Q: My 87 year old father lives alone. His house has become increasingly dirty, but he refuses to get help, even though I’m sure he needs it. I’m worried that he’s becoming incompetent, but he doesn’t want to go see the doctor. What can I do?
A: This situation does come up a fair bit with aging parents and relatives. I’m sorry to say there usually are no easy solutions. But there are definitely things you can and should do, and it’s better to act sooner rather than later.
Let’s review what you can do. I’ll also explain what I’ve learned about “incompetence” over the years, and how doctors usually play a role in the evaluation of such older adults.
Then, I’ll share some thoughts on how older people and families can plan ahead, to avoid facing this kind of dilemma. And then last but not least, I share a few thoughts on taking care of yourself as you go through this.
What’s probably going on with your father
The usual concern, for a person of this age, is that the person may have developed a dementia such as Alzheimer’s disease.
This is a pretty reasonable worry, since an estimated 30% of people aged 85+ have dementia. And of course, if your older parent seems to be doing worse than before, when it comes to activities that require mental organization (such as keeping a house reasonably clean), that further increases the chance that some kind of brain deterioration is causing problems.
But, we should never start by jumping to the conclusion that someone has developed dementia.
The main thing you wrote above is that you’re worried about a dirty house and a refusal to get help. This could be due to thinking problems. But it could also be due to pain and mobility problems, combined with a common reluctance to accept assistance.
Still, I have to admit that in many similar cases that I’ve encountered, the older person does have cognitive impairment. And we do often find it’s substantial enough and irreversible enough to qualify as dementia. (For more on dementia diagnosis, see my post “How We Diagnose Dementia: the Practical Basics to Know.”)
Now, even if he does have dementia, that doesn’t mean we can’t improve his thinking. I often find that by adjusting medications or the older person’s situation, we can optimize brain function and help the person manage better, despite the underlying dementia.
We also sometimes find that an older person is experiencing delirium from an illness or other health problem, which can make the thinking worse than usual.
So, getting him the right medical evaluation and optimization is key. You might even be able to get him to the doctor not by saying “You need to be checked for dementia,” but by saying “We need the doctor to help you feel your best and be your best, since that helps you keep living at home for as long as possible, which you’ve said is important to you.” (It’s key to frame your suggestions as ways to help your father achieve his health and life goals. See more tips on what to try saying here.)
Of course, these are all things that can be found out after the older person has been medically evaluated, and by someone who knows how to assess cognitive symptoms correctly.
Part of your frustration is that your father doesn’t want to go see a doctor. So you’re stuck: worried that something’s wrong, worried that your father has become “incompetent,” and unsure as to how to move forward since your father is refusing to cooperate. Let’s talk about your options for doing something, despite your father’s reluctance.
How to get help in helping your father
Start by asking yourself whether you think your father really might have lost mental insight and abilities, as opposed to simply making choices that you disagree with. (See “8 Behaviors to Take Note of if You Think Someone is Getting Alzheimer’s“.)
If you think he really is cognitively impaired, then you probably should consider pushing things a little more, to get him the help he seems to need.
I would also encourage you to make a list of specific concerns and red flags. You can use the “Quick Start Guide to Checking Older Parents” or a similar checklist, to help you identify specific problems that need attention.
Once you’ve decided how worried you are about dementia, and listed the key problems to address, here are some resources that can help:
- Your father’s regular doctor. This can be a good place to start, especially if it’s a doctor who has known your father for a while. Contrary to popular opinion, the HIPAA regulations (which govern the privacy of health information) do not preclude you, an adult child, from contacting your father’s doctor and relaying your observations and concerns. You can see if the doctor is willing to hear you out on the phone, and then do send in your concerns in writing, since those will usually be scanned into the chart. The doctor may be able to help you persuade your father to come in. On the other hand, if the doctor waves off your concerns saying there’s nothing to do, you’ll need to look elsewhere for help. And you’ll want to look for a doctor who is more up-to-date on the medical care of seniors with cognitive impairment. (See this post for related ideas.)
- Adult Protective Services (APS). To find contact information for your local APS office, enter your father’s zip code in the locator at Eldercare.gov. APS caseworkers respond to reports of abuse or neglect of seniors, including “self-neglect.” Generally, the identity of the person reporting a concern to APS is kept confidential, so your father wouldn’t be told you reported him (although he may have his suspicions of course). APS offices tend to be overworked and underfunded, as is often the case for social services. But in principle, they will look into the situation, visit your father, review medical information from his doctor, assess his capacity to understand risks and give informed consent, and take action to ensure his safety if warranted. APS does sometimes initiate a court petition for legal guardianship of an older person. For more on APS, click here.
- Social worker experienced with older adults. To find a social worker to help you troubleshoot the situation, you can try calling your local Area Agency on Aging (see the Eldercare.gov locator again). Some primary care offices also offer social work services, especially if they are bigger or serve vulnerable populations. You can also try asking around at local senior centers. That said, in my experience, it’s rare for social workers to visit aging adults at home unless they are sent by a home health agency. So although it’s worth looking for one, if you want someone to go see your father at home — which you probably do — you may need to pay for a geriatric care manager or other “senior problem solver”.
- Geriatric care manager or eldercare expert. These professionals usually have to be paid out-of-pocket, and they specialize in helping aging adults and families get through all kinds of late-life challenges. They usually have a background in social work, gerontology, nursing, and/or family therapy. I have worked with several of them and they are quite helpful to families. They can do things like coach adult children on how to more constructively discuss difficult topics, mediate family conversations, and help families find the right kind of help. To find a professional affiliated with the Aging Life Care Association (formerly the National Association of Professional Geriatric Care Managers), visit AgingLifeCare.org.
How to know if an older person is “incompetent”?
Now, you’re getting help because presumably you want to help your father with his goals, which for most seniors include maintaining independence, dignity, and quality of life.
But you also mentioned a worry that he is becoming “incompetent.” This is an important question to address, and families often ask me to weigh in on this. What I tell them is that as a doctor,it’s not for me to say whether the person is “competent.” Instead, my role is to help assess an older person’s capacity to make medical decisions, and also to identify underlying medical problems that might temporarily or permanently affect decision-making.
You should know that the term “incompetence” was historically used to refer to a legal determination. In other words, it’s up to courts, not doctors, to say whether someone is incompetent. This is governed by state law so different states have different criteria. But overall, if someone is found in court to be incompetent, they often will be assigned a guardian or conservator to manage decisions on their behalf.
To decide whether an older person is legally competent, the court will need to know about the person’s ability to manage certain major types of decisions. These might include:
- Medical consent capacity
- Sexual consent capacity
- Financial capacity
- Testametary capacity
- Capacity to drive
- Capacity to live independently
For more on incapacity, see this article: Incompetence & Losing Capacity: Answers to 7 FAQs.
The tricky thing about capacity is that it can certainly change depending on the day and situation. For instance, a person who is sick and delirious might temporarily lose all the above capacities. A bad depression could also affect capacity for some time. People with dementia or other forms of cognitive impairment are also prone to have their mental capacities fluctuate somewhat, depending on the day and whether their brains are functioning at their best.
So how do doctors and psychologists weigh in on capacity? The truth is that it’s pretty variable, and it’s also an area of law and clinical practice that is evolving.
For the best information on how clinicians should address issues related to capacity in seniors, I recommend this resource, which was created as a joint effort between the American Psychological Association and the American Bar Association.
“Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists“
Obviously, as it’s written for clinicians rather than for the public, it’s rather long and technical. (There are links to similar handbooks for lawyers and for judges here.) But if you really want to understand this topic, that’s the best info I’ve found.
But bear in mind that although the handbook above describes the best recommended practices, many clinicians may practice a little differently, often due to lack of time or training.
For instance, because medical problems often interfere with an older person’s mental capacities, doctors are routinely asked to weigh in. In principle, when asked about someone’s capacity, a doctor should first want to know “Capacity to do what, or decide what?” And then the doctor should write a statement specific to that question, providing documentation supporting his or her conclusions. The doctor should also ideally state whether any incapacity seems likely to be permanent or not.
But that’s not how things often work in the real world. In practice, I’ve often been asked just to say whether an older person “has capacity” with no additional specifications. I’ve also seen many doctors write vague statements saying “Mr. So-and-so has lost his mental capacities.”
How valid are such statements? I don’t really know, and suspect it depends on the jurisdiction and the purpose to which the doctor’s note is used. For instance, some people have trusts or other services that require a “doctor’s statement” in order to allow someone else to step in, and these may have different standards compared to the courts.
How to plan ahead to avoid these problems
The very best approach, of course, is for an older person to have previously planned for this situation. By this, I don’t mean simply completing paperwork in order to designate a relative or friend as durable power of attorney for health, and also for finances.
Don’t get me wrong, planning ahead with such power of attorney paperwork is very important and very helpful. (Read more about this here: How to Avoid Problems Due to Aging Incapacity: The (Better) Durable General Power of Attorney.)
However, such power of attorneys don’t quite address the situation that all aging adults should plan for: the possibility that they’ll be cognitively slipping and unable — or unwilling — to admit it and let others assist as needed.
I have only rarely seen older adults prepared for this, even though everyone has a fairly substantial chance of developing Alzheimer’s or another dementia provided they live long enough. (Remember, about 30% of those aged 85+ are cognitively impaired, and it goes up to about 50% of those aged 90+.)
Being a doctor, rather than a lawyer, I’m not qualified to say what constitutes the best preparation. I will say that the better situations that I’ve encountered occured when an older person had:
- Created a trust,
- Designated a trustee or fiduciary to take over when needed,
- Specified what conditions would trigger trustee take-over, and
- Specified what the care priorities should be in the event that the older person was unable to make decisions.
But again: I am not a lawyer and this is not legal advice. The expert advice consistently is to plan ahead, plan ahead, plan ahead.
To that I would add:
- Hope for the best
- Plan for the likely (eg eventual severe dementia if you’ve been diagnosed with mild dementia)
- Plan for the quite possible (a fall in which you break a hip, eventually developing dementia, etc)
Your father did not plan for this situation. However, as you help him work through the current situation, keep the above planning principles in mind! You’ll almost certainly have more to plan for, especially if he does end up diagnosed with dementia (which means you or someone else will need to make decisions at some point).
Don’t forget to take care of yourself!
As I said at the beginning, this kind of situation is hard to sort through.
It’s messy, and complicated, and stressful, and also tends to bring out whatever family tensions tend to come out when families face problems.
So. If you are worried about an aging father who lives at home alone and might be “incompetent,” you can’t just focus on helping your father. You’ll also have to start equipping yourself to handle what is likely to be a stressful and messy time for the next several months to years. Investing a little time — and possibly a little money — in this will pay off for your father, for you, and for those around you.
The basics of this include making sure you get enough sleep, regular exercise, nutritious food, activities that refresh the soul, and all the other things that are good for humans.
I would also recommend cultivating a mindfulness practice, if you don’t already have one. I have heard good things about the free guided meditations by Tara Brach, or you can try an app such as Headspace. The key is to do at least 10 minutes every day.
Last but not least, you’ll need support from friends and family. It’s also usually helpful to get support from others facing similar challenges with aging parents; you can find these in-person and online. (The most active caregiver forum I’ve found is at AgingCare.com.) You’ll connect with people in similar situations, who will provide helpful suggestions and will completely understand when you need to vent your frustrations.
Good luck!!
Let’s share resources & ideas!
Have you come across any good resources for addressing concerns about mental capacity, or legal incompetence?
Can you recommend any planning approaches, to avoid the messy situation this person is facing? (I’d especially like to hear about any books that really help families prepare for this type of situation.)
If so, please please share below! I’m always looking for more information and resources on this topic, since I see it come up for families all the time.
You can also learn more about incapacity and incompetence in this related article:
Incompetence & Losing Capacity: Answers to 7 FAQs
Thank you for this detailed and thoughtful article on a most difficult subject! I heartily concur with the ‘plan ahead’ mantra.
Six years ago I was determined to be the next of kin to a 94 year old spinster aunt with Alzheimer’s, who lived alone in a rural location, and who I’d not seen since I was a child.
The legal process of appointing me as her conservator was time consuming, intricate, exhausting and expensive. Now, this may vary from state to state, and be somewhat dependent on the financial resources of the elder subject, but had she put some safeguards in place earlier, much of that could have been avoided.
I will say that the experience has spurred me to critically evaluate each medical and financial decision with regard to the future. And that’s not really as daunting as it sounds. It can be as simple as including a trusted family member or friend on your contact info at the doctor’s office. Or adding a trusted adult child to your online account access.
Thanks for your comment. Yes, I consistently hear that conservatorship is expensive and time-consuming. A care manager colleague also pointed out to me that conservatorship in California means one has to periodically return to the court and account for what has been done.
That is lucky for your aunt that you were able to step in!
Thank you Dr. Kernisan for writing this article. It is one of the best and most thorough explanations on these challenges that so many people face but don’t know how to handle. I look forward to sharing this with my audience.
Thank you, glad you found it helpful!
I appreciate all the info included in your article.
My 96 yr old dad lives next door. Mom is private pay in nursing home costing dad $3000 a month – half his monthly income. They signed Power of Atty to me 2 yrs ago as well as making a Will making me sole heir, but now my 46 yr old brother was released after 20 yrs in/out of prison for drugs and my dad has gone nuts about him again !!
Dad says he wants my brother to have “as much as me”.
(I never asked for any thing and worked hard at my jobs, retiring early after 26 yrs teaching because they needed help getting to dr appts erc.
Dad Already gave my brother half their savings (only $20,000 in savings because dad spent hundreds of thousands over past 20 yrs on brothers lawyers and rehabs and paying off hit checks, etc.)
And my brother owes over $50,000 in back child support.
And since dad is paying ALL my brothers expenses now for apt, 2 autos, insur, groceries, etc my brother is not even looking for a job.
I know my dad has Alzheimers. He is a retired state judge, and even his lawyer friends told me they would testify he is incompetent, but I can imagine the fight in court if I try to have him declared incompetent.
He just gave my brother a deed for 30 acres of land to use as collateral to build a house for my brother – (bulldozers are clearing the land today) and I believe he is already using drugs again.
I feel so helpless and hopeless that dad will literally spend every penny.
I know you cannot offer legal advice, but reading your article has helped me think of a few things to try.
Thank you
Wow, sounds like a difficult situation. I cannot offer legal advice but if your father has Alzheimer’s and doesn’t entirely understand the ramifications (financial and other) of his decisions, then it’s justified to take action to protect your father. Taking financial advantage of an older person can sometimes also constitute elder abuse
Some ideas to consider:
– Approach your father’s doctor, express your concerns, and ask for assistance. Doctors can help assess your father’s capacity for these transactions. Depending on how the power of attorney form is worded, sometimes a clinician’s letter can enable the POA to take action and override the person.
– Contact your local area agency on aging for advice and assistance. They might be able to help you determine whether you’d be justified in reporting the situation to Adult Protective Services.
– If you truly believe your father may be lacking mental capacities, when your father prepares to engage in a legally binding transaction, you may want to bring up your concerns to the professionals involved. Some will delay the transaction while they wait for confirmation that the older person has mental capacity to complete the transaction.
– Get help from an elder law attorney if you can afford to do so.
You should also express your concerns to your father, but I’m assuming you’ve already attempted this. Sometimes a conversation mediated by a geriatric care manager or other professional is more productive, because they have experience managing these types of difficult conversations.
Last but not least, I recommend you listen to my podcast interview with attorney Carolyn Rosenblatt; she specializes in sorting out these types of situations and provides a lot of insights during the episode.
Good luck!
Such a difficult situation as of course you don’t want to be patronising to your father, but equally if he needs help, he needs help. There are lots of options available. One good option to consider if you are worried about his safety while living alone is a personal alarm which he can press if he is in trouble. It will give you some peace of mind!
My name is Beverley Sandler and I am a highly qualified Counsellor in Manchester. I read your post with great interest and can relate to a lot of what you have said.
Just a quick thank you for creating the content.
Thank you for reading, I’m glad you find it useful.
Hello,
I have read all the posts on this topic…however, I have a different problem.
My mother is 74, and is losing her memory, and has type 2 diabetes. She retired over 4 years ago, and lives alone. My problem is this, She has a “friend” that says he is an RN, and used to work at a local prison for 30+ years. Things have gotten really bad between my mom and I in the last few months, due to this person filling her head with lies. He has her thinking Iv’e been stealing form her, (I use to pay her bills, rent, buy her meds etc.) I had to stop doing this for her, and let her do her own thing because this person
has gotten into her head. BTW, she’s also an alcoholic. I found out through an online background check that this man isn’t who he says he is. He’s not an RN…but is a L.V.N. has no record of ever working at said prison, never been married, has a bunch of homes under other woman’s names around the age of my mom, and too many alias’s… He goes to moms every night, plies her with as much wine as she can drink, (did I mention she has type 2 diabetes?) and is now telling her she needs to put her car in his name so he can get her insurance…I’m at my whits end!…I have no idea what to do, who to call, but this clown is dangerous!, and I can’t get through to her…Please help me.
Lisa Marie
Yikes. He does sound like a very shady character and I can see why you are worried for your mother. It also sounds like a potential financial abuse situation. There are a couple options for you to get help.
– Call Adult Protective Services. You can find your local office by using the Eldercare.gov Locator; just put in your zip code. You can also find your local Area Agency on Aging at Eldercare.gov, and they might have other resources for you.
– Consider reporting the situation to the police. (They may or may not intervene, but they should be able to tell you who else you can call.) You might even get this person to back off by telling him you are reporting him to the police.
– Consider looking into a capacity evaluation for your mother, or possibly guardianship. Adult Protective services sometimes initiates this, if they think a situation warrants it. You might also be able to learn more about this through nonprofits in your area, or you may want to consult with an elderlaw attorney. If your mother is losing her memory, is alcoholic, and is making choices that put her wellbeing and safety at risk, then she may need at least partial oversight from a conservator or guardian. Establishing such oversight is done through a court process. The alternative is to invoke a durable power of attorney and establish that she has become incapacitated, but often when these situations come up, the older person has not set up a durable power of attorney.
I have more on capacity and incapacity here:
Incompetence & Losing Capacity: Answers to 7 FAQs
Good luck and keep going! Although she probably doesn’t appreciate it right now, your mother is very lucky to have you looking out for her. I think Adult Protective Services will be a good starting point, but also sounds like you may have to think about how you can oversee things for you mom longer-term.
Your email about this couldn’t have arrived at a more appropriate time. Thank you so much for people like you who are helping people like me navigate a completely alien area which I didn’t see coming!!. I’m UK based, the only person that can help my 74 yr old mum, who lives on her own & refuses help, despite severe arthritis, numerous falls and mobility problems, and like everyone I have my own home & life to manage 15 miles away, and have health issues myself. I’m just gathering as much info as I can on help/advice etc and your email popped up 🙋♀️ We have a website called CarersUK full of helpful info. If I find any other resources along the way I’ll let you know, but there is a free course on mindfulness on a website called Futurelearn, which I’m about to register for. I think I’m going to need it! Thanks again Dr Kernisan.
Hello and thanks for sharing your story.
I am a huge fan of mindfulness for caregivers; basically it’s essential to start investing in improving and maintaining your own abilities to cope with stress and uncertainty. Good luck and keep in touch!
Occupational therapy practitioners are highly trained in this area and can work with both the patient and their families to approach and evaluate a situation such as the one described in this article. More importantly, they are trained do it in a non-threatening way. The environment might need to be modified to simplify the process of keeping it clutter free and manageable.
I have found that it’s crucial to involve the patient in the process to use their volition and come up with solutions that specifically individualized to their needs. For example, I had a patient who could not stand at the sink long enough to do the dishes, so they would pile up in the sink. This was a drastic change for her and her children noticed. She was a proud lady and she didn’t want to be a bother to her kids. Working with her, we came up with a simple solution of keeping soapy water in the sink and having her drop the dishes in to soak after her meals. This made it is easier for her to throughout the day go and and rinse them and put them on the drying rack without spending ten min at the sink. We also modified her kitchen set up so she could easily sit down to perform the task or meal prep and changed her where she stored items to make it easier for her to have access to cabinets. This is just a small example. I hope it helps.
Thank you so much for the great work you do Dr Kernisan. I really enjoy your podcasts and articles and always learn a lot from them.
Thank you for sharing this example. I agree that occupational therapy (OT) is often very helpful and would love to see more older adults accessing this type of help.
Most older adults will need a referral from a health provider, to get an OT evaluation. My own patients have sometimes gotten them at home as part of home health care services, which they get either due to recent hospital discharge or because they are homebound and have a need for skilled services.
What a great article–jam packed with good ideas and resources. I have also found the daughterhood.org website to be very helpful.
So glad you liked it. I, too, am a fan of Daughterhood.org and often encourage people to visit that site.
“How to plan ahead to avoid these problems”
Many mentally healthy, educated older people do not want to live if they are “incompetent”.
This has been a taboo subject – but I find more older people are talking about this openly.
. . . and “planning ahead”
Well, one may “not want to live if ‘incompetent’,” but arranging for alternatives is tricky, and a failure to plan at all often results in family members have to go through a lot of difficulties.
I think it will always be a tough topic that many people avoid, but agree that more and more people are becoming open to planning.
Great info! Look forward to learning more!
Thank you, glad you are finding this helpful!
Wow, this is so informative. My in-laws just had a visit from APS today. We have no idea who called them but they are blaming us. We have been paying their bills for them online for about 8 months because my mother-in-law kept overdrawing their checking account. It’s not hard to do, they are on a very tight budget with only their Social Security checks for income. They have not had any NSF charges or utilities turned off while we have been helping. In addition, we do their grocery shopping and lawn care for them. This past weekend my mother-in-law threw a fit and told us she no longer wanted us to do this for them (they still owe us about 1/2 of an $800 loan we made them to catch up their mortgage payments). we even tried to persuade them to open a separate account for the bigger SS check (his dad’s), just to draft the fixed bills out of, but they refused when we said my husband’s mom shouldn’t have access to it since she has a habit of pulling money out that isn’t really there. Now APS shows up at their door and they are convinced we did this to them. I didn’t even know this could happen, but it may be a blessing. My father-in-law refuses to bathe (we bought him baby wipes as a last resort), won’t allow us to get him help (although the VA might provide it). They have a poor relationship and he sleeps most of the day to avoid his wife. I could go on and on, but what I need to know now is what will happen now that they are on the radar of APS?
So, what you’re describing is not uncommon, but it is indeed stressful for families and everyone involved. Sounds like there are some concerning issues going on. Interesting that you don’t know who called APS. It is actually possible that it was a health provider, as they are mandated reporters in many states.
In terms of what happens next, that is extremely variable. APS offices are locally run, often locally funded, and what they do is determined by their local policies and also state law. You could call your local Area Agency on Aging or even the APS office, and they might be able to tell you more about how the process usually unfolds in that area.
Re Social Security, there is a representative payee program for people who are having difficulty managing their funds appropriately. The SSA website says “If you are concerned that someone you know becomes incapable of managing or directing the management of his or her benefits, please call us at 1-800-772-1213 (TTY 1-800-325-0778) to request an appointment to discuss your concerns. Generally, we look for family or friends to serve as representative payees.” Your husband may want to look into this further.
Otherwise, I would generally recommend avoiding arguing with your in-laws, and trying to instead establish as positive a relationship as possible. When older adults feel heard, understood, and respected, they are more willing to consider accepting at least a little help. Of course, the problem is that adult children are often quite frustrated and stressed out by the situation, plus many have loaded relationships with our parents to begin with. So it’s not so easy to be positive and understanding and validating, but I can tell you that the more confrontational your encounters with your in-laws, the harder things will be.
Good luck, hope things improve soon!
My father has been getting really difficult to help recently. He doesn’t want to go to the doctors, but he really needs more medication to help him with his pains and aches. Thank you for the advice about wording things in a different way to help him go to the doctors. I will make sure, I always let him know that I want to help him. I am also thinking of finding a nice assisted living service. My dad is my priority, but I also need to make sure I am taking time for myself as well.
Sorry that your father is getting difficult to help. Yes, I agree that you can help him get more out of his doctor’s visits, but also be sure to take time to yourself, as you mention. Good luck!