Assessing the Risk of Living at Home



by James A. Wilkinson

What You Need to Know

A caregiver must look carefully at an elderly personís problems to determine whether independent living is still appropriate or if some level of assistance is needed. In some cases, the elderly may no longer be safe in the home, even with assistance, and new housing may be needed.

            If more than one person lives in the home, look at each personís problems and needs individually, and consider what would happen if one person moved out. Letís say, for example, that a married couple lives together in their home. The wife is frail, but quite self-sufficient.  Her husband, on the other hand, needs help with basic daily activities, including dressing, bathing, and moving around. because the wife is no longer able to assist her husband with these activities, their living arrangement is unsafe for both of them. If he were to get intensive home care or move to an assisted-living facility, she could continue living at home. However, if she eventually had to move to a nursing home and he stayed in the house, he would still need constant care and housekeeping services.

            Even when one personís condition poses a threat to the other, an elderly couple may not want to be separated after all their years together. However, if either of them is able to understand the issues, you should raise the question of living arrangements. Try to get them to agree that one or both of them has to move. If they insist on staying together and are mentally competent, there is little that you can do, even if one poses a serious risk to the other. However, if one is incompetent, you can ask a court to appoint you his or her legal guardian. If the court agrees, you can then move the elderly person to a safer environment.


What to Look For

Condition of the Home

A homeís physical condition may be the first sign of potential problems.  Signs of neglect may indicate that a clean and safe home is more than the person can handle, either physically or financially. If itís just a matter of upkeep (such as uncut grass and dirty windows) or minor maintenance (such as peeling paint), there may be no need to worry. It could mean that the homeís appearance is simply no longer important to the elderly person. However, if thereís structural damage to the home, itís time to be concerned.

            Piles of dirty dishes; the odor of urine or excrement (whether human or animal); an infestation of bugs or roaches; evidence of rodents or animal damage; a filthy bathroom; spoiled food in the refrigerator or pantry; dirty clothes, sheets, and towels; broken appliances or fixturesóall are strong evidence that the person is no longer capable of living alone safely. Whether the danger is physical (as in the risk of fire or falling) or involves quality of life (inadequate nutrition, lack of heat), you should consider alternative housing or, at the least, intensive home care or housekeeping services.



In some cases, the home may be fine, but the elderly may show signs of inappropriate thinking or behavioróhaving no food in the house, turning the furnace off in the winter, storing the iron in the refrigerator, acquiring unnecessary items (two refrigerators, four televisions, and a new set of encyclopedias, for example), and so on. Other times, the elderly personís behavior doesnít change, but friends sense thereís a problem, even if they canít articulate what it is. When an elderly personís behavior or personality changes, he or she will likely be unaware of its significance, and others may dismiss it as an eccentricity. The fact is, changes like these are serious and should be monitored.

            In addition to the obvious, look for more subtle signs that assistance may be needed. Check the pantry and refrigerator to see if the elderly person is eating three meals a day. Malnutrition is a common problem among the elderly, especially as their ability to perform routine activities deteriorates. Do you see any unpaid bills or utility shut-off notices? Is the elderly person getting calls from bill collectors? Are objects disappearing from the home? Do you find that thereís not enough money to pay the bills, even though there should be?

            Do you find packages containing worthless gifts or prizes? Have there been any calls from people who will only speak with the elderly person, or who tell you that more prizes have been won? These are signs that the person is being victimized by a scam or fraud.

            Because the elderly are often victims of ďcontractorĒ fraud, you might also be concerned if the person becomes involved in a major home-remodeling project. sometimes the services are paid for but never provided. In other cases, a small problem turns into a major repair.  Tell the elderly person that you would like to discuss any remodeling projects before he or she signs a contract or makes a nonrefundable deposit. If you suspect the person is being victimized, donít hesitate to contact the local postal inspector or police, even if a contract has been signed and the work has already been done.

            Physical, mental, and emotional problems are also signs that some level of assistance is needed. Any of the following behaviors should cause immediate concern. The elderly:

            Canít remember if or how much medication they took, or they forget to take their medication altogether.

            Are unkempt, dirty, or smelly, or they refuse to dress appropriately, change clothes, or bathe.

            Report falling, or show evidence of a fall, but minimize the problem or canít remember it happening.

            Fail to eat regularly or properly, for any reason. Be concerned if they canít remember how to cook, when to eat, if they have eaten, or what they ate. Any sudden weight loss or evidence of malnutrition or dehydration may indicate a serious problem.

            Appear to be lip reading; fail to acknowledge the telephone, the doorbell, or a knock at the door; or donít respond to a sudden, loud noise. An undiagnosed hearing deficit is a serious safety problem.

            Have problems with any of the Activities of Daily Living or Intermediate Activities of Daily Living (see checklist below).

            Show fear of living alone or of another person. Fear should be dealt with immediately, especially when accompanied by mysterious lumps, bruises, or skin tears.

            Tend to wander out of the home or dress inappropriately for the weather.

            Become reclusive and spend hours in a bedroom or darkened room.

            Donít make sense when answering simple questions.

            Insist on driving even when it poses a risk to themselves and others.

            Appear to be abusing alcohol or medications, including over-the-counter medications.

            Smoke in the house, despite a tendency to nod off or fall asleep while smoking.

            Suddenly begin adopting stray pets and insist that itís okay to live with more than two dogs or cats.

            Show a major personality change, especially violent outbursts, striking others, verbal abuse, or swearing.

            Forget recent phone calls or visitors.


Social Contacts

How isolated is the elderly person? Do you know who his or her friends are and how to contact them? Is the person an active part of the community? Does he or she get calls or visits from friends, neighbors, caregivers, or clergy? How often does the elderly person get out of the home to shop, go to church, or visit friends? Is the community relatively safe, or is the person locked in the home and afraid of going out, even during the day? If he or she remains at home, will home care and housekeeping services be easy to arrange? If the person has become reclusive and has little contact with people outside the home, continuing to live alone could be dangerous.



A Geriatric Assessment

It is difficult to be objective when assessing the physical, mental, and emotional health of a person you care for. Caregivers may be overly sensitive to minor problems, while minimizing severe impairments to avoid facing the fact that the elderly personís condition is declining.  Even if a caregiver tries to be objective, itís hard to know how to measure an elderly personís condition. For these reasons, a comprehensive geriatric assessment may be needed at some point.

            If the purpose for the assessment is to determine whether or not the elderly person can continue living at home, request a home visit. Most urban and community hospitals have teams of doctors, nurses, therapists, nutritionists, and social workers who specialize in geriatric care and can perform assessments in the home. They can determine if itís safe to continue living independently, if in-home assistance is needed, or if a more appropriate living arrangement is necessary.


Involving the Family

Try to get everyone to agree up front that an independent assessment is needed, and to abide by the outcome. If another caregiver or family member strongly opposes the idea of an independent assessment, it can lead to state involvement, litigation, and perhaps a family feud. If there is opposition at the start, donít assume that everyone will suddenly become rational and agree to ďdo the right thingĒ just because theyíve read the assessorís report.

            If the elderly person is mentally competent but absolutely refuses to cooperate, you must proceed cautiously. Encourage him or her to talk to a physician. A physician may be able to convince the person to reconsider his or her decision. If the elderly person still refuses to participate, there is little you can do.

            Keep in mind that the more evidence you collect to verify specific problems with the elderly person and his or her living conditions, the easier it will be for othersóincluding the elderlyóto accept the conclusions of the assessment. Ultimately, the facts are what they are.  The best way to reach a consensus is to help everyone involved confront those facts. remember, unless itís an emergency, a geriatric assessment will take time. This time can be used to forge consensus within the family.

Assessment Results

If the geriatric assessment doesnít turn up any major problems, and the living environment is basically okay, thereís no reason to upset the status quo if the elderly person doesnít want to move or doesnít want in-home assistance. Although you may want to investigate housing options for the future, donít force a change when one isnít clearly warranted.

            However, if the geriatric assessment reveals problems that canít be corrected with in-home assistance, itís time to select a more appropriate living arrangement. Youíll need to decide where the elderly person will live and how much time you have to make the change. In general, the sooner the move is made, the better.

            The assessment may show that the elderly person can continue to live at home, but only with assistance. If this is the case, there are a number of eldercare services and assistive devices designed to help the elderly live safely and comfortably in their home.



While few of these scenarios will fit your situation exactly, you can help a professional focus on potential problem areas by selecting the best answers to the following questions. The answers may also help identify a need for specific caregiving services and determine if the current caregiving arrangement is adequate.



This first list focuses on the most basic activities of daily living, or ADLs, measuring the elderly personís ability to perform them without assistance. A mental or physical disability can lead to difficulty in any of these areas. The inability to perform even one of these activities is serious and will require caregiving assistance. For each of the following activities, check the level of assistance the elderly person requires.



[ ] No assistance needed

[ ] Can bathe, but is often dirty

[ ] Some help needed

[ ] Lacks strength or agility to bathe safely



[ ] Full control of bladder and bowels

[ ] Occasional bladder accidents

[ ] Occasional bowel accidents

[ ] Accidents caused by decreased mental capacity

[ ] Regular problems with bladder or bowels--needs diaper



[ ] No assistance needed

[ ] May need help with certain things, such as buttons or shoes

[ ] Can dress if someone selects clothes

[ ] Can dress, but isn't concerned about clothes or appearance

[ ] Needs help dressing and undressing



[ ] No assistance needed

[ ] Needs some help

[ ] Forgets to eat or eats at odd times

[ ] Can feed self, but needs help with certain foods or a specific diet

[ ] Swallowing problems; food must be pureed

[ ] Must be fed


Moving around

[ ] No assistance needed

[ ] Needs walker/cane for balance or support

[ ] Needs to hold onto someone or something

[ ] Needs wheelchair

[ ] Can move around, but waits for assistance

[ ] Needs help getting in or out of chairs

[ ] Needs help getting in or out of bed

[ ] Essentially bedridden


Using toilet

[ ] No assistance needed

[ ] Needs assistance getting on or off toilet

[ ] Needs assistance getting clothes off or on

[ ] Forgets what the toilet is for

[ ] Needs bedpan or portable toilet at night

[ ] Needs bedpan or portable toilet both day and night



This list covers what are considered intermediate activities, or IADLsóa personís ability to complete tasks that require simple planning, reasoning, and judgment. Although some of these topics may raise gender issues (an elderly man may never have prepared his own meals, for example), try to determine if the person would be able to perform the task.



[ ] Knows what needs to be done and does it without prompting

[ ] Will do it, but only if prompted

[ ] Cannot do it, even if prompted


Taking medicine

[ ] Remembers to take medicine according to directions

[ ] Will take it according to directions if reminded

[ ] Cannot be trusted to take medicine properly, even if reminded


Preparing meals

[ ] Can plan and prepare a meal

[ ] Cannot plan, but can prepare a simple meal if assisted

[ ] Cannot plan or prepare even a simple meal


Managing money

[ ] Can manage finances and pay bills

[ ] Cannot manage finances, but can write checks with help

[ ] Cannot manage finances or pay bills


Minor repairs

[ ] Can identify problem and either fix it or call for assistance

[ ] Knows something is wrong, but cannot fix even simple things

[ ] Cannot identify problem, not even to ask for assistance



[ ] Can use the telephone and find a number

[ ] Can use the telephone if number is known

[ ] Cannot use the telephone



[ ] Can travel alone using private or public transportation

[ ] Can plan travel, but needs assistance

[ ] Can travel beyond neighborhood only if all arrangements have been made

[ ] Cannot travel alone under any circumstances

From A Family Caregiver's Guide to Planning and Decision Making for the Elderly by James A. Wilkinson. Copyright © 1999 by James A. Wilkinson. Excerpted by arrangement with Fairview Press. $16.95. Available in local bookstores or call 800-544-8207 or click here.