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• Posted August 21, 2023

More Americans Grow Old Alone, and Faltering Minds Bring Risks

An estimated 26 million Americans 50 and older live alone, and researchers estimate that more than 4 million have dementia or cognitive impairment.

That means a large number of older Americans are at risk for medication mix-ups, unsafe driving, wandering and missing important medical appointments. And, a new study warns, the U.S. health care system is ill-equipped to address the needs of this population.

"Our study is significant because it provided, for the first time, strong evidence that it is much more difficult to care for patients with dementia who live alone," said lead author Elena Portacolone, an associate professor at the Institute for Health & Aging at the University of California, San Francisco. "As a result, in the United States, patients with dementia who live alone may not receive the best possible care."

For the study, her team interviewed 76 health care providers in California, Michigan and Texas. They ranged from doctors to home care aides.

Providers raised concerns about mentally impaired patients who lived alone, noting they were isolated, lacked advocates, had incomplete medical histories, required difficult interventions and had unmet needs. Many had no emergency contacts listed and were sometimes ignored by medical professionals until a serious health episode occurred. Those living alone were most likely to be women, poorer and without a partner.

These factors increase their risk for untreated medical conditions, self-neglect, malnutrition and falls, the study said.

Kate Wilber, chair of the USC Leonard Davis School of Gerontology in Los Angeles, reviewed the findings.

"Over 80% of long-term services and support for people is provided by friends and family, and if someone doesn't have friends and family, either living with them or in the community, they need care, especially if someone's living with dementia as the disease progresses,"she said.

"One of the reasons people avoid care, avoid providers coming in is they don't want to have their freedom taken away, and there's a great fear of being placed in a nursing home," Wilber explained.

That, she added, is a likely outcome if someone at high risk is living alone.

Costs are also a factor. The study estimated that only 21% of cognitively impaired adults who live alone are covered by Medicaid, leaving most of these adults ineligible for subsidized services like home-care aides. In addition, aides are usually provided only for a limited time after a severe medical episode, the study noted.

"Millions and millions of dollars are spent by the government of the United States in research to delay or treat dementia,"Portacolone said. "Given the needs of older adults who live alone with dementia, it would be wise to devote resources for programs supporting older adults who live alone with dementia, as well as the professionals doing everything they can to care for this population."

Countries like Germany and the Netherlands, meanwhile, set aside government funds for long-term care of the elderly.

In the United States, there are some highly innovative programs, but they are few and far between, Wilber said.

"For example, Los Angeles city enlisted meter readers and people delivering the mail to pay attention: Is there anybody that looks like something is going on that may be problematic?" Wilber said. "But it's also how do you enlist the community, neighbors, friends, people that go by the house every day?"

She said it's also important to consider each individual's autonomy.

"I think the rest of us think, well, this person is older and frail and has health conditions and of course they'll want us to come in and help, but what would we want for ourselves?" Wilber said. "And so I think that's always an important issue, how we frame it."

The study was published Aug. 18 in JAMA Network Open.

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SOURCES: Kathleen Wilber, PhD, professor and chair, gerontology, USC Leonard Davis School of Gerontology, Los Angeles; Elena Portacolone, PhD, MBA, MPH, associate professor, Institute for Health & Aging, University of California, San Francisco; JAMA Network Open, Aug. 18, 2023