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Wednesday, August 26, 2015

When Your Adult Child Moves Back Home

A tough job market, student loan repayments and high rents are forcing adult children to move back in with their parents. Experts say setting ground rules that are amenable to all will stave off problems later.

Some of the tales from parents whose grown children moved back in with them can be heartbreaking and maddening. For example, a 22-year-old with a beauty-school diploma stays in bed until the afternoon, won’t help with household chores and uses her parents’ car to go out with friends. A 31-year-old lived with his parents while recuperating from surgery and refused to pay rent after he went back to work. He told his mother, "No parent does what you do and charges their kid rent." Meanwhile, he stays up all night playing Xbox, for which he pays $1,000 a month (from Empowering Parents ).
While these stories might be extreme, many older parents can probably relate. A 2011 Pew Research Center study found that 29 percent of adults ages 18-34 say they had to move in with their parents in recent years. More adults are living in multi-generational households than at any time since the 1950s, according to a Pew analysis of Census Bureau data.

Show Them the Door

Next Avenue offers “50 Ways to Send Your Boomerang Kid Packing.” Here are a few tongue-in-cheek tips:
  • When you know your daughter is going to borrow your car, leave the gas tank nearly empty.
  • When your son is out for the day, remove the bed in his room. Tell him the only sleeping option is an air mattress in the living room or the sofa in the den.
  • Stop paying their cell phone bill.
  • Reminisce—a lot. Start with the 1960s and work your way through the '80s in painful detail.
  • Turn the Wi-Fi on and off at random times. Tell your boomerang that your provider said service is going to be intermittent for an undetermined length of time and there might even be periods with no Internet connection.
  • Watch a steady diet of 60 Minutes, CNN and CNBC.
  • Play a constant soundtrack of ’70s rock—better yet, lite FM.
  • Cancel subscriptions to Starz and HBO. Sorry, Charlie: No more Game of Thrones.
  • Clear the house of soda, snack foods, microwave meals and anything that your child can easily grab at 2 a.m. You’ll be doing yourself a favor in more ways than one.
Last year, the New York Times reported that 1 in 5 people in their 20s and early 30s is currently living with their parents. The phenomenon is so common that there’s a term for it: boomerang children. High unemployment rates, enormous student loans and many cities’ high housing costs leave young adults with little means to pay rent. It’s a different situation than when baby boomers were young and eager to leave home, and jobs were plentiful. 
Today, many parents are happy to have their children return home because they can establish a relationship that may not have existed when their kids were younger. At the same time, empty-nest parents may be enjoying their freedom and resent their child returning home. It’s a new situation: Both parent and child are meeting each other as independent adults. Because of the inherent challenges, experts recommend setting ground rules. 
Discuss Expectations 
It’s important talk about what each person expects from these new circumstances. Having a discussion before your child moves in with you can prevent problems later for everyone. Consider asking these questions:
  • What is the time limit for living at home? When does your daughter expect to move out? When would you expect your daughter to be living on her own? Timing can be linked to finding a job or saving enough money for a security deposit on an apartment. Or, choose a time period: Maybe everyone will need space in six months or a year.
  • Will your son help with household chores—cleaning, walking the dog, shoveling snow?
  • What about groceries? Will you cook the meals for your daughter? Or will she microwave her own pizza?
  • Will your son do his own laundry?
  • If your daughter goes out, do you want her to let you know if she’ll be late or where she is? Or will she let you know that she doesn’t want to be worried about? Maybe she doesn’t want her parents hovering over her, like when she was young.
  • Are friends allowed over, or how about parties? Especially, how do you feel about letting your daughter’s boyfriend stay the night? Are you OK with your son or daughter drinking at home?
  • Will you let them borrow the car? Are they covered with your insurance?
  • What about television use, especially when different generations have their favorite shows?
Schedule times to revisit the game plan, either weekly or monthly, to see how everyone’s doing with the arrangement and which problems or new circumstances have cropped up. 
Be Clear About Money 
Discussing how much your child will contribute, especially for rent, is a difficult and sensitive topic. While most parenting experts agree that charging some rent is a good idea, to prepare the adult child for living on a budget, there is no hard and fast rule for how much. About half the boomerang kids who move home pay some sort of rent, and almost 90 percent help with household expenses, according to a 2012 Pew Report.
Making the rent too high prevents your child from saving money and moving out, while rent that’s too low gives them little incentive to find work. It partly depends on the parents’ and children’s financial situation. One expert suggests using the average cost of a rental in your area as a basis for setting monthly payments. Another says parents should charge 30 percent of their child’s income, if they are working, just as a rental property or mortgage company would calculate how much a person can afford to spend on housing. If your child doesn’t have a job, you can have him do household chores as payment. 
Beyond rent, should you ask your child to contribute to grocery, utility and gas bills? As much as you want to help your child, it’s important to take into account your needs and consider retirement and how much you will need to live comfortably. Keep in mind that your children have more years to make money than you do. 
Treat Each Other With Respect  
When having your child move back home, there are also emotional aspects to consider, and finding a balance between hands-off and hovering is helpful. Experts say it’s important to remember that your child is now a young adult, who has been independent for several years.
Says one young man: “I would just love for my parents to understand that I am not the same person I was when I last lived with them in high school. I don’t eat the same food, go to bed at the same time or hang out with all those same people. I still do my own laundry and don’t need instructions on how to lock the front door when I come in late.” 
It’s probably not necessary to wait up all night for your child to come home from a party. You shouldn’t assume that your child will always be home for dinner or that you always need to cook for them. It’s best, as in any adult relationship, to offer advice only when asked. Sometimes your children just want you to listen and provide emotional support. 
On the other hand, your children need to respect you. For example, they need to let you know if they aren’t going to make it home for dinner after you volunteered to cook their favorite meal. They shouldn’t treat you like the parent who always cleans up after them. Your children should be able to express gratitude for your generosity in sharing your home (not theirs) and not act like they are entitled to their old bedroom that you’ve been using as an office.
Don’t forget to consider your own needs. Do you need privacy or an opportunity for you and your spouse to spend time together? Are there other children still living at home who also have needs? Or, with your child home, maybe you’re happy to have companionship and help around the house with difficult chores. When having your adult children move home, experts advise not basing your decisions on feelings of guilt that you’re not being a good parent. 
You may find yourself in a situation where your children are getting too comfortable, maybe with all that home-cooking and the familiarity of their old room. If your grown kids are showing no signs of leaving, you can take some slightly hostile actions to get them to leave, like making a habit of banging pots and pans at 7 a.m. or taking up the trombone. See sidebar for more humorous suggestions. 
 “Adult Children Living at Home? Part II: 9 Rules to Help You Maintain Sanity,” Empowering Parents 
“What to do when your adult child moves back home,” June 26, 2013, Washington Post 
“How To Set Money Ground Rules For A Boomerang Kid,” June 3, 2015 Forbes 
“Coping With Your Unemployed Adult Child,” Nov. 15, 2013, Huffington Post  
“5 Key Things To Remember When Your Adult Child Moves Home,” April 4, 2014, Huffington Post  
“5 Steps To Survive Your Adult Child's Return Home,” July 9, 2014, Huffington Post  
“6 tips for living with boomerang kids,” Bankrate 
 “It’s Official: The Boomerang Kids Won’t Leave,” June 20, 2014, New York Times
When Your Adult Child Moves Back Home was featured in the August Senior Spirit Newsletter.
Blog posting provided by Society of Certified Senior Advisors.


Monday, August 24, 2015

Medications Can Ease the Pain of Arthritis

There is no cure for osteoarthritis, one of the most frequent causes of disability among older adults. However, both traditional and alternative medications can ease the pain of this debilitating disease that affects one-third of those over 65.

Virginia, 89, can no longer open jars because of the arthritis in her hands. Even washing dishes has become too painful. She’s not alone. It is estimated that one-third of individuals age 65 and older suffer from osteoarthritis, the most common form of arthritis in older adults (referred to in this article as arthritis, even though there are other types, such as rheumatoid). Arthritis is one of the most frequent causes of physical disability among older adults, and females are especially susceptible. A woman has a 50-50 chance of developing arthritis at some point in her life (Harvard Women’s Health Watch). 

The disease affects hands, low back, neck and weight-bearing joints such as knees, hips and feet. More than just painful, arthritis can be debilitating, making daily activities such as dressing, putting on shoes, walking, climbing stairs and getting in and out of chairs and bathtubs a challenge. Arthritis in the knees can lead to disability due to the pain. With the associated pain, the person becomes less active, which can lead to other health issues, including weight gain, not wanting to socialize, and other physical and emotional challenges. 

Non-Medication Therapies

Besides medications, other treatments can help arthritis sufferers:

Heat and cold. Apply heat with warm towels, hot packs or a warm bath or shower to increase blood flow and ease pain and stiffness. Meanwhile, cold packs (bags of ice or frozen vegetables wrapped in a towel) can reduce inflammation, relieve pain or numb the sore area.

Gently rubbing arthritic joints can increase blood flow and bring warmth to the affected area, easing sore spots. Because arthritic joints can be sensitive, see a massage therapist who specializes in treating people with arthritis.

Special footwear and insoles can reduce pain and improve walking. Splints or braces provide extra support for joints and/or keep them in proper position during sleep or activity. Use splints for limited periods because it’s important to exercise joints and muscles to prevent stiffness and weakness.

Assistive devices.
A cane may take weight off your knee or hip as you walk. Carry the cane in the hand opposite the leg that hurts. Grabbers or reachers can help you pick up items or extend your reach.

Transcutaneous electrical nerve stimulation (more commonly known as TENS).
A small electronic device directs mild electric pulses to nerve endings that lie beneath the skin in the painful area. This treatment works by blocking pain messages to the brain and by modifying pain perception.
The biggest risk factor for arthritis is getting older. After years of wear and tear, the cartilage, which is the tissue that cushions the ends of bones within the joint, begins to fray, wear away and decay. In some cases, cartilage may disappear, leaving bones that rub up against each other, known as bone-on-bone articulation, which contributes to the pain.  

Traditional Medications
Unfortunately, there is no cure for arthritis, only measures that can help to relieve the pain. Many people turn to acetaminophen (such as Tylenol), which can relieve mild to moderate pain but doesn't significantly reduce the associated muscular inflammation. Though the side effects are minimal, taking more than the recommended dosage over a prolonged period of time can lead to possible liver damage. You can have periodic laboratory work to check if the medication needs to be altered.

In fact, leading medical authorities have recently recommended that total daily acetaminophen dosing be limited to under 3000 mg/day. The U.S. Food and Drug Administration (FDA) has restricted pharmaceutical companies from putting more than 325 mg of acetaminophen in any “combination” pain medication, such as Percocet (oxycodone plus acetaminophen) or Vicodin (hydrocodone plus acetaminophen). This was due to patients mistakenly taking these combination products and also taking extra acetaminophen tablets, which resulted in more than the recommended total acetaminophen daily dose.

To reduce inflammation, doctors suggest non-steroidal anti-inflammatory (NSAID) drugs such as ibuprofen (Advil, Motrin, etc.) and naproxen (Aleve, etc.). However, NSAIDs can potentially cause an upset stomach, ringing in your ears, cardiovascular problems, bleeding problems and liver and kidney damage, according to the Mayo Clinic, which recommends that they not be used by people over 65 and those who have or have had stomach bleeding. At the same time, the National Institutes of Health advises seniors to use NSAIDS with caution. Recently, the FDA announced it is strengthening an existing label warning that NSAIDs increase the chance of a heart attack or stroke.

Stronger NSAIDs are available by prescription, while topical drugs have fewer side effects and may relieve pain just as well. Talk to your doctor about which pain medication is best for you.

Nutritional Supplements

Two nutritional supplements have long been touted for relieving joint pain—glucosamine and chondroitin—but studies have been mixed, with some finding benefits, while most indicate that they work no better than a placebo. If you're allergic to shellfish, you shouldn’t use glucosamine. Also, be aware that glucosamine and chondroitin may interact with blood thinners such as warfarin and potentially cause bleeding problems.

Another nutritional supplement, avocado-soybean unsaponifiables, is a mixture of avocado and soybean oils. Widely used in Europe to treat knee and hip arthritis, this supplement acts as an anti-inflammatory and may slow or even prevent joint damage. It’s always advisable to check with your healthcare professional (physician, pharmacist) as to any potential interactions with other medications.

Alternatives to Drugs

You don’t have to rely on traditional medications to ease arthritis pain and discomfort. Amazingly, one of the best treatments is exercise, including strengthening exercises such as yoga, aerobic activities that include brisk walking, range-of-motion activities and balance and agility exercises. For those who are overweight or obese, doctors recommend losing weight to ease pressure on your joints. Another positive action is to eat foods that can help combat inflammation throughout the body, including beans, flaxseeds, walnuts, green leafy vegetables and omega-3 fatty acids from cold-water fish such as salmon and tuna.

Recent studies suggest that Chinese acupuncture may ease arthritic pain. Scientists think the inserted needles stimulate the nervous system to release natural, pain-relieving chemicals. A large study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Center for Complementary and Alternative Medicine found that acupuncture relieves pain and improves function in knee arthritis and serves as an effective complement to standard care.

For other non-medication relief, see the sidebar. 

Herbs That Fight Inflammation 

Certain herbs have anti-inflammatory properties that may help reduce arthritic pain. However, because there is a lack of scientific studies to confirm these benefits, talk to your doctor first to avoid potentially life-threatening side effects (from Healthline). 

Aloe vera. One of the most commonly used herbs in alternative medicine, aloe vera is known for its healing properties, and the gel can be applied topically to soothe achy joints.  

Eucalyptus. Topical forms of eucalyptus leaves can treat arthritis pain. These leaves contain tannins, which may be helpful in reducing swelling and the resulting pain from arthritis.  

Ginger. The compounds that give ginger its strong flavor also have anti-inflammatory properties.  

Green tea.
Use this popular tea in the form of beverages, tablets or tinctures to treat arthritis inflammation. The National Center for Complementary and Integrative Health found in a 2010 study that green tea might help both osteoarthritis and rheumatoid arthritis patients.  

Turmeric. Used in cooking to make curry, this herb may work best in fighting joint pain when taken orally. This herb can be found in capsule form in some health food stores.  

New Research 

Because arthritis is slow to develop, research on new treatments is also slow. One drug that looked promising was strontium ranelate, which has been used to treat bone loss in Europe. Strontium is thought to inhibit the activity of cells that break down bone. However, more research has shown an increased risk of heart attack, and its use is limited to women with a high risk for bone fracture. 

Another new therapy is using stem cells to help regenerate healthy tissue. The Emory Orthopaedics & Spine Center in Atlanta is one of the few places in the country that offers this treatment, which cautions that it works only for select patients.

During the procedure, a physician extracts stem cells from bone marrow in the patient’s hip or from the stomach’s adipose tissue. The doctor injects the stem cells into the patient’s damaged joint. Because the stem cells are from the patient’s own body, the risk of rejection is very low. 


“Alternative Treatments for Arthritis,” WebMD 

“An Arthritis Treatment Worthy of the Pope and Kobe,” October 15, 2012 The Atlantic 

“New ways to beat osteoarthritis pain,” Harvard Women’s Health Watch 

“Osteoarthritis,” Mayo Clinic

“Senior Arthritis: Symptoms & Care,” A Place for Mom 

“Treating Osteoarthritis Naturally,” updated June 15, 2015, Everyday Health 

“What Is Osteoarthritis?” NIH Senior Health

Medications Can Ease the Pain of Arthritis was featured in the August Senior Spirit Newsletter.
Blog posting provided by Society of Certified Senior Advisors.

Tuesday, August 18, 2015

Finding Your Way to Safe Driving

As we age, there’s no doubt that driving gets more difficult. For one, our reactions are slower, as our physical and cognitive functions decline. This comes at a time when there are more distractions and congestion on the roads. Luckily, technology offers solutions. 

As we age, there’s no doubt that driving gets more difficult. For one, our reactions are slower, as our physical and cognitive functions decline. This comes at a time when there are more distractions—GPS, cell phones, digital music players—and more congested roads and aggressive drivers. 

Many states get tough on older drivers. While only one state, Illinois, requires a road test for elderly drivers, many mandate that people 70 and older renew driver’s licenses in person, rather than by mail or online. Some require more frequent renewals or written or vision tests (New York Times).
Tips for Safe Driving

You can offset some of the effects of aging by changing your driving habits and other practices. The Centers for Disease Control and Prevention advises:
  • Exercising regularly to increase strength and flexibility.
  • Asking your doctor or pharmacist to review medicines—both prescription and over-the counter—to reduce side effects and interactions.
  • Having eyes checked by an eye doctor at least once a year. Wear glasses and corrective lenses as required.
  • Driving during daylight and in good weather.
  • Finding the safest route with well-lit streets, intersections with left-turn arrows and easy parking.
  • Planning your route before you drive.
  • Leaving a large following distance behind the car in front of you.
  • Avoiding distractions in your car, such as listening to a loud radio, talking on your cell phone, texting or eating.
  • Considering potential alternatives to driving, such as riding with a friend or using public transit.

As a group, senior drivers are at higher risk of having a serious collision per mile driven than any other age group except for those under age 25. Starting at age 75, fatal crash rates increase, and rise notably after age 80, according to the Centers for Disease Control and Prevention. This is largely due to a greater susceptibility to injury and medical complications among older drivers rather than an increased tendency to get into crashes. Across all age groups, males had substantially higher death rates than females.

Yet, statistics show that since the 1990s the number of car accidents involving older adults has been decreasing. One reason could be that older drivers are self-limiting their driving. Surveys show that senior drivers are making fewer trips, traveling shorter distances, or avoiding driving at night on interstates or in bad weather. Another cause is that older adult drivers are less likely to drink and drive than other adult drivers. Improvements in driving technology also help. 

Driving More Difficult for Seniors 

The average driver makes about 20 major decisions during each mile driven and often has less than one-half second to react to avoid a potential collision, according to SeniorDriving.AAA. That means processing information in a fast-paced environment, making a quick decision and taking action based on your decision. Being in situations where you have to decide and react quickly is a challenge for any age, but our older minds need more time. On average, the human brain begins to slow down slightly beginning around age 30. 

Strength, coordination, flexibility and reaction times all have a major impact on your ability to drive safely. The following factors tied to aging make driving more difficult.

Vision. Research shows senior drivers need significantly more light to see than teen drivers do. Over the years, pupils get smaller and don’t dilate as much in dark conditions, making it harder to see. By age 60, eyes need three times as much light to see as they did at age 20, which is why it gets harder to drive at night. Particularly bad is the glare from oncoming cars, because age increases the time it typically takes to recover from glare.

Medical conditions. As we get older, chances are greater that we’ll have physical limitations or dementia that can affect driving ability. For example, pain or stiffness in your neck can make it harder to look over your shoulder to change lanes or look left and right at intersections to check for other traffic or pedestrians. Leg pain can make it difficult to move your foot from the gas to the brake pedal. Memory problems can cause confusion about our location or how to get to our destination. At the same time, medications and chronic conditions can interfere with driving.   

Hearing. Aging is the most common cause of hearing loss, which usually becomes more noticeable after age 50. Men tend to be affected more often than women. Hearing loss can be dangerous if you are driving and can’t hear sirens or railroad warnings.   

Help from New Technology 

Last year, the National Highway Traffic Safety Administration released a five-year safety plan for older drivers, which cited advances in collision avoidance. For example, there are now cars that use a beep or light to alert the driver to obstacles behind or in front of the car. In addition, cars can slow down if it appears that the driver isn’t braking. The safety administration is also contemplating a “silver” car rating system to help identify cars that better protect older drivers and passengers (New York Times). 

Other technological features that make driving safer, not just for seniors but for everyone, include:
  • Emergency response systems in the vehicle to get help if needed
  • Smart headlights that can direct the light beam around a curve to illuminate the direction of travel
  • Front and side air bags for the driver and passengers
  • Seatbelts adapted for older adults’ stature and weight
  • Self-parking cars
  • Electronic stability control, a technology intended to increase a vehicle’s stability and bring it back into its own lane
  • Alerts to help distracted/drowsy drivers avoid accidents
  • Controls that the driver voice activates
(from “Seniors Behind the Wheel – When Safety Impacts Independence,” Senior Care Corner).

In the future, we may see autonomous braking and driving, and cars talking to each other. Automakers and the U.S. Department of Transportation are working to wirelessly “connect” cars with the world around them. This technology could alert drivers about possible hazardous conditions ahead, such as dangerous curves or accidents. (“Connected Vehicles Could Let Seniors Drive Safely for More Years,” Senior Care Corner). 

The most helpful technology for older drivers, according to experts assembled by the Hartford and the MIT AgeLab, include “smart” headlights that adjust the range and intensity of light to improve night vision and systems that warn the driver if the vehicle is straying from its lane (New York Times). 

Back to Driver’s Ed 

Most everyone remembers their first driver’s education class and the sheer terror or joy of being behind a wheel for the first time. Older adults can avoid the terror of being behind the wheel with online or classroom-based driving courses for seniors. The largest is the AARP Smart Driver Course. Topics include rules of the road, defensive driving techniques, safely changing lanes and making turns at busy intersections. 

Similarly, AAA’s DriveSharp is an online brain fitness program, which boasts that it can cut your risk of a car crash by up to 50 percent, increase useful field of view by up to 200 percent, help you react faster to dangers and boost driver confidence. The course also presents the most recent driving techniques and latest vehicle technologies.

While many insurance companies offer discounts to drivers who take these courses, the evidence is not solid that they prevent traffic accidents, and research on this topic is limited. However, one study “examined whether 16 hours of training on a commercial training package improved older adults’ performance in a high-fidelity driving simulator. Data showed no differential improvements between the training group and a control group on any driving performance measure following training. The commercial training program did not improve the simulated driving performance of older adults” (from “Examining the Efficacy of Training Interventions in Improving Older Driver Performance,” 2012, Proceedings of the Human Factors and Ergonomics Society Annual Meeting).

Perhaps you are driving the wrong kind of car. AARP and AAA teamed with the American Occupational Therapy Association to develop CarFit, which offers drivers a free opportunity to check how well their vehicles fit their need for proper seating, sight lines and more.

If you are not sure about your (or someone else your concerned about) driving skills, you can enlist the services of driver rehabilitation specialists, who can evaluate your driving in order to determine your ability to be on the road. 

Lastly, there are simple things you can do to make driving safer, such as avoiding high-traffic areas and rush hour. For other suggestions, see sidebar, “Tips for Safe Driving.” 


“An Alternative to Giving Up the Car Keys,” New York Times 

“Connected Vehicles Could Let Seniors Drive Safely for More Years,” Senior Care Corner 

“Medical Conditions & Medications,” SeniorDriving.AAA 

“Older Adult Drivers: Get the Facts,” Centers for Disease Control and Prevention 

“Age and Driving,” Help Guide Senior Driving, SeniorDriving.AAA 

“Seniors Behind the Wheel – When Safety Impacts Independence,” Senior Care Corner

Finding Your Way to Safe Driving was featured in the June 2015 edition of Senior Spirit
Blog posting provided by Society of Certified Senior Advisors.

Monday, August 10, 2015

Laugh Your Stress and Pain Away

Although the phrase “Laughter is the best medicine” has been around for a while, new research is showing it may be true. A good chortle or guffaw can reduce stress and pain, among other health benefits. You can sign up for laughter therapy and be part of a new movement to formally introduce laughter into people’s lives.


Laughter has really changed my life. I feel happier and more focused about things that make me happy. It has changed me from being a serious person to a much lighter person. I also use laughter as my personal stress management therapy to keep my stress levels low, as I have a very stressful job. —Brigette, Denmark, Laughter Yoga website.

Laughter classes and workshops might appear ridiculous. After all, we all know how to laugh, right? Yet, in a high-stress and fast-paced world, many people don’t seem to have the time or focus to let loose a giggle.

Recent research has found that the effects of a good chortle can reduce stress and pain, boost the immune system, provide social connections and make people happier. It’s part of a new movement to formally introduce laughter into people’s lives, including at senior living facilities. It started with Laughter Yoga and its clubs, and now there’s even a Laughter Wellness Institute and Laughter Online University to help tickle your funny bone.

Health Benefits

While it may be hard to imagine that a good laugh can have health benefits, a good guffaw changes us physiologically. We stretch muscles throughout our body, our pulse and blood pressure go up and we breathe faster, sending more oxygen to our tissues. A good laugh shouldn’t leave you in stitches but instead help you feel relaxed through your whole body.

Although research has found health benefits related to laughing, scientists aren't sure if it's the physical act of chuckling or whether people who laugh have a positive attitude or enjoy the company of others (we’re more likely to laugh in a group than by ourselves)—both traits that have been shown to increase longevity. Though the bulk of research has been subjective rather than evidence-based, and experts have yet to do definitive research, studies have shown that laughter can:

Improve your immune system. Laughter can turn negative thoughts, which cause stress, into positive ones, thereby decreasing stress hormones. Because increased stress is associated with decreased immune system reaction, some studies have shown that the ability to use humor may raise the level of infection-fighting antibodies in the body and boost the levels of immune cells.

Stimulate organs. Laughter increases your oxygen intake; stimulates your heart, lungs and muscles; and triggers the release of endorphins, the body’s natural feel-good chemicals. It improves the function of blood vessels and increases blood flow in the heart, which can help protect against a heart attack and other cardiovascular problems.

Relax the whole body. A good, hearty laugh relieves physical tension and stress, leaving your muscles relaxed for up to 45 minutes afterwards. It can also improve sleep.

Relieve pain. Laughter may ease pain by causing the body to produce its own natural painkillers. It may also break the pain-spasm cycle common to some muscle disorders.

Improve your mood. Laughter can help lessen depression and anxiety and make you feel happier, if only temporarily. A happier state of mind makes it easier to cope with difficult situations and helps you connect with other people.

Laughter Yoga

One of the main forms of laughter therapy is laughter yoga. Started in 1995 by an Indian physician, Madan Kataria, who wrote a book, Laugh For No Reason, the program has grown to thousands of Laughter Clubs in more than 72 countries and is practiced in companies, senior living facilities, schools, colleges, fitness centers, community centers, prisons, hospitals, homes for the physically and mentally challenged and cancer self-help groups, according to the Laughter Yoga website.

Laughter yoga is different than “spontaneous” giggling that comes from watching a funny movie, hearing a good joke or seeing your cat accidentally roll off the table. Instead, it relies on a set of exercises that stimulate laughing and use yoga breathing (deep and from the diaphragm). This “voluntary” chuckling has the same benefits as true laughing, especially since fake snickering often turns into the real stuff.

You do laughter yoga in groups, with lots of eye contact and playfulness, and this form of yoga can even provide benefits for the humor handicapped —introverts and those who have no sense of humor. Laughter yoga’s exercises involve movement, such as arm waving, which adheres to the yoga philosophy of a strong connection between body and mind. “If one changes the quality of thoughts, one can feel a change in body behavior. Conversely, if one can bring a change in body behavior, one can experience the change in mental state” (from the Laughter Yoga website).

One exercise is Lion Laughter, derived from a yoga posture. You stick out your tongue while keeping your mouth open. With eyes wide, you stretch your hands like the paws of a lion and roar, followed by laughing from the belly.

Another exercise is Cell Phone Laughter, in which participants hold imaginary mobile phones and try to laugh, while making different gestures and moving around in the group to meet different people and laugh.

To find a laughter yoga group near you, visit the website.

A similar concept, Laughter Wellness is a health program that uses therapeutic laughter and associated techniques to enhance health and well-being. To achieve benefits and a few giggles, the program uses three primary tools: low-impact aerobic exercise that works the mind and emotions, neuroplasticity that restructures brain neurons to be more positive and creative and a safe space for people to connect.

Beneficial for Seniors

Laughter therapy is well-suited for older adults. Laughter exercises are low-impact, requiring you to simply open your mouth, move your arms and possibly move your legs. For patients with Alzheimer's or dementia, who no longer comprehend humor or have become nonverbal, laughter yoga can relieve stress and provide emotional benefits from interacting with others.

In terms of psychological benefits, a 2011 study of laughter yoga, published in the International Journal of Geriatric Psychology, found that laughter yoga classes were at least as effective as exercise classes in relieving depression among elderly women. And laughter yoga significantly decreased depression compared to a control group that didn't exercise or participate in laughter yoga.

Another study reported in the Journal of American Medical Directors Association in August 2014 examined the effects of 9-12 weekly humor therapy sessions in 35 nursing homes. The conclusion: “We confirmed that humor therapy decreases agitation and also showed that it increases happiness.”


“The effects of humor therapy on nursing home residents measured using observational methods: the SMILE cluster randomized trial,” Aug. 15, 2014, Journal of American Medical Directors Association

“How Laughter Helps Seniors Stay In Good Health, Good Cheer,” Laughter Online University

“Is Laughter the Best Medicine?” June 07, 2014, National Geographic

“Laughter is the Best Medicine,” Help Guide

“Stress relief from laughter? It's no joke,” Mayo Clinic

“Give Your Body a Boost—With Laughter," Web MD

Laugh Your Stress and Pain Away  was featured in the July 2015 edition of Senior Spirit.

Blog posting provided by Society of Certified Senior Advisors.

Wednesday, August 5, 2015

The ACA's 1332 Waivers: An Opportunity for State Innovation

The Affordable Care Act includes a little known provision called Section 1332 Waivers that allows individual states to waive or replace some key provisions that could change the way health care coverage is delivered.

Over the next year or two you will be hearing much more about a seldom discussed provision of the Affordable Care Act, called Section 1332 Waivers, 2017 Waivers, or State Innovation Waivers. What they really are is a unique opportunity for any state to fundamentally restructure its approach to health care reform by waiving and replacing some very key provisions of the Affordable Care Act. By doing so, individual states could design and implement a system for expanding and delivering health care coverage that could look very different from the program established under the ACA.

State innovation waivers were the brainchild of Senator Ron Wyden, D-Oregon. As a result of his efforts, section 1332 was included in the ACA when it passed in March of 2010. Eight months later, the section was amended through bipartisan legislation and in February of 2011, it was both lauded and endorsed by the Obama administration.

Individual states have often been called the local laboratories for national reforms. And opponents of the ACA have argued that state-based initiatives are a better alternative than a system imposed through federal regulations and mandates. State innovation waivers provide that opportunity. Under section 1332, states would be allowed to waive one or more of four central provisions in the ACA beginning on January 1, 2017:

The Individual Mandate. States could modify or eliminate the federal individual mandate provision that requires individuals to purchase health insurance coverage or pay a tax penalty. Alternative options could include expanding or narrowing exemptions, increasing or decreasing penalties, implementing a late enrollment penalty (like the one used in Medicare), or limiting open enrollment opportunities. 

The Employer Mandate. States could alter or eliminate the ACA’s “employer responsibility” provision that imposes federal tax penalties on large employers (with one hundred or more full-time equivalent employees) who fail to offer affordable and comprehensive insurance coverage. Alternative options include exempting mid-sized employers, raising or lowering the  requirements for qualifying coverage, modifying the definition of covered employees, or requiring a percentage of the company’s payroll to be paid in benefits or taxes.

This mandate has been postponed twice by the Obama administration and is currently the focus of a lawsuit filed against the President by the U.S. House of Representatives. Barring any legal action, the mandate will take affect for large employers in 2015. For
medium sized employers with fifty to ninety-nine employees, the provision has been postponed until 2016.

Essential health benefits and subsidies. States can modify the ACA rules governing essential health benefits and premium subsidies within the limits set by section 1332. The state alternative must ensure that insurance coverage is as comprehensive and affordable
as it is under the ACA. Alternatives could include expanding or reducing subsidy eligibility, reducing subsidy grace periods, adjusting income boundaries for cost-sharing eligibility, or designing an alternative benefit and subsidy strategy.

Qualified Health Plan Certification and Health Insurance Exchanges. States can eliminate or alter ACA provisions regarding the certification of Qualified Health Plans (QHPs), including essential health benefit (EHB) requirements, annual limits on total cost sharing, actuarial value standards for metal tier plan categories (bronze, silver, gold, and platinum), as well as the definition of individual, small, and large group insurance markets. 

States can also modify or eliminate the requirement to establish health insurance exchanges as the exclusive mechanism for enrolling consumers and determining their eligibility for subsidies. Alternatives include replacing current exchanges with one or more private marketplaces, eliminating the non-exchange market, allowing state exchanges to function as an active purchaser in rate setting, and allowing subsidy eligible consumers to purchase coverage directly from an agent or broker. 

However, not all provisions of the federal health care law can be sidelined. States can’t reinstate preexisting condition exclusions or eliminate the guaranteed issue of coverage. Insurance companies can’t re-establish old rating factors (like claims history or gender rating) that are prohibited under the ACA. And states will have to prove that their alternative plan would provide coverage to at least as many people as the ACA would cover without the waiver. 

A state plan must also offer “coverage and cost sharing protections” against excessive out-of-pocket costs to ensure that consumer spending is at least as affordable as plans currently offered in the state or federal exchanges. In addition, coverage must be just as “comprehensive” as that currently offered in the exchange. The chief actuary of the Centers for Medicare and Medicaid Services (CMS) will be required to certify coverage as “comprehensive,” based upon data from the waiver state as well as other comparable states. Finally, since the state plan will be federally funded, the waiver can’t increase the federal deficit.

Under the 1332 waiver, federal funding for premium and cost-sharing subsidies, including premium tax credits, cost-sharing reductions and small business tax credits that would normally go to consumers and businesses, will now be provided directly to the state in order to pay for the state’s plan. The federal Department of Health and Human Services would determine the annual “pass through funding” based upon an analysis of subsidy costs in other states not operating under a 1332 waiver. 

The latest challenge to the ACA in the Supreme Court, King v. Burwell, which was heard by the court on March 4, 2015, could have an impact on innovation waiver funding. That ruling will determine whether states with federal rather than state-based exchanges can receive subsidy funding. Ironically, depending on how the court rules, Republican-controlled states that would like to implement major reforms under the waiver may be denied access to that source of funding. Without that funding, those states would find it very difficult to implement an alternative plan. Without the subsidies provided to federal exchanges, which states could spend differently under a 1332 waiver, those states would be denied the largest source of funding that they could use to implement an alternative plan.

Getting a Waiver

Even though there is no official deadline for applying for an innovation waiver, states will have to begin that process as early as possible this year. To begin with, the state legislature must pass a bill that authorizes the state to apply for a waiver. And that debate and process could take a substantial amount of time. 

Once authorized, the actual waiver application must include the provisions to be waived, an actuarial and economic analysis of the alternative plan, an implementation timeline, and a ten-year budget proposal. The state must also indicate how the plan would meet the ACA’s goals of coverage expansion, affordability, cost containment, comprehensive coverage and the impact on provisions of the ACA that will not be waived. After the waiver proposal is produced, the state will also be required to solicit and receive public comments on that proposal.

The application for the waiver must be approved by both the Secretary of Health and Human Services as well as the Secretary of the Treasury. Unlike the current federal waiver approval process, which can take months or years, the approval or rejection of a 1332 waiver application must be completed by the federal government within 180 days in order to expedite implementation. 

If the waiver is approved, long-term compliance will be monitored by both the state and federal government. The state will be required to hold a public forum within six months of the initial approval in order to solicit and receive comments on implementation. These public forums will be repeated every year.

One major focus of these waivers may be the Medicaid expansions created under the ACA. However, 1332 waivers do not give states the authority to make changes either to Medicaid or the Children’s Health Insurance Program (CHIP). Changes to those programs
have to be initiated through the existing Medicaid waiver authority, specifically something called a section 1115 waiver, which was created before the ACA became law. Under that waiver, changes to Medicaid must be “budget neutral,” which has limited what states were able to do in the past. 

Under new regulations, states can ask for a 1332 and 1115 waiver in a single application. A proposal that might be rejected under the Medicaid waiver’s budget neutrality provision might be approved under the umbrella of a 1332 waiver, which offers greater funding flexibility.

States Seeking Waivers

Some states have already picked up the gauntlet. Vermont was the first state to declare that it would file for a 1332 waiver. Legislation was passed in 2012, and Vermont health care agencies began meeting with CMS in 2014. Vermont’s waiver application is currently in progress and proponents hope to begin soliciting public input this year.

The purpose of the waiver would be to establish a “universal and unified” single-payer healthcare system. Under the waiver, Vermont would create a publicly financed gold-level benefit plan that would be paid for through redirected ACA subsidies and additional state funding.

In 2014, the Hawaii state legislature passed a bill to create a task force to explore a 1332 waiver. That task force began meeting in 2014 with the goal of introducing legislation in 2015 and implementing the waiver proposal in 2017 or later. Hawaii wants to keep its 1974 ERISA exempt employer mandate (instead of the mandate imposed by the ACA) and use the waiver to support improvements in the health care system in addition to coverage. 

The New Mexico state senate has introduced legislation in 2015 (SJM002) to set up a 1332 task force. Minnesota has also shown interest in using a 1332 waiver to modify its basic health plan to improve coverage options for low-income residents and support
wider delivery reforms.

Arkansas and Iowa are currently exploring privatized versions of the ACA’s Medicaid expansions through the existing Medicaid waiver authority.
However, one state senator in Arkansas has already announced his intention to introduce legislation in 2015 that would combine that effort with a 1332 waiver application. 

While it is too soon to tell whether these state efforts will ultimately be successful, it is clear that other states will likely follow their lead. Some states may follow Vermont’s approach and pursue large-scale reforms. 
Other states may take up far smaller and more
modest changes.

In either case, the ACA’s section 1332 provisions offer a practical state-based alternative to the very old and hyper-political “repeal and replace” debate. Here is the opportunity for single payer advocates on the left, free market advocates on the right, and everyone else in between to offer alternatives that could deliver results equal to or better than the ACA. •CSA

Bob Semro is a policy analyst for the Bell Policy Center, a non-partisan, nonprofit research and advocacy organization in Denver, Colorado. He currently serves on the Health Plan Advisory Workgroup for the Colorado Health Benefits Exchange. Contact him
at 303-297-0456, ext. 225, or
The ACA's 1332 Waivers: An Opportunity for State Innovation was published in the Spring 2015 edition of the CSA Journal. 

Blog posting provided by Society of Certified Senior Advisors

Monday, August 3, 2015

The Hidden Costs of Long-Term Care

The costs of long term care are becoming prohibitive. But the hidden costs are the ones to look out for when planning for care.

As senior-serving professionals, many of our clients will face the issue of where to live to
receive long-term care. There are choices, each with its own pros and cons. Whether the choice is living at home or in a community setting, long-term care is or will be needed.

Caregiving affects all of us. As former First Lady Rosalyn Carter, said, “There are only four kinds of people . . . those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need care.” Care comes with a cost. And the cost of care, especially long-term care, is staggering regardless of wherever, whenever, and by whomever it is given.

As professionals, we must shout in full voice to all who will listen: “Plan for long-term care.” And most especially, we must give clients the fullest picture of the cost of long-term care, beyond the cost of “room and board.” It’s the hidden costs that can add significantly to the basic cost of room and board.

Donald’s story. Donald sought care management services when telephone calls from his mother, her caregivers, and the homecare agency became too much. Donald’s mother lived independently, but she was a twelve-hour drive from Donald, her only child, with a family of his own and a professional life. With care management services, his mother was relocated and settled into a senior community, minutes from Donald’s house.

When the relocation was being planned, it was suggested to Donald that he do the math for his mother’s monthly long-term care (LTC), using a figure of $10,000. He was shocked.

Donald, a financial professional, could not understand why the projected cost of his mother’s care, as determined in the relocation care plan, far exceeded the cost of care cited in Genworth Financial’s cost of care survey. For example, The Genworth survey covers the national median cost of a homemaker, home health aide, adult day care, assisted living facility, and skilled nursing facility. However, it does not take into account
the add-ons or “hidden costs” of long-term care. 

Linda’s story. Linda’s father, a widower, recently died at 102. He had the usual trajectory of care arrangements—home with no help, home with a homemaker, home with an aide, care in rehab, and finally a board and care home where he died. Linda’s father had a long-term care insurance (LTCI) policy, which was in effect. However, his policy, purchased years before, only covered care in a nursing home. Therefore, he had to private pay in the small assisted living home. Newer long-term care policies are not as restrictive as older policies such as Linda’s father’s policy. Nowadays, most long-term care policies follow the individual, rather than being restricted to care in a nursing home.

Linda’s misunderstanding of long-term care and Donald’s sticker shock are both common. Linda assumed that long-term care referred to care in a “facility.” And Donald did not realize that the Genworth survey did not include the “real” cost of care.

Understanding the Meaning of Long-Term Care

Here is a useful, pithy definition for professionals to share with a client: “Long-term care is care that a person requires from someone else to help them with physical and emotional needs over an extended period of time.” 
Long-term care is not place-specific, and may be needed and delivered at home or in an institutional setting.

One commonly held misconception is that Medicare pays for long-term care. Medicare does not pay for long-term or custodial care. Rehab or sub-acute care is not considered a long-term care need and is not covered, long term, by Medicare. Medicaid is the government-funded program that funds long-term care and varies state by state in where and to what extent care is provided.

Also, it’s important to understand the difference between long-term care (LTC) and long-term care insurance (LTCI). Long-term care (LTC) means care that will be required over time. It is also referred to as custodial care, when a person needs help with activities of daily living. Long-term care insurance (LTCI) is a privately-funded vehicle that can help defray the cost of long-term care when certain criteria are met. However, it rarely covers 100 percent of the costs of long-term care.

Another issue that confuses consumers who are entering the LTC landscape is the absence of a standard nomenclature. What constitutes assisted living, independent living, or skilled nursing care, varies significantly from facility to facility, even within the same
city. There are “board and care homes,” “small assisted living homes,” “personal care homes,” for example, depending on the state. So, a “housing arrangement” can have many names, and provide varying levels of care, programs, and services.

For example, Facility #1 calls itself “an assisted living community,” but does not provide long-term care for the memory-impaired. Facility #2 calls itself an “active senior community,” but also offers several levels of care, depending on the resident’s needs. Facility #3 calls itself a small, assisted living home, but provides only room and board, and no care. 

For long-term care delivered at home, the landscape can be equally murky when privately paid homecare is needed. The problem is that the homecare industry does little to educate consumers about the difference between an agency and a registry. This is an important distinction and can have far reaching implications. Simply put:

• An agency employs its caregivers.
• A registry staffs or refers caregivers for in-home care.

And, regulations for each vary by state.

Oops, I Thought That Was Covered 

Professionals who work with older adults and their families should explain what long-term care is, and the host of expenses that accompany it. For example, many facilities advertise that transportation is provided or available. What they do not often explain is that transportation is limited, often to certain days, and restricted by distance. There is often a charge when transportation is provided beyond the mileage limit or when provided on a facility’s “off day” when transportation is not scheduled. It is especially challenging to schedule an appointment on the days and times when transportation is available. So, then comes the cost of going back and forth to appointments and activities when transportation is not available from the facility.

Too often, older adults and their families learn about the add-on costs after the fact. It is common that when visiting a long-term care facility, emphasis is on the model room, while services and programs are often not fully explained, and the potential resident or
potential resident’s family is told to read the admission material. Most often, they are in crisis and critical information is overlooked.

For a client considering a move to an assisted living community, it is important, that advisors emphasize that an assisted living facility is real estate, a space, usually for sleeping with meals and programs included in the basic cost. Stress that care is provided at an additional cost. While there are a few situations where there is a bundled cost that includes room and board, programs, and other services, they are limited.

A Los Angeles Times article ( 2002), “Assisted Living’s Hidden Fees,” cited a 1999 report by the General Accounting Office: “Marketing material, contracts, and other written material provided by the facilities [long-term care facilities] are often incomplete and
vague or misleading [and] only 25 percent of facilities routinely provide their document to prospective residents before they decide to apply for admission.” While that article was published fifteen years ago, much remains the same.

The Consumer Consortium on Assisted Living 
developed a guidebook with Metropolitan Life Insurance that suggests some questions families should ask when they are considering a long-term care facility:

• Does housekeeping include only light dusting, and is there any extra charge for cleaning bathrooms, floors, and windows? Is there a separate fee for doing personal laundry?

• Do units have separate telephones and how is billing handled?

• Are monthly residence and fees still charged if a person is away in the hospital, or on an extended 
visit with relatives?

What to Tell Clients about Long-term Care Costs

It is expensive, and the cost of care wherever it is given rises about 4 percent annually. Here are some of the hidden costs that can come with long-term care.

Transportation. Advise your clients that it will not always be safe or convenient to transport their older or disabled loved ones in car. Private, wheelchair-accessible and accessible transportation comes with a cost. And the transportation provided by a retirement community, assisted living, or nursing home may not be available when it is needed. So, this can be an added expense, particularly when special transportation
is needed. In one case, the cost to transport a client’s mother to and from a funeral in a wheelchair van cost $200. But it was worth easing the emotional toll on everyone.

Supplies. There is a cost for personal care needs, whether the person is at home or in a facility. For example, in many facilities, there is a charge for disposable supplies, as well as for the number of times they are changed. Supplies often used in long-term care
include disposable gloves, wipes, blood pressure kits, thermometers, first aid supplies, toilet tissue, disinfectant spray—the list goes on. 

Downsizing, Moving, Relocation. Hiring a downsizing or moving specialist might be the answer to the emotional toll a move from home can be, or de-cluttering a house to make it safer and appropriate for long-term care. While there is a cost to hiring a specialist, it is often wiser to hire a professional, especially when the house is packed with household
items accumulated over many years or there is a hoarding situation.

Clothing. Buying adaptive clothing that suits the needs of the person needing care is a solid investment. In the course of caring for an individual, clothes will be ruined or lost and will need to be replaced. For example, for a person with a special need—such as a
wheelchair user—purchasing clothes appropriate and designed for a wheelchair user can be another overlooked expense. Clothing companies that specialize in adaptive clothing are on the rise. Just fifteen years ago, finding clothing for a wheelchair user was virtually impossible. A person’s dignity is often related to how they appear to themselves and others.

Dietary Supplements/Special Nutritional Supplements. Medicare only covers special dietary supplements like Ensure or Jevity when prescribed by a doctor. Vitamins or over-the-counter medications add to the cost of long-term care.

Furnishings. It is important to factor in the cost of new or replacement furniture. For example, a reclining chair might be in order. Or a larger TV, better lighting, or a bedside commode might be needed—all to enhance the person’s quality of life and be a help
to the caregiver. Too often, caregivers struggle to give bedside care without a conveniently situated bedside table. Or, they strain their backs to give care in a bed that is too low. An electric hospital bed is especially essential for those needing bed care. An electric bed is covered by Medicare under certain circumstances. Or it can require a monthly rental amount. Often overlooked is the need to replace armless chairs with chairs with arms. Otherwise, for the person with mobility issues, trying to sit in a chair without arms is a safety risk.

Equipment. It’s important for care professionals to know some of the ins and outs about various equipment that older adults may use. Wheelchairs need to be sized specifically to the individual user, including the seating system, arm rests, back support, and foot
rests. And walkers and canes need to be correctly adjusted to fit the height of the user. On average, a manual wheelchair for daily use will cost between $1,000 and $2,000, excluding any special add-ons. 
The cost of an electric wheelchair varies widely from $7,000 upwards, sometimes exceeding $25,000. A properly fitting wheelchair is critical for the person using it. Medicare only covers the cost of a wheelchair under specific guidelines. When considering buying a wheelchair, factor in the cost of a wheelchair carrier for the car, especially if it’s is electric. Consider other potential equipment costs such as a shower chair, hand-held shower head, grab bars (beyond the bathroom), and a Hoyer Lift. This is used for transfers when a person requires 90-100 percent assistance to
get into and out of bed.

The home. A significant cost to consider is retrofitting the house if the plan is for the person to age in place. The costs of retrofitting can extend beyond the cost of grab bars! It may be that a ramp is needed or a doorway widened, sinks lowered, or a roll-in shower
installed. At the ultimate end would be remodeling the entire house using Universal Design. Universal design refers to buildings, products, and environments designed
to be accessible to older people, with and without disabilities.

One-on-one care. There may come a time when the person who needs long-term care will require one-on-one, round-the-clock care, also referred to as private duty care. This can happen following discharge from a hospital of an older loved one. Most people never think about the cost of one-on-one care, especially if they are considering a move to assisted living. Assisted living means caregiving to a degree. Often due to a care recipient’s increased agitation, frequent need to be repositioned, or wandering, one-on-one care in an assisted living facility may be required. 

As the preference for long-term care beyond an institutional setting continues, the demand for paid caregivers will increase. According to the April 2012 “Occupational Outlook Handbook,” a publication of the Bureau of Labor Statistics, U.S. Department of Labor: “Employment of home health aides is expected to grow by 70 percent from 2010 to 2020, much faster than the average for all occupations.” This, of course, signals that the hourly wage of a homecare worker will increase, as it should.

Genworth Financial publishes an annual survey of the cost of care across the United States. The example below is an excerpt from the Genworth survey and shows the increase in yearly cost for years 2014, 2029, and 2039 for a home health aide in Washington, D.C., Colorado, and California:

An overlooked way to reduce the cost of one-on-one care, especially when it is provided at home, is to pay a family member or friend. This is possible legally when a long-term care service agreement has been formalized. Such an agreement goes by a variety of names—support services agreement, eldercare contract, family care or caregiver contract, or personal care agreement. While it may be best to direct the family to an elder law attorney to create the agreement, it can be done without an attorney. But it would be wise to have an attorney review the agreement. A resource for creating such an agreement is the Family Caregiver Alliance.

Care Levels. It’s important to understand exactly what is provided for a specific care level. In a long-term care facility, whether a large facility or smaller group home, the various care levels can be amorphous. For example, one assisted living facility might have five care levels, each at a different daily rate. It all depends on the amount of care the person requires. At one urban facility, for this year, the base cost for level one is 
$30 per day and the highest level, $115 per day. Regardless, there are add-on costs for a level of care in an assisted living facility. 

Medication management can be an unexpected expense. In a long-term care facility, the cost depends on how many times medications are given in a twenty-four-hour period. Basically, the more pills, the more the add-on costs to the daily basic room and board.

Taxes. In no uncertain terms, paying a caregiver “under the table” is illegal. If a client decides to hire a caregiver privately, let them know that the IRS has specific
guidelines for household workers. Unfortunately, many families think it is o.k. to pay a caregiver under the table in order to pay a lower hourly or live-in wage. This is illegal. Professional advisors are ethically bound to advise clients that this is illegal and why.

Some of the care expenses can be a tax deduction.

An accountant or tax attorney who is familiar with eldercare can help. Clients should ask for, if it is not provided, a yearly “resident care verification” document that gives a breakdown of expenditures in an assisted living facility.

Assistive devices. Hearing aids, special devices to assist with daily activities, non-covered aids like special eye glasses, or retro-fitting a car with hand controls may be called for. There is a wide range of helpful, assistive devices for both the caregiver and care receiver. For example, a personal sound amplifying product known as a “pocket talker” may be useful to someone who misplaces or loses hearing aids. A New York Time article, (2013), “When Hearing Aids Won’t Do,” commends the pocket talker as a useful
alternative to hearing aids.

Professionals can prepare their clients for potential long-term care by educating them about the array of professionals whose expertise can save time, money, and emotional toll. While these professionals—care managers, elder law attorneys, financial planners, senior move specialists, daily money managers, geriatricians, to cite only a few—come with a price, remind your clients that good advice comes with a price and the benefit may well outweigh the cost. 

The Bottom Line 

Long-term care, wherever it is delivered, will take a chunk of money. Try as a person might to cut corners, the person may end up spending more emotional and financial currency than might otherwise be necessary. And compromise a quality of life. When long-term care is needed, preparation and planning is the key to quality living. Steve Weisman, in his book, A Guide to Elder Planning: Everything You Need to Know to Protect Yourself Legally & Financially (2004), writes: “Studies predict the cost of nursing homes will approach $200,000 per year by year 2030 when the last of the baby boomers will reach age sixty-five.” 

As professionals, we are in the position to broaden the thinking of boomers, in particular, to imagine and create alternative long-term care arrangements beyond the nursing home or assisted living facility. For families facing long-term care for a loved one, we have an
opportunity to unpack the cost of long-term care and to explain to clients some of the ways that it can be funded when it is needed.

Statistics show that someone turning sixty-five has an almost 70 percent chance of needing some type of long-term care. As professionals, we must reinforce the importance of prepari
ng for its costs. It is no longer the thing to do—it is the smart thing to do. •CSA

Irene V. Jackson-Brown holds a Ph.D. and is certified as a geriatric care manager (CMC) and Certified Senior Advisor (CSA). She is founder of a care management company, The Art of Eldercare, a divison of Jackson-Brown Associates, LLC. She is a member of the
National Association of Professional Geriatric Care Managers, and the CSA Journal Editorial Board. Contact her at 202-722-4205,, or visit

The Hidden Costs of Long-Term Care was published in the Spring 2015 edition of the CSA Journal. 

Blog posting provided by Society of Certified Senior Advisors