My father recently went into the VA Skilled Unit because he had been hospitalized for forgetting to take his insulin and heart medicine.  My father is 94 years old, has lived alone and taken care of himself for many years, he is incredibly healthy even though he has a heart condition.  His memory is failing.  We need to find assisted living for him.  He is intelligent, able to communicate well, will probably not pass the Goold Test as he is too well for that criteria to get into VA Residency Unit. What the staff doesn’t see is that my father is really, really good at covering up his forgetfulness, and at keeping up appearances.  Before he entered the hospital he had quit taking care of his hygiene, wasn’t taking his meds (unbeknown to us), started wearing the same clothes day in and day out, and was no longer interested in eating much.  Now at the VA he has blossomed, is eating like a horse, looks great.  What do we do?  He has very little money.  He is an incredible man.  Help!


Dear Help! This is Cliff. The nurses who perform his Goold Assessment (which is a testing procedure for older adults and disabled people over 19 years of age to determine their eligibility for long-term care services) will use standardized cognitive assessments that will likely detect his memory and cognitive impairments.  Given his history and the sensitivity of cognitive assessment instruments (about 80% or better for ones that assess both memory and executive functions in mild impairment, 100% in severe dementia), along with assessments done, they should be able to determine the appropriate level of care for him. But your input will be important. From your description, he has improved quite a bit from his condition when he was first hospitalized. This suggests that while he was ill, he suffered from “delirium” or a transient worsening of confusion during a period of illness. Now you’re seeing his underlying cognitive impairment that may be severe enough to consider dementia. There are many causes of dementia, many, such as Alzeheimer’s disease, are permanent and progressive. I hope he does qualify for the VA Residency Unit, but if he doesn’t, I’m sure he will qualify for other care homes.

But I have to ask: Does he want to return to his own home?  Without knowing more about him, it’s conceivable that this would be possible with home support services. For example, if his functional decline leading to the hospitalization was fairly quick (days or weeks), it may have been due to depression or a physical illness (e.g. urinary tract infection, respiratory infection, poorly controlled diabetes, hypothyroidism, anemia, adverse medication reaction, etc.) that has since been treated. In other words, did he have acute illness that caused confusion and self-neglect that resulted in the hospitalization? Now that he’s feeling better, he may be able to return home with home health and community support services to monitor his well-being, safety, hygiene and medication management. This assumes that he is motivated to return home and is now able to manage basic physical self-care such as walking, dressing and toileting.  Even if your father has mild to moderate dementia (as I suspect he does) he may be able to live at home a while longer if certain precautions are taken to help him stay safe. That said, he seems to be thriving in a supervised setting and probably appreciates having people around to talk to and offer help and support when needed.

Dear Help! This is Len. I am glad my buddy Cliff cautioned that you not rule out the possibility that your father may be able to return home at some point. It appears that at the VA he literally got “just what the doctor ordered” and, as a result of that specialized help, is now thriving. It may well be that he was not receiving the equivalent form of specialized help while at home. Home care services are available, and in Maine we have increasingly emphasized the importance that people be able to “age-in-place” or remain at home if possible. It is a well known fact that the vast majority of older adults want to remain in the familiar surroundings of their home and community for as long as possible even if their health is less than ideal. Assistance with medication management appears to be particularly important in your father’s situation as well as someone who can help do some periodic monitoring of his daily schedule of actiivities. The hospital discharge planner or a community care manager at the local Area Agency on Aging could help determine what a good plan of care at home would look like. Whatever the plan leads to – home or assisted living – make sure that your dad is fully involved in the discussion and decision-making process.    



Cliff Singer

About Cliff Singer

Dr. Cliff Singer is a geriatrician and psychiatrist who is Chief of Geriatric Mental Health and Neuropsychiatry at Acadia Hospital and Eastern Maine Medical Center and an Adjunct Professor at the University of Maine in Orono.