Most seniors (and their family caregivers) share a common goal: avoiding nursing home placement at all costs. But when an elder’s needs increase, it’s important to recognize and accept when it’s time for a higher level of care.
Older adults typically rely on family caregivers and various home and community based services to support their wish to age in place. These resources are a godsend for seniors, but for most families, there are limitations to the type of care and support that can be realistically provided in a private home.
When a loved one is already receiving in-home care services or living in an assisted living community, changing needs are more likely to be noticed by providers and addressed in care conferences. On the other hand, community-dwelling older adults who rely exclusively on unpaid care from family and friends do not typically enjoy the same level of formal care planning and elder care expertise.
In these scenarios, family caregivers are responsible for monitoring changes in their loved ones’ physical and mental health, functional abilities, and quality of life. They must also regularly evaluate and update the care plan they’re following and research options for meeting these changing needs. Learning about the different levels of elder care will help ensure your aging loved one receives the appropriate kind of care in a timely manner, especially as their condition becomes more serious.
Signs It’s Time for Nursing Home Care
New or Worsening Health Problems
As we live longer, age-related decline and chronic health conditions become more prevalent and more debilitating. Recent research conducted by the Centers for Disease Control and Prevention (CDC) found that more than half (63.7 percent) of Americans age 65 and older are living with two or more of the following chronic health conditions:
- Arthritis
- Cancer
- Chronic obstructive pulmonary disease (COPD)
- Coronary heart disease
- Asthma
- Diabetes
- Hepatitis
- Hypertension (high blood pressure)
- Stroke
- Weak or failing kidneys
Health care becomes incredibly complex for seniors who have multiple morbidities and take multiple prescription medications to manage them. As an elder’s health declines, their immune system often weakens, making them more susceptible to common ailments and infections like urinary tract infections (UTIs) and the flu. Rather than a brief bout of illness that can typically be treated with a trip to a primary care physician and supportive care at home, the severity of their condition may necessitate frequent emergency room visits and hospitalization. They get the treatment they need there, but these acute care settings are not intended for such regular use. Repeated visits indicate a growing need for ongoing medical supervision and skilled nursing services, such as wound care, administration of medication via IV or injection, tube feeding, or catheter care.
Short-term stays in senior rehabilitation settings (also referred to as skilled nursing facilities) following medical setbacks become increasingly common as well. Unfortunately, many seniors who enter this cycle of repeated hospitalization and rehabilitation do not fully regain their prior level of functioning. An older adult in a senior rehab facility whose condition does not improve typically cannot be discharged home safely. Instead, they are recommended for permanent placement in a nursing home where they can get the skilled care and supervision they need around the clock.
Declining Functional Status
A senior’s functional status is typically assessed based on their ability to independently complete the six essential activities of daily living (ADLs):
- Eating
- Personal hygiene
- Dressing
- Ambulating
- Continence
- Toileting
Instrumental activities of daily living (IADLs) like medication management may also factor into overall functional ability and care decisions as well. Normal age-related decline and the progression of chronic illnesses commonly result in increasing dependence on others for assistance with IADLs and ADLs.
Although help with ADLs is categorized as unskilled personal care, both the cause(s) and consequence(s) of functional impairment are often medical in nature. For example, a stroke may cause muscle weakness and/or neurological damage that affects one’s ability to walk, control one’s bladder, bathe and eat. Even temporary impairment in these areas increases the risk of falling, UTIs, pressure ulcers, malnutrition and dehydration, all of which can further undermine one’s overall health and functioning.
ADL dependence is so closely associated with frailty and disability that most elder care providers and even government programs like Medicaid and the VA use functional status as a factor in determining the level of care a senior needs. Requirements are specific to individual facilities and programs, but an inability to complete two or more ADLs generally constitutes a “nursing home level of care.” Keep in mind that assisted living facilities do provide some supervision and help with ADLs, but it is limited and does not include 24/7 nursing care.
Advancing Dementia
Seniors with Alzheimer’s disease or other forms of dementia experience functional losses and may develop additional health problems as their cognitive abilities decline. However, memory loss and dementia-related behaviors often complicate long-term care decisions for families.
A memory care facility is appropriate for dementia patients who require significant assistance with ADLs, 24/7 supervision by staff trained in dementia care, specialized social and recreational programming, and secured premises to prevent wandering. However, these settings do not provide the level of skilled nursing care that nursing homes do.
Dementia patients who have other serious medical conditions that require careful monitoring and treatment would likely be better served in a nursing home setting. Additionally, placement is typically a better fit for seniors with severe dementia who are no longer ambulatory or able to participate in their own care. (Note that hospice care for advanced dementia can be provided in any setting—a private home, memory care facility, nursing home, hospice house, etc.)
Increasing Care Plan Challenges
Lastly, it is important for families to assess their own needs and challenges when weighing loved ones’ care decisions. It’s true that a senior’s medical and functional status should dictate whether it’s time to move to a nursing home. However, caregivers tend to be so focused on seeing to daily needs and preventing/addressing the next medical crisis that they can lose track of how significantly a senior’s physical and mental health have changed. Taking a step back to assess your caregiver burden and consider other care options can provide a clearer picture of what is best for your loved one—and for you.
Accepting the Need for Nursing Home Care
Medical, financial and/or logistical challenges often mount as a loved one ages and requires more and more hands-on assistance. Yet, seniors and caregivers alike often struggle or downright refuse to accept that their current care plans are no longer sustainable. Whether consciously or not, denial plays an important role in long-term care decisions. Family caregivers and many seniors see the writing on the wall but are afraid of and resistant to acknowledging the reality of the situation.
Read: Coping With the Decision to Put Your Parent in a Nursing Home
Recognizing the signs above is only part of deciding that a loved one needs nursing home care. Coming to terms with this decision is difficult for many families, and some seniors never stop denouncing it even after placement. The bottom line is that nursing homes provide the highest level of long-term care available and only admit residents who demonstrate a clinical need for their services. If a senior meets the medical and functional criteria for admission to a nursing home and cannot receive this care in another setting, then it is safe to say that placement is necessary for their health and quality of life.