Clinical Perspectives on Living Alone With Memory Loss

See related case.

American lifestyles have changed over the last 20 years, with more adults opting to live alone. Approximately 25% of people with early dementia live alone,¹ and the percentage is expected to increase as Baby Boomers age.

Providing clinical care to people who live alone with dementia is challenging, as they rarely report their own memory loss, much less seek medical attention for it. Instead, they are brought to their primary care providers (PCPs) by concerned family or friends or a social agency in a time of crisis. Disabilities from dementia that affect living alone include loss of executive function, time sense, visuospatial perceptual function, judgment, and memory. These impairments result in loss of daily function as well as psychotic symptoms, malnutrition, social isolation, hoarding, financial mismanagement, exploitation, and risks to safety. Common safety risks include driving, using the stove, falling, brandishing weapons, and using medications improperly.²

People who live alone with dementia need the structure provided by others, without which they become fearful and suffer misperceptions resulting in frequent calls to family, friends, and police. Social friends or neighbors may recognize the problems yet be too uncomfortable to address the issues. Some may contact family, if there is family, who may choose to not become involved. When help is offered, the person who lives alone with dementia may refuse. Under HIPAA regulations, PCPs cannot contact the families of people who live alone with dementia without consent.

Few social agencies can help, and Medicare does not pay for visiting nurses because dementing illnesses fall outside of the definition of “skilled care.” Social services are predicated on advocating for cognitively intact clients. If a potential client refuses social services, as is often the case with people who live alone with dementia, the agency can try to be involved but must respect the client’s refusal. In many states, there are few social mechanisms to deal with these vulnerable adults.

So, what is a provider to do?

• Screen elders for cognitive function annually. The Montreal Cognitive Assessment is a reliable screen for mild cognitive changes. Discuss findings of cognitive changes with patients who live alone and suggest that they begin to plan for a day when more assistance is needed. Suggest contacting the nearest Area Agency on Aging for assistance with planning for eventual needs, keeping in mind that the majority of supportive and in-home services are out-of-pocket expenses and require 4-hour minimum use. Few agencies can provide 24-hour supervision.
• When treating a person who lives alone with dementia for conditions that require medications, think carefully about prescribing only essential, minimum-risk medications, as the probability of medication errors is high. People who live alone with dementia may refuse medications, mix up tablets, take too many of a certain medication, and mix them with unknown over-the-counter agents. Often, the risk of mistake outweighs the potential benefit of the treatment. Prescribe once-daily doses of as few medications as possible.

Finally, if you feel that the person is experiencing failure to thrive, report the situation as “self-neglect” through the channels for dependent adult abuse in your state.

Financial disclosure:Dr Hall had no relevant personal financial relationships to report. Dr Yaari is a consultant for Amedisys.

References

1. Lehmann SW, Black BS, Shore A, et al. Living alone with dementia: lack of awareness adds to functional and cognitive vulnerabilities. Int Psychogeriatr. 2010;22(5):778–784. PubMed

2. Alzheimer’s Association. 2012 Alzheimer’s disease facts and figures. Alzheimers Dement. 2012:8(2):131–168. PubMed​