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.
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. (Unsure of dementia vs Alzheimer’s? Here’s a good explainer about dementia and how it related to Alzheimer’s.)
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.)
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.
For more tips on how to get an aging parent to see the doctor, even if they’ve been resisting, watch this video:
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 aging adults with cognitive impairment. For more on how the doctor should evaluate cognitive impairment, see here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.
- 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 older adults, 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 “eldercare 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 aging adults 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 older adults, 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 occurred 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 became permanently 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).
If you’d like to learn more about how to talk to your father about your concerns, and how to know when to step in, I cover this in more detail in my free training for families; see below.
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. A variety of free resources are available online, and there are also apps such as Headspace and Calm. The key is to do at least 10 minutes every day. Or for more support, enroll in a mindfulness-based stress reduction course, such as this one.
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. You’ll connect with people in similar situations, who will provide helpful suggestions and will completely understand when you need to vent your frustrations.
This article was first published in 2015. Because I have gotten SO many questions about these types of situations, I wrote a book to walk families through what to do, and it covers the question of incompetence. Learn more here. This article was last reviewed & revised with minor updates in March 2022.
Lesley Huckaby says
My mom was diagnosed a few years ago with dementia. Last year she was diagnosed with Alzheimer’s. We have Durable POA. We had cameras placed in her home to monitor her for safety. She can do self care and basic meal prep. Sometimes she eats only once per day. She lives in another state about 1000 miles from me. She sends emails and text messages. She seems coherent, then tells stories about events that are not real. For example: when paying her bills she is paranoid and cancels established online payments for electricity and other utilities. She then is late with payments and does not understand why. We pay the bill using her account which we have access to. then she later accuses us of stealing from her. She hits curbs frequently when driving. She has accused family of stealing from her. They removed an old lawn mower that no longer worked, replaced it with a new one that is easier to use. When she was having a confused moment she decided that it was a theft of her property. When visiting her, she became distressed and called other family to say she was fearful and needed to call the police to have family arrested for visiting. She escalated and could not be redirected. She then said she was afraid of being murdered by the visiting family. We called to tell them. They were stunned, because they had been having a nice time together and made plans with her for the next day for more fun. The cancelled further visits. Mom does not remember having felt that way or why. She doesn’t even remember the event. She regularly accuses those helping her of wrong doing. We have educated, compassionate family members trying to help her keep her independence. Her doctor told her it was time for assisted living. She decided that she would do assisted living, chose where to go, then later became fixated on family supporting her decision.she accused us all of conspiring to have her locked away for life. Sent many distressing emails and informed everyone she would never leave her house to visit anyone for fear that they would have her locked up. Fast forward two weeks and she was calling distant relatives asking if they would like to buy her house so she can move somewhere warm. ( she does not need to sell her home to do that). She has asset protection, but she still has legal authority to sell her property on a whim. Some days when asked where she will move to she says some place warm. No realistic plans. When discussing the dynamics of finding a place, she says walking distance so she doesn’t need to go far for exercise. When we ask about her dog. She then says, oh him too. It’s as though we need to ask her a question at a time for her to make a plan, because she doesn’t consider it until she is asked. She answers rationally, then after a few questions becomes distressed. Then gets fixated ( because she becomes anxious) about why we would ask her those questions- basic questions. Then accuses us of trying to keep her from her dreams. We are just helping her in the moment for what she wants to plan. However there are basic things she needs to consider. Then she plans a drive across country. She studies the map then tell us she is leaving for fresh air and open road. We ask if she an her dog are going to air BNB or hotel then she is not sure what we are talking about. Accuses us of trying to take control. How do we proceed getting her care and protecting her assets. When she can veto POA?
Leslie Kernisan, MD MPH says
Thanks for sharing your story. I’m sorry you are facing these challenges. They are very common in dementia, but that doesn’t make them easy to navigate.
Re vetoing POA: in principle she can do it when she wants to, provided she has “decision-making capacity” when she does it. If she has dementia and is operating under delusions or confusion, she may not have the legal capacity. However, you might have to involve a lawyer to help determine this. What I would recommend is keeping detailed notes regarding her difficulties and trying to get other people (e.g. her doctor) to confirm her confusion and delusions.
In terms of other ways to protect her assets: I would recommend consulting with a local Aging Life Care Professional (also known as a geriatric care manager), for help navigating this type of complex situation.
We do also coach families through navigating this in Helping Older Parents with Early Memory Loss (which includes QA sessions with me and with geriatric care managers), and you can learn more about that program here: https://betterhealthwhileaging.net/helping-older-parents/
I need help with my father he’s 67 and has a family history of dementia… His mood has become out of the ordinary..hes said things he’s never said to my sister and my sister is in fear of his words and actions…he no longer performs daily tasks as usual…my mother has told me he hasn’t showered in a week and smells…has only done his laundry 1 time in almost 2 months…my mom and dad aren’t together…he showed up at my mom’s unannounced…my mom can’t put him out because of his age and me.. My father wasn’t there for me but how can i help him…he needs the help from someone …plz help me …i don’t want anyone else to give up on him I’m what he has left everyone else gave up…im at wits end and bout to give up…and i dont want to…
Nicole Didyk, MD says
I can hear from your comment that you care for your dad and are worried about the changes you’re seeing.
I recommend Dr. K’s book: When Your Aging Parent Needs Help: A Geriatrician’s Step-by-Step Guide to Memory Loss, Resistance, Safety Worries, & More. It has practical advice for how to communicate with your parent and family members.
If you can get your father to a medical professional, they can help ensure there isn’t a medical issue that’s brought about the changes you describe.
This article discusses things to try when your parent is irrational: https://betterhealthwhileaging.net/qa-4-things-when-aging-parent-irrational/
Remember that you also need to look after yourself. No one person can do it all alone, no matter how much they may want to.
Juan Estrada Jr says
my dad has drinking problems and anger management issues
Nicole Didyk, MD says
Hi Juan. I’m not sure how old your dad is, but most of my experience is with older adults, aged 65 and up.
When a parent is living with mental health and addiction problems that aren’t well managed, it puts a strain on the whole family. AL-Anon or Ala-Teen are great resources for families of people with alcohol issues: https://al-anon.org/for-members/group-resources/alateen/
M Goodman says
I was wondering if the neurotrax computerized test is is a final accurate test for dementia /Alz, etc and what your thoughts on this would be.
Nicole Didyk, MD says
I just took a look at their website and it appears to be a service that does cognitive testing and generates a report. Some of the tests they list are ones that a psychologist, neurologist or geriatrician might use in the office (for example the “Go-No-Go” and “Stroop interference” tests).
These kinds of tests can pick up patterns of cognitive performance that could be in keeping with dementia, but it takes much more than a cognitive test result to establish a dignosis of Alzheimer’s disease or some other type of dementia. In this article, Dr. K explains how we come to that diagnosis in Geriatrics: https://betterhealthwhileaging.net/how-to-diagnose-dementia-the-basics/
Thank you for writing this very informative article. I was surprised to read your statement of “30% of adults over 85 will develop dementia.” I have read in several places that it is 50%. I would appreciate you citing your source, so I might refer to it. It is less than I have been telling families, so it is an encouraging number. So many people think that it is 100% normal to have memory loss, which we know it is not.
Nicole Didyk, MD says
Thanks for your comment! I tend to use the data about dementia from the Canadian Study of Health and Aging, which I will admit, is getting a little old now, but seems to be accurate. For sure, the prevalence of dementia depends on the setting and we know that in a nursing home, about 70% or more of older adults are living with dementia of Alzheimer’s or another type.
I was able to get my mother to stop driving in 2013 after she got lost several times in her tiny unincorporated town. She refused to move, allow in-home assistance, or see a doctor during the last decade. When I consulted with the attorney that did her trust many years ago, I was told it would be expensive to pursue Conservatorship, would most likely fail, and I needed to wait for something really bad to happen. I retired early after 2 years of trying to assist her as a single parent commuting to a stressful job. After retiring, I was at her home 2-3 times a week a 2-hour roundtrip from my home. Many bad things happened over the last 9 years with no resolution: Excessive drinking & smoking, bills not paid, dormant bank accounts, 2 trips to the ER (including 5150 by Sheriff). 2 APS cases by neighbors (both closed by APS because refused to accept help), wandering, excessive calls to the Fire Department, maintenance issues like flushing things down the toilet, and other erratic behavior including cutting phone lines at jacks in the house. She turned 88 last September and the last year became too much for me. Last summer after the 2nd APS report, they asked for a copy of her trust. Her lawyer provided it to them. After reviewing it, APS stated there was nothing they could do. In late September, there was a multi-day power outage and I brought her to my house to stay with me and my now-husband. After a couple of days, the severity of her Sundowner’s became readily apparent with hallucinations, imaginary phone calls, abusive language, and bodily threats to us. In the morning, we called 911 and she was sent via ambulance to the ER in the middle of our Pandemic lockdown. Doctors determined she did not have a UTI and formal diagnosis of moderately severe dementia. Behavioral Health @ Hospital said she needed to be in a care facility, but the discharge planner would be pressuring me to take her home. Subsequently, the discharge planner said there were no physical issues and insisted I take her to my house. I refused and after many phone calls with the hospital, I was able to get 2 doctor’s letters of incapacitation to activate Springing Power of Attorney and Durable Power of Attorney For Health Care Decisions. I worked with the agency and arranged placement into a small Memory Care facility. I arranged for her to be in-home health care program for care within the facility. Recently, that program’s doctor did find another physical issue through recent lab tests. Back in 2014, APS stated that she was a Self-Neglector. and this State has made it almost impossible to navigate these situations. At this point, at least she is in a safer situation, getting care, and bills are paid. As an aside, the Springing Power of Attorney has not been honored in all situations even though legally it should be acceptable per Trust attorney.
Nicole Didyk, MD says
Thanks for sharing your story and what a journey you’ve had with your mom! I’m so happy to heat that she is in a safe place now.
I’m sorry that you had so much trouble with getting the right care for your mom, and it’s disappointing that the attitude you report was that “it’s only dementia, no physical issues”! Dementia is a major neurocognitive disorder that can affect health in so many ways, and is not a normal part of aging.
Good for you for being such a resourceful advocate and being persistent. Hope you and your family stay safe and well.
Patricia Rosser says
I have a 74 year old non family member living with me. She has had 4 stokes, and is a diabetic. She has some memory loss. She can’t remember things that happened yesterday or today. And when she does it will be days later and only bits and pieces of it. She can not read or drive. She can bath herself, make a some foods but not cook on the stove. She is verbally abusive to myself and others in the house. None of her family wants anything to do with her. HOW DO I GET HER OUT OF MY HOUSE? I am expecting a baby in May and need the room she is in. We have given her a 30 day verbal notice back in July and she is still here. She thinks she can live on her own. And she says her doctor says there is nothing wrong with her mind and she can live on her own. She says she wants to move out but don’t like any of the apartments I have taken her to see.
Nicole Didyk, MD says
It sounds like you’re in a tough spot with this older individual. Situations like the one you describe are complicated, and getting out of such an arrangement probably depends a lot on whether there is a legal agreement (like a lease or contract). In any case, it would be a good idea to contact a lawyer about what needs to be done to get a person to leave your home, especially if there are health issues that might make a move more challenging.
Bonnie Erxleben says
Your article is very informative. We are currently encouraging my husband’s Mom and Dad to go to “assisted living” of some sort. They told us they were ready, we had a family meeting to plan this out, and now they are refusing to go. They have dementia and are falling more frequently, they are not safe to live alone at all. They are so cantankerous, I’m not sure anywhere will be able to keep them without something saying you have to be here. Going to Dr Monday and will start there, we are really trying to be reasonable with them, but it’s out of control right now.
Nicole Didyk, MD says
I’m so sorry to hear about the situation with your in-laws, and it’s actually very common for people to vacillate about a decision to move to an assisted living type of setting. It’s great to hear that your in-laws have agreed to go to the doctor next week,and sometimes the voice of the physician can carry more wright than family members.
Dr. Kernisan has a lot of helpful advice about how to manage with aging parents, especially in the Helping Older Parents Membership.
This article about how to respond when there’s resistance may also be helpful. It’s often a slow, gradual and arduous process of finding common ground and balancing respect for the parents with some gentle pushing. Good luck!
Thank you for the detailed information in your post and a big thank you to everyone who shared their very personal experiences! I actually am on the opposite end I need to.have legal documents prepared in advance in case I would become legally incapable of making decisions in the future. I am a single mother of 3 daughters ages 29, 27 & 17 and I do not want to leave my children with the burden of trying to gain access to information or be denied resources necessary for medical and financial decisions as I do have medical issues.
After reading this post I am definitely convinced I need to move quickly to set this up for my family. I would really hate to leave a burden on my girls!!!
Thank you again you are so appreciated!
My mother in law who is 91 yo has dementia. In the past year and a half it has gotten worse. My husband and I live with her and try to take care of her the best that we can. We both work outside of the home 40 hours plus a week. On an average my mother in law is left at home by herself approx. 10 hours a day. she thinks that she lives somewhere else and is always asking us to take her “home”. My sister in law is POA and isn’t really helping, she is constantly taking trips for “work”. She’s gone on an average from 2 days to 2 weeks. Supposedly, my sister in law is trying to get hospice to come in and help. She has yet to make an appointment with my mother in laws doctor. I’m personally my mother in law’s caregiver and it’s really starting to get to me to the point that I’m considering leaving. I don’t know what else to do. APS has been called twice and really hasn’t been much help. The POA is doing nothing to help.
Nicole Didyk, MD says
Hi Karon. You paint a picture of a very frustrating situation, which is common when trying to help an older parent and look after your own life. It sounds like the situation is not sustainable for you. I would encourage you to get help identifying other options for your mother-in-law’s care and also for negotiating oversight with your sister-in-law. Dr. K’s Helping Older Parents program would be one way to do this, and is more affordable than paying a local geriatric care manager, which is another approach to getting help solving these types of caregiving situations. Good luck!