Cognitive Cliff: Addressing Dementia and Solitude Challenges in the United States

In the United States, around 25% of older adults experiencing cognitive decline are living by themselves, presenting a variety of risks and difficulties. Recent research highlights the inadequacy of the U.S. healthcare system in meeting the needs of these individuals, in contrast to the more efficient support systems found in European countries, Japan, and Canada.

These patients frequently miss medical appointments, mix up their medications, and lack a reliable emergency contact.

About a quarter of elderly Americans who suffer from dementia or mild cognitive impairment reside alone, leading to dangers like unsafe driving, getting lost, confusion over medication, and failing to attend healthcare appointments.

A study published in JAMA Network Open by a team from the University of California, San Francisco, reveals that the American healthcare system is not fully equipped to address the specific requirements of individuals living alone with cognitive impairments. As the overall population ages, this group is expected to grow.

According to Elena Portacolone, PhD, MBA, MPH, from UCSF’s Institute for Health and Aging and the Philip R. Lee Institute for Health Policy Studies, living alone for these patients is a significant social determinant of health, comparable in impact to factors like poverty, racism, and limited education.

The study involved interviews with 76 healthcare professionals, such as doctors, nurses, social workers, and home care aides, across California, Michigan, and Texas. These professionals work in memory clinics, home care services, and social services.

Healthcare providers expressed concern over patients neglecting medical appointments, not answering follow-up calls, and forgetting the purpose of their appointments, which leads to them falling off the healthcare radar. A physician mentioned the lack of sufficient staff to reach out to these patients effectively.

Discharging a patient under these circumstances is likened to ‘sending a kid out to play on the freeway.’

Some patients were unable to provide missing information in their medical records, making it difficult for healthcare providers to track their cognitive decline. Many lacked emergency contacts, leaving them without any familial or friend support in crises.

These patients face risks of untreated health issues, self-neglect, poor nutrition, and falls. A house service coordinator noted that calls to Adult Protective Services were often ignored until the patient’s situation deteriorated significantly.

A major issue is that these patients often go unnoticed until they are hospitalized due to a crisis, such as a fall or medication mishap. Some are discharged without adequate support systems. In one instance, a patient was sent home with a taxi voucher, equated by a psychiatrist to ‘sending a kid out to play on the freeway.’

These findings criticize the U.S. healthcare system’s failure to provide subsidized home care aides for all but the poorest patients, as stated by Portacolone.

In the U.S., roughly 79% of individuals with cognitive decline have incomes too high to qualify for Medicaid-subsidized home care aides in long-term care, with a threshold of $20,121 yearly for a single person in California.

While Medicare covers adults over 65, subsidized aides are mainly provided after acute incidents like hospitalizations, for limited hours and durations. Most patients have to pay out-of-pocket for long-term care, which is not sustainable as cognitive impairment can last for decades. Medicaid-provided aides are often underpaid and receive limited training in caring for older adults with cognitive challenges.

In comparison, a larger percentage of people in parts of Europe, Japan, and Canada benefit from subsidized home care aides, as reported by Portacolone in a 2021 review of 13 countries.

The study by UCSF’s Division of Geriatrics underlines significant gaps in the U.S. health system’s care for people with dementia. Kenneth E. Covinsky, MD, MPH, a senior author of the study, emphasizes that while Medicare spends millions on marginally beneficial drugs, it refuses to fund essential support for vulnerable dementia patients.

The researchers advocate for a system where comprehensive supports are funded by an expanded Medicare and Medicaid. This is increasingly important, says Portacolone, as effective treatments for cognitive impairment are unavailable, and older adults are expected to live longer, often alone.

Reference: “Perceptions of the Role of Living Alone in Providing Services to Patients With Cognitive Impairment” by Elena Portacolone et al., 18 August 2023, JAMA Network Open.
DOI: 10.1001/jamanetworkopen.2023.29913

Frequently Asked Questions (FAQs) about Dementia Care Challenges

More about Dementia Care Challenges

• Cognitive Decline in the Elderly
• Healthcare Systems and Dementia Care
• Challenges of Living Alone with Cognitive Impairment
• U.S. Healthcare System vs. International Standards
• Elderly Healthcare Risks and Support Needs
• Subsidized Home Care Aides in the U.S.
• Geriatric Care and Medicare Policy
• Long-term Care for Cognitive Impairment