Monday, September 29, 2014

Cognitive Impairment and Normative Aging

Most people believe that memory decline is a normal part of aging, but this is a myth. Memory tends to slow with age like other functions, but decline in the ability to remember things is not a normal part of the aging process. It’s important to understand and recognize the difference.

One of the most common questions health professionals face when working with aging
populations and hearing complaints of memory loss, forgetting names, and having difficulty finding words is, “Is this normal?” As people get older, these experiences become frightening. Americans worry that these are signs of one of the greatest fears that they face as they age: losing their mental capacity (Charlton Research Company 2005).

The prevalence of dementia in North America is expected to rise by 35 percent from 2007 to 2050 (Brookmeyer, Johnson, Ziegler-Graham, and Arrighi 2007). Projections have health professionals and research organizations working hard to develop methods of assessment and early interventions, designed to detect and slow the progression of cognitive decline and diminished functional ability. The question remains: Is memory loss, difficulty concentrating, or other noticed change normal?

Understanding Cognition
To understand cognitive decline, it is first important to understand cognition. Cognition is a singular term for a broad range of overarching concepts. These include our abilities in domains, such as: 
  • Language (the ability to speak and understand spoken communication); 
  • Visual-spatial construction (the ability to understand the world around us and our place in relation to it);
  • Non-verbal reasoning (the ability to use things like remote controls, drive, and complete other more visually dependent mechanical tasks);
  • Attention, concentration and, tracking (the ability to focus on information);
  • Memory and learning (the ability to remember both in the short and long term, and our ability to acquire and keep new information);
  • Executive functioning—commonly known as higher functioning (the ability to sort and categorize information, and problem solve).
What is “Normal” Aging? 
The normative process of the aging mind is something of debate in the medical profession. But there is a foundational understanding of what are normative cognitive changes and what are warning signs of greater decline to come. The truth is, most of us do not experience cognitive impairment as we age—we experience cognitive slowing. As people age, there are detectable changes in the brain. Its weight declines by 10 percent by age eighty, blood flow diminishes, nerve conduction slows, and nerves experience cell death (Patel and Holland 2012). Cognitive abilities decline gradually with these changes, but tend not to affect overall function or activities of daily living. 

Studies have shown that even with gradual decline,the majority of cognitive abilities remain within a normal range (one standard deviation from the mean) throughout most of the lifetime (Hedden and Gabrieli 2004). What falls below this range as we get older
(late seventies and early eighties) is our ability to think quickly (processing speed), and our numeric ability such as paying bills and calculating tips (Hedden and Gabrieli 2004).

Most people believe that memory decline is a normal part of aging, but this is a myth. Memory tends to slow with age like other functions, but decline in the ability to remember things is not a normal part of the aging process. It takes us longer to retrieve the information we are looking for. The same is true of learning. While we could acquire information relatively quickly and retain it well when we were younger, it takes more effort to process, store, and retrieve information as we age. To summarize, as we age, we
can expect to take more time to think things through, spend more effort learning, and occasionally have difficulty remembering something, but eventually these tasks are completed.

What is Cognitive Impairment?
Impairment in whole domains of cognition, even with adequate time and assistance—such as being unable to remember familiar things, having difficulty with planning or problem solving, not being able to communicate or understand words—is not normative aging. Impairment in these domains however does not necessarily mean the person is experiencing a degenerative disorder. The severity of the impairment (mild or severe), the onset, rate, and precipitating factors all play a significant role in diagnosis and treatment. 

Diagnosis of cognitive impairment. With the transition from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition-text revision, to the Manual’s fifth edition (DSM-5; APA 2013), cognitive decline has been streamlined into mild and major neurocognitive disorders. These diagnoses come with subtype categories that include impairments consistent with the neurodegenerative diseases, such as vascular dementia and dementia of the Alzheimer’s type, as well as impairments consistent with other diagnoses, such as traumatic brain injury, and substance/medication-induced neurocognitive disorders.

Diagnosis is based on the severity and domains of cognitive deficits, interference with functional ability, and behavioral disturbances (APA 2013). Even if these aspects of a diagnosis are present, the decline is not necessarily permanent, especially in the case of delirium or substance-induced neurocognitive disorders. With diagnoses of mild neurocognitive impairment, although some patients progress to dementia, others remain
stable, or even improve (Patel and Holland 2012). 

Cognitive Screeners 
When assessing for specific diagnosis, medical professionals often use cognitive screeners that assess functioning in most of the cognitive domains mentioned. These types of screeners could include the Mini Mental Status Exam (MMSE) or the Montreal Cognitive Assessment (MoCA). These are “normed” tests, meaning they have been applied to a wide range of the population and have a particular cutoff point that demonstrates impairment greater than what we would expect from age-related decline. Although these screeners assess a range of domains, they give a global score for overall cognition. For example, an overall score of twenty-five or lower on the MoCA is concerning, because the vast majority of people score a twenty-six or above (unless they have an education below eighth-grade level). Depending on the level of impairment and corroborating information, a diagnosis may be made based on a screener, or additional, more comprehensive testing may be necessary.

Cognitive screeners have the same limitations as other screeners in the medical community. Where they may have sensitivity to a particular diagnosis (they will demonstrate cognitive impairment when it is present), they do not necessarily have specificity (the ability to accurately diagnose a specific problem, like dementia). Even when a score suggests impairment, it does not necessarily indicate the diagnosis or prognosis. Dementia is known to significantly impact executive functioning, language, working (immediate) memory, visual-spatial ability, and verbal memory (UCSF Memory and Aging Center 2014), but many other diagnoses and developmental components of the lifespan do as well. These include depression, delirium, traumatic brain injury, cerbrovascular accident (CVA) such as a stroke, transient ischemic attack (TIA)—often
known as “mini strokes”—learning disability, and lack of education, to name a few. Cognitive complaints are also a common side effect of many medications and whole treatment protocols, like chemotherapy.

If clients of CSAs or other professional advisors express concern about cognitive impairment, it is important to encourage them to seek medical consultation. It is not necessarily a dementia. Despite its expected increase in prevalence by the year 2050
(Brookmeyer et al. 2007), dementia’s current prevalence rates are lower than most people expect (18.9 percent of the population aged seventy-one to seventy-nine, 37.4 percent of the population aged ninety and older) (Plassman et al. 2007).

When seeking consultation with medical providers on cognitive complaints, patients as well as their care providers (spouses, children, concerned friends) should provide information on the onset (timing) of complaints, recent stressors, historical and recent injuries,current medications, lifetime substance use, family history of cognitive impairment, and any functional complaints (problems driving, paying bills, or preparing food). It is sometimes helpful to write these down before meeting with a medical professional. If a screener is administered, it is important to know that it may detect cognitive impairment, which clients may have already detected themselves. But it cannot provide the diagnosis by itself. As mentioned before, many different diagnoses can result in cognitive impairments that are not dementia and may fully resolve, improve, or at least remain stable.

Franklin D. Roosevelt famously said in his inaugural speech, “We have nothing to fear but fear itself.” In the realm of cognitive impairment, this is not an absolute truth, but it is a relative one. The fear of cognitive decline is often more significant than the decline itself, and more intense than the resulting diagnosis. •CSA


Carilyn Ellis is a psychology intern at the Salt Lake VA Medical Center, specializing in Palliative Care,Geriatric Home-Based Primary Care, Outpatient Mental Health and Neuropsychology. She has a master’s degree in clinical psychology and is a Psy.D. (doctor of psychology) candidate at George Fox University in Newberg, OR. She can be reached at

Cognitive Impairment and Normative Aging was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Monday, September 22, 2014

Write Your Living Will Now to Ease Burdens Later

A living will is a legal document that indicates what medical treatments and life-sustaining measures you want or don't want. If the time comes when you can’t make your own decisions, a living will can be valuable for your family and doctor and help ensure your preferences are honored.
Approximately 80 percent of Americans fail to share their wishes for their end-of-life care, leaving family members and doctors to decide what life-saving measures to perform. Not only can this result in family quarrels, but you may receive care that is more aggressive than you desire. For example, CPR (cardiopulmonary resuscitation), which has a low success rate, can be violent and leave patients in worse condition. Not only does it make sense to write a living will as you get older and become increasingly prone to chronic illness, but it is also wise to understand the treatment options and their risks. A living will is a legal document that indicates the types of medical treatments and life-sustaining measures you want or don’t want, such as cardiopulmonary resuscitation (CPR), feeding tube, and mechanical breathing (respiration and ventilation). In addition to a living will, people are also encouraged to have an advance directive known as a medical power of attorney (POA). (See “Assigning Medical Power of Attorney is Both Difficult and Easy,” October 2012, Senior Spirit).

A medical POA is a legal document that designates an individual—referred to as your health care agent or proxy—to make medical decisions on your behalf if you’re unable to do so. Like the POA, the living will becomes a tool to help your family and medical staff determine the life sustaining measures and medical treatments to pursue at the end of your life if you are unconscious or not capable of deciding on your own.

In addition to executing a living will and medical POA, it’s important to discuss your beliefs and wishes with family members and your doctor. If they know beforehand what measures you want taken—and, just as important, why—when the time comes, the process can be easier and less stressful for everyone. (For where to find forms, see sidebar.

Important Questions to Ask

When writing your living will, give serious consideration to the kind of treatments you want. Questions to ask yourself include:

  • How important is it to be independent and self-sufficient?
  • What would make me feel that my life was not worth living?
  • Do I want treatment to extend life in any situation?
  • Or only if a cure is possible?
  • How might my decision about life-sustaining treatment be different if I was 50, 70 or 90 years old?
  • Would the treatment lessen my suffering?
  • What kind of burdens and side effects will the proposed treatment impose?
  • What are the potential benefits and risks associated with CPR, a feeding tube, ventilation, etc.?

(Adapted from Mayo Clinic and American Hospice.)
Weighing CPR

When a person stops breathing or the heart stops beating, medical personnel administer CPR, which can consist of two stages: chest compressions (forceful pressing on the chest to stimulate the heart) and artificial respiration (mouth-to-mouth rescue breathing). In addition, personnel may use electric stimulation and special medicines to resuscitate a stopped heart. CPR can help keep oxygenated blood circulating through the body, which can help prevent brain and organ damage. Without CPR, a person is likely to become unconscious almost immediately and will die in 5-10 minutes.

However, when a patient has an advanced life-threatening illness (such as late stages of cancer) and is dying, CPR may not provide any benefits (Family Doctor). Additionally, the survival rate after CPR is only 15 percent, but it decreases to 2 percent for the frail and elderly (Allina Health). If successfully, CPR may result in a sore chest, broken ribs or a collapsed lung, especially in elderly patients with fragile bones. Though they may survive, those especially who are older and/or frail may have a drastically reduced quality of life, suffer from brain damage or other health complications, and may require ongoing medical support (e.g., ventilator).

Other Treatment Considerations

Other treatment considerations to consider when executing a living will include (adapted from the Mayo Clinic and American Hospice):

Mechanical ventilation. A person who is unable to breathe sufficiently may need to have a tube inserted down the nose or throat (referred to as intubated), or surgically through the neck, into the trachea. This connects to a ventilator (breathing machine), which breathes for the patient. However, for those with certain lung and heart diseases, the likelihood of resuming normal functioning after removal from the ventilator is low. Intubated patients can’t talk and may need medicine to keep them comfortable. Some patients who survive may need to be on a breathing machine in the intensive care unit (ICU) for a while. Bacteria in the tubing can result in pneumonia, and patient immobility can lead to psychosis, skin breakdown and progressive weakness.

Nutrition and hydration assistance. To keep a patient alive, medical professionals will automatically supply the body with nutrients and fluids intravenously or via a feeding tube. If you are seriously ill or close to death, life-sustaining treatment will not be stopped unless spelled out in your advance directives. Permanently unconscious patients can sometimes live for years with artificial feeding and hydration. If food and water are removed, death will occur in a relatively short time due to dehydration, rather than starvation. Such a course of action generally includes a plan of medication to keep the patient comfortable.

Admission to the ICU. The ICU is generally meant for a person who is reversibly critically ill and who desires full resuscitation should cardiorespiratory arrest occur. But patients can suffer from isolation, as visitors are restricted, and immobilization, as well as disruption by light, noise, diagnostic tests and therapeutic interventions, which are uncomfortable and potentially painful. A frail patient is prone to develop ICU psychosis.
Additional Considerations

 Including a do-not-resuscitate (DNR) order in your living will may only prevent CPR, not other life-saving measures. Some people add a DNI—do not intubate. An alternative that is gaining popularity is AND—allow natural death. An AND advises doctors to offer only comfort measures, because any other aggressive treatment, such as intubation, may only prolong suffering. AND also conveys a positive, and perhaps gentler, message to those who must decide whether to continue life-saving measures for their loved one.

If your illness is terminal, you can also request in your living will that you want palliative care, which focuses on quality of life and dignity by helping a patient remain comfortable and free from pain until life ends naturally.

Some living wills encompass more than just DNR or DNI requests by spelling out your thoughts about dying, which can be more helpful to your doctors, friends and family when deciding what kind of end-of-life care you want. One of the more well known is Five Wishes, which goes beyond medical issues to deal with personal, emotional and spiritual concerns. The downloadable form includes questions about how comfortable you want to be, how you want people around you to treat you and what you want your loved ones to know when you’re facing the end of your life.

Five Wishes was written by Jim Towey, who worked with Mother Teresa and was inspired by her care and concern for others. His organization, Aging with Dignity, is a national nonprofit that aims to affirm and safeguard the human dignity of individuals as they age and to promote better care for those near the end of life. He introduced the Five Wishes will in Florida in 1997, and a year later, to the nation. Today, Five Wishes meets the legal requirements in 42 states, and millions have used the form to specify their desires.


“Advance Health Care Directives and Living Wills,” Help Guide

“Advance medical directive facts,” Medicine Net

“Cardiopulmonary Resuscitation (CPR),” Family Doctor

“CPR and Advance Care Planning: What You Need to Know,” Allina Health\

“Download Your State’s Advance Directives,”
“How Misconceptions Among Elderly Patients Regarding Survival Outcomes of Inpatient Cardiopulmonary Resuscitation Affect Do-Not-Resuscitate Orders,” Journal of American Osteopathic Association

“Living wills and advance directives for medical decisions,” Consumer Health, Mayo Clinic

“Medical Issues to Be Considered in Advance Care Planning,” American Hospice Foundation 

“What Do a Living Will and Power of Attorney for Health Care Cover?” Nolo (Law for All) 

“What is a Living Will?” All Law

Write Your Living Will Now to Ease Burdens Later was featured in the  August 2014 Senior Spirit newsletter.

Blog posting provided by Society of Certified Senior Advisors 

Monday, September 15, 2014

Cognitive Impairment and Normative Aging: Understanding the Differences

Family fights over the care, legal, and financial issues of aging relatives, can have disastrous results. Using a skilled mediator can make all the difference in achieving peace, harmony, and resolutions.
Family disputes can be among the most painful of all. People who are related by blood or
marriage may have such close ties that they fully understand not only how to do the right
thing for each other, but also how to hurt each other. When caregiving is involved and financial issues come up, it can bring out either the best or the worst in families.
Emotion is deep and old resentments can surface. Some families turn to dispute resolution with an outside professional to assist them when they get so mired in conflict they cannot find their way out.

The following two examples of actual cases (names changed) illustrate how families deal with these distressing conflicts. Mediation was a successful alternative for one family, enabling them to resolve their differences for the sake of an aging parent. Note the
choices each family made and the effect on the outcome of the conflict.

The Case of the Three Brothers

Three brothers are engaged in battle over their mother, Margaret’s, living situation. She has severe dementia and can’t care for herself independently. She has run out of money. Her only remaining asset is her home and she wants to stay there.

The oldest brother, James, seized power over her finances from the middle brother, Paul. James convinced his mother to appoint him the power of attorney and the agent on the healthcare directive, and displaced Paul, who had always been on both documents. Margaret wasn’t competent to sign anything when James made this move, but he didn’t seem to care. That infuriated Paul. Little brother Joe was somewhat passive, but sided with Paul. The three never got along very well, even as children, and their communication did not improve as they grew up. They largely avoided one another until now.

Without communicating with his brothers, James decided to move Margaret to an assisted living facility that cared for people with dementia. It would be in her neighborhood, she would have her own room, and her house would be sold to pay for it. A deposit was paid and the move was set.

When Paul heard of this, he became enraged, told Joe, and they both threatened to sue James. In response, James found a lawyer and began guardianship proceedings. There was no money in their mother’s checking account to pay the lawyer, so James promised
the attorney that she would get paid when the house was sold.

Margaret’s long-time estate attorney, not the guardianship lawyer, suggested mediation. She urged the siblings to stop upsetting their mother and each other by using a neutral person—a mediator—to help them try to reach some agreements.

This sounded like a good solution. With the mediator’s guidance, they could figure out a way to be more civil to each other and work toward a less aggravating future while caring for their mother. However, James refused to go to mediation. The guardianship case continues to move through the courts. Thousands of dollars will be needlessly wasted
on litigation that pits brother against brother. No one is likely to come out a winner, regardless of what happens in the case.

Who’s In Charge of Dad?

Three sisters were embroiled in a conflict over their father’s care. He was frail, needed help at home, was easily confused, and thought he was somewhere else most of the time. One of the sisters lived nearby and the other two sisters lived far away. They didn’t trust the sister nearest their father, and had reached the point of not speaking to one another. A professional handling their day-to-day finances understood the conflict among the siblings and she suggested mediation.

Surprisingly, all three sisters agreed to mediation. Four sessions took place over the phone, as all were distant.

The sisters gradually worked out their disputes. Each one had a point of view. Mistrust had dominated their communications for months and they had become hostile with one another. With discussion, each was able to ask questions, get information, and begin
to clear up misunderstandings. They made rules with the mediator’s help, and when they started to follow them, the trust they needed was re-established. They came to many agreements about how to best take care came to many agreements about how to best take care of their father, and finally reached a level of peace that had not been present in their dealings with each other for years. Their underlying mistrust, some of it going back to childhood, was not addressed, as mediation is not therapy, but they were able to work together to make the quality of their father’s life better.

Their father was well off financially so the family hired a nurse care manager and good home-care workers. The nearby sister was the liaison for everyone. She texted her siblings daily on their father’s situation. A few months later, their father died suddenly. But
now the daughters could look back on the time they cared for him during what turned out to be his last months, and knew that they had done their best for him. Mediation had enabled them to work together for their father’s benefit and for theirs as well.

Families at War
Family conflict is not at all uncommon when it comes to dealing with aging loved ones. Their old hurts, resentment, and emotional dysfunction emerge when they have to come together over the care or finances of an aging parent. Sometimes, they cope with not getting along by avoiding each other completely. This can go on for years. When a crisis happens, such as hospitalization of a parent, they are forced to not only see each other but make decisions together.
Being forced to make decisions as a group is even more difficult when the older adults in the family have not signed an advance healthcare directive (power of attorney for healthcare decisions), or a durable power of attorney for finances. However, even with these documents in place, as with James’ case, manipulation and influence over his vulnerable mother could undo what she had done when she was competent to sign
the documents.
In James’ case, he failed to communicate altogether, acted alone, and caused a fresh set of conflicts and resentments that could have been avoided. Conflicts over how to spend an aging parent’s assets are common. What needs to be examined closely is how to
avoid having the situation escalate to a legal fight. Unfortunately, litigation seldom works to benefit families in conflicts like this. Often, people engaged in these battles do irreparable harm to each other in the process. It’s a lose-lose ending.

In other situations, such as the three sisters, families choose to use an outside person to help them do what they have been unable to do by themselves. As you can tell from the outcomes of both of these true behavioral patterns, the choice families make affects
 their relationships with each other in the long term. Mediation won’t fix every fight, but according to, it’s statistically at least 80 percent effective in bringing people in dispute to agreements. Families that do not get along should be advised to
consider mediation as an option to make things better for everyone. An objective, neutral outsider can do a great deal to help family members reach agreements and resolve issues.'

The Mediation Process

Mediation is a voluntary process involving a trained, neutral mediator, and at least two parties in dispute. The parties meet, whether in person, by phone, or Skype. Mediation is a lot more than just talking things over. Mediator training is extensive, covering both the art and science of how the process works. A minimum of forty hours of training with both dispute resolution theory and mock mediation sessions is standard in the field. Mediators must have a basic understanding of how conflict works, how to de-escalate it, and how to ensure that all participants in mediation are heard. Mediators develop skills in drawing out the underlying emotions associated with conflict. They also use creative approaches to help the parties in conflict devise ways to resolve their disputes.

Many mediators have much more than forty hours of training. Some states certify mediators, but in most states there are no formal licensing requirements.

During mediation, the parties describe what they want to accomplish and the mediator takes on the task of making sure that every party at mediation has a chance to suggest possible solutions. The mediator leads the discussion and asks questions. The parties make their own decisions. The end result of a successful mediation is a written agreement or a set of agreements. Each person present has a voice in what happens. People do not have to like each other to reach agreement, but they often have to give up something to get something.

The mediator does not judge who is right or wrong or what the parties should decide. Rather, the mediator is a guide, referee, source of suggestions, and creative neutral party who finds common ground. The mediation agreement is a contract that all parties sign, and it is enforceable in court.  Apart from the written mediation agreement, all aspects of the process are confidential. What happens in mediation stays in mediation.

Finding a Qualified Mediator 

Mediators are usually independent, though some work in community-based organizations. Some are lawyers, though being a lawyer is not required. The best mediator for any dispute is a person who is experienced with the issues at hand. For example, a mediator
who works with older adults should have solid working knowledge of common areas of conflict concerning seniors and families, and know the community resources they can use to help solve their problems. Legal, healthcare, and emotional health issues may come up and it is important to find a mediator with expertise in one or more of these fields.

Some mediators work in a team approach, called co-mediation. Especially for larger groups, this can be very effective. Two mediators can see more problems from more angles and offer better suggestions than a single mediator can. and are independent resources for finding a mediator in your area. Other sources are dispute resolution services in local organizations, courts, or legal services groups dealing with older adults. Some courts have sponsored
programs for mediation, and some offer low-cost mediation for parties who represent themselves. However, one does not have to have a court case to find a mediator. The field of mediation for family disputes about aging individuals is emerging as a separate specialty, and there are relatively few mediators experienced in this area as compared with general mediation. It is referred to as “elder mediation” in the legal and mediation


Community-based organizations may offer free or low-cost mediation of this kind of dispute by using volunteer mediators. The drawback is that the volunteers may be new mediators, or may lack expertise or subject matter experience in the issues in dispute. The amount of time a mediator can work with a family may also be limited. Outside of community mediation services or low cost clinics, mediators generally work
independently on a fee for service basis.

Private mediators charge by the hour, often at rates similar to an attorney’s fees. The cost can be high for several sessions of mediation in a complex matter. However, it is certain to be much lower than the cost of any litigation. If you think of it as a preventive strategy to avoid paying ongoing attorney’s fees and court costs, mediation is a clear winner with excellent chances of success.


Unfortunately, family conflicts are common. People are living longer, creating more issues about running out of money, who is going to care for them, and loss of independence. Dysfunctional family members have to make decisions about these matters, which brings
out underlying long-standing problems. Fortunately, mediation is emerging as an excellent way to address these issues. It can help people reach agreements about many of the problems families face. Those who feel the pain of a family conflict or who witness it, should consider using mediation as a way to relieve the anguish and find a path to a more peaceful outcome. If you are a professional or an advisor to families at war, you are
in an excellent position to suggest using mediation, a tried and true method to reach agreements. •CSA


Carolyn Rosenblatt has more than forty years of experience in her combined professions of nursing and legal practice. She has worked extensively in geriatric caregiving as well as legal problems of aging, and is co-founder of, a resource for families, located in San Rafael, California. She blogs weekly at Aging Parents on, and is the author of The Boomer’s Guide.

Mediation: Finding a Way to Resolve Family Conflicts was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Tuesday, September 2, 2014

CSA Spotlight, Nakia Street

As a young girl, I had always enjoyed being around older adults. My brothers and I loved going to grandma’s house because we knew that something exciting was going to happen there. Strange, I know, but Grandma El was in a class by herself. Grandma’s house was the best! She had all kinds of pictures, whatknots, stories to tell, and her circle of friends were down-right funny. The laughter and joy of them telling old stories of “you remember when?” would fill the room. I can remember imagining myself being right there with them on their journey, as they told their stories. Before you knew it, the house was full of friends, family and food. OMG, the food was great!

Even as an adult, I still find myself socializing and leaning more toward seniors. Volunteering in senior centers when I find the time is a must. It’s something about the wisdom and knowledge they have to share that I just can’t get enough of. My mother is the same way. She has been a Private Duty Nurse/Caregiver and is well-respected in the community. She is the only woman I know that has a waiting list of potential employers ready to hire her as a Private Duty Caregiver. No kidding around! They want “Bobbie Street” to take care of their parents. She has made lasting impressions on every person she has met over the years. I watched her walk, how she talked to people, and how she cared for whomever she came into contact with, and I modeled after her. As the years went by, I often thought of how to turn this into a family business. Yes, I’m my own little Duck Dynasty. Taking something your parents started and pushing it to the next level. Now, I’m nowhere near the millions Phil Robertson is bringing in but the concept is there and it’s in the stages of something great. So I completed LPN school in 1999, Registered Nurse degree in 2002, worked several years in Assisted Living which led to my provisional licensure as a Category II Specialty Care Assisted Living Administrator, and finally the Certification as a Certified Senior Advisor, which sealed the deal. Now, since the necessary tools are in place, it’s time to start this business. 

As of today, I am the owner of Divine Help In Home Care & Assistance, LLC. “A Ministry of Helps for Senior Care”. I knew eventually I would have to make the decision to leave my current position as Program Director of a local non-profit to fulfill the calling and destiny in my life full time. It was not an easy decision, to step out on faith and leave sure ground. I think I cried the first six months of leaving my job and remember thinking what have I done? Finally, the tables turned in my favor and I began to get referrals, clients, and formed a community and networking partnerships in rural Northeast Alabama. Truly, I would not take anything from my journey, thus far. 

Working with seniors and the aging population is more ministry to me and not just a job or career. Everybody can’t do this. It takes a special person to work with special people. We all have been given a gift and I have been given the gift of helps and love every minute of it. Some of my friends ask me, “Girl, how in the world can you do that?” and my reply is, “I’m working in my gift”. It’s easy to do what you love and what you have been gifted to do. My words of advice is to cherish and love the senior population because they have paved the way for so many of our hopes and dreams. Honor them for their sacrifices and you will be honored days to come. Give to them and it will be given unto you. There is so much wisdom packed in their spirits and you would be crazy not to draw from those deep wells and reservoirs. Oh what a joy it is to help seniors and families. Their eyes have seen so many hills, mountains and even valleys. Take advantage of every opportunity they give you to learn and draw from them. 

So, what led me to CSA certification and education? In our line of work, education and networking is key to the success of our business and maintaining clients. I have held this certification since 2011 and it looks great on my resume or when I’m speaking to potential clients who want to know more about my background. Even with 20 years of experience in nursing and caregiving, this certification only expanded my knowledge about senior care, Social Security, Medicare benefits and how to help with primary caregiver issues. The support of the staff and website tools are excellent resources for my clients and necessary for the growth of my business. I will continue to hold this certification and encourage others in my field to do so as well. 

Nakia Street, CSA 
Certified Senior Advisor 
Assisted Living Administrator- Category II 
Divine Help In Home Care & Assistance, LLC. - Owner 
"A Ministry of Helps for Senior Care"

Nakia was featured in the July 2014 Senior Spirit newsletter.
Blog posting provided by Society of Certified Senior Advisors

Tuesday, August 19, 2014

Motivational Interviewing: Fostering Behavioral Change in Older Clients

Motivational Interviewing is about helping people overcome ambivalence in making important life decisions. Advisors are in a position to guide their clients through the process.

One of the most common conditions to the human experience is ambivalence, the experience of having “mixed feelings.” Ambivalence is often the root of difficulty that
people have in committing to a decision. Any commitment we make has consequences, both good and bad. Think of many of the thoughts you have had, and the commitments you have wanted to make in your lifetime. These could include losing weight, financial
planning, calling or writing that friend you’ve been thinking about. Losing weight sounds lovely, but it also comes with hard work and sacrifice, as does financial planning. Chances are, you know intimately the experience of ambivalence. You also likely know the
frustration of working with an ambivalent person. We all have an internal pull to resolve the ambivalence of others, to push a little harder or to justify a little more the reason for change in the face of statements like “yes, but,” and “well, I’m not really sure.” 

As a therapist, I work with a lot of ambivalence, and as advisors, I am sure that you do as well. There is a tool we use in my industry known as Motivational Interviewing (MI). Initially developed by Dr. William Miller (1983) as a method of aiding people with addictions in resolving their ambivalence around sobriety, MI has developed into one of the most productive and widely used set of clinical tools in the world of healthcare. MI is founded on the belief that all people are more ambivalent than they seem about a particular thought or anticipatory commitment. It also assumes that people have motivation for these thoughts and commitments that we, as advocates, can aid them in understanding, fostering, and eventually transmitting into action. MI is a collaborative conversation that strengthens someone’s own motivation for and commitment to change
(Miller 1983). 

The mission of the Society of Certified Senior Advisors (SCSA) is to “improve the lives of seniors by providing an integrated approach to working with senior clients.” (SCSA 2014.) One of the foundational aspects of this mission is building relationships with seniors and their support networks. Relationships foster the mutual trust, commitment, and willingness necessary to participate in the reciprocal nature of the advisor-client contract. Embedded within these professional relationships is the belief that the advisor knows the needs and motivations of the client, and aspires to act in the best interest of the client. MI is a phenomenal method of fostering relationships through understanding motivation for change and aiding the client’s goal setting. 

You do not need to be a clinician to use MI. It does not require years of training or specialized certification. But it does take a shift in mindset and a degree of patience and self-control that is often a new experience for practitioners. This starts by understanding the “Spirit of Motivational Interviewing” (Miller 1983) and then using the tools of the method. Rollnick and Miller (1995) describe the “spirit of MI” as: 
  • collaborative (versus confrontational or authoritative), 
  • evoking the client’s own motivation (rather than trying to bestow it),
  • honoring the clients’ independence and autonomy in making decisions in their own lives.
The Spirit of MI
Collaboration. MI is a partnership. This is an occasion where you step down from the role as “expert” and step into the role of partner and guide to the ultimate viewpoint and experiences of the client. It really doesn’t matter what you think about the change or
your idea of how to enact it. It matters what the client thinks, wants, and is willing and able to do. 

Evoking the client’s own motivation. Motivation comes in many shapes, sizes, and forms. We often use the terms intrinsic (coming from within, like an aspiration to do something due to a desire to be a “better person”), or extrinsic (an outside motivator, like money, fame, or acknowledgement). Try not to judge motivators; they all serve the same purpose, and don’t be quick to assume that one size fits all. Motivation is often deeply personal and individual. Your task is to discover what motivates your client.

Honoring the client’s autonomy. We must never forget that the true power for change is within the client. Clients have a right to their thoughts, feelings and decisions. They’re the ones who are going to do the work and live with the outcomes. That means we
respect where they are coming from, what they are thinking, what they want and are willing to do to get it, even if we disagree (within legal and ethical boundaries,
of course).

Now that you understand the spirit of the method, let’s talk about the tools you will use to help your clients achieve the change they hope for and often need. The “Principles of MI” ( 2014; Miller 1983) are overarching concepts, which
each has a set of tools that will guide your work with your clients. These principles are thematic for a reason. You already have your own innate personality styles, methods of communication, and advocacy. Be guided by the principles, while maintaining your own authenticity in interacting with your clients. Remember the principles are not necessarily sequential. You can use all of the principles each time you interact with your client or just one if the situation serves. 

The Principles of MI
Empathy. Change is hard and conflicting. You have to do different things, give things up, and it stresses the status quo of your life. Begin first with acknowledging this for your clients and really trying to see the world from their viewpoint. Why is this particular decision hard for them? What are they feeling conflicted about? Express that empathy. Join, reflect, summarize, and affirm. Show them that you’re listening, you care, and
you understand.

Client: I just never thought we would reach this point. I never thought I would have to make decisions for my dad. 

Advisor: What a hard place to be in. You want to respect your father’s right to make decisions for himself, but you also want to help him and make sure he gets what he needs. I think this is a difficult position for all adult children.

Foster self-efficacy. In the end, it is the client who has to follow through with the commitment. This means that clients need to believe they are capable of achieving the changes hoped for. In MI, we support this self-efficacy by reminding them of previous successes: “I remember when I first met you, you told me about how you…” and highlighting abilities the client already has. “I’ve always been impressed by your ability to….”


Client: I just don’t know if I can do it. Downsizing, selling my things, moving to a new home. It all feels so overwhelming.

Advisor: I think it would feel overwhelming for everyone. Tell me about another time in your life when you felt overwhelmed. What did you do then? 

Roll with resistance. This is perhaps the hardest and easiest part of MI. Hard in the beginning, and so much easier as time goes by. You are just there to support the client. If you start getting the “yes, buts…,”its time to back off and change tactic. Go back to empathy. You’re pushing too hard. The more the client fights against you, the more they are justifying the reasons not to change. Your actions in MI should always move the client in the direction of the positive change they originally expressed to you.

Client: Yes, but I don’t know if I need to get a living will now. I mean it’s not like I’m going to die tomorrow.  

Advisor: I understand. You feel that you don’t need to draft a living will until you know you’re going to need it. Let’s talk about that. What will things look like when you’re ready to draft a living will? 

Develop discrepancy. This may feel like the most counterintuitive principle of MI, but it is perhaps the most powerful. People do not like ambivalence. It is uncomfortable, and they can only take it for so long. They are compelled to anchor. Fostering this discrepancy
in your clients between their values, who they want to be, what they want to do, and where they are now is key. It is the proverbial fire underneath the frying pan. Discrepancy should be gradual—that is, don’t lose your supportive, empathic style in the process
of heating things up. Move slowly in the direction of helping your clients see that their current actions are actually inhibiting, rather than supporting their end goals. These tools are fun to use, and can foster amazing results, but remember you need your clients
to know first that you are on their side, you believe they can do it, and you’re willing to be flexible and roll with their concerns. Once you have this foundation, give some of these tools to aid in developing discrepancy a try:

Using the ruler as a tool: Ask your client, “On a scale of 0-10 with zero being “it’s not going to happen” to ten being ’I’m going to follow through right after we’re done!’ where are you right now?” Suppose the client responds with a three. “Okay, what would it take for you to move one step closer to a ten?” Remember, there is no wrong point on the ruler, and ALWAYS ask what it would take to move closer to the goal. Never reinforce
the reasons not to. 

Query extremes: Ask your client, “What is the worst part about the way things are now?” What is the best?” What if you chose not to….” Notice the emotion and discomfort behind these questions. That’s healthy. Remember you’re targeting the current behavior (what the client is already doing) to elicit a desire to change to the goal behavior.
Query values and the congruence of current behavior: Ask you client, “If I were to ask, what your top three values are, what would you say?” “Where does your current behavior fit in with these values?” 

In the beginning, MI can feel like more work, because it is often hard to hold back on all of that insight and knowledge we have. However, think back to those times in your life when you were ambivalent. Did you need someone to tell you why what you wanted
was important to you? Did you need someone to tell you how and when to enact this change in your busy schedule? Chances are, you were already aware of these things, but you weren’t as aware of the true values and reasons for wanting to commit to this goal. You weren’t aware of that spark that you needed to move forward with the commitment. This is the foundation you are providing for your clients through the use of MI—increasing
their awareness of what they truly value and motivates them to achieve their goals.
Once this foundation is established, your expertise can truly shine and will be sought out and appreciated due to its contribution to their already strong motivation and commitment. As advisors to older adults, you have the knowledge they and their families need to make decisions, commitments, and achieve goals. The skill of motivational interviewing will aid you in working with clients with clearer focus and stronger commitment to the use of your services in achieving their goals. •CSA

Carilyn Ellis is a psychology intern at the Salt Lake VA Medical Center, specializing in Palliative Care,Geriatric Home-Based Primary Care, OutpatientMental Health and Neuropsychology. She has a master’s degree in clinical psychology and is a Psy.D. (doctor of psychology) candidate at George Fox University in Newberg, Oregon. She can be reached at

Motivational Interviewing: Fostering Behavioral Change in Older Clients was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Monday, August 4, 2014

Headed for the Future: A Boomer's Guide to Returning to College

It’s never too late to return to academic life, and the wave of baby boomers flooding college campuses proves it. They are pursuing new and advanced degrees for encore careers, updating professional skills, and indulging their love of learning. Going back to school has never been more exciting. 

At seventy-eight million strong, baby boomers continue to change the world, obliterating the notion that age is a meaningful variable in the decision about going back to college. According to Hunt (2012), “Adults returning to college today make up almost 20 percent of enrollments, which is double what it used to be when they were the young eighteen-year-old demographic.”

Older adults engage in higher education for many reasons. Some go back to fulfill “dreams deferred” and transition into encore careers. Others, who may have lost retirement savings during the recession, go back to update existing skills and maintain employability; and some return to class for mental stimulation, to remain socially engaged, and indulge a love of learning. Regardless of motivation, it is useful for advisors and their clients to discuss both the benefits and challenges of going back in order for this new cohort of college students to fulfill their personal and professional goals.

Hollywood and Beyond
With the motto, Curiosity Never Retires, the Osher Lifelong Learning Institute (OLLI) conducts scholarly courses for individuals ages fifty and older at 117 colleges and universities across the country, with 113,000 members paying annual dues from two to six hundred dollars a year (Hasson 2013). Osher offers a wide variety of classes with topics tasty enough to satisfy any intellectual appetite, from “The Hollywood Novel,” “Current Research Topics in Astronomy,” and “American Environmental History.” Online examples of lifelong learning opportunities without tuition include those provided by the Emeritus Program through Continuing Education at the San Diego Community College District and by the State of Ohio, where “under Ohio law, residents sixty and older can audit classes for free at thirteen public universities and twenty-three community colleges, space permitting, with the professor’s approval.” (Brown 2011.)

While the benefits of lifelong learning have been well documented, a recent study suggests that the well-being of entire communities is based, in part, on the extent to which their older citizens participate in formal and informal learning activities (Merriam and Kee 2014). Further, and with a wider perspective, higher education among older adults impacts the economy and welfare of the national and global community as well, as explained in a Lumina Foundation report (Pusser et al. 2007), “Returning to Learning: Adults' Success in College is Key to America’s Future.” The study notes that fifty-four million adults lack a college degree and thirty-four million have no college experience at all, suggesting insufficient preparation among the nation’s adults to compete in a dynamic global economy.

The New Currency
The urgency for adults to pursue higher education has also been addressed by President Obama, as reported by U.S. Secretary of Education Arne Duncan in the Adult College Completion Tool Kit (Tolbert 2012) who notes, “Shortly after taking office, President Obama set a bold goal: By 2020, the U.S. will once again have the most highly educated, best-prepared workforce in the world. In order to meet this goal, the President challenged every adult to complete at least one year of postsecondary education. In today’s knowledge economy, education is the new currency. Put simply, we must dramatically increase overall rates of educational attainment to ensure the success of individuals in the workplace and safeguard our country’s prosperity in the global economy. To do this, adult learners across America must enter and succeed in postsecondary education in ever greater numbers.

Researchers Kelly and Strawn (2011) add that the country needs to graduate 10.1 million students between the ages of twenty-five and sixty-four with Associate and Bachelor degrees by 2020 in order to match the best performing countries throughout the world in college attainment.
A major, nationwide program addressing this issue is the Plus 50 Initiative. In 2008, the project started with ten community colleges across the country to encourage creative curricula designed to address the needs of baby boomers to remain “active, healthy and engaged in careers and projects that matter to them” (AACC 2014). Examples of projects from early grants include retraining experienced nurses to mentor new nursing students, training individuals to become seasonal guides at national parks, and providing business education through online classes in tax preparation and medical transcription. 
But this was just the beginning. In 2010, the Plus 50 Completion Initiative was launched for eighteen community colleges throughout the nation to focus on degree and certificate completion for adults over age fifty. The three-year evaluation report released in August 2013 demonstrates the success of the program and the desire of boomers to participate in workforce education. With a goal of serving nine thousand students, instead it enrolled 16,507 participants earning 7,192 professional credentials in the fields of accounting, agriculture, business, health, human services, culinary arts, early childhood education, and many others (Learning for Action 2013). 
The most recent iteration of Plus 50 began in 2012 as the Plus 50 Encore Completion Program. This initiative is designed to help ten thousand baby boomers complete degrees or certificates in the high demand fields of education, health care, and social services (AACC 2014). Training in these areas is intended to provide pathways to employment as well as a means for boomers to give back to their communities and to the world. 
When Life and Learning Collide
But nobody said it would be easy. At age fifty, Erik Amerikaner had held executive positions at companies across the country. But when asked to relocate in China, the vice-president and former CEO opted instead to pursue a teaching credential at Chapman University in San Luis Obispo, California. Today at age sixty-two, he has been teaching information technology for twelve years and has been honored as a Certified Educator by the National Board for Professional Teaching Standards. Although he loved going back to college, he notes, “The hardest part was working full time during the day while going to school at night.”
Although Amerikaner had the tenacity to push through to completion, most do not. Data from the National Center for Educational Statistics show that just slightly more than a quarter (28 percent) of fulltime, and a mere 5 percent of part-time older students go on to finish their college studies (Schepp 2013). In discussing the explanation behind their poor completion rate, Schepp reports findings from the Apollo Research Institute indicating several reasons why adults drop out. Examples include anxiety over college-related expenses, guilt about spending too little time with loved ones, and concern over their ability to succeed.
While the cost of higher education is an understandable stressor, new online tools can help potential students select an educational program that best fits their finances. They include the United States Department of Education College Affordability and Transparency Center (2014), and the College Navigator (2014) produced by the Institute of Educational Sciences of the National Center for Educational Statistics. In addition, potential students need to apply for federal financial aid, as well as the myriad of scholarships available each year. A comprehensive resource addressing the cost of education is 501 Ways for Adults Students to Pay for College, by Tanabe and Tanabe (2013), underscores the value of spending serious time seeking out scholarships that support adults. 
In addressing the guilt stemming from spending less time with family and friends, advisors can help clients learn to clearly communicate their needs by using “I messages.” An example is for the student to replace angry, accusatory statements such as “Don’t make me feel guilty all the time” with “I care about you and I’m sorry that I can’t go to the family picnic on Sunday. But at this time in my life, I’m choosing to attend college and I need to study. This is important to me, and I hope you’ll understand.” 
Finally, potential students need to consider whether colleges that run by semesters, quarters, or rapid-fire, month-long terms will best fit into their lives. Online education with classes that are generally asynchronous and can be accessed any time of the day or night, continue to grow in popularity. Although some believe that online education is less demanding than traditional classes, this is false. Online offerings are obligated to demonstrate the same rigor as their classroom counterparts. However, for online students to be successful, they must be comfortable with technology, exceptionally motivated, and have enough self-discipline to persevere without the commitment of classroom attendance. In her book, The Adult Student: An Insider’s Guide to Going Back to School, Dani Babb, Ph.D. (2012) discusses online learning, including considerations about attending public versus private programs, and an explanation of the issues regarding a college’s accreditation and the potential impact on a student’s career choices.
While college degrees and professional certificates generally result in lower unemployment and better paying jobs, job hunting is rarely easy at any age. However, a wide variety of resources are available to assist older adults in their job search. “New Trends in Retirement Jobs” is a CSA online article providing job seekers and advisors with extensive, practical suggestions for a successful outcome. Lastly, they should visit the websites of their local state employment offices, to inquire about workshops designed specifically for those seeking encore jobs or careers. 
When baby boomer Tamara Sprigel started college, her youngest of four children was twelve. She was going through a divorce and anxious to complete a degree in psychology. “At one point I carried twenty-three units. The toughest part was keeping the family going while I was in school, but I loved college.” She now has a Ph.D. in clinical psychology and is a licensed marriage and family therapist. Gail Smith also went back to college after her children were grown. She earned a bachelor’s degree in behavioral psychology, but not for specific career aspirations. Her goal was to feed something deeper—a validation of her ability to succeed. “As a result, I now have an ‘I can’ attitude rather than ‘maybe not me.’” 
To prove it’s never too late, this year, at age sixty-four, Susan Miedzianowski proudly earned her Ph.D. in Human Services and Gerontology. After obtaining a master’s degree on her fortieth birthday, she returned to school to reach the ultimate academic milestone. Now an adjunct professor at multiple universities, she hopes her perseverance will inspire other older adults to pursue their lifelong dreams. 
It is not uncommon among adult learners to express a sense of pleasure about their college experience. Professors enjoy having older adults in class and often observe that they’re among the most engaged. Mary Lange, Supervisor of Programs for Older Adults at Mt. San Antonio College in Walnut, California, and Chair of the California Community of College Educators of Older Adults adds, “As an educator, embracing the fact that older adult learners bring to the classroom a rich background of real-world experiences that add to the academic setting is very empowering for both students and faculty. Therefore, uniting faculty and students to foster knowledge that encourages student participation, mentoring, and personal education goals is a synergistic approach that is beneficial to all generations.”
Accordingly, with support from policy makers and leaders like Lange, along with colleges and universities across the country, the new “senior class” is changing the paradigm of higher education as an institution for young adults. Kanter (2006) recommends the term even higher education to describe the college experience for older adults. She explains, “This isn’t going back to school. It’s using school to move forward.”

Thus, as boomers use college to move forward, they exemplify the concept of “mindfulness,” described by researcher Ellen Langer (2014) as “the process of actively noticing new things. It is the essence of engagement.” CSAs and other professionals who work with older adults can support their clients’ mindful engagement in higher education by:

1. Helping clients define their goals and then locating appropriate educational programs to fulfill those goals. 

2. Exploring all avenues for financial aid.

3. Researching a wide variety of instructional delivery options.

4. Facilitating clients’ use of effective communication skills.

5. Teaching clients simple methods for time management, memorization, note taking and expository writing.

6. Encouraging clients to utilize college and university tutoring services, as well as study groups to solidify academic skills.

With support from advisors, family, and friends, older adults will continue going back to school for both lifelong learning and professional development fully engaged, and headed for the future. •CSA

Karen Gorback earned a Ph.D. in education from the University of California, Santa Barbara. She is currently a commissioner on the Council on Aging for the City of Thousand Oaks, California. She recently published her debut novel titled Freshman Mom, a contemporary story about a divorced mother who goes back to college. Contact her at, or visit her website at 

Headed for the Future: A Boomer's Guide to Returning to College was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Wednesday, July 30, 2014

Look Both Ways Before Getting a Reverse Mortgage

One American dream is home ownership. For many older adults, the continuing dream is living in our homes as long as we can. For that reason, reverse mortgages, which are a loan against the equity in your house, sound almost too good to be true. You have the option of receiving monthly payments that allow you to stay in your home, and the loan doesn’t require repayment until you die, sell your home or when your home is no longer your primary residence. The proceeds of a reverse mortgage are tax-free, and many reverse mortgages have no income restrictions.

However, you can also look at reverse mortgages as an expensive loan, because when you leave your home, you or your heirs have to repay the loan, plus interest. AARP, for one, recommends using reverse mortgages only as a last option for older homeowners who are cash-poor and face high health care costs. Others view a reverse mortgage as a good tool for older adults to manage their finances, especially when used in conjunction with other assets.

The Federal Reserve reports that the combined debt of Americans from the ages of 65 to 74 is rising faster than that of any other age group. In recent years, many older adults, especially baby boomers, have turned to reverse mortgages because their savings have not kept pace with their expenses. In fact, boomers ages 62 to 64 now represent 20 percent of prospective borrowers (62 is the earliest age you can apply), according to a recent survey by MetLife Mature Market Institute. Nearly half the people considering a reverse mortgage today are under 70.

Getting Tough
Borrowers can choose from several options for reverse mortgage payments—from a monthly payment to a lump sum payment or using the funds as a line of credit—tailored to fit your needs. To discourage borrowers from using the reverse mortgage to take care of financial problems, such as paying off bills, the FHA launched new rules in October 2013, reducing the payment a borrower receives if they take the entire amount immediately (“Reverse mortgages: Safer, but far from risk-free,” February 7, 2014, CNN Money).

Requirements for Borrowers
The FHA requires borrowers to:
  • Be 62 or older.
  • Own your home outright or have a low mortgage balance that can be paid off at closing with proceeds from the reverse loan.
  • Have the financial resources to pay ongoing property charges, including taxes, insurance and other obligations, such as condominium fees.
  • Use the home as your primary residence. Vacation property is not eligible.
  • Receive consumer information from a reverse mortgage counselor (one approved by the FHA) prior to obtaining the loan.

Costs Associated with Reverse Mortgages
A reverse mortgage is a loan, so you must pay loan-related fees. Because a reverse mortgage is a home equity loan that isn’t based on your income or credit score, and lenders don’t receive interest until the loan comes due, the lender takes on unique risks. Lenders may offset these risks by charging higher fees.

Origination fee: Reverse mortgage origination fees depend on the value of your home. If the value of your home is less than $125,000, your fee can be up to $2,500, but if your home is worth more, you can be charged 2 percent of the first $200,000 in value plus 1 percent of the value above $200,000, with a cap of $6,000.

Mortgage insurance premium (MIP): This fee is paid to the FHA to protect both the lender and the borrower. If you take less than 60 percent of the available funds in the first year, you pay 0.50 percent of the appraised value of the home; if over 60 percent, the upfront MIP will be 2.50 percent. For example, on a $200,000 home, that’s a difference of $4,000.

You are also charged an annual MIP of 1.25 percent on the outstanding loan balance, although this fee doesn’t come out of your available loan proceeds. Rather, it accrues over time, and you pay it once the loan is called due and payable.

Appraisal fee and other closing costs: These fees are the same as you would pay on a traditional mortgage. Home appraisal fees vary by region, type and value of home, but average $450. Other fees—for credit reports, escrow, recording, title insurance, surveys and other items—can range from $1,000 total to more than $2,000.

Interest on the loan: Interest rates depend on whether the loan is fixed or variable. Because the borrower makes no payments during the life of a reverse mortgage, interest is not paid on a current basis but instead accrues, at a compounded rate, through the life of the loan until repayment occurs at the end.

At the current average interest rate of about 5 percent for a reverse mortgage plus insurance, a lump sum mortgage balance of $100,000 would increase by about 6.6 percent a year and the debt would double in 11 years to $200,000 (CNN Money). The interest rate on a reverse mortgage is often higher than the rate for a more traditional home equity loan.

Downsides to Reverse Mortgage
One of the biggest advantages of reverse mortgages is that if you or your spouse stays in your home until the surviving spouse dies, you never need to repay the loan. That means that there will be less, if any, equity in the house for your heirs, although using the reverse mortgage payments to pay your expenses can mean that you have more liquid assets, such as IRAs and mutual funds, to leave behind.
If you die before selling the home, it is sold to cover the loan amount. Any shortfall is covered by the mortgage insurance. If your heirs want the home, they must pay the lesser of the loan amount or 95 percent of the appraised value (made at the time of the loan). Whatever happens, no debt is passed along to the estate or heirs.

Because you still own your home, you must pay property taxes, hazard and flood insurance, utilities, fuel, maintenance and other expenses. Just as in a regular mortgage, if you don’t pay your property taxes and homeowners insurance, you’re in default, and the bank can foreclose on your house.

You have to repay the loan when you move out and haven’t lived in the home for a year, including entering a long-term care facility. Having to repay your reverse mortgage at a time when money is likely already tight can be difficult for most people. However, in some states, Medicaid considers a reverse mortgage a loan rather than income, which can make it easier to qualify for Medicaid. (On the bright side, if the property is “upside down,” which means that the property is worth less than the amount of the reverse mortgage, then the insurance used in the transaction at the time of the reverse mortgage covers that difference. The borrower or heirs are not responsible for the difference.)
Finally, interest on reverse mortgages is not deductible on income tax returns until the loan is paid off in part or whole.

Before deciding whether a reverse mortgage would work for you, consult with a competent financial planner and elder law attorney. Your Certified Senior Advisor can assist you in directing you to a qualified reverse mortgage professional who can help you with the process of determining if it might be appropriate for you. One key thing to remember is that although you can qualify for a reverse mortgage beginning at age 62, the older you are when you apply, the greater the percentage of your home equity you will be able to turn into cash to help meet your financial needs.

“5 Reasons to Avoid a Reverse Mortgage,” Dec. 11, 2012, US News Money
“Reverse Mortgages,” Federal Trade Commission
“Are Reverse Mortgages Helpful or Hazardous?” April 2013 AARP Money
“Are Reverse Mortgages Risky?,” March 5, 2012 National Reverse Mortgage Lenders Association
“Reverse Mortgage Insurance Explained,”

Look Both Ways Before Getting a Reverse Mortgage was featured in the June 2014 Senior Spirit newsletter. You can subscribe to the monthly Senior Spirit newsletter by clicking here!
Blog posting provided by Society of Certified Senior Advisors