Aging-In-Place and Its Limits

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer


July, 2019

Last month I wrote about advance directives and promised to explore powers of attorney (POAs) this time, but I’m going to defer that for a month and instead address “aging-in-place”, its value and limitations. Mt Vernon is actively planning a laudable community-wide program to allow more people with physical and/or cognitive limitations to remain here with help. Vienna, given its twin city status in Tom Ward’s “metroplex”, would be a logical partner as well.

People who age and/or develop limiting disease conditions, don’t suddenly lose all their abilities. They usually retain and can still use many of their skills and community memories to contribute to our social network. But new limitations may make it impossible for them to live in our very rural towns on their own. So, the aging-in-place program goals must include the development of support systems that complement their deficits. Hence either town government or local organizations must look for ways to help, including many non-profits, like Mt Vernon rescue, the Mt Vernon Community Partnership Corporation and its Neighbors to Neighbors home maintenance program, Neighbors Driving Neighbors (NDN), the Vienna Grange, the Dr. Shaw Library, and many others. 

Short-term impairments usually are so transient that no organized help is feasible or necessary, unless no family is around to help. However, some impairments, like delirium following major illness or inadvertent medication intoxication, may last several months and can be amenable to help if short-term facility rehabilitation is not available. Permanent impairments of vision, cognition, or mobility (walking and driving) are, however, the most common. People who suffer macular degeneration may no longer be able to drive, but everything else works. Those with cognition impairment may lose some, but not all, their skills, doing what are medically called “Activities of Daily Living” (ADLs) and “Instrumental Activities of Daily Living” (iADLs). 

There are 6 ADLs: 

  • Bathing
  • Climbing stairs
  • Walking indoors and out
  • Feeding Self if food is prepared
  • Dressing self
  • Toileting self

And 8 iADLs:        

          iADLs Each may be helped by these>                          Alternative aids

  • Using the telephone                                                      Medical alert systems
  •  Shopping for food, clothes and repairs                        Grocery deliveries
  •  Preparing food, including cooking                                Meals on wheels
  •  Doing house work                                                        Neighbors to Neighbors
  •  Doing laundry                                                               ditto
  •  Driving (or using public transportation)                        Neighbors Driving Neighbors
  •  Managing own medications                                         Visiting nurses
  •  Managing own finances                                               Family or other POA

Generally, a person can manage in his/her own home (age-in-place) if they have all or almost all their activities of daily living, or perhaps all but stair climbing (depending on their house setup), and/or walking outdoors. Instrumental ADL impairments usually need to be covered less frequently than daily and may be amenable to family, purchased substitutes (for example, like substituting medical alert systems for emergency telephonic skills), or community support systems.

So, these limitations are helpful to bear in mind when choosing interventions that would be most helpful to supporting aging-in-place. Missed by this list are the interactive social supports that usually come with them and are, themselves very important. For instance, talking and interacting with the neighbor drivers themselves, rides to local events, hair dressers, , or to other social activities are at least as, if not more important than rides to medical visits. But aging-in-place in a person’s own home is likely not to work if the person is incontinent, wanders and gets lost, falls down a lot, can’t bathe, dress, or feed themselves much of the time.

A final issue, as programs are planned, is how to find people who need the help. We know Mt. Vernon has a population of about 1650; precise numbers by age group and other parameters won’t be available until the 2020 census comes out, but getting those a year or more from now is important to do. In the mean time we can presume at least 20% or 330 are over age 65 and 10% or 165 are over 75 by state-wide statistics. Those people are thus more vulnerable to the cognitive and physical deficits that may interfere with their ability to take care of themselves at home alone. NDN, as an example, struggles with how to reach out and offer services to people with transportation needs. Low income residents are particularly needy because of their shortage of financial resources. Those who are both over 65-75 and under federal poverty levels have greater and increasing need with age, but may also be the hardest to find. NDN is getting help from town offices to identify and distribute offers of help to these folks. Sharing these efforts with others trying to do complementary interventions would make sense. 

I hope Mt. Vernon will be successful and suggest including Vienna and perhaps other adjacent towns in some of the programs they develop. But all-in-all, there are benefits to be shared both by those we help and our communities, which benefit from the continued involvement of individuals like Betty White, who continues to help run the Mt. Vernon food bank.