Assisted Living: Starting the Conversation

By Amanda Lambert

In all the years I have worked with older adults I have never heard anyone say: “I think it is time to go to assisted living!” The idea of going to assisted living almost always arises from an elder’s children, a doctor or even perhaps someone like me, a geriatric care manager who will make the suggestion realizing all the while that the client may object. It may be time to start the conversation.
So, under what circumstances should a discussion of assisted living take place, and equally important, how should this discussion take place? Here are some typical circumstances under which the idea of assisted living is considered:
• Conditions in the home have become unsafe due to a person’s inability to manage everyday functions.
• A medical event leads to hospitalization, possible subsequent rehabilitation with a recommendation that a person not return home (or at least not return home without 24 hour care.)
• Private caregiving in the home becomes unaffordable to the extent that the cost equals or exceeds the cost of assisted living.

Your chances of avoiding the nursing home are directly related to the number of children you have,”
– Atul Gawande, Being Mortal: Medicine and What Matters in the End

The same could probably be said of assisted living, but there are many variables to be considered. Are family members nearby and willing to assist with care? What is the financial situation of the family? And last, but certainly not least, what does the elder want? Families often come to me and ask that I assess an elder’s ability to remain safely in their home due to dementia or debility. My assessment may indicate that a person is not safe without additional care being brought into the home or a move to assisted living, but this conclusion has value only if the client’s wishes, feelings, and awareness of their situation are considered. For some clients “least restrictive environment” may mean paying caregivers to come to the home. For others it may mean assisted living but approximately 95% of the clients I assess want to stay at home. Some are willing to incur the intrusion of caregivers coming into the home, and some will refuse help all together.
There is no hard and fast rule about how to have a discussion about assisted living, but here are some tips that I give family members:
• Talk openly and honestly about your concerns. Be specific. Try and stay objective and avoid becoming overly emotional or argumentative.
• Listen. Ask the elder what they see as concerns, and be prepared for the fact that they may see nothing wrong even in the face of glaring problems.
• Know that the topic of money will most likely come up. Do your homework and have a financial plan in place that will address cost issues. For example: selling the home; taking out a line of credit; tapping into long term care insurance; family chipping in, etc.
• Be prepared to negotiate. Suggest a trial period of hiring caregivers to come into the home with a defined date of “checking in” to see how it is going. Propose a respite stay in assisted living while you are out of town. A respite stay is a short term stay in a room in assisted living that is fully furnished. It can be a good way to try out assisted living without making a commitment.
• Accept that there may be nothing you can do. Assuming that an elder has capacity, then they are entitled to make bad decisions. However, don’t give up and don’t get mad. It won’t help. Try and keep a positive attitude, and humor can help: