My 92-year-old aunt, who is cognitively impaired and requires a walker or wheelchair to get around, still lives in her own apartment, where round-the-clock home health aides help her get to and from the bathroom, bathe, dress and undress, and go outside each day for some fresh air. The aides shop, prepare and serve meals, do light housekeeping and make sure she takes her medications on time.
But last month, my aunt's long-term care insurance ran out, and her meager savings will soon do the same. Then what?
Her daughters, both of whom work to support their families, cannot afford the $150 a day for 24-hour care by a certified home health aide, and my aunt has nothing to sell that could bring in the needed cash. Nor does she yet qualify for Medicaid or have a terminal illness that would justify hospice care, which would be covered by Medicare.
Complicating matters, her daughters long ago promised that they would not put her in a nursing home.
Such dilemmas are increasingly common as people live longer. The number of Americans 65 and older is expected to double to 80 million in the next three decades. People 85 and older are the fastest-growing age group; by 2020, there will be 6.6 million people in that age bracket, when rates of debilitating ailments soar.
Most Americans over 65 will eventually need help with the so-called tasks of daily living - eating, dressing, bathing, shopping and the like. But with family members spread all over the map or unable to be full-time caregivers for other reasons, the need for new and better options will only increase.
When asked, 80 to 90 percent of older people say they want to remain in their own homes as long as possible. Yet remaining in one's home indefinitely is not always the best choice, even if it is financially feasible. As life draws near a close, many older adults need more care than can be provided safely at home. Simply finding reputable home health aides can be a nightmare, and family members often are forced to fill gaps in even the best caregiving plans.
The challenge is all the more difficult when no one has thought through the options before a serious illness or injury makes it impossible for elders to return home without full-time help.
Many elders living independently need outside help long before they require round-the-clock care. A range of assistance and housing alternatives has rapidly sprung up to meet this demand. Many focus on improving accessibility in the home and access to neighborhood conveniences.
An older person living in the suburbs who can no longer drive may become isolated, lonely and at risk of malnutrition if there is no person or community service to shop for her and take her places. Even stairs are a major obstacle.
Elinor Ginzler, director of the Cahnmann Center for Supportive Services at the Jewish Council for the Aging in Rockville, Md., writes that "the ability to age in place is greatly determined by the physical design and accessibility of a home, as well as community features like the availability of nearby services and amenities, affordable housing and transportation options."
Organizations like Staying in Place, a nonprofit group of volunteers, helps people age 50 and older in Woodstock, N.Y., and surrounding communities "maintain active, independent, fulfilling lives in their own homes." For $125 a year (plus $50 for each additional household member over 50), the organization assists with paperwork and technology; free or low-cost transportation; referrals to discounted service workers; information about, and transport to, local classes and cultural and social activities; and recommendations for home health care agencies and personnel.
Other services that are free or low-cost include Meals on Wheels; friendly visiting; shopping services accessed by phone or computer; activities at senior centers; and adult day care centers.
There are also more costly commercial organizations like Home Instead Senior Care, an international network of more than 900 independently owned franchises that provide in-home nonmedical care for elders and support for their caregivers.
The organization sponsored a yearlong online study of 1,631 caregivers, 697 of whom were assisted by paid in-home nonmedical care. The study found that people receiving the additional paid care required 25 percent fewer doctor visits and were more likely to participate in adult day care.
Sadly, many aides are seriously underpaid. Home Instead, for instance, has lobbied to keep home health care aides exempt from minimum wage standards.
Henry Cisneros, former secretary of the United States Department of Housing and Urban Development and editor of the book "Independent for Life: Homes and Neighborhoods for an Aging America," points out that "Americans are aging in traditional homes, neighborhoods and communities that were designed for yesterday's demographic realities, not those of today or the future."
Mr. Cisneros advocates changing our communities so that the elderly can remain in them. "Homes can be retrofitted, new age-appropriate homes built, existing neighborhoods reconnected, and new communities planned," he wrote. For example, to accommodate declining eyesight, homes can be fitted with brighter bulbs, better lighting locations, easily accessed controls and nighttime guide lights.
Mr. Cisneros sees a pressing need for affordable packages of home modifications and maintenance to make residences more suitable for older people.
"A certified renovation package for aging in place could include roll-under kitchen and bathroom sinks, grab bars, curbless showers, lever faucets and door handles, a zero-step entrance, and wider doors and hallways," he wrote.
While such changes have a price tag, they may cost a lot less than current care alternatives for the elderly.
Needed changes at the community level include affordable small-scale housing and cluster housing situated in walkable communities with nearby amenities, businesses, health facilities and public transportation.
Borrowing from the design of assisted living facilities, individual dwelling units might be located around a common space that includes dining areas and social rooms.
For elders who want to be near family members yet maintain their independence, so-called accessory dwelling units with their own kitchens and bathrooms are being built near or attached to family homes.
How to Know When Home Alone Is No Longer a Good Idea
Paula Spencer Scott, senior editor at Caring.com, recently compiled a guide to help families determine when the time has come to move older relatives from their homes and into a more supportive environment or, alternatively, to bring in a home health aide who can provide assistance. These signs to look for and questions to ask are adapted from Ms. Scott's recommendations.
¶ Recent accidents or close calls, like a fall, medical scare or minor car accident.
¶ A slow recovery. How well was a recent illness weathered? Did it develop into something serious? Was medical help sought when needed?
¶ Worsening of a chronic health condition. As problems like chronic obstructive pulmonary disease, dementia or congestive heart failure progress, more help will be needed.
¶ Greater difficulty managing the so-called activities of daily living, like dressing, bathing and cooking.
¶ Bodily changes, like obvious weight loss or gain, increased frailty or unpleasant body odor.
¶ A loss of active friendships, including outings with friends, visits with neighbors or participation in religious or other group activities.
¶ Days spent without leaving the house, perhaps because of difficulty driving or a fear of using public transportation.
¶ Is someone checking in regularly? If not, is there a home-safety alarm system, a personal alarm system or a daily calling service in place?
¶ Is someone nearby to assist if there's a fire, earthquake, flood or other disaster, and does the older resident understand plans for a catastrophe?
¶ Mail in a chaotic state, scattered about and unopened. Are there unpaid overdue bills, surprising thank-you notes from charities, piles of unread magazines?
¶ If an older relative is still driving, go along for a ride and look for failure to fasten the seat belt or heed dashboard warning lights; signs of tension, preoccupation or distraction while driving; damage to the vehicle that may indicate carelessness.
¶ In the kitchen, signs of excess or forgetfulness, like perishables well past their expiration dates.
¶ Favorite appliances are broken but not scheduled for repair.
¶ Signs of fires. Look for charred stove knobs or pot bottoms, potholders with burned edges, a discharged fire extinguisher. Do smoke and carbon monoxide detectors have live batteries?
¶ A once-neat home now cluttered, spills that were not cleaned up, grime coating bathroom and kitchen appliances or an overflowing laundry basket.
¶ Neglected plants or pets.
¶ Signs of neglect outside the home, like broken windows, debris-filled gutters and drains, uncollected rubbish and an overstuffed mailbox.
¶ Ask friends and neighbors whether your family member's behavior has changed lately.
¶ Ask the person's doctor whether you should be concerned about the person's health or safety and whether a home assessment by a social worker or geriatric care manager may be advisable. If you expect resistance from the person, ask the doctor to "prescribe" a professional evaluation.
¶ If you are the primary caregiver, how are you doing? Are you increasingly exhausted, depressed or becoming resentful of the sacrifices you have to make to care for the person?
¶ Consider your older relative's emotional state. If she is riddled with anxieties or increasingly lonely, then it may be time to make a move for reasons other than health and safety.
