Living alone is linked to higher cognitive decline risk

Living alone's impact on caring for cognitive impairment patients.

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The increasing prevalence of cognitive decline and its impact on elderly individuals has drawn attention to various factors that can exacerbate this condition. One significant factor is living arrangements, mainly living alone. The study aims to shed light on the potential risks of living alone for individuals experiencing cognitive decline.

Unsafe driving, wandering away from home, confusion with medications, and missing medical appointments are significant concerns for individuals experiencing cognitive decline. A recent study published in JAMA Network Open on August 18, 2023, led by researchers from University of California San Francisco, highlights that the healthcare system in the United States needs to prepare to support people with cognitive decline who live by themselves. This group is expected to grow in numbers due to the aging population.

Living alone can have a significant impact on the health of these patients. The effects are as substantial as factors like poverty, racism, and limited education, according to Elena Portacolone, Ph.D., MBA, MPH, the study’s first author. She is associated with the UCSF Institute for Health and Aging and the Philip R. Lee Institute for Health Policy Studies.

In this research, 76 healthcare providers were interviewed. These included doctors, nurses, social workers, case workers, and home care assistants. They worked in various places, such as memory clinics, home care services, and social service centers in California, Michigan, and Texas.

Comparing discharging a patient to letting a child play on a freeway, some healthcare professionals expressed concerns about patients who lacked essential information in their medical records. It led to uncertainty about the progression of their health issues. Surprisingly, some patients didn’t even have emergency contacts listed – no family or friends to rely on during emergencies, as shared by a case manager.

According to healthcare providers, these patients faced risks like untreated medical problems, neglecting their well-being, poor nutrition, and a higher likelihood of falls. A coordinator for home services also highlighted that calls to Adult Protective Services were sometimes ignored until the patient’s situation became highly critical.

Elena Portacolone, Ph.D., MBA, MPH, said, “An estimated 79% of people with cognitive decline have an income that is not low enough to make them eligible for Medicaid subsidized home care aides.”

The weak support system for these patients led to a troubling situation where they often went unnoticed until a crisis, like a fall or medication issue, landed them in the hospital. Shockingly, some were sent home without any proper support in place. In one instance, a patient was even given a taxi voucher, a situation likened to letting a child play on a busy freeway, as explained by a psychiatrist.

These findings reveal severe problems within our healthcare system. The lack of subsidized home care aides for all but the lowest-income patients is a glaring issue, according to Portacolone.

“Nearly 79% of people with cognitive decline in the U.S. don’t have low enough income to qualify for Medicaid-supported home care aides for long-term assistance,” she noted. She mentioned that in California, a person living alone needs to make $20,121 or less annually to be eligible. While Medicare is available for adults over 65, she explained that subsidized aides are usually provided only after significant events like hospitalizations, and they come with limitations on hours and duration.

“Most patients have to pay out of their own pockets, and considering cognitive decline can last for many years, this is not sustainable for many. She added that Medicaid-based aides are poorly paid and often receive limited training for older adults with cognitive decline,” she added.

People in parts of Europe, Japan, and Canada have better access to subsidized home care aides. Portacolone referred to a 2021 review she led, covering 13 countries, which highlighted this contrast.

The study’s outcomes expose significant shortcomings in how our healthcare system cares for those with dementia. According to senior author Kenneth E. Covinsky, MD, MPH, from the UCSF Division of Geriatrics, even though Medicare is investing heavily in new drugs with minimal benefits, it’s crucial to remember that necessary support for vulnerable dementia patients often goes unpaid by Medicare and other payers.

The researchers propose a solution where substantial support is funded through an expanded Medicare and Medicaid system. This is becoming increasingly important, explained Portacolone, because effective treatments to reverse cognitive decline are unavailable, family dynamics are changing, and older adults are expected to live longer, often independently.

Journal Reference:

  1. Elena Portacolone, Tung T. Nguyen et al., Perceptions of the Role of Living Alone in Providing Services to Patients With Cognitive Impairment. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2023.29913.