Rural Nursing Homes Closing at an Alarming Rate, Scattering Residents and Disrupting Families

When I was the Chief Medical Officer of one of the nation’s largest nursing home chains, people would often ask me ‘what keeps you up at night?’  My answer was always the same: that rural facilities - those that often depend on a single physician, that provide dozens of jobs for local residents, and that allow families to keep their loved one’s with advanced dementia nearby - that these facilities would be unable to provide care for one reason or another, and would have to close.  These are facilities far afield from urban centers, medical schools, and value-based demonstration projects.  Where physicians were mostly shutting practices down, not starting new ones.  Unfortunately these fears were well founded.

There were over 16,800 skilled nursing facilities (SNF’s) in the US back in 2000, just as I became interested in geriatrics, dementia and long-term care.  Today there are 1,200 fewer SNF’s;  thousands of beds have been taken out of circulation, especially in rural areas.  While some close for safety/quality reasons, the majority shut their doors for financial reasons.

In rural states these closures create undue burdens on pateints with dementia and their families.  An article in the NYT a few weeks back describes the scattering of residents when very rural nursing homes close their doors for good.  In one case a resident was relocated 220 miles away, across state lines, in an effort to find a new ‘bed’ that could care for him, by any measure an unacceptable situation.  The patient traveled seven hours across state lines only to pass away three days later.  That an older adult with advanced dementia should suffer the same fate from a man-made ‘eviction’ as folks do after hurricanes and other natural disasters is shocking to me.

States should provide better rates to SNF’s that care for our most vulnerable elders.  Some state rates are barely enough to keep the lights on.  South Dakota is a case in point, with the lowest rate in the nation.  At $131 per day facilities loose money on every resident.  Think about the last time you paid less than that for just a hotel room, forgetting for a moment the personal care, the medications, the social activity and of course three square meals a day.  Where rural SNF’s are in danger, underwriting or subsidizing partnerships with local entities might help.  Loosening zoning restrictions to allow mixed-use healthcare enterprises can attract local investment, allowing for satellite rehabilitation facilities or clinics.  

Rural communities are already hurting in many ways. SNF closures add insult to injury, increase unemployment, penalize the elders who poured their hearts into those communities over a lifetime, and can inadvertantly rip families apart.  Surely we can do better.

The New Dementia Narrative: Risk Reduction and Prevention Take Center Stage

Everyone knows someone today who’s dealing with dementia, and as a geriatrician that means a lot of questions come my way. Questions about parents who recently had cognitive testing, about the role of assisted living, about prevention—you name it. Dementia is out there in a way it never was before. People have questions, and they need answers.

Dementia is not a normal part of aging

This is where I always start. It’s true; dementia is not a normal part of aging—it is notinevitable. But it is really hard to talk about dementia. In this sense dementia is the cancer and heart disease of yesteryear, often shrouded from public view by secrecy and shame, which is ironic because resources abound. Innovative tools, practices, and technologies are emerging for the field of dementia care. People with dementia are learning to endure and thrive in ways that seemed impossible a generation ago, while communities around the world are understanding how to better support their neighbors and loved ones with dementia through specialized programs and activities.

Dementia doesn’t equal Alzheimer’s disease

Most dementias are not curable, but the risk of developing dementia can be decreased by treating depression, longstanding heavy alcohol use, high cholesterol, and heart disease. Because nearly one-third of dementias have a vascular component, anything that improves the health of one’s arteries and veins throughout her lifetime will lead to less cell death in the brain, lower memory loss, and a decreased risk for dementia.

Your brain likes it when you work out

Of all the strategies known to prevent or delay dementia, exercise may be the most impactful. Researchsuggests vigorous exercise leads to changes in brain chemistry and more and tighter connections between neurons, which may build one’s degree of resistance to dementia. Exercise also helps to improve mood, so depression is another risk factor for dementia that exercise can modify.

Anticholinergics may affect cognition permanently

New research is pointing to another risk, one that geriatricians have warned about for years. According to a recent article by The New York Times, long-term use of anticholinergics, including certain antidepressants and medications for things like incontinence, epilepsy, and Parkinson’s disease may increase one’s risk for dementia over time. We’ve known for a while that anticholinergic medications can cause acute delirium—lots of medications have side effects—but this longer-term link with dementia is new.

The study, well designed and conducted in England, compared prescription patterns in the three to 13 years preceding a diagnosis of dementia in 59,000 people with a matched sample of 225,000 people who did not develop dementia. They calculated the total “anticholinergic burden” individuals were exposed to over time, like the way we think about radiation exposure over time. Those with the highest exposure over time—people with daily use of a strong anticholinergic medication for over three years—showed a nearly 50 percent increased odds of developing dementia.

These findings serve as a wake-up call to all physicians to pay closer attention to the anticholinergic burden as their patients live longer, and for patients to look for less anticholinergic alternatives if long-term use is recommended.

Learn more about dementia

As you continue to learn from a growing body of research and collaborative communities, remember that knowledge is power. Armed with greater wisdom and empathy, we can overcome the narrative around dementia and equip the current generation of people with dementia, their loved ones, and their caregivers with the resources, support, and courage to thrive.