Dr. Hawes, a professor of health policy and management at the Texas A&M Health Science Center, happens to be one of the nation's leading experts on long-term care. "I've been in this business for 35 years," she told me in an interview. "But when my mother said, 'I'd rather die than go to a nursing home — promise me you'll never put me in a nursing home,' I felt like every other child feels. It's a knife to the heart."
Remind me, in 20 years or so, not to try extracting The Promise from my daughter, because it's not a vow that can be kept without a crystal ball. With great effort, Dr. Hawes and her husband, who's also a long-term care expert, managed to keep her mother in their home for eight years. But not everyone can make that happen.
The great interest in assisted living over the past 20 years stems, in part, from families making The Promise. Assisted living — a term encompassing a bewildering variety of facilities, from small family-operated homes to 100-unit complexes -– has advantages and disadvantages, but chief among its attractions is that it's not a nursing home.
When families can no longer keep an older adult in his own home (the almost universal preference) and are investigating congregate living, "that's everyone's first thought," said Lisa Gwyther, the veteran social worker who directs the Duke Family Support Program in Durham, N.C. "Everyone says, 'My mom doesn't belong in a nursing home,' so they think assisted living, regardless of her medical needs or prognosis."
But assisted living won't work for everyone, either. I consulted Ms. Gwyther and Dr. Hawes for guidance on which older people are likely to do well there and which will need the greater supervision and higher staff ratios a good nursing home can offer.
"Good nursing home" is not a contradiction, by the way, despite the industry's longstanding and well-documented problems. "Nursing homes have gotten a bad rap," Ms. Gwyther said. There are good ones, and there are seniors who need them.
For instance, "anyone with moderate to severe cognitive impairment and problem behaviors like resisting care or becoming alarmed if someone tries to help them shower generally belongs in either a dementia unit with well-trained staff or in a nursing home," Dr. Hawes said. In standard assisted living, "there's not enough staff to help."
Ditto for seniors with complicated medical conditions that require regular monitoring — for instance, those whose use of blood thinners involves regular testing to adjust the dosage. Assisted living doesn't provide much health care, so residents risk becoming what Ms. Gwyther calls "frequent fliers — they're going in and out of hospitals for conditions that could perhaps be treated in a nursing home."
Medication management — a program to provide the right dose at the right time — can take place in either type of facility, but Dr. Hawes points out that in most states assisted living staff cannot legally administer medication, and may only hand it to a resident. So someone who stuffs pills into her purse, or whose dementia means that moments later she won't remember to swallow them, may easily fall off her drug regimen.
Assisted living can pose a problem for seniors with incontinence, too. Frequently, the marketing director says an assisted living facility can accept someone who's incontinent. But, Dr. Hawes cautioned, "she means, 'As long as she can change her own briefs.' What you mean is, 'She needs help getting changed four times a day and needs the sheets changed every other day.'" Housekeeping staff in assisted living typically change linens weekly.
Further, federal regulation provides greater protection for nursing home residents. State regulations govern assisted living, and they vary widely. "Assisted living facilities can ask you to leave, and they do," Ms. Gwyther said. "Nursing homes can, too, but you have more rights."
Nevertheless, assisted living can work well for people with mild cognitive problems, who particularly cherish privacy (private apartments being more common), who are sociable and alert.
Years ago, Dr. Hawes told me that the ideal candidate for assisted living was Miss Daisy, the character in the play and the film starring Jessica Tandy. Miss Daisy, lucid and opinionated, didn't need extensive nursing or personal care, just transportation, light housekeeping and meals, and the attention of the courtly Morgan Freeman. If that's your mother, she may not need a nursing home.
At least, not yet. Families shopping for facilities hear a lot about "aging in place." Marketing directors may imply, or even say, that this will be your parent's last home. But however suitable assisted living may be when a resident moves in, the average stay is a little over two years, and the most common reason for moving out is needing more care than it can provide.
Despite The Promise, then, "this is probably a temporary solution," Dr. Hawes said. The most frequent destination when residents leave assisted living: nursing homes.
http://newoldage.blogs.nytimes.com/2011/06/10/assisted-living-or-a-nursing-home/
