How to Have Difficult Conversations About Aging With Loved Ones

When a loved one starts to forget things, starts repeating stories, or is physically ailing, it’s heartbreaking. The country collectively watched an example of this as President Joe Biden’s voice weakened over the past few years; he lost his train of thought during a high-stakes debate and then pulled out of the campaign.

“One of the things that makes it stressful is that people wait to have hard conversations until they are sort of imminent, and decline is happening,” said Louise Aronson, a geriatrician and professor of medicine at the University of California, San Francisco, in a recent episode of KQED Forum. “And so the person who is declining is feeling more threatened. If you begin sooner, then they’re more part of the process, and they feel a sense of control.”

These difficult conversations — even in private settings — remain surprisingly rare. However, geriatricians point to numerous tools and resources that can make the transition easier.

Making an optimal plan for elderhood

“The most helpful way to approach the conversation is to think about the tension between the two parties,” said Dr. Katherine Ward, a geriatrician with Stanford Senior Care. “The child is most concerned about safety in the older adult’s environment, and the older adult is most concerned about their independence. And so if you look at that tug of war, you can discuss the benefits and risks of both.”

Both parties may avoid the conversation altogether because they find the decline depressing. If a senior refuses to talk about the future, Aronson suggested expressing concern. A child can say something like, “I love you, and I am worried. I see that you didn’t pay your bills last month. Or, I see that your shirt is on backwards. Can we talk about getting some help?”

Or either party may make false assumptions. Seniors may assume they will move in with their children when the time comes, but younger generations may not have the time or resources to be an adequate caretaker. Cultural expectations can exacerbate these differences.

If or when making a care plan is difficult within a family, Aronson recommended a mediator or intermediary with cultural and linguistic fluency aligned with the senior.

Staying at home

Many seniors may prefer to live independently for as long as possible. Medicare covers the cost of a “home safety evaluation,” where an occupational therapist visits and then suggests modifications for a home like grab bars, ramps and increased lighting. Preferred Care at Home provides this service for free. And, online DIY resources offer checklists to assess the safety of a home.

Government assistance may be a critical resource for older adults. In California, the Home & Community Services program includes caregiver assistance, adult day health care, and legal support. However, there is not a centralized access point for these programs and applications can be confusing. The California Advocates for Nursing Home Reform offers a quick guide to help people get started.

For families separated by distance, a geriatric care manager, usually a licensed nurse or social worker who charges by the hour, can help make a care plan and find services.

The Health in Aging Foundation and Eldercare Locator can help families access a network of healthcare professionals specializing in geriatrics, or help connect families to in-home help, transportation options and offer guidance on financing care. Meals on Wheels is a tool to ensure access to nutritious meals.

If it is time to hand over one’s driver’s license, Aronson said, you can make it easier by thinking about what role driving played in that person’s life. “Maybe it was getting out of the house. Maybe it was alone time. Maybe it was time to go explore. Are there other ways of getting those same pleasures?”

All along the way, Aronson said, an elder should lead the conversation by sharing their preferences, hopes and priorities.

When is time to consider a residential care facility?

Families will have to weigh independence versus the benefits of social contact, because studies show that isolation and loneliness is bad for your health. Living in a community can be protective against developing cognitive impairment or dementia.

If a family member begins to show serious signs of mental or physical decline, it may be time to relocate an elder to a residential care facility like an assisted living facility or a nursing home.
Some red flags signaling it’s time for a safer place to call home:

• Unsteady walking up and down stairs
• Frequent falls
• Struggling to calculate the tip at a restaurant
• A serious financial mistake
• Losing track of daily medications

If you can afford it, an assisted living facility is likely the first option. There are lots of online resources to help people find and vet complexes. Unfortunately, facilities vary greatly in both quality and cost.

“Historically, Medi-Cal [the state’s insurance for people on a limited income or disability] does not pay for assisted living outside of a really small and very income-limited assisted living waiver program,” Maura Gibney said. “So then we’re talking about private pay, and the average cost of an assisted living facility in California is $5,000 a month and up. We regularly talk to people who are paying $7-10,000 a month for an assisted living facility.”

What about a nursing home?

If frequent falls lead to visits to the emergency room, it may be time to consider long-term care in a nursing home. But, Gibney says this is a last resort, “At this point in California, it’s really difficult to find a ‘good nursing home.’”

If possible, she recommends visiting homes ahead of time. “Trust your gut. Does it smell? Are residents freely moving around? Or is everyone in bed? Are they dressed? Does the facility feel clean? Do the staff greet you when you come through?”

All medical experts stressed that making a plan for elderhood varies within each family, but the earlier you can start the conversation with a loved one, the more likely an elder will live out their final years in a dignified and comfortable environment.

“This may not be popular, but I’d say every one of us should probably start thinking about our final chapter in our 60s,” Aronson said.