not the only issue, but it is a prerequisite for enjoying a good quality of life.

Preventing falls

Your first priority should be preventing falls. Falls are among the most common accidents in homes. Older people are at risk for falls because keeping your balance as you age is more difficult, and it’s harder to readjust your feet to regain your balance if you slip. Arthritis can limit your range of motion. Many older people suffer bone loss, or osteoporosis. Hips are the most likely joints to be injured because people tend to fall on their sides. Falls are often the first step in a cascade of decline that ends up with a hospital stay and eventual placement in a nursing home or death. Fortunately, many fall-prevention measures are easy to take and are not expensive. Here’s a checklist for falls prevention adapted from the National Center for Injury Prevention and Control, a division of the CDC. Another valuable CDC publication is available for family caregivers.

• Floors:
  • When you walk through a room, do you have to walk around furniture? If so, make a clear path by moving the furniture.
  • Are there throw rugs on the floor? If so, remove them or use double-sided tape or a nonslip backing.
  • Are there papers, books, towels, shoes, magazines, boxes, or blankets on the floor? Pick them up and keep them off the floor.
  • Do you have to walk over or around wires or cords (like lamp, telephone, or extension cords)? Coil or tape cords and wires next to the wall. You may need an electrician to put in another outlet.
• Stairs and steps:
  • Are shoes, papers, or other objects on the stairs? Remove them.
  • Are some steps broken or uneven? Have them repaired.
  • Does the stairway have a light? An electrician should install an overhead light and light switch at the top and bottom of the stairs. (Use an energy-saving type of light bulb so it doesn’t need to be changed as often.)
  • If there’s carpet on the stairs, make sure it’s firmly attached to every step.
  • Make sure that handrails are not loose or broken and that they’re on both sides of the stairs.
  • To make seeing the stairs easier, paint a contrasting color on the top edge of all the steps. For example, use a light color paint on dark wood.
• Kitchen:
  • Are often-used items on high shelves? Move them to lower shelves (about waist level).
  • Is your step stool unsteady? If you must use a step stool, get one with a bar for support. Never use a chair as a step stool.
• Bathroom:
  • Tubs and shower floors are often slippery. Put a nonslip rubber mat or self-stick strips on the floor.
  • Install grab bars inside the tub and next to the toilet. Make sure you have this done by someone who knows how to place them correctly and securely. The screws should be installed in the studs in the wall, not in the tiles, or the grab bar will pull loose.
• Bedroom:
  • Is the light near the bed hard to reach? Make sure a sturdy lamp is close to the bed.
  • Is the path from the bed to the bathroom dark? Put in a night-light, preferably one that turns itself on after dark.

Handling clutter and hoarding

Your survey of the home may have uncovered an unpleasant secret. Perhaps unread newspapers and magazines have accumulated, the refrigerator is full of rotting food, or the cats have taken over the bathroom. This behavior is not just difficult to look at, but it also can be a fire and safety hazard. Some of this accumulation is clutter. Bending down to pick up papers may be difficult for a person with arthritis, or a person with vision problems may not be able to read the sell-by date on foods. But sometimes the accumulation of stuff rises to the level of hoarding, which is a more serious problem. Hoarding interferes with ordinary life by making it impossible to use the space as intended and impedes access in an emergency. You may be tempted to overlook the problem because one good cleaning would get rid of the worst of the mess. But it’s not something that should be ignored, and if you get rid of the piles of what you call junk and your relative considers priceless, he or she will only refill the space as quickly as possible. There are many theories about what causes this kind of behavior, which may be related to depression, anxiety, prior losses, or other mental-health issues. Hoarding is one manifestation of obsessive compulsive disorder (OCD). Dealing with hoarding requires consultation with experienced mental-health and home-organizing professionals who can negotiate the cleanup in nonjudgmental ways. A useful article prepared by the University of California-San Francisco is available. Another resource is the International OCD Foundation.

Preventing burns

Burns are a common problem in the home. Even a minor burn can lead to infection and serious consequences. Older people literally have thinner skin that’s more susceptible to scalding from hot water or burns from electrical appliances. To keep older people safe from burns at home, make sure that you:

• Replace electrical cords that are broken or cracked.
• Replace electronic devices, heaters, or appliances that overheat, spark, or smoke.
• Use a power strip rather than an extension cord.
• Keep electrical appliances away from water.
• Unplug small appliances such as toaster ovens and coffeepots when not in use.
• Keep a three-foot zone of safety around the stove, oven, and microwave.
• Use microwave-safe cookware.
• Set the water temperature to a maximum of 120 degrees Fahrenheit (this may be a job for a plumber or apartment building staff).
• Use a humidifier that sprays cool mist rather than hot steam.
• Have smoke alarms installed and change the batteries twice a year. You can use changes to and from daylight saving time as your reminder.

Smoking in bed is still a common cause of fires. Do everything you can to prevent this dangerous habit.

A comprehensive brochure with guidelines for preventing burns from the Hearst Burn Center at New York Presbyterian Hospital is available.