The Hidden Side Effects of Nutritional Drinks for Seniors

From meal replacement weight loss plans to protein shakes for building muscle, people of all ages frequently turn to nutritious sustenance in liquid form for a variety of reasons. After all, it’s easy to pack nutritional supplements and multivitamins into a beverage and still make it taste good. Unfortunately, some people have an over-reliance on these nutritional drinks and don’t realize how harmful they can be if used incorrectly. Nowhere is that more apparent than in care for elderly people. 

Studies of appetite decline indicate that older adults frequently experience a loss of appetite for a wide variety of reasons, from physiological changes in the digestive tract, disease, weakening of related senses like taste and smell, and psychosocial causes like depression or delirium. The medication elderly people have to take is also likely to have one or more of these changes or causes as a side effect. 

This loss of appetite can lead to conditions like weight loss, poor bone health, undernutrition, and loss of energy. Sweet nutrition drinks can be a great way to occasionally replace calories that would have been consumed in a meal, but they rarely have the same nutrients as a healthy diet would offer. 

Over-reliance on high-calorie nutritional drinks can lead to harmful health problems related to obesity like high blood pressure and kidney disease. A certain amount of weight gain is great for elderly people who have lost too much weight, but too much can cause harmful effects.

Caring for a loved one as they age is no easy task and nutritional drinks too frequently present as relief for caretakers and family members. But without the proper considerations of the effects of those drinks and the advice of a registered dietitian or a physician, elderly people could face harmful side effects. 

Why Do Elderly People Experience a Loss of Appetite?

Older adults – sometimes as young as fifty – start to experience physiological changes that can lead to a loss of appetite. Health problems can exacerbate this process, but even elderly people in otherwise good health naturally tend to become less active and thus their bodies require less energy to get through the day. Metabolism tends to slow down as a response to this. 

But if they don’t need as many calories each day, then eating less should be okay, right? Actually, simultaneously as their metabolism is slowing down, elderly people’s bodies’ ability to process nutrients and put them to use in our various bodily processes becomes less efficient. So they need less energy, but they need more nutrients. 

That’s why so many people, including some registered dietitians and nutritionists, rely on nutrient drinks for elderly people who have trouble getting enough to eat. They aren’t a good long-term strategy, but for older adults with chronic health issues and those on medications that can affect appetite a nutritional shake every now and then could help. 

Another reason elderly people might experience a loss of appetite is because of reduced mobility. That could make it hard to get to the grocery store or even to feed themselves. Studies and anecdotal evidence from registered dietitians who work with older adults indicate that many elderly people who experience loss of appetite from lost mobility or because of medical issues like memory loss, nutritional drinks are easier to drink. 

Ensure, one of the most popular nutritional drinks on the market, has 220 calories and 14 grams of sugar.

What Nutrients Do Elderly People Need Most?

As with people of all ages, older adults need a few key macronutrients like protein, healthy fat, and carbs. They don’t need nearly as many carbs, especially if they’re not able to move as well. Nutritionists have long debated and studied the effect of various nutrients on elderly people. For example, short trial studies once led professionals to believe that higher protein intake led to less protein in urine, which in turn led to increased bone loss. However, in 2000, a study found that the exact opposite is true: a higher protein intake reduces bone loss in elderly people. 

Dietary fiber is another important nutrient for older adults. It promotes heart health, intestinal health, and protects against other metabolic issues. Also important are omega-3 fatty acids, which are found in many vegetable oils like walnut, flaxseed, and hemp oil as well as animal fats from fish, chicken eggs, and squid. These acids protect against cardiovascular issues and may also guard against diabetes and cognitive decline, although its full range of benefits are still being studied.

Fiber is also important for maintaining digestive health. Micronutrients like Vitamin E, Vitamin B6, Magnesium, Vitamin B12, Folic Acid, and Vitamin D are also chronically missing or underconsumed in the diets of most elderly people. 

Unfortunately, while most nutrition drinks might have some of these nutrients on the label, they aren’t an effective source for satisfying the nutritional needs of elderly people, or anyone else for that matter. 

What is in Nutritional Drinks?

Some of these nutrition shakes and other drinks might have large amounts of vitamins on the label, but there are also frequently high amounts of sugar, which can lead to unhealthy weight gain for elderly people. As an example, one 16 oz. bottle of Ensure, one of the most popular nutritional drinks on the market, has 220 calories and 14 grams of sugar. They say that much sugar only represents 28% of the daily value, but that’s based on a 2,000 calorie daily diet. Elderly people very rarely reach anywhere near that amount. 

Even for someone who does eat 2,000 calories a day, drinking almost a third of your sugar intake in a single sitting and getting only 10% of your calories from it is not a healthy balance. For elederly people who are struggling with glucose control or have blood sugar problems, this can be a huge issue. 

Furthermore, a bottle of Ensure lists 14 vitamins and 13 minerals. That single serving represents anywhere between 20 and 50% of the recommended daily value for vitamins like vitamin C, vitamin D, vitamin K, biotin, choline, niacin, and riboflavin, among others. It’s a similar situation with the minerals. 

That may sound nice enough, and for people who do need around 2,000 calories per day and want to make sure they get some healthy nutrients, a bottle of Ensure can be a nice supplement. But if an elderly person is drinking more than one or two bottles per day, they can get way more nutrients than they need. 

For some of these vitamins and minerals, that won’t lead to any huge issues. If they’re on medication, there can be complications from high levels of certain things that interact badly with what’s in their medicine. 

Over consuming vitamins and minerals can also cause side effects like dizziness, vomiting, and diarrhea, and might even increase the likelihood of heart disease and cancer. Vitamin deficiency is bad, but if an elderly person is already experiencing a loss of appetite and they begin to have problems with their digestive system because they overconsume nutritional drinks on a daily basis, they’re going to stay away from food even more to avoid trips to the bathroom

3 Ways to Fit Nutritional Drinks Into Elder Care Diets

Whether you’re looking after a loved one or working as an elder care professional, there are many ways to effectively use nutritional drinks like Ensure or Boost to help people who are experiencing appetite loss. However, take care to meet with a licensed dietician or a physician before settling on a diet plan to make sure you don’t cause any health issues.

1. Use Nutritional Drinks as a Snack

The nice thing about these drinks is they aren’t very good at satiating appetite. Since they don’t cause people to get that “full” feeling, they can be consumed in the afternoon or between meals. Doing so will allow the elderly person to keep doing what they should be doing, which is getting the majority of their nutrients from real, whole foods like veggies and high-quality protein from meat or dairy products. 

When you are experiencing loss of appetite, mealtime can be more like a dreaded chore than the break in the day that most of us might see it as. Filling in the gaps, or even using one of these drinks as a reward for eating a meal earlier in the day, can be a nice way to help elderly people avoid repetitive patterns that can cause depression after long periods of time. 

2. Make Your Own High-Protein Nutritional Shakes

If the appeal is the easy digestion, the smartest thing to do is make them from scratch using real, whole foods so that the elderly person is still getting the food they would get from a healthy diet of solid foods. Using egg whites, milk, or nut ingredients can help boost their protein consumption, which will be good for maintaining lean muscle mass and keeping the immune system in working order. 

You may also be able to find a protein powder that isn’t too high-calorie. Making nutrient shakes with protein ingredients is also a great way to use ingredients that are sweet enough to taste even when the sense of smell and taste are receding. Peanut butter is a great option to add to a nutrient shake. You can even add some ice cream or rich chocolate for an additional treat. 

There is some evidence that blending certain fibrous ingredients reduces their usefulness in the body. Some ingredients like bananas and flax seed blend up without destroying their nutritional content. With a little research, it’s easy and fun to find out what ingredients work best and suit the taste of the older adult best. 

3. Prevent Dehydration with Nutritional Drinks

Dehydration is a serious problem with older adults. This is doubly true if they have reduced mobility or don’t tend to work up a sweat during the day or if they have incontinence issues they feel embarrassed about. There are some homemade versions of these drinks that aren’t dairy-based but rather involve substantial amounts of water. Mix fruit or citrus together with water and it will be much more palatable. 

The nutritional benefits of drinking enough water are numerous no matter how old you are. It helps with all bodily processes and it might even help build up a little bit of an appetite, depending on the reasons for the loss of appetite in the first place. 

Drinking enough water can also help maintain the urinary system, although if there’s a background cause this may not be the case. Metabolism may get a boost when the elderly person isn’t dehydrated, plus brain function could improve and the likelihood of kidney disease will go down.

How Many Nutritional Supplement Drinks Can You Drink in a Day?

This is a critical question, even for younger adults who use drinks like Boost or Ensure as nutritional meal replacement. There’s a different answer for manufactured drinks with lots of sugar and the healthier homemade kind. 

For the drinks you can buy from companies like Nestle or Ensure, it’s really not wise to drink more than two a day. Now, the advice is split on this point. Some registered dietitians say you should only drink one of these nutritional drinks if it’s replacing a meal, while others say they should only work as a snack because they don’t actually give the same well-rounded nutritional value of a healthy diet made up of solid whole foods. 

Using these drinks for meal replacement is really only advisable if it’s temporary, irregular, or due to an emergency condition and therefore recommended by a physician or registered dietitian. The bottom line is they can create problems of their own and only real whole foods will give elderly people the nutritional balance they need to enjoy their older years. 

Ensure’s website says elderly people can have up to size of these drinks a day, but that would give them three times the amount of vitamins they need based on a 2,000 calorie diet. If someone is in a state where they’re drinking that many nutritional drinks a day, they’re creating new problems with their diet. 

Many times, organic juices are a great supplement to a healthy meal instead of other “nutritional drinks”.

Hidden Side Effects of Nutritional Drinks

The issue with many elderly care diets is that either the person themselves or the people taking care of them are still thinking about diets as if it were for a younger person. It might not be the case that low-fat options are always the best choice. In the end, if you can get them to eat any kind of solid, whole food, it will always be preferable. Bodily processes will be regulated and it can help boost the mood of the elderly person. 

The mental side effect of over-reliance on these drinks is often overlooked. But elderly people, even if they have memory loss or other cognitive issues, are frequently aware that they are living on a liquid diet. This can also lead to diarrhea, and that’s even more embarrassing. The feeling that they are no longer normal or capable is one of the worst feelings, and feeding them a steady diet of nutritional drinks might make that situation worse. 

Another side effect of nutritional drinks for seniors is that they can be habit-forming. It’s not that they’re addictive or anything that bad, but if they become the routine it can be difficult to break out of that. If the structure of the elder care is such that there isn’t someone around to cook at all times and the elderly person can’t do it themselves, then the nutritional shake will become the norm. If they contain a lot of sugar, they’ll be increasingly appealing as people build up a taste for them. Breaking out of that cycle with whole foods can be difficult. 


The bottom line is that these nutritional drinks can be a great help if they’re just used to fill in gaps a few times a week. There are plenty of ways to use smoothies and other nutritional drinks to build a healthy diet in elder care. Using them to prevent dehydration is one way. They can also be high-protein and help to keep the body working normally. 

If you are going to use nutritional drinks in elder care, the best way to do it is to use whole foods and blenderize them to make a drink that is full of nutrients and won’t oversaturate the body with a flood of vitamins and minerals. Overconsumption of vitamins and minerals can lead to diarrhea and other issues, to say nothing of consuming loads of sugar in manufactured drinks like Ensure or Boost. The homemade shakes are almost sure to be tastier than the store bought variety anyway, and it will add more variety to the diet to prevent repetition and brighten the elderly person’s mood overall. 

Nutritional drinks can interact poorly with medications. If you are trying to formulate a healthy diet for an elder care patient, check with medical professionals and registered dietitians before making significant changes. Many times, you can bring a list of current medications and work out a healthy diet with a registered dietitian so that you can be sure it’s tailored to the individual person. 

How to Find Transportation Services for Seniors

Chronic diseases like arthritis and the effects of aging on physical activity levels, strength, and balance can all lead to reduced mobility in seniors. Just because they may have some degree of doesn’t mean older adults don’t still have regular errands like medical appointments, trips to the grocery store, pharmacy runs and other healthcare-related necessities, or visits to loved ones. Transportation for seniors can be challenging to navigate, but luckily, current technology is making it easier and faster to get a loved one safely where they need to go.

Standard transportation options such as the metro or bus may not be feasible given the health and range of mobility of a given elderly person. There are other options, though, such as paratransit services, ridesharing apps like Lyft or Uber, or volunteer drivers who are happy to help seniors get around. 

Emergency transportation to a doctor’s appointment or the emergency room might be covered under Medicare/Medicaid or private insurance providers. These types of plans might even have some allowance for transportation options, including ridesharing apps. For older adults who aren’t able or just prefer not to use smartphones, there are other apps like GoGoGrandparent that will allow them to use rideshare apps like Lyft and Uber in the USA by calling one of a pair of phone numbers. 

Security is one of the biggest concerns most people have when they use one of these transportation options for a loved one. Rideshare apps like Lyft and Uber typically display the make, model, and license plate of the car. Family members can see exactly where their loved ones are through the app and set an exact pick-up and drop-off point. Some private transportation options even have door-through-door service, which means the driver will help elderly fares to the front desk or lobby of a building. 

Finding transportation for seniors can be worrying, but it doesn’t have to be. Read on to find out all the different ways to help seniors with limited mobility continue their daily routine safely.

Loss of Mobility and Its Adverse Effects

Beyond directly impacting their ability to move around on their own, loss of mobility can also have lasting repercussions on elderly people’s mental health, social life, and physical wellbeing. In fact, as this study mentions, mobility is a crucial determinant of health and quality of life among elderly people. 

If the loss of mobility is less severe, like minor arthritis, then it might only prevent the elderly person from walking sometimes. However, more serious medical conditions or loss of strength can cause elderly people to stay inside all day. If loss of mobility leaves someone stuck sitting down for most of the day, the amount of lean muscle in their body will continue to dwindle, meaning their mobility level will be on a continuing downward slope. 

In the most severe cases, the inability to get up and go to the restroom can lead to physical problems like UTIs or body sores. People weren’t meant to stay inside all day with little contact. As elderly people with limited mobility lose touch with friends and loved ones or go through entire days with little to no stimulation, they can quickly become depressed. That can have adverse effects on their appetite, leading to many other health problems. 

Finding transportation for seniors is not just about getting their errands done. It’s the only way to make sure they can continue truly enjoying their golden years the way that they want to. For some seniors, a loss of mobility reduces the activities they can take part in. But there are still plenty of ways for them to get around. 

Public transport can be one of the cheapest option for elderly people if they are able and if you can come with them.

Public Transit for Older Adults

Navigating a metro or bus system can be frightening for elderly people. Unlike private transportation, the other people on public transit systems won’t necessarily concern themselves with the needs and conditions of elderly people sharing their bus or train. 

In the United States, most cities have buses if they have any public transit available at all. However, in some places, there are additional public transportation options. The Americans with Disabilities Act (ADA) has set forth requirements for fixed-route public transit, making it more accessible and easier to use. For older adults who are able, one of the following might be a great way to get around:

Above-Ground Public Transit

Your city might have bus routes, light rail, or streetcars to help people traverse a few blocks or several miles. Many people may not be familiar with how the public transit in their system works, but the ADA lays out some standards that make buses, rail, and stations much easier for older adults. For example, the ADA says every public transit facility must have accessibility equipment like lifts, ramps, and security devices to keep wheelchairs from moving. 

Signs and communication devices (i.e., stop announcements) must also be clear and accessible to everyone. They offer braille and large print options. As long as the elderly person is capable of navigating the route, there are many ways that public transit has been made accessible thanks to the ADA.

Below-Ground Public Transit

In the USA, only about 15 cities have subway systems. In some cities like Atlanta and Charlotte, the commute time can be twice as long on the metro than it would be with private transportation. However, in larger cities like New York City and Chicago, the subway can be the fastest way to get around. It may seem scary sending an older loved one off on a metro train. Still, these forms of public transit are also obliged by the ADA to give priority seating and accessibility options, just like the above-ground transportation options. 

The most important consideration to make with regards to public transit is whether an elderly person has had experience with navigating such a system before. If they have never lived anywhere with a subway, sending them into the cavernous NYC Subway is probably going to overwhelming. However, if they took buses and trains in their younger years, continuing to use them while they’re able could not be the best way, but it could also be a comfort to them to take public transit.

Paratransit Services

Vans specially tailored for people with impacted mobility are mandated by the ADA, albeit only where fixed-route services already exist. It’s up to the specific public transit area agency to decide whether they want to offer door-to-door service or curb-to-curb service. If an elderly person does have extreme difficulties getting from the curb to the door, or if there are barriers in the way, the driver may also be obligated to help them to the entrance or lobby of their destination. 

These paratransit services are only required to cover a distance of ¾ of a mile past either end of an existing fixed-route service, so they’re only handy in cities that have a robust public transportation system. However, they are specifically aimed at elderly people who have suffered a loss of mobility or have a disability, so if they are available, they’re a great help. 

How to Find Transportation Services for Seniors

Besides public transit, there are many private transportation options to help seniors go about their daily business, visit loved ones, and go to doctor’s appointments. Here are some of the most convenient ways for older adults to travel:

1. Rideshare Apps (Lyft, Uber, etc.)

The gig economy is still in its infancy, but companies like Lyft and Uber have made it easier than ever for a car to pick up riders at their doorstep and take them to a specified drop-off point. They are geared toward people who can use a smartphone, but services like GoGoGrandparent allow elderly people to use Lyft and Uber by calling a phone number rather than having to learn how the app works. 

Most of the time, Lyft and Uber rides function as private transportation, meaning there won’t be anyone else in the car other than the rider. For elderly people, a caretaker or loved one can ride along without any added expense. These apps are generally inexpensive, usually costing less than a taxi, but there are fare increases at peak hours. As a fringe benefit, the elderly person will have someone to talk to during the ride. 

One beneficial thing about rideshare apps is that they might be covered by Medicare/Medicaid or private insurance. Frequently, to provide non-emergency transport to the insured without ado and at the lowest possible cost, the insurance company will call an Uber or Lyft driver. That means the insured won’t have to bother with an app or a phone call, and the insurance will get billed. 

2. Taxi Services

Perhaps the first idea many people think of when they need fast transportation, traditional taxis can still be hailed by phone and trips scheduled in advance. However, in many places, taxis have fallen behind rideshare apps like Lyft and Uber in terms of technology, which means they might be difficult for elderly people to use. They’re often quite expensive. 

If the cost is not so important, then taxis can be a great form of non-emergency transportation for short distances. Like public transit, taxis are most appealing to elderly people who have spent their lives riding in taxi cabs. 

3. Demand Response, a.k.a. Dial-A-Ride

Many municipalities provide a service where senior citizens can schedule a pick-up and drop-off with an accessible vehicle. Usually, there are many people with individual pick-up and drop-off points, so these are different than the paratransit option that depends on the existence of fixed-route public transit.

If there is no public transit available, demand response might be the best option. For example, Santa Barbara, in California, doesn’t have a metro, but it does have a bus system. To use the Dial-A-Ride service there, people must be physically or mentally unable to use the bus service. That way, it’s guaranteed the service reserves to help seniors who need it.

4. Medicaid Non-Emergency Medical Transportation

For Medicaid beneficiaries who need help getting to medical appointments, the Non-Emergency Medical Transportation (NEMT) Medicaid provides is likely to be the best way to get to the doctor. Medicaid doesn’t require pre-approval for emergency medical transportation like ambulances or medical aircraft. They do, however, pre-approve the type of destination that NEMT will cover. 

While it only works for transportation to doctor’s appointments, hospitals, and other pre-approved locations that have to do with health care, it’s convenient for elderly people who are already covered by Medicaid. If they are covered, NEMT is the only transportation service that is free for Medicaid beneficiaries. Unfortunately, the same coverage is not offered to Medicare beneficiaries. 

5. Transportation Voucher Programs

Local and state governments are typically involved with the implementation of transportation voucher programs. Participants receive an allowance of either trips, miles, or dollar amounts to use for school, religious trips, health care appointments, shopping, and other categories. These vouchers might be awarded on economic status or based on mental or physical faculty. 

Each town, city, municipality, or state runs its voucher programs differently, and there aren’t necessarily voucher programs in every place. Check with the local governments or use the Eldercare Locator to see if there’s one in your area.

Transport services like Uber can be convenient for elderly people who might not be able to drive any longer.

6. Volunteer Transportation Programs

Frequently operated by faith-based organizations, these programs are a great way to get rides with customized pick-up and drop-off points with a volunteer driver who is kind and friendly. Just like all the other transportation options, the presence and availability of volunteer programs vary with location. Some may have limitations in distance or number of trips per week, and they definitely should only be used as non-emergency transportation. 

One nice thing about volunteer programs is that volunteer drivers are frequently young people or family-oriented. Plus, they’re doing it entirely as a service, so they’re much more likely to be conversational and allow for more customized journeys.

Learning to Use Public Transit for Seniors

There are also many programs, frequently operated by the public transit authority itself, that will introduce public transit and teach elderly people how to do it. If the loss of mobility isn’t severe or the elderly person is completely capable, then learning how to travel with public transit can be a fun learning experience. Of course, these programs are as limited as access to public transit is in the USA. But many cities have bus systems and might have travel training with a local area agency to help seniors get around on public transit on their own. 

Private Transportation & Senior Care Services

Where the budget allows, hiring an in-home caretaker might be the best way to ensure an aging loved one is protected and can still live normally. In many cases, the caretaker might have their own vehicle, so offering the client some transportation from time to time could be included in the payment. This will require discussion, but it’s not an unusual request for caretakers to occasionally drive clients around. 

This option also gives elderly people the ability to have one person they’re familiar with helping them. Look out when shopping around for a caretaker, though. Many of them are working for home care services that want to maximize their client base to make more money, so the caretaker may only have an hour or less to visit and take care of meals and other things for the client. If you want transportation options with a family caregiver, it will probably have to be a private agreement for long-term care to make sure they’re concentrating on your loved one.

When to Use Senior Transportation Services

When an aging loved one can’t get around quickly enough, the choice to use other transportation options is clear. However, many older adults have trouble recognizing when they should give up driving in their own personal vehicles. It can be a tough choice because, as we all remember from our teenage years, driving is tantamount to personal freedom. 

In one article, the University of Alabama recommends asking two questions to help determine whether alternative transportation options are needed. 

  1. For health or physical reasons, do you have difficulty climbing up ten steps or walking a quarter of a mile?
  2. Because of underlying health or physical reasons, have you modified the way you walk ten steps or walk a quarter of a mile?

These two questions are a helpful test of mobility loss because it still leaves the person in question in control. Hearing that you can’t drive anymore from a doctor is one thing, but admitting it to yourself on your own terms is more manageable. 

Also, remember that failing eyesight and mental ability, including reaction time and spatial awareness, can also affect the decision to stop driving or to use more independent transportation options like public transit. It will take some serious consideration, but in the end, it will depend on the unique condition of the elderly person. 


Finding a low-cost transportation option for seniors can be challenging, especially in areas without public transit options. Senior citizens have many options for scheduling transportation, or they may have access to travel training programs that can show them how to use public transit. 

For those who are uncomfortable or not capable of making their way to a bus stop and navigating the fixed-route transit system in their city, there are also options from Medicaid and volunteer programs that work to fill the gaps. 

Deciding to stop driving is painful and emotionally challenging for many senior citizens. Transportation needs don’t change just because we can no longer drive ourselves. However, when that time comes, there are still plenty of other transportation options that allow aging loved ones to get around on their own or with help so they can spend their golden years the way they want. 

How You Can Get Paid for Being a Family Caregiver

Becoming a family caregiver is done unexpectedly for most people. Normally, it’s brought on by unforeseen circumstances or a sudden change in the health of an aging parent or loved one. It can begin with small tasks and then balloon until a family member is taking care of filling prescriptions, doing laundry, cooking, and even bathing and feeding a loved one.

According to the Family Caregiver Alliance, approximately 43.5 million caregivers provided unpaid care to an adult or child in 2015. All the evidence indicates that that number is increasing every year as the baby boomer generation ages. Unfortunately, although the economic value of unpaid caregiver services was estimated to be $470 billion in 2013, it’s very rare that there is any way to be paid for any of the work. 

Unless the care is paid for by Medicaid or another organization, the only way to get paid is to have the family member receiving care or other family members contribute to the payment of the caretaker. There are a few ways to reach such an agreement, but it can be complicated and many families find themselves arguing or overreacting about such payment when under duress because of the failing health of a loved one. 

Of the ways that family caretakers do manage to get paid for their efforts, Medicaid is one of the most popular. Medicare does not cover any payment to family caregivers at all, but Medicaid has a provision called the 1915(c) HCBS waiver that might allow it. However, it’s left up to the state to define how Medicaid is rolled out and how their home- and community-based services (HCBS) are implemented and what the eligibility requirements are. 

Eldercare can be incredibly taxing on families. Long-term care can stretch budgets and strain relationships, and while the amount of reimbursement the limited options available do give family caregivers is not much, it can help with daily costs and, in some cases, defer the opportunity cost of giving up a paying job to take care of a loved one. 

Money payment for senior care done by a family member is hard to come by. To get it, you might have to live in the right place or have the right kind of insurance. There are many organizations out there to help family caregivers get financial assistance or reimbursement for certain types of home care. The whole process can seem overwhelming and an elder law attorney might be required to truly know whether there’s a way to get paid. 

It would be impossible to write a guide that could say for sure whether a given reader could get money for eldercare. But this article will serve as a solid jumping-off point and hopefully give you some ideas of where to look if you want to be a paid caregiver for an elderly parent or other family members. 

What is Eldercare? Home Services vs. Health Services

First things first, you should make sure you’re doing the type of thing that’s widely considered family caregiving. There is a wide range of duties that a family member might take on for another who needs it. These can be divided into two categories, which are home services and health services. Home services are non-medical and don’t require a license to perform, which is why family members so often become responsible for them. 

Examples of home care services include what are referred to as Activities of Daily Living, or ADL. Everything we have to do in our daily lives becomes an activity of daily living for aging people who can no longer perform all or some of these tasks themselves. 

It might be grocery shopping, cooking, cleaning, transportation, or laundry for elderly parents. It could also be assistance with doctor’s appointments, taking medicine, getting dressed, using the bathroom, or bathing. If there’s a bigger loss of mobility, it might be necessary to help with getting out of bed or performing medical assistance with physical therapy, breathing treatments, wound cleanings, injections, or feeding tubes. 

Health services are more complicated and should be taken care of by a physician or trained professional. Day-to-day medical case management is often done by an RN appointed by the physician. Catheters, IVs, parenteral nutrition, speech therapy, occupational therapy, and serious wound care all fall under this category.

Then there are all the legal and financial things we all have to handle. Between monitoring payments, bank accounts, wills, and insurance payments, eldercare is essentially doing the work of two lives at once. If there aren’t other family members to help and the care recipient is completely unable, a single person can quickly be overwhelmed. 

One role of a caregiver to to help their patients perform tasks they are no longer able to perform as easily on their own.

10 Ways to Get Paid for Family Caregiving

As difficult as providing for an elderly parent or other care recipient is, navigating the complicated system of government eligibility requirements, classifications, local regulations, and health insurance policies to try and get paid for family caregiving can be a nearly endless process and that payment may well never come. 

Luckily, so many people are family caregivers that it’s easy to say which methods are most likely to get you paid as the primary caregiver. Here are 10 places to start your search:

1. Veteran’s Aid

There are many government programs that could possibly pay family members for senior care, but the U.S. Department of Veteran’s Affairs (VA) is one of the most likely. They have a Family Caregiver Assistance program that has two eligibility requirements. The person rendering care services must be either a spouse, son, daughter, stepfamily, or extended family member, and they have to live full-time with the care recipient or be willing to do so once designated as a family caregiver. Secondly, the care recipient must have been discharged from the U.S. military or have a date of medical discharge and have a serious injury (including TBI, psychological trauma, mental disorder, etc.) that was caused or made worse by their active duty service on or after September 11, 2001.

The care recipient should also require a family caregiver for at least six months. This program allows the care recipient to appoint one primary and two secondary family caregivers. They may receive a monthly stipend, health care benefits through the VA’s civilian health department (CHAMPVA), and up to 30 days of respite care per year in addition to education and counseling resources and transportation reimbursement if the care recipient needs to travel to receive care. 

In case the care recipient is a veteran but doesn’t qualify for the Family Caregiver Assistance program, they might be covered under the VA’s Program of General Caregiver Support Services, which has much more general eligibility requirements. The VA also has Caregiver support coordinators and a helpline. 

2. Social Security Supplemental Security Income Benefits

If the care recipient is eligible for and at least apply for regular social security benefits to qualify for SSI. Other eligibility requirements include being between the ages of 18 and 65, having never been married, not being blind, being a U.S. citizen residing in one of the 50 states, D.C., or the Northern Mariana Islands, and not having received SSI benefits in the past. Unlike regular Social Security payments, the SSI program doesn’t depend on contributions from paychecks in the past. 

There are some other benefits that are typically available to care recipients who qualify for SSI, such as SNAP or regular Social Security payments. Just like these other programs, SSI is reserved for low-income individuals. 

3. Medicaid Cash and Counseling Program

Cash and Counseling provides payments to a care recipient for the duration of the time they need care. Of course, since it’s a Medicaid program, its exact parameters are decided at the state level, which means you’ll have to see what the eligibility requirements are and how much caregiver support you can expect to get from a cash and counseling program. 

Cash and Counseling is a self-directed program. The basic idea is that in order to better align with individual preference and reserve professional medical facilities for those who have no other options, Medicaid recipients should be able to hire their own caretakers. This is done after a physician assesses the care recipient’s needs with the caretaker and outlines a weekly personalized care plan that allows for an estimate of hours per week or month that will be required for the caretaker to deliver the care. From that care program estimate, a budget amount is decided and monthly stipend granted.

Qualifying Medicaid beneficiaries can benefit from more control and a more personalized care plan with a Cash and Counseling program, but make sure that the family caregiver isn’t overworked. Some states may have additional steps for the assigned caretaker, such as licensing or paying some payroll tax out of payments they receive through the Cash and Counseling program.

4. Family Caregivers Tax Credits

The IRS has something called the Family Caregivers and Self-Employment tax. As with all taxes, this one is a bit complicated to understand. Generally, it applies to people who are employed to provide in-home care whether or not they are related to the care recipient. If the caregiver is a family member, there is a chance that no tax will be owed, but the caregiver could still be obligated to pay an employment tax on the payment received. In almost all cases, payment received for rendering home care services should be reported on the family caregiver’s taxes, even if the caregiver isn’t required to pay taxes on it. 

Claiming an elderly parent as a dependent when they are housebound or otherwise unable to care for themselves might be the most direct way to deduct payments for medical services and other needed health care from your taxes. Generally speaking, it’s required that you pay for 50% or more of their cost of living to be able to claim elderly parents as dependents. It’s even possible to claim a friend or honorary family member as a dependent if they have lived with you for a year or more. 

Deductions for medical care are mostly only available for bills paid out that have not been reimbursed by health insurance, including flex spending and health savings accounts. If the situation surrounding the care recipient meets the eligibility requirements, the family caregiver can claim up to $3,000 per individual and up to $6,000 for two or more. 

5. The National Family Caregiver Support Program

This government program gives grants to states based on the amount of their population that is over 70 years old. One of the central goals of this program is to assist family caregivers and make it easier to care for elderly parents at home as long as possible, rather than sending them to an institution or nursing home. It covers several things, including:

  • Assistance and information to caregivers about accessing services
  • Counseling, support groups, and caregiver training
  • Supplemental services
  • Respite care

The availability to have paid respite care is essential for family caregivers to avoid burnout, especially when rendering long-term care. If there’s only one primary caregiver, going long periods without any breaks can lead to stress and have negative effects on overall mental health. This could cause resentment for the entire situation. Here are the eligibility requirements for the National Family Caregiver Support Program:

  • Adult family members or other informal caregivers age 18 and older providing care to individuals 60 years of age and older
  • Adult family members or other informal caregivers age 18 and older providing care to individuals of any age with Alzheimer’s disease and related disorders
  • Older relatives (not parents) age 55 and older providing care to children under the age of 18; and
  • Older relatives, including parents, age 55 and older providing care to adults ages 18-59 with disabilities

For more information on the NFCSP, click here.

A long-term healthcare policy can potentially cover a caregiver’s expenses.

6. Purchase a Long-Term Care Insurance Policy

The best way to stay prepared for the financial burden of the high level of care aging parents will need in their later years is to buy a long-term care insurance policy through a well-known company like AARP well ahead of time. The downside to these plans is that they can be quite expensive, but if you are protected by one, these policies can cover medical expenses that aren’t covered by traditional health insurance. It will vary with the policy, but they are generally used to cover the activities of daily living like bathing, dressing, and getting in and out of bed. 

Long-term care insurance policies are tricky because most won’t let the care recipient apply for coverage if they already have a debilitating condition like Alzheimer’s. It’s wisest to buy the coverage in your 50s or 60s well before you need it. In the end, it will be much cheaper to have coverage through one of these policies, which are great ways to make up for what normal health insurance and Medicare don’t cover.

Another thing to make sure of when you buy the policy is whether or not it will cover payments to family caregivers. Not all long term care insurance does, and even worse, if they don’t offer this coverage then the insurance agent won’t even bring it up most of the time. Asking about it upfront is critical to get coverage and have a family member as a live-in paid caregiver.

7. Take Paid Family Leave

These days proper paid family leave seems to be vanishing at most companies, but if you are lucky enough to have it then it might include payments for family caregiving. Check and see if your paid leave does have this provision and see how long it lasts for. The worst part about this strategy is that it likely won’t last long, so it’s a better stopgap option than a long-term plan. Large companies tend to offer something like 3 – 4 months for family caregiving, but if it appears the care recipient will be in need longer than that, paid leave can still be a nice way to get paid while the family figures out a game plan.

8. Pay for it As a Family

If there is more than one primary caregiver or at least some siblings or other family members to help, then there are two ways that the family can pay the caregiver. The simplest way is to simply pool some money together and give it to the caregiver for expenses. Many families that try this run into trouble, though, because the stress of the situation can lead to arguments and occasionally even ruined relationships. 

If the care recipient has some money put away, it can also be used to pay for the care. Just like the pooling option, though, this one can lead to disputes. In both cases, it would be extremely wise to work with an elder law attorney beforehand to draw up a personal care agreement that clearly states the duration, amount, and duties of the primary caregiver. It’s the smartest way to keep everyone in the family on the same page, plus everyone can come together to work on the personal care agreement together. 

9. Medicaid Waivers and HCBS

HCBS, or home- and community-based services, are implemented using Medicaid waivers that allow states to come up with custom ways to roll out the Medicaid program. Like the other options that stem from Medicaid, HCBS will depend on the care recipient’s Medicaid eligibility. HCBS is a way to offer in-home supportive services and personal care services to those who need it. 

Here are the eligibility requirements for states’ HCBS programs:

  • Waiver services mustn’t cost more than providing these services in an institution
  • Care recipients and other participants’ health and welfare must be ensured
  • Standards used to meet the care needs of the target population must be reasonable and effective
  • The plan should create individualized and person-centered plans of care

For now, almost all states have some form of HCBS programs in place. The waiver programs that most consistently lead to personalized consumer-directed care plans are in states like New Jersey, Rhode Island, New York, and California. State Medicaid programs vary widely, so you’ll have to check with your state’s Medicaid website.

10. Find Funding Through Private Organizations

There aren’t many organizations that will pay family care providers and the ones that do exist tend to concentrate their efforts on care recipients with specific mental health or cognitive issues like Alzheimer’s or Parkinson’s. However, care recipients with these diseases do have long-term care needs that are more intense than others. Regardless of whether your loved one has these specific issues, it’s fairly easy to check for private charities or faith-based organizations that can help out, even if it’s only a little bit. 


As relatives age, the relationship dynamic changes between them and younger family members. Sometimes, they can be more like adult children than grandparents, aunts, or uncles. Regardless, almost everyone needs some degree of home health care at some point and the vast majority of people rely on family members to tend to their care needs. 

This arrangement can be very stressful for family members and a significant reason for that is the financial strain. Many people forsake their own careers and life goals for a time to care for an elderly parent or relative and getting paid for that effort can reduce stress, burnout, and other negative mental health effects. 

There are many ways to attempt to recoup the costs of eldercare. State Medicaid programs are a great place to start depending on the care recipient’s Medicaid eligibility. Other government programs may have long waiting lists and, just like long-term care insurance, it’s best to investigate coverage before it’s needed. 

Many places have area agencies for location-specific plans like HCBS. Finally, arrangements with family members to pool money or make a personalized care plan are great options if there are enough people, but it’s wisest to hire an elder law attorney to avoid disputes. If you are able to find a way to get paid for being a family caregiver, it can be a huge relief. 

The 3 Types of Adult Day Care

Managing the long-term care of a loved one can be difficult. Many people turn to family caregivers and other family members to get the senior care they need. Frequently, that means living full-time with family members. The high care costs of elder care can be made even more unbearable if the younger family members providing care services are unable to work because the care takes up so much of their time. 

Long-term living facilities for seniors like nursing homes are too expensive for many, and the care recipients themselves seem to prefer family caregivers by and large. Luckily, there are adult day care centers where seniors can go during the day so that their family members can still go to work, run errands, or take some respite from providing care. 

These adult day cares come in three varieties. Some are only geared toward giving the care recipient a social environment to interact with others and enjoy activities throughout the day while others are built to provide health services to the older adults who stay there. The third type of adult day care is tailored to older adults with cognitive conditions like Alzheimer’s or Parkinson’s. 

Adult day cares offer lots of care options and give family caregivers a bit more freedom. They tend to cost much less than nursing homes or medical  or assisted living facilities that offer full-time housing. Plus, the older adults who need adult day care centers tend to prefer the social activities and interaction that senior centers give to sitting at home isolated and waiting for family members to return from work. 

For some, staying at home may not be an option. People with Alzheimer’s Disease and similar cognitive conditions can’t be left alone for any period of time once it has progressed past a certain stage. These older adults can be taken to a specialized adult day care that will watch them for a few hours a day. It’s much better than the opposite, where the older adult is left at a nursing home and only sees family members for a few hours a day once in a while. 

Choosing the right kind of adult day care is a hard choice, especially when the care recipient may not be able to voice their opinion on the matter. Understanding the three kinds of adult day care centers will help give you an idea of which suits your family member best. This article should work as a more detailed guide to adult day care centers so readers know what they’re dealing with. 

What is an Adult Day Care Center?

Adult day care programs are run by both for-profit and nonprofit organizations. Some may be faith-based or even headquartered on church property, while others might be in a newer building. Regardless of their organizational status, they generally all have social activities, plenty of social interaction, and occasionally a physical activity element such as light physical therapy. 

Adult day care centers might have a common room and outdoor area, or they can resemble classrooms. There might be musical instruments or radio, plus board games and other daily activities. If the older adults happen to be active seniors, they can even take field trips. In many ways, they do operate in much the same way as a day care for children would. Of course, since they are groups of older adults, the daily activities tend to be a bit different. 

Most adult day care centers will have at least one registered nurse on hand.

The 3 Types of Adult Day Care

Adult day care centers can be split into three groups, based on the ability of the older adults who are sent there. Sometimes a single day care might have its members organized into groups based on their cognitive ability, but it’s more likely that the entire adult day care will be one of the three types below to avoid confusion.

1. Social Adult Day Care

For older adults who enjoy social activities like cards, book clubs, discussion groups, music, bingo, field trips, and holiday celebrations, social adult day care is the best option. Participants’ mental faculties and personal tastes are accommodated at these centers, and there may even be visits from children’s day cares if the location allows. 

Most social adult day care centers try to look out for the members’ well beings by having some element of light physical activity or walking involved when possible, but there are generally not professional medical services on-hand. Almost all social adult day cares have a registered nurse around and some proximity to a medical center is always a strong selling point, but this first type of adult care is not meant for people who need constant help. 

The care given at these centers is still considered assisted living, but older adult members at a social adult day care are still able to do activities of daily living on their own. That generally includes using the toilet and feeding themselves, although there are staff on hand to help. 

2. Adult Day Health Care Centers

More sophisticated health services are available at adult day health care centers. While social adult day care might have hearing tests or blood pressure gauges all or part of the time, adult day health care (ADHC) centers have RNs and provide various kinds of therapy to seniors who need it. Medical records and an evaluation by a physician are needed to enroll at an ADHC center.

Older adults who have suffered a stroke or frequently exhibit confusion are the most frequent participants at ADHC centers. These facilities often have speech therapy, physical therapy, and occupational therapy for resident seniors. It’s also possible to have medication monitoring and general health monitoring at ADHC. These centers are sort of a middle ground between social adult day care and the specialized facilities that can take care of resident seniors with Alzheimer’s and other cognitive conditions. 

Many people in the early stages of such cognitive conditions go to an ADHC. They might later transfer to a more specialized adult day care if the need arises. Staff will be more involved with the activities of daily life at ADHC than they are at social adult day care.

3. Specialized Adult Day Care

For an adult day program for those with cognitive decline, memory loss, or disease like Alzheimer’s or Parkinson’s, a specialized adult day care will be necessary. The staff are all trained to handle the specific characteristics of older adults with cognitive difficulties. There are several ways that care providers have theorized treating dementia, Alzheimer’s, and simple memory loss in older adults. Today, many facilities rely on comforting fictions to some degree, but there are others that are better-suited to people who have moments of memory loss in between periods of lucidity, or vice versa.

It will likely take a little more shopping around to find the right specialized adult day care because it will have to both align with the condition of a care recipient and also be able to appeal to their specific personality. However, it can be a huge relief to have some rest. After respite, care for a senior family member is much easier. In fact, many people find that they are able to act more like a family member and less like a nurse if they can take their loved one to a specialized adult day care, even if it’s only during business hours.

How to Find an Adult Day Care Center

When searching for adult day care services, it can be a challenge to find a place where you’re comfortable leaving your loved one in the charge of strangers. There are many area agencies that can help find adult day centers, and some are even sponsored by Medicare and Medicaid provided the care recipient is already a beneficiary. 

The National Adult Day Services Association, or NADSA, has plenty of resources on its website to find the right adult day care center. They also have a searchable database. Many adult day medical care facilities also have reviews online from people who have used their services before. Depending on what state you’re in, there might be a .gov domain website that has a list of adult day care resources for residents. The Eldercare locator is also a fine option.

What to Look for in an Adult Day Care Center

In addition to the particular needs of the care recipient, there are some other factors that should come into play when you’re looking for an adult day care center. Here are some examples, although this list in non-exhaustive:

  1. Are there social activities, like knitting, cards, a basketball hoop, music, plays, and so forth?
  2. Is it safe and secure, both from the inside and from the outside?
  3. Do they offer physical activities?
  4. What kind of food do they serve, and are they capable of catering to special diets?
  5. Does the nursing facility offer additional programs such as support groups for caregivers and extended respite care when the caretaker needs it?
  6. Can social services be contacted if they aren’t already provided onsite?
  7. Are they respectful of limits regarding care costs, and is there financial assistance available for low-income people if necessary?
  8. What sort of health monitoring do they have? Blood pressure and hearing only, or more?
  9. How many of the activities of daily living can they help with?
  10. Is speech therapy, physical therapy, or any other program offered as well?
  11. Can they offer transportation to and from the facility?

Monitoring the personal care of an aging loved one can’t be done by just a few family members alone. Many try to give loved ones full-time home care, but that’s a sure fire way for everyone – possibly including the care recipient – to get cabin fever and get at each other’s throats. An adult day care center that offers all or most of the things listed above will be the best option to get the specialized personal care that loved ones who are in declining health need.

Paying for Long-Term Adult Day Care

Day care facilities for older adults run easily more than $50 a day, depending on how much care they offer and where they’re located. Even if you only need it during business hours five days a week, that’s still a pretty sizable bill. Unfortunately, the gov doesn’t offer financial assistance through Medicare. However, there are a few other places you can look to try and pay for your loved one’s personal care needs. 

Medicaid does offer coverage to low-income people. NASDA may also have some resources to find private grants or charities if your loved one has Alzheimer’s Disease, Parkinson’s, or something similar. Veterans’ Benefits are also likely to have some coverage depending on how long the care recipient served. Private individual health insurance may or may not cover adult day care services, but it’s more likely they don’t unless you specifically asked for it when you bought the policy. The best insurance you can have is long-term care insurance.

Positive Effects of Adult Day Care

According to many studies, including research from the National Adult Day Services Association, using adult day care services reduces stress in both caregivers and the recipients they look after. Many daily stressors are likely behind this, but it also makes logical sense. From the caregiver’s perspective, being stuck with a loved one who may not remember who you are all the time or any of the time is not a good way to spend a whole day, especially not for weeks or months on end as may happen during long-term care. 

For older adults who need adult day care centers, having an afternoon filled with social activities and a variety of interesting things to concentrate on will leave them feeling better. The NADSA research also indicated that isolation can be as harmful to the human body as smoking tobacco can. Using adult day care centers is the best way to prevent that additional harm from a loved one who is already in cognitive decline. 

Adult Day Care and Improved Quality of Life

Composite studies of our quality of life have described it as comprising the following fields:

  • Physical functioning
  • ADLs
  • Social functioning
  • Emotional functioning
  • Mental health

Examining participants in adult day care centers, it is clear that their quality of life generally improves with the use of these nursing facilities. That may have a lot to do with the social interaction that comes with personal care in an adult day care. The social activities may also have a slight physical element or there could be additional activity from field trips or walks around the grounds that can boost health broadly. 

Participants report that their daily activities are less limited after a significant amount of time spent at adult day care. Now, of course, these kinds of responses are difficult to elicit from people who suffer memory loss or Alzheimer’s Disease, but family members of these participants frequently report similar positive results. Overall, it’s great not just for the loved ones who need the care but also a relief for family caregivers. 

Adult day care centers often encourage daily exercise.

How Does Adult Day Care Help Caregivers?

Respite care is something that many family caregivers don’t pay attention to until they’re already burned out. It can be hard not to be at a loved one’s side full-time as they battle cognitive conditions or ill health from the aging process, but every caregiver needs to take some time off for their own good and the good of their family members, including those receiving care. 

Time off is one of the most obvious benefits, but many family caregivers use adult day care as a way to continue working so that they can afford to give in-home care at least some of the time. Financial assistance isn’t always available and adult day care is the only option for families with older adult members who can’t be left alone. Even in larger families, people have to go to school and work. Plus, living a normal social life is important for everyone, and nobody wants to be the one whose aging prevents their family from having a fulfilling life.


Deciding to adult day care services for a loved one is a difficult – sometimes even heartbreaking – choice. But compared to the cost of a nursing home, these care services are the best way to give older adults fulfilling social activities and prevent them from suffering in isolation. 

Even if they have cognitive conditions like Parkinson’s or Alzheimer’s, an adult day care can help them enjoy their time during business hours when the rest of the family has to work or go to school. It can help prevent burnout in family caregivers and in many cases has led to a deeper emotional connection between family members because they aren’t bickering about managing a loved one’s care. 

There are many things to consider when choosing an adult day care center, but it all depends on who your loved one is and how their body is handling the aging process. Luckily, there are plenty of resources out there to help families and loved ones make the best decision.

Medicaid’s Look-Back Period Explained (Penalties and Exemptions)

Medicaid was created in 1965 to offer medical insurance to certain protected groups of people, like low-income or disabled citizens. Unlike Medicare, which is federally operated and available generally to people over age 65, Medicaid is funded partly by the federal government but its parameters and eligibility requirements are decided on the state level. Standards and available coverages differ depending on your state of residence. 35 states have expanded Medicaid while 16 have yet to do so. 

For many people, Medicaid is the only way they can afford long-term care in old age. Medicaid benefits cover nursing home or in-home care for those without the money to pay for it themselves through private long-term health insurance. To try and make sure Medicaid benefits are given only to those who need it, Medicaid has a look-back period during which the finances of a Medicaid applicant or couple applicant affect their Medicaid eligibility. 

To explain why, consider a hypothetical individual who has done well for themselves, making enough money and owning enough property to be somewhere well over his or her state’s Medicaid asset limit. As the individual gets closer to old age, they decide they’d like to protect themselves in case the need for long-term care arises. Rather than purchase private long-term care insurance, they decide Medicaid is cheaper. So, they gift their house and a significant amount of their savings to children, spouses, family members, or charities until they qualify for Medicaid.

This attempt to “spend down” one’s assets doesn’t work if it’s within the look-back period. Medicaid will review applicants’ finances for a set period of time, 5 years in 49 states, and 2.5 years in California. During that period of time, any asset transfers, gifting, or selling of property could lead to Medicaid ineligibility. 

The five-year look-back period is meant to discourage people from trying to “bankrupt” themselves just to qualify for Medicaid. If a Medicaid applicant has more countable assets in that five-year period of time and sold them for below fair market value, they are penalized with a Medicaid penalty, which means they are barred from receiving Medicaid for a period of time. That period of time varies widely by state, but it can lead to months or even years of Medicaid ineligibility in states like New York. 

Understanding the Medicaid look-back rule is important for anyone who has to rely on Medicaid and may come close to the asset limit. For many people, they have some countable assets that will put them over the asset limit but won’t help them pay for long-term care if they need it. For others, estate planning should be done before the need for long-term care arises and mental faculty may diminish. To properly pass on assets to family members without inadvertently incurring a period of Medicaid ineligibility, you have to understand the look-back rule. 

The look-back rule, as with pretty much everything to do with Medicaid, is extremely complicated, and failing to properly handle assets before applying for Medicaid can drastically affect how and whether you will be able to get the long-term care you need. Take the information in this article as a kind of basic explainer, but know that it does not serve as legal advice and is not a guide to personal estate planning. 

Proper Medicaid eligibility planning should be done with the help of an elder care law firm or elder law attorney who understands Medicaid in its most current form. This article will present some basic information on the Medicaid look-back rule for general knowledge. 

When Does the Look-Back Rule Apply?

Medicaid has many programs and since it’s not controlled by the federal government, the programs in each state are different. They also have different eligibility requirements and so the look-back rule may be applied for some programs and not others depending on where the Medicaid applicant lives. 

In general, the look-back rule will kick in when applying for SSI, Medicaid long-term care insurance, and regular Medicaid. All of the Medicaid programs and coverages that apply to elderly people are affected by the look-back rule, including nursing home coverage and home- and community-based service (HCBS) waivers. 

While Medicaid is widely accepted, it’s important to know about your coverage beforehand.

Asset Limit for the Five-Year Look-Back Rule 

For Medicaid, owned property is divided into countable assets and exempt assets. Not every asset will count toward the asset limit, but determining which will and which are exempt is exceedingly difficult without an elder law attorney or Medicaid preparation expert. 

As an example, in many states, the asset limit for a single Medicaid applicant is $2,000 in countable assets. However, the applicant’s home doesn’t count in most places provided its fair market value is below $595,000. In some states, the fair market value of an applicant’s home can be up to $895,000, and California doesn’t have any limit on the fair market value. Any debt still owed on the house is subtracted from the fair market value for Medicaid’s asset limit.

Couples in which both spouses are Medicaid applicants are allowed to have $4,000 in countable assets. One new change to the Medicaid rules is that, for a married couple where one spouse is a Medicaid applicant and the other is the “community spouse,” meaning they aren’t applying for Medicaid, then the applicant spouse can transfer countable assets to the community spouse. They can have up to $2,000 in jointly-owned assets and the community spouse is allowed to have up to $128,460 in countable assets that are individually owned. This is called the Community Spouse Resource Allowance, or CSRA. A house is not counted toward the asset limit if the community spouse lives in it. 

Income Limits for Medicaid

Besides countable assets, there are also limits on the amount of money a Medicaid applicant can make while they are a beneficiary. In 2020, that limit per single individual Medicaid applicant is $2,349 per month to qualify for both nursing home and long-term care Medicaid. Generally, spouses’ incomes are counted separately. If one spouse applicant is moving to a nursing home or receiving home care through an HCBS waiver, the other spouse can use part of the applicant spouse’s income to pay for living expenses. This scheme is called the Minimum Monthly Maintenance Needs Allowance.

If each spouse is a Medicaid applicant, then they can each make up to $2,349 per month. If applying for the Aged, Blind, or Disabled Medicaid coverage, then the income limit is much less, likely because it can be harder to make the same income amount if you fit into these categories and need long-term care or a nursing home. The ABD income limit varies by state, but about half the states have a $783, and most of the other half have a $1,063 individual limit and a $1,437 limit for couples. For ABD Medicaid, spouses’ incomes are counted together, even if only one spouse fits the ABD category and is applying for Medicaid on that basis. 

Penalties for Medicaid’s Look-Back Rule

If, after review of all of a Medicare applicant’s financial transactions, a large transfer of assets or selling off of countable assets for less than the fair market price, the applicant will incur a period of ineligibility, which means they will be barred from accessing Medicare coverage for a specified period of time. 

The way they calculate the period of time during which a Medicare applicant will be ineligible (the penalty period) is based on something called the penalty divisor or private pay rate. This is either the average monthly cost or the daily average cost of nursing home care, which is increasing every year alongside the cost of live-in care as the baby boomer generation ages and requires more and more long-term nursing home care. 

Medicaid will take the total value of transferred assets and divide them by the penalty divisor, which is determined by the state. The resulting number will represent the timeframe of the penalty period.

Examples of Medicaid’s Look-Back Period Penalties

The look-back rule is very complicated and based on very minute details. Financial transactions for the last 5 years (or 2.5 in California) are considered, which means Medicaid applicants have to review their financial transactions for that time period before submitting a Medicaid application. Medicaid planning with an elder law attorney is going to be the best choice for a personalized plan, but here are a few illustrative hypothetical examples to help understand Medicaid’s look-back period and the possible penalty periods that can result.

Look-Back Period Sample #1:

For a simple example, let’s imagine a single woman from Missouri wants to apply for long-term nursing home care with Medicaid. After reviewing her financial transactions, Medicaid finds the woman has been gifting her daughter about $5,000 per year during the five-year look-back period. Medicaid sees that she has given away $25,000 in total during the time period. 

The average monthly cost of a semi-private room in a nursing home in Missouri is about $5,000. Her gifting amount of $25,000 divided by the average monthly cost of $5,000 equals 5. That means her period of ineligibility will last for 5 months. 

Look-Back Period Sample #2:

Let’s say this woman from Missouri isn’t single. She has a husband who doesn’t need Medicaid coverage and therefore will remain a community spouse. Together, they own a house with a fair market value of $350,000. She has not been gifting her daughter $5,000 a year during the five-year look-back period in this example. Rather, let’s say she has $28,460 in countable assets which she transfers to her husband, adding to his $100,000 in countable assets. In this case, there is no penalty period because the community spouse is just at the CSRA limit. 

However, if she has $120,000 in countable assets and transfers assets to her husband who already has $128,460 of his own in countable assets, then she could incur a penalty period of two years! (That’s 120,000 divided by the $5,000 average monthly cost of a nursing home in Missouri.)

Look-Back Period Sample #3:

Homeownership can complicate things. What if the woman from Missouri lives in a house with a fair market value of $475,000. The house is completely paid off, but she sells it to her daughter for $275,000 as part of her estate planning. Well, the $200,000 difference is going to incur a penalty period of 40 months based on the average monthly cost of a nursing home in Missouri. 

Of course, if the house is not paid off and the woman still owes $100,000 on it, then Medicaid should only count $100,000 of the difference in the sale price and the fair market value of the house. In that case, the penalty period would be cut in half, but it would still be 20 months. 

Look-Back Period Sample #4:

As you can see, these calculations are complicated even in the most simple hypothetical situations. Just to demonstrate how convoluted they can get, let’s add a few more details. 

For starters, imagine the woman now resides in Virginia, where the average monthly cost for a private room in a nursing home is about $8,500. She has a community spouse who will not submit a Medicaid application of his own. Together, they have $100,000 in countable assets. They own a house with a fair market value of $600,000 and owe $150,000 on it. The husband has his countable assets of about $50,000. The Medicaid applicant wife has $25,000 of her own countable assets. 

Before submitting a Medicaid application, the wife transfers her $25,000 to the community spouse and gives the other $100,000 to him fully. Now, the community spouse husband has $50,000 of his own assets, the $100,000 that used to be shared, and the $25,000 that used to belong to his wife. That’s a total of $175,000, well over the $128,460 CSRA. However, they owe $150,000 on the house, which means their official countable assets are at about $25,000, which is fine as long as the husband is not a Medicaid applicant. 

To complicate things, let’s say they only owe $50,000 on the house and the wife has also been gifting her daughter $5,000 per year for all five years of the look-back period. 

Now, the husband still has $175,000 in countable assets. Subtract $50,000 they owe on the house and he’s at $125,000, just below the CSRA limit. No penalty period is incurred. Then, add $25,000 that the woman was gifting to her daughter. Now, the husband has $150,000. That’s $21,540 over CSRA. Divide that by the $8,500 average monthly cost for a nursing home and you get a penalty period of about 2 and a half months. 

Medicaid was created in 1965 and is a public health insurance program in the United States that provides health care coverage to low-income families or individuals.

Common Mistakes with Medicaid’s Look-Back Period

As you can tell from the fourth example, calculations can get complicated very fast. In that last example, the woman will only face a penalty period of 2.5 months, but if they pay $8,500 per month in nursing home costs, that’s $21,250. Depending on the nature of their countable assets, that could be a ton of money. The husband may be faced with selling off assets to pay for her care. 

In that hypothetical, the mistake was gifting $5,000 to the daughter. Here, we’ll take a closer look at that and a few other common Medicaid mistakes:

  • Gifting: People often mistakenly believe that gifting won’t count during the look-back period because the federal government doesn’t apply a gift tax beneath a certain amount. Medicaid does count gifts and for good reason. Anyone with a significant amount of countable assets could simply give them to family members once they were too old to enjoy them and get their care through Medicaid. 
  • Selling for Less Than Fair Market Value: Much like gifting, selling assets for less than they’re worth will incur a penalty period. People most commonly attempt this with houses, but that can create the biggest penalty period for most people. Other items can also cause penalties, though.
  • Irrevocable Trusts: Since these are also called Medicaid Qualifying Trusts, there is a common misconception that they are not counted in Medicaid’s review of the five-year look-back period. An irrevocable trust is an agreement where one party transfers assets to another who holds them for the first party. Even though, as the name implies, irrevocable trusts are not reversible by the grantor, Medicaid still looks at them as gifts and will count them as such if they’re signed within the five-year look-back period.

Exemptions to Medicaid’s Five-Year Look-Back Period

We’ve already mentioned most of the common exemptions. The best one for married couples where one is a community spouse is the CSRA limit. Disabled children can also receive transferred assets. Family caretakers may also be able to receive payments that won’t be counted in the five-year look-back period.

Under some conditions, a house can be transferred to a sibling of the Medicaid applicant. The sibling should already own partial equity in the home and have resided there for at least one year before the transfer. 

The best way to turn liquidity into uncountable assets is to pay off debt or pay off a mortgage on a house. Once the house is paid off, provided its fair market value is under the limit, the money you spent on it won’t cause a penalty period. Estate planning with a living will can ensure it is passed on to a family member. 


Submitting a Medicaid application is unbelievably complicated and should not be done without the help of a Medicaid planning professional or elder care attorney. The reason they have so many conditions is to make sure Medicaid’s protection is given to the classes of people it was meant to help, namely low-income and disabled people. It will take lots of time to prepare, especially if you’re applying for Medicaid because of a sudden illness. If you start early enough, you can use estate planning and accepted methods of making your assets uncountable for Medicaid’s five-year look-back period. Hopefully, this article helped introduce the policy and how it might affect people in different situations. 

13 Leg Strengthening Exercises for Seniors & The Elderly

After the age of 40, muscle mass and strength weaken. This means we can perform less and less physical activity. Over the age of 50, strength loss increases by 15% after each decade. Muscles start to atrophy when they aren’t being used. Meaning if you don’t use it, you lose it. Sarcopenia is the biggest cause of this disability in older adults. Sarcopenia is a phenomenon that occurs in our muscles when calcium begins to leak from the ryanodine receptor channel complex. These are a group of proteins in our muscle cells. The more calcium we lose, the weaker our muscles get. The best way to minimize this problem is, you guessed it, strength training! We will focus particularly on leg exercises for seniors and why they are important.

Why Should Seniors Exercise? 

Of course, everyone knows that exercising improves your quality of life. But as we get older, exercise becomes increasingly necessary. The longer you stay healthy and active, the longer you will be able to retain your independence. Combining aerobic activity and strength training is the best thing you can do to promote your health. 

Strength training of the lower body is especially important because your legs are the balance and support system for the rest of the body. Having strong leg muscles is vital when you stand up from a chair and climb stairs. And having good balance in your legs lowers the risk of falls. Falls account for 30 to 40% of injuries in the elderly. They are so common among seniors that an older adult is admitted to the hospital every 11 seconds due to a fall. And, a senior dies every 19 minutes due to a fall. Not only are falls extremely deadly, even a minor one can be debilitating. It can lead you or your loved one into a long downward spiral of degrading health. It is unrealistic that you will be able to completely prevent senior falls. However, regular exercise reduces that risk factor by 23%. 

Not only will exercise reduce your risk of falls, but you will have more energy, lose weight, prevent and counteract disease, and improve the functioning of your brain. Exercising regularly reduces your risk of getting Alzheimer’s disease by a whopping 50%. And, keeping the weight off helps your joints not to be overburdened. This prevents osteoarthritis. Osteoarthritis is the most common form of arthritis. It occurs when the cartilage that protects your bones begins to wear out over time. So let’s keep those legs moving!

Exercises for Seniors to Avoid 

Before we get into some of the best leg exercises for seniors, we briefly want to touch on what exercises seniors should avoid. Please remember that a good portion of popular exercises we see in the gym are not meant for the elderly. Most hardcore exercises are meant for younger adults who want to lose weight and gain muscle. Since older adults have issues with joint pain, poor balance, poor posture, and deteriorating muscles, these exercises are not ideal. An elderly person could easily become injured. A few leg exercises for seniors to avoid are:

  • Leg press
  • Squats with weight
  • Long-distance running
  • Rock climbing
  • HIIT (high-intensity interval training)

Getting Started

So you or your loved one are motivated to start an exercise program. Or perhaps you are a live-in caregiver who wants to motivate your client. We honor and admire your courage to make a change. However, you must keep in mind that results do not come quickly. You must be patient as seeing results takes time. Ease into it. It usually takes about 4 weeks to see results after you start exercising regularly. Your strength and endurance will increase gradually. Below we have included low-impact strength and balance exercises for seniors. These exercises are recommended to be performed 3 times a week. And, we recommend starting at 10 repetitions each. The more strong and comfortable you feel, the more you can slowly increase your repetitions. This exercise routine should never hurt. Please stop immediately if you are in pain.

Exercising the legs is especially important for seniors.

1. Ankle Circles

This exercise is a great way to warm up the legs and feet. Keeping your ankles flexible is important for maintaining balance, stability, and flexibility. Having strong ankles are important for maintaining control as you walk. They help you stop and change directions. They also help keep us standing up straight and supported over our center of gravity. You can easily perform ankle circles in a sitting position. If you are sitting for a prolonged period it is a good idea to do ankle circles to keep the blood flowing. Here’s how ankle circles are done:

  1. Sit in a chair in an upright position. 
  2. Keep your left foot flat on the floor. Lift the right knee in the air and draw a circle with your right foot. Repeat 20 times.
  3. Draw a circle with your right foot in the other direction. Repeat  20 times. 
  4. Perform the same exercise with the left foot.
  5. If you are unable to lift your knee into the air, try simply extending your knee out instead. Try the exercise while standing for more of a challenge. Ankle circles while standing will challenge you and help improve your balance. 

2. Hip Marching

This exercise targets your hip flexors and thighs. You will be able to walk farther and faster. It also helps you pick your feet up so you don’t trip over things. In this exercise, you can use 2 to 5-pound ankle weights for an extra challenge.

  1. Sit up straight in a chair with your feet flat on the floor.
  2. Inhale as you slowly lift your left knee into the air as high as you can.
  3. Exhale as you slowly lower back down to the ground. Repeat 10 times total.
  4. Do the same with your right knee.

3. Knee Extension

This exercise is especially useful for knee rehabilitation and improving your range of motion. If you have a knee injury, consult your physical therapist first to see if this exercise could be right for you. Having flexible and functioning knees are so important for balance, standing, and avoiding injuries. In this exercise, you can use 2 to 5-pound ankle weights for an extra challenge.

  1. Sit up straight in a chair with your feet flat on the floor.
  2. Inhale as your lift and slowly straighten your left knee in front of you. Tilt your toes towards you as best you can. Hold for a few seconds.
  3. Exhale as you slowly return your left foot to the ground. Repeat 10 times.
  4. Do the same with your right knee.

4. Calf Raises

Strengthening your calves is important for balance and walking. These are the powerhouse of your legs and aid you in the ability to push off of surfaces as you walk. Calf strength is also important for walking up hills and through uneven surfaces. We recommend doing these chair exercises a couple of times a day. Getting the blood pumping up from your lower legs to your brain will help avoid you getting light-headed and prevents fainting. 

  1. Stand behind a chair, holding onto the back of it for balance. Keep your back straight. 
  2. Inhale as you slowly raise to your tip-toes as high as is comfortable for you. Try not to move the rest of your body.
  3. Exhale as you lower slowly back down to your feet flat on the floor.
  4. Repeat 10 times.
  5. For an extra challenge, try without holding onto the chair. Or, try only using a few fingers. 

5. Standing Knee Flexion

This exercise targets the hamstring muscles and increases your ability to bend and flex your knee. This improves standing and walking, which means better balance and less risk of falls. In this exercise, you can use 2 to 5-pound ankle weights for an extra challenge.

  1. Stretch your hamstring for a few seconds before starting this exercise.
  2. Stand up straight behind a chair, holding onto the back of it for balance.
  3. Inhale as you slowly raise your left foot behind you, bending your knee backward. Try to bend your knee into a right angle, or as far as you comfortably can. Do not bend at the hips.
  4. Exhale as you slowly return your left foot to standing flat on the ground.
  5. Repeat 10 times.
  6. Do the same with your right foot.
  7. For an extra challenge, try without holding onto the chair. Or, try only using a few fingers.

6. Side Hip Raise

Strengthening your hips is essential for walking and side-stepping. Keeping your hips healthy and strong prevents osteoarthritis of the hips. In this exercise, you can use 2 to 5-pound ankle weights for an extra challenge.

  1. Stand up straight behind a chair, ribs lifted, holding onto the back of it for balance. Your feet should be hip-width apart. 
  2. Inhale as you slowly lift your left leg to the side. Try to keep your foot in a right angle, toes pointing forward. Proceed to as high as is comfortable for you. Do not bend at your hips.
  3. Exhale as you slowly return your leg to the ground.
  4. Repeat 10 times. 
  5. Do the same with your opposite leg.
  6. For an extra challenge, try without holding onto the chair. Or, try only using a few fingers.

7. Sit to Stand

Of all the exercises listed here, this is the most important. The ability to get up from a chair, toilet, bed, or out of a car on your own is one of the biggest keys to maintaining your independence. This exercise is essential for leg and hip strength. Repeat this exercise as often as you can to stay strong. Use a walker or other form of support if needed. For an extra challenge, hold 2 to 5-pound dumbbells, in each hand, against your chest.

  1. Stand tall directly in front of the chair, the back of your knees touching the seat. 
  2. Inhale as you slowly lean forward and bend from your hips toward the chair. Stop before you sit down.
  3. Pause, then exhale as you slowly raise yourself back into the standing position.
  4. Repeat 10 times.
  5. If you have trouble stopping before the chair, you can sit down and then get up from there.

8. Heel Stand

This exercise promotes the stretching of the ankle, which gets the blood flow in your legs going. Focusing on this area is essential for your ability to stand and balance. Keeping your heels strong will allow you to step over things without tripping.

  1. Stand up straight behind a chair, ribs lifted, holding onto the back of it for balance. 
  2. Exhale as you slowly rock back onto your heels, lifting your toes from the ground.
  3. Inhale as you slowly lower your toes back flat on the ground
  4. Repeat 10 times.
  5. Stand up straight behind a chair, ribs lifted, holding onto the back of it for balance. 
Lunges are a great way for seniors to workout their legs.

9. Lunges

Strengthening your quadriceps and hips are important for standing, balancing, and walking. These muscles are also helpful for getting up out of a chair and lifting things. The more comfortable and stronger you get with this exercise, the deeper you can lunge. To further challenge yourself, hold a 2 to 5-pound weight in each hand.

  1. Stand up straight, feet shoulder-width apart, with your hands on your hips.
  2. Exhale as you slowly step forward with your left foot. Keep your torso standing up straight and your right foot planted.
  3. Inhale as you slowly return your left foot to the starting position. Repeat 10 times.
  4. Do the same thing with your right foot.

10. Straight Leg Raise

This exercise is especially good for your hip flexors, abdominal muscles, and quadriceps. These in turn help with your flexibility and balance. For an extra challenge, add a 2 to 5-pound ankle weight to each foot.

  1. Lay straight on your back on a mat. Make sure that your lower back is touching the floor. Start with your left knee bent with your left foot on the ground, while keeping your right leg straight. Keep your palms flat against the ground.
  2. Inhale as you slowly raise your right leg (still straightened) to the height of your left knee. If possible, hold the position for 10 seconds. 
  3. Exhale as you return your right leg to the starting position.
  4. Repeat 10 times. 
  5. Do the same thing with your left leg.

11. Partial Squats

This exercise targets your quadriceps and hip flexors, which means an increase in hip flexibility. This is important for your ability to stand up from a chair or to step over something. And the longer you can stand up and balance on your own, the longer you can be independent. To further challenge yourself in this exercise, hold a 2 to 5-pound weight in each hand.

  1. Stand up straight behind a chair. Keep shoulder blades and ribs lifted, holding onto the back of it for balance. Inhale.
  2. Exhale as you slowly bend your knees as low as you can comfortably go. Make sure to keep your upper body straight.
  3. Inhale as you slowly return to the starting position. 
  4. Repeat 10 times.
  5. For an extra challenge, try without holding onto the chair. Or, try only using a few fingers.

12. Hip Extension

This exercise is great for hip muscles and glutes, aiding you to stand firm and walk confidently. Maintaining strong hips is vital for your overall leg function. Avoid arching your back in this exercise to prevent injury. For an extra challenge, add a 2 to 5-pound ankle weight to each foot.

  1. Stand up straight behind a chair, ribs lifted, holding onto the back of it for balance.
  2. Inhale as you slowly extend your left foot back as you keep your knee straightened. Your foot should stay at a right angle. 
  3. Exhale as you slowly return your left foot to the starting position.
  4. Repeat 10 times.
  5. Switch sides, and do the same thing with the right foot.
  6. For an extra challenge, try without holding onto the chair. Or, try only using a few fingers.

13. Step-Ups

This is an important leg strengthening exercise as it focuses on one very important skill: stepping up. Being unable to climb stairs seriously limits places you can go. This exercise will help build your glutes and quadriceps so you can climb stairs and step over things. For an extra challenge, add 2 to 5-pound ankle weights to each foot.

Forward step-ups:

  1. Stand up straight at the bottom of the stairs. Hold onto the railing for support.
  2. Slowly step up with your right foot, firmly planting it fully on the step.
  3. Follow with your left foot.
  4. Slowly step back down with your right foot, then with your left.
  5. Repeat 10 times.
  6. Do the same thing but starting with your left foot pushing up first. 

Sideways step-ups: 

  1. Standing at the bottom of the stairs, turn your body 90 degrees to your right. Your feet should be parallel to the stairs. Your left foot should be right next to the bottom step. Hold onto the railing with your left hand.
  2. Slowly step your left foot onto the crevice of the first step, butting it up against the second step. 
  3. Slowly step your right foot next to the left, then bring it back down to its starting position.
  4. Bring your left foot back down to the floor level.
  5. Repeat 10 times.
  6. Switch sides, starting with your right foot. Repeat the exercise with your right foot stepping first. 

We genuinely hope you can incorporate these leg exercises for seniors into your daily activities. Taking the time to improve your or a loved one’s health now will benefit the long run. If you are in further need of finding a caregiver or other assistance, we are here for you. Post a job with us to hire someone to help you when things get too difficult. 

How to Understand & Minimize Sundowners Syndrome

Sundowning syndrome, or nocturnal delirium, refers to a change in mood, personality, and behavior that occurs in the late afternoon, evening, and at night. Sundowners syndrome is not a disease but a group of symptoms. It occurs in people with cognitive impairments like dementia, and most notably, Alzheimer’s disease. Sundowners syndrome affects 20 to 45% of Alzheimer’s patients. 

Alzheimer’s disease is a disorder that progresses as brain cells waste away and expire. The main symptom of Alzheimer’s is memory loss. Alzheimer’s disease is the most common cause of dementia. It makes up 60 to 80% of dementia cases. The greatest known risk factor for Alzheimer’s disease is age. Most people with Alzheimer’s disease are 65 years of age or older. However, as many as 200,000 Americans under 65 have early-onset Alzheimer’s disease. Alzheimer’s is a progressive disease. It starts with memory loss and progresses to the inability to hold a conversation or respond to their environment. There is currently no cure for Alzheimer’s disease, though there are treatment options for symptoms. Learn more about Alzheimer’s disease at and the national institute of aging.

Dementia is a general term for a decline in cognition, behavioral, and social skills. While Alzheimer’s is a specific disease, dementia is not. A person with dementia gradually becomes unable to function independently. There are many different types of dementia, and there are many conditions that cause it. Mixed dementia happens when different forms of dementia happen to the brain simultaneously. Sundowning can occur at any stage of these diseases. However, sundowners syndrome usually peaks during the middle stages of Alzheimer’s and mixed dementia. It usually fades as dementia progresses into the later stages.

Symptoms of Sundowners Syndrome

Sundowners syndrome, sometimes known as “late-day confusion,” may be difficult to detect in its early stages. This is because the symptoms may be subtle and inconsistent. Early signs include agitation, restlessness, suspiciousness, confusion, irritability, disorientation, and becoming demanding during the night. As Sundowners progresses, these symptoms become more pronounced. Some of the most common symptoms include:

  • Difficulty sleeping/insomnia
  • Hiding objects
  • Pacing
  • Wandering
  • Rocking
  • Restlessness
  • Visual and auditory hallucinations
  • Emotional outbursts
  • Crying
  • Paranoia
  • Delusions
  • Extreme agitation/mood swings
  • Fear
  • Anxiety
  • Depression
  • Anger
  • Confusion
  • Vertigo
  • Bladder incontinence
  • Stubbornness
  • Violence
  • Yelling or screaming
  • Shadowing/mimicking
  • Increased tremors

It is important to note that these behaviors alone do not necessarily mean the person has sundowners syndrome. The behaviors could be manifestations of delirium, varying types of dementia, sleep disturbances, or Parkinson’s disease. What most notably distinguishes these symptoms as sundowners syndrome is the fact that they occur consistently in the late afternoon, evening, and nighttime hours. Symptoms tend to develop between 4:30 in the afternoon to about 11 at night. They appear when daylight begins to fade and may get progressively worse as night falls. Sundowning syndrome usually starts at about the same time of day for each individual. It usually lasts a few hours, and then most return to their regular selves.

Delirium can be easily mistaken for sundowner’s syndrome. It is important to first rule this out as a possibility when examining your loved one’s symptoms. Delirium is a medical condition in and of itself. However, people with dementia are highly susceptible to it. People with delirium experience confusion as well as changes in attention span, moods, perceptions, and activity level. To determine whether your loved one is experiencing delirium, it is important to look at the timing. Delirium sets in much quicker than sundowners syndrome. It occurs quickly over the span of days or weeks, while sundowners syndrome occurs over months or years. Also, delirium occurs throughout the day while sundowners syndrome occurs only in the late afternoon through the nighttime period. 

The onset of symptoms varies from person to person. In some cases, sundowning syndrome symptoms begin to interfere with the body’s sleep-wake cycle. The sleep deprivation then triggers more episodes of sundowners syndrome and also triggers more dementia symptoms.

How quickly sundowners syndrome progresses is a direct reflection of how their dementia is progressing. Dementia tends to progress slowly in the early stages and can get faster in the later stages. It is also important to remember that everyone progresses differently. Some factors that may affect the rate of progression are genetics, cardiovascular health, physical health, age, and other pre-existing medical conditions. Unfortunately, there is no cure for dementia, and thus no cure for sundowners syndrome. You can, however, lessen its effects by knowing the triggers and learning to minimize them.

It’s always important to monitor your loved ones or your patients if they are sundowning.

Triggers of Sundowners Syndrome

Monitor your loved one’s behaviors. It is important to notice any triggers that cause these behaviors to occur. We have compiled a list of some of the triggers that may bring on the symptoms of sundowners syndrome: 

  • Sensory deprivation or overload
  • Low light or excessive light
  • Increased shadows
  • Unmet physical needs like hunger, pain, fatigue
  • Boredom
  • Limited mobility
  • Social isolation
  • Increased stress
  • Hearing/vision loss
  • Not feeling safe/secure
  • Anxiety, fear, depression
  • Sleep problems/deprivation
  • Hormonal imbalance
  • Unfamiliar environment/hospitalization
  • Medications wearing off
  • Reminding when they were younger
  • Expecting a spouse or children to come home
  • Having a frustrated/exhausted caregiver
  • Unexpected change
  • Difficulty separating dreams from reality
  • Presence of an infection, like a urinary tract infection (UTI)
  • Disruption of the circadian rhythm
Stress can be one of the leading causes of sundowners.

Cause of Sundowners Syndrome

There is still very little known about why sundowners syndrome occurs. The exact cause remains unclear. Some believe that the neurological changes that happen during the progression of Alzheimer’s disease affect the internal body clock. This could mean that the part of the brain that signals when you are awake or asleep is starting to break down. 

The setting of the sun triggers a reduction of dopamine levels in humans. Melatonin is then produced to prepare the body for sleep. In dementia patients, the production of melatonin has decreased. It is theorized that this may affect other neurotransmitter systems. And when the body’s internal clock is disrupted in this way, this can leave your loved one confused and exhausted. In turn, their behavior and mental state can be negatively affected. 

How to Minimize and Deal With Sundowners Syndrome

  • Keep predictable bedtime, waking, meal, and activity times: Try to keep your loved one’s daily schedule in a routine. This helps keep your loved one stay calm. Unexpected stresses can keep them agitated. Try to especially have evening routines that signify the day is coming to an end. For example, have them put their pajamas on at the same time every evening.
  • Notice patterns: Pay attention to certain times, people, activities, or places that seem to trigger the symptoms. Use this knowledge to adapt your loved one’s daily routine.
  • Monitor what they eat and drink: If your loved one is not eating enough, hunger pangs can trigger symptoms. Try to have dinner early so they will be more likely to go to bed earlier. If your loved one is a diabetic or borderline diabetic, he or she may react to the change in glucose level. Avoid large meals. Blood pressure drops after a large meal which means a smaller amount of oxygen reaching the brain. This reduction in oxygen levels can trigger an episode.
  • Only allow limited amounts of sugar and caffeine in the morning hours: You do not want any extra stimulants to keep them awake. Also, avoid alcohol and nicotine. 
  • Avoid napping during the day: They mustn’t nap in the afternoon. This will keep them awake at night, which is when sundowners occurs. Try to keep your loved one awake as much as possible during the day.
  • Get a vision check: The better your loved one can see, the less they will experience visual hallucinations.
  • Do not raise your voice or make any unexpected movements: Remain calm and do not touch them unexpectedly.
  • Ask questions to identify unmet needs: Sometimes your loved one is unable to communicate to you when they require something.
  • Do not rationalize or argue: It is fruitless to ask your loved one to explain things that don’t make sense. 
  • Keep him/her busy with activities to promote sleepiness at night: Plan things to keep them busy. Take your loved one on a long walk. Organize crafts. Visit family members. Keep them engaged to improve their sleep quality
  • Keep the curtains drawn: You want to avoid your loved one seeing the sky change from light to dark.
  • Keep the environment well-lit: Turn on all the lights. You want to decrease shadows and increase visibility. Low lighting exacerbates symptoms.
  • Avoid any sudden changes in light: This could trigger an episode.
  • Make sure doors and windows have child-proof locks and are secure: Take this precaution in case your loved one tries to escape in a fit of agitation. Make sure the environment is safe enough to allow your loved one to wander the house during the night. Remove any potentially dangerous items in areas they have access to. 
  • Maintain a peaceful environment: Keep your loved one away from commotion, noise, and distractions during the time of their usual episodes. Turn off violent news and loud action movies. Avoid boisterous children running around the home.
  • Declutter: Keeping the house free of clutter can prevent confusion for your loved one, as well as minimize possible accidents.
  • Plan calming activities for the early evening: You want to keep your loved one distracted during this time. Play cards. Help them with a crossword puzzle. Watch a relaxing movie or tv show. Help your loved one do the dishes or fold towels together. Bring your household pet around to help comfort your loved one. 
  • In the evening, do not encourage stimulating activities that will keep him/her awake: This could include anything movement-related.
  • When he or she is in an unfamiliar place: Bring familiar possessions, such as photographs.
  • Play gentle music or nature sounds that your loved one finds relaxing: Pick out some music from your loved one’s era. They will be soothed by the familiar music. 
  • Allow your loved one to sleep where he/she is most comfortable: This could even be in his or her favorite rocking chair. Give your loved one the choice of where they sleep.
  • Keep a night light on: Dementia patients experience changes in vision and perception. Keeping a light on helps reduce agitation when the room feels dark, frightening, or unfamiliar to them. 
  • Seek medical advice if you suspect an underlying issue: If Sundowners symptoms develop quickly and you suspect an underlying issue, such as sleep apnea, incontinence, or a urinary tract infection (UTI). Incontinence could be keeping your loved one from getting enough sleep, and a UTI can leave them confused and agitated. Talk to a doctor to resolve these underlying issues.
  • A low dose of melatonin can help ease symptoms: An average recommended dose is 6 mg for at least 4 months. It is said to help decrease behavioral symptoms such as agitation, especially combined with exposure to bright light during the day. Though you do not need a prescription, please consult your doctor before you try. Since melatonin is subject to prescription regulations, your doctor must recommend a melatonin product that has been licensed and meets pharmaceutical standards. It is also important to be aware of any possible drug interactions when adding any new medications or supplements to your loved one’s regimen. Even though sundowners syndrome is not curable, you can consult a doctor about possible medications that could help deal with symptoms: These might include hypnotic, anti-anxiety, and neuroleptic medications.
  • Bright light therapy: Treatment with a bright light is said to help sundowners improve the sleep-wake cycle and decrease nighttime activity. As a result, sundowning behaviors are said to improve. Examine the sleep cycle of your loved one to determine when to expose them to bright light. You could try 2 hours of morning light, or 2 hours of evening light, or 1 hour of both. Another option is to consider purchasing a full spectrum light box for your loved one. A light box is like a lamp, but much brighter than your normal indoor lighting. Your loved one mustn’t look directly into the light. It is best incorporated into their average daily activities. 
  • Aromatherapy: Particularly lavender oil has been said to cause a significant decrease in nighttime behaviors. It is important to note that studies have had some conflicting evidence, so it is wise to consult a certified aromatherapist if you are interested in this option.
  • Music therapy: A trained and certified music therapist can use musical experiences to help diminish symptoms of sundowning. These decreased symptoms can include agitation, anxiety, irritation, and disturbances in nighttime behavior.
  • Dronabinol & Cannabinoids: Cannabinoids have been shown to mediate important brain functions, such as cognition, motor activity, and mood. Please consult your doctor. 
  • Antipsychotics:  Commonly prescribed for agitation and psychosis by doctors. Although short-term trials show modest effectiveness in terms of aggression, taking antipsychotics to require a careful risk versus benefit assessment. Exposure to antipsychotics can cause negative side effects, including confusion and impaired cognition. Studies show an increased risk of death, cerebrovascular accidents, and myocardial infarction. Antipsychotics should be considered only after trying non-pharmacologic therapies.
  • Prolong enrollment into a senior care facility: The longer your loved one stays in a familiar environment that feels comfortable for them, the less likely they will have symptoms. 

Sometimes symptoms can be triggered in a care facility due to the bustle of activity during the afternoon or evening. These noises may trigger a reaction in the Alzheimer’s patient to perform behaviors that they would do in the past at that time of day. For instance, the noise would remind them of their children coming home, so they would start preparing a meal. It is best to keep them busy at this time of day with an activity that will distract them from the sounds. If your loved one is awake and triggered, here are a few things you can do to help:

  • Approach him or her calmly.
  • Try to determine if he/she needs something.
  • Remind him or her of the time.
  • Meet them in their version of reality if they are experiencing hallucinations or delusions. Reassure him or her that everything is okay. Validating them will help calm them more than trying to use logic to explain the situation.
  • Do not restrain him or her physically. Allow your loved one to pace around under your supervision.

One of the constants in your loved one’s ever-progressing disease is you. Make sure to stay flexible in this difficult process. Sundown syndrome is not the same in every person, and the symptoms are not always predictable. Keep your daily regimen of self-care to keep yourself useful in your loved one’s trying time. Enlist the help of other family caregivers or employ a home care worker. Consider enrolling your loved one into memory care or think about live-in care if you find your loved one’s symptoms rapidly increasing. Do not be afraid to get help if your loved one’s disease overwhelms you. We are here for you.