Eleanor Feldman Barbera, Ph.D.

According to recent reports, one-third of the baby boomers who will be arriving at the doorstep of long-term care are unmarried. Many of them have no children. Just as our healthcare system relies on unpaid family caretakers, LTC relies on close family members who help our residents through their stays.

The demographic trends, however, suggest we need to prepare for increasing numbers of residents without close relatives.

Below are four ways we can expect this shift to impact our residents, and suggestions for how we can adapt to this change:

1. Lack of POAs, healthcare proxies or legal guardians

The Problem: Currently, most residents have someone available in their lives to make medical and legal decisions on their behalf. This trusted helper is able to collect the documents necessary to apply for Medicaid, for example, or to sell a home for the resident. 

Typically, family members are informed of the need to sign or gather paperwork, and the nursing home awaits the documents. They generally arrive with or without further prompting, allowing for successful completion of the transactions.

In the absence of an involved family member, these essential activities are virtually impossible for a resident to accomplish independently from inside the nursing home, no matter how robust their condition. Residents, who often make a sudden trip from home to hospital to nursing home, generally don’t have important phone numbers, access to legal papers, Internet connectivity, or the wherewithal to make arrangements on their own, from afar, in the middle of a health crisis.

As we begin to see increasing numbers of elders in this situation, it will become apparent that what we are viewing is not an individual problem, but a systems problem.

The Solution: As a system, we’ll need more court-appointed powers of attorney, proxies and guardians available to our residents, as well as a greater emphasis on obtaining advance directives and community supports. Streamlining the process of obtaining these assistants will make life easier for everyone, and can be accomplished using some of the methods below:

When assessing social supports upon admission, we can educate residents about the need for assistance in navigating their healthcare. It’s important to plant the seed early in admission because we can expect this idea to meet with resistance as residents struggle to maintain their independence. We can explain that obtaining helpers is not a reflection of a personal failing, but is unavoidable in a complicated healthcare system.

We can offer increased independence via discussion of advance directives, which allow residents to make their own decisions regarding their healthcare.

We can discuss with residents who among their family, church, and community members might be willing to assist them with their care and begin outreach toward potential helpers. Offering prepared pamphlets or other educational materials about what is involved in taking on a specific caregiving task will allay the concerns of those considering a helper role and reduce the burden on the social work staff communicating the information.

Within our facilities, we can increase our connections to the local community. There we might find church volunteers, for example, who would be willing to take an active role in the lives of our residents, such as signing a back-up agreement for home healthcare or becoming a legal guardian.

We can help residents create a personal caregiving team by connecting more distant relatives or friends who may be able to offer only limited assistance, but together meet the needs of the resident.

We can increase the number and training of social workers in our centers, so they can take on the additional tasks required to address the above suggestions in a manner that enhances the reputation of the facility.

2. Lack of errand-runners

The Problem:  A LTC facility often becomes the resident’s entire world, but not all of their needs can be met within the walls of the facility. A major and important function played by family members is that of procurer of outside items. Currently, residents rely on their family members to bring them home-cooked foods, clothing or items from the community, such as a favorite lotion or shampoo.

Residents without family or friends have come to rely on the kindness of strangers, like their roommate’s daughter, or the friendly aide who makes a grocery store run on her lunch break. This lack of control over formerly simple tasks leads to frustration and depression. Chores such as fixing a watchband become monumental in a nursing home. Using generic toothpaste instead of the brand enjoyed for 70 years can be a twice-daily reminder of lost independence.

Again, what appears to be an individual problem is actually a systems problem within each setting. An increase in the number of single residents will propel us to adjust the way we handle resident needs. 

The Solution:  Access to outside items can be offered in many different ways, and they all increase the independence and control of the residents while reducing the time spent by staff (formally or informally) on obtaining goods for residents who don’t have available family or friends.

LTC facilities could follow the lead of military bases, which are also self-contained worlds, and offer commissaries where residents can make purchases and order specific items as needed.

Another option is a regularly scheduled mobile store that visits residents on their floors, thereby offering access to those unable to leave their rooms. Savvy facilities will purchase items in bulk, sell them at a reasonable price, and create an income stream that pays for the service, and more.

Many boomer singles will expect the independence of being able to purchase their own supplies via the Internet, using a debit card linked to their nursing home bank account. The resident satisfaction and promotional opportunities provided will be well worth the time and minor expense of setting up this system.

An official errand-runner can roam from floor-to-floor and fill orders from the residents, offering an invaluable service to the facility.

3. Lack of social connectedness

The Problem: With far-flung family members and distant relatives, residents are likely to feel disconnected and alone, increasing their likelihood of depression. Many single residents have managed in the community with help from friends and neighbors. Entry into long-term care removes them from their neighborhoods, and the easy, frequent contacts with neighbors. Friends are likely to be in the same age range, and may be experiencing their own health problems that make it difficult to visit.

Single, childless residents often lack a connection with younger, able-bodied family members. They may not feel comfortable asking for assistance and emotional support from those not in their immediate family.

The Solution:  Increasing social contacts for our most isolated elders can be accomplished through a multi-pronged approach using the skills of various team members.

Proactive recreation departments already work to create connections between residents so that they form new friendships with those in the facility. With increasing numbers of singles, it will become more important than ever to establish welcoming committees, provide groups that facilitate the interactions between residents (rather than being passive listeners), and to introduce residents with similar interests and energies.  (For more on this, see my free report, Nursing Home Activities: Leadership Strategies for Maximum Socialization.)

Social workers can make efforts to reach out to more distant relatives and establish a “call chain” that allows greater connectedness between family members while not increasing the burden on any particular relative, or on the LTC staff. For example, while one friend or relative will be needed as the main contact person, if each person in the chain is responsible for calling another chain member, entire groups of people can be notified of resident needs or well being.

Facilities can provide Internet access with the opportunity for free video calling (such as Skype), to increase their involvement with distant friends and relatives.

Simple techniques such as having a visitor’s log in the resident’s room can provide guests with information about who else is visiting and when. It will become immediately apparent when there are periods with no visitors, and steps can be taken to activate the “call chain” established by the social worker.

Psychological services can be considered for very isolated residents to help them resolve interpersonal conflicts that might be leading to estrangement, for example, or to facilitate connections within the facility.

4. Increased interest in romantic relationships

The Problem: Among the current cohort of nursing home residents, romantic relationships tend to be the exception rather than the rule. Most single residents I’ve encountered have given up on romance decades ago and wouldn’t dream of getting involved again in their later years.

With an increasing number of single or divorced residents from the more liberal baby boomer generation, however, we’re likely to see an increase in courtship and sexual activity. The problem isn’t the activity, but the lack of a unified staff approach to handle what is likely to become a regular occurrence. 

The Solution: Training staff and establishing policies and procedures will reduce the many challenges for facilities in attending to resident sexuality. Some of the issues to be addressed are:

Evaluating residents to ensure medically safe sexual interactions

Offering resident education and provision of prophylactics to prevent the spread of sexually transmitted diseases

Evaluation of capacity to consent

Provision of rehabilitative services to help residents adapt to physical changes so they can engage in what might be considered an activity of daily living

Creation of a safe, private environment for couples

Staff education on facility policies and on providing a respectful approach to the sexuality of elders, including lesbian, gay, bisexual and transgender individuals

Involvement, as needed, of social service and psychological services to address the interpersonal dynamics created by romantic liaisons in the “small town” environment of LTC facilities, such as break-ups, deaths, declines, and jealousies.

Conclusion: The coming baby boom and its cohort of singles will bring additional challenges to LTC. Many of these problems already exist in smaller numbers. Efforts to address them now will improve care for our current residents, prevent future difficulties, and offer an opportunity for facilities to distinguish themselves as forward-thinking providers with a focus on good customer service.

More Americans Rejecting Marriage in 50s and Beyond, Swarns, Rachel L., New York Times, March 1, 2012.

Unmarried Boomers Confront Old Age: A National Portrait, Lin, I-Fen, PhD and Brown, Susan L., PhD, The Gerontologist Vol. 0, No. 0, 1-13 dol:10.1093/geront/gnc141

Eleanor Feldman Barbera, PhD, the author of The Savvy Resident’s Guide, is an accomplished speaker and consultant with over 16 years of experience as a psychologist in long-term care. This blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.