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Alarming reality: One in four Americans with cognitive impairment lives alone

In the busy era of modern life, the dangers of living alone with cognitive impairment may go unnoticed. But according to an alarming revelation from UC San Francisco, a significant number of older Americans face the challenges of cognitive decline daily, and often on their own.

Approximately one in four older Americans diagnosed with dementia or mild cognitive impairment lives alone. These individuals are susceptible to many dangers ranging from unsafe driving to wandering outside of their homes, confusing medications, and missing critical medical appointments. 

U.S. health system is unprepared 

Ultimately, the researchers concluded that the U.S. health system is largely unprepared to support individuals living solo with cognitive impairments. 

The repercussions of such a setup are profound, akin to the impacts of poverty, racism, and low education on one’s health, according to study lead author Dr. Elena Portacolone.

How the study was conducted

For the investigation, the team interviewed 76 healthcare providers spread across three states – California, Michigan, and Texas. 

The interviewees hailed from various specialties, including memory clinics, home care services, and social services.

What the researchers learned 

The picture painted by these professionals was disturbing. From patients who lost track of why they had medical appointments to those who remained unreachable for follow-ups, the gap in care was evident. 

One physician expressed frustration, saying, “We don’t necessarily have the staff to really try to reach out to them.”

In more serious instances, some patients couldn’t supply missing information on their medical charts. The lack of emergency contacts for many left healthcare providers at a loss. 

A system in crisis

A case manager pointed out the grim reality: many patients had “not a family member, not even a friend to rely on in case of a crisis.” The subsequent risks of untreated conditions, malnutrition, falls, and self-neglect loomed large.

The overarching challenge remains the lack of a robust infrastructure to identify and support these individuals before they face a severe crisis, like a medication-induced reaction or a fall. 

Some were discharged without a support system in place. In one case, a patient was sent home with a taxi voucher – a situation that a psychiatrist likened to “sending a kid out to play on the freeway.”

Disturbing trend

Furthermore, Dr. Portacolone highlights a concerning trend in the U.S. health care system. While 79 percent of people with cognitive decline don’t qualify for Medicaid-subsidized home care aides in long-term care due to their income bracket, paying out-of-pocket becomes unsustainable for many. 

“Most patients need to pay out-of-pocket and since cognitive impairment can last for decades, it is unsustainable for most people. Aides that are available via Medicaid are very poorly paid and usually receive limited training in caring for older adults with cognitive impairment,” said Dr. Portacolone.

By contrast, subsidized home care aides are generally available to a significantly larger percentage of patients living in parts of Europe, Japan and Canada, said Dr. Portacolone, citing a  2021 review of 13 countries, of which she was the senior author.

Rethinking priorities

“In an era when Medicare is going to spend millions of dollars for newly approved drugs with very marginal benefits, we need to remember that Medicare and other payers refuse to pay far less money to provide necessary supports for vulnerable people with dementia,” said study senior author Dr. Kenneth E. Covinsky of UCSF’s Division of Geriatrics.

The researchers believe in reimagining a healthcare system with robust support funded by an expanded Medicare and Medicaid. This will become increasingly critical in an age where childlessness and divorce are rampant, and older adults are living longer – often in solitude, noted Dr. Portacolone. 

This research is published in the journal JAMA Network Open.


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