“Fate Worse Than Death”: Long-Term Care’s Independence Crisis: Aging-in-Place Planning Offers Solutions

A recent study highlighted by NBC Right Now, titled “Fate worse than death: Many long-term care residents lose all independence, study says,” paints a grim picture of life in long-term care (LTC) facilities. The headline is attention-grabbing, and for seniors and families planning for the future, the subject study underscores the importance of aging in place strategies to preserve independence and autonomy.

THE STUDY

Published on April 23, 2025, "Cognitive and Functional Decline Among Long-Term Care Residents," is a retrospective cohort study (meaning an observational study that uses existing data to examine individuals by looking back in time to assess how past variables relate to specific outcomes) involving more than 120,000 Canadian residents followed for up to 5 years.  One aspect of the study was interviewing residents to determine their goals in seeking long-term care and their feelings about long-term care. The study provides a compelling glimpse into older adults’ fears of losing independence, and the trajectories of needs while in long-term care. 

Study Results: Some of the key findings of the study include: 

• Many people lose all independence soon after entering long-term care;

• About 20% lose the ability to make everyday decisions within five years of admission, and 13% become totally dependent for all personal care including bathing, toileting and eating;

• Residents living with dementia may be at risk of spending more time living in states of impairment than residents who have no cognitive impairment; the increased survival of residents with dementia may reflect the natural history of dementia as a progressive terminal disease with great variability in survival time, ranging from 3 to 15 years.

• Advance directives may play an important role in reducing time spent living with severe disability; residents with Do Not Resuscitate (DNR) or Do Not Hospitalize (DNH) orders experience shorter periods of institutionalization while suffering profound impairment associated with a loss of all independence.

• The standard care practice of providing longevity can leave residents in states that they consider "worse than death," contradicting the goals that residents view as most important.

• Despite advance care directives, 25% of long-term care residents have at least 1 transfer to the hospital every 6 months, and many die shortly after a hospital transfer. 

Indeed, in the introduction to the study, the authors write:

"Patients, including healthy outpatients and those with serious illness, consider states such as being “unable to get out of bed,” “unable to communicate,” or “unable to reason or remember” as worse than death, and yet these outcomes are rarely explicitly discussed. [citations omitted].  Pursuing longevity-focused care when a person is living in a state they consider worse than death is contrary to resident-centered principles for which LTC homes strive. However, pursuit of longevity against a patient’s wishes may occur because preferences change when death is imminent and because substitute decision-makers and clinicians are partial toward life-prolonging treatment when clinical outcomes or resident preferences are uncertain."

Researcher Assessments: The researchers released statements regarding their findings and assessments:

• Dr. Ramtin Hakimjavadi, lead researcher, a resident in internal medicine at the University of Ottawa in Canada, and one of more than fifteen medical professionals that authored the study, characterized the findings:

"In interviews, long-term care residents have expressed that loss of independence is more distressing to them than the thought of dying. [Residents aren’t receiving the best care] if we don’t talk about the possibility of severe disability and ask about the circumstances when life prolonging treatments would not be acceptable."

• Senior researcher, Dr. Daniel Kobewka, an investigator at Bruyère Health Research Institute and adjunct scientist at the Institute for Clinical Evaluative Services in Ottawa, advised that: 

“[r]esidents, their family members, and care teams should have open discussions about what quality of life means to the resident, considering the possibility of prolonged disability. Planning ahead can help ensure that future care aligns with personal values, including the choice to prioritize comfort and dignity over life-prolonging interventions.” 

Call to Action: The study represents a call to action. 

• The Health Care Industry:  Clinicians and health care professionals are called to consider critically  life-prolonging treatment, appropriate for the healthy and recovering, as being contrary to the wishes and consent of residents that "follow a frailty trajectory with no clear terminal phase...experienc[ing instead] a progressive decline in cognition and physical function after admission due [for example] to the accumulation of chronic conditions." Care for these residents must be guided by their wishes and goals, ensuring dignity and quality of life for residents and care partners. 

• Residents: Residents should make their wishes and goals explicit.  At a minimum that means executing Durable Powers of Attorney for Health Care, Advanced Directives in the form of a Living Will and Advanced Directives for Dementia, and a broad form HIPAA release in favor of trusted health care decision-makers. Residents and their families should consider a DNR, DNH, and where appropriate, Physician Orders for Life-Sustaining Treatment (POLST). Residents should also consider aggressive, comprehensive aging in place planning, and a robust estate plan to protect a resident's independence, decision-making, and dignity.   

Study Limitations: The authors acknowledge key limitations:  

• First, all studies that use administrative data have a risk of bias from misclassification or incomplete capture of variables, which the researchers addressed by using validated definitions when possible and maintaining consistency with previous research. 

• Second, the study did not stratify data by the type of dementia (e.g., Alzheimer, Lewy body, or frontotemporal dementia) given the available data. Although different dementia subtypes carry distinct trajectories and prognoses, the researchers concluded that their findings reflect residents living with Alzheimer dementia given its prevalence relative to other subtypes.

• Third, the length of stay observed in the study is subject to local admission and aging-in-place policies, which vary by jurisdiction.

• Fourth, while the study aimed to inform resident-centered decision-making in LTC through the identification of resident-important cognitive and functional impairments, resident and caregiver perspectives may differ from those of the patient partners who informed this study. The researcher believe that, nonetheless, their data provides a foundation for communication and future studies to consider functional and cognitive impairments as outcomes for prognostication. 

• Fifth, the  study has limitations in generalizability. The findings are generalizable to regions with a similar LTC population of mostly older adults with frailty and chronic conditions requiring continuous care. However, the  population studied may be older and have higher levels of frailty and health burdens at admission because of the prioritization of home care in Canada compared with regions with less emphasis on home care or with more flexible LTC eligibility criteria. Additionally, the publicly funded single-payer system in Canada may result in a more homogenous population compared with regions using a third-payer system, which may have a more diverse LTC population. This difference may limit the generalizability of our results to other regions.

The Study Is Worthy of Serious Considerations Despite the Limitations

There are number of reasons that this study deserves attention despite the acknowledged limitations.

1. Peer Review and Credibility: Published in JAMA Network Open, a peer-reviewed, open-access journal with a strong reputation the study benefits from rigorous editorial oversight. The authors are affiliated with reputable institutions  and have expertise in health policy and aging, enhancing credibility. No funding conflicts are disclosed, reducing bias concerns.
2. Methodology: A retrospective cohort study afforded the researchers an immense sample size, and a fairly long period over which to follow subjects. The weakness of these types of studies, data quality/bias, was addressed by using validated definitions when possible and maintaining consistency with previous research. 
3. Generizability: There are obvious differences between the Canadian health care model and the U.S. model.  Aging in place planning is public policy in Canada and is heavily subsidized.  The concern was that Canadian residents might be older and in worse health than, say, in the U.S.  Although U.S. commitment to aging in place in Medicare  may not be as robust, there is some semblance of public support, for example, in the adoption of alternatives available in Medicare Advantage Plans, the recent "Hospital at Home" initiative of Medicare, and Medicare/Medicaid's Program of All-Inclusive Care for the Elderly (PACE) program for adults 55+ who need nursing home-level care but can live safely in the community, which provides comprehensive services (medical, social, home care) through an interdisciplinary team, centered at an adult day health center, with in-home support.  More importantly, with the risk of asset loss from long-term care spend down, U.S. residents are much more likely to avail themselves of institutional care alternatives, meaning the populations of LTC residents may not differ dramatically.  Moreover, it appears to me that the quality of care in Canada is higher given that the rehospitalization rate described in the study was an average of every six months, while U.S, residents run an almost one-in-three risk of rehospitalization in the first 28 days of care from just medical "mistakes."
4. Is the Headline "Fair?": The headline, “Fate worse than death: Many long-term care residents lose all independence, study says,” is undeniably dramatic. The phrase “fate worse than death” is emotionally charged, invoking despair and finality. While it risks overgeneralizing, implying that all long-term care leads to catastrophic outcomes, the headline isn’t entirely unfair. Loss of independence is a profound fear for seniors, and the study’s emphasis on this issue aligns with documented concerns. For example, a 2023 New York Times article notes that many aging Americans struggle to stay independent due to a fragmented long-term care system, supporting the study’s premise. The hyperbolic tone serves a purpose: it grabs attention and sparks discussion about a critical issue.

Aging-in-Place Solutions to Preserve Independence

The study’s findings underscore why many seniors prefer to age in place—remaining in their homes or communities with support tailored to their needs. Aging in place planning, a cornerstone of this blog, empowers seniors to maintain independence, dignity, and control. Below are solutions commonly explored here, designed to address the risks highlighted by the study:

• Home Modifications for Safety and Accessibility: Modifying the home to accommodate mobility or health challenges is a proactive step. Common upgrades include installing grab bars, widening doorways, adding ramps, or creating single-level living spaces. These changes reduce reliance on institutional care by enabling seniors to navigate their homes safely. For example, a walk-in shower can preserve independence in bathing, directly countering the loss of control noted in the study. 

• Multigenerational Living: Multigenerational living is a powerful strategy for aging in place, offering financial savings, emotional support, and caregiving flexibility. By reducing reliance on institutional care, families can avoid spend-down and preserve assets, aligning with elder law goals. However, success requires planning. For more see the article: Aging in Place: Multigenerational Living as a Strategy to Avoid Institutional Care and Support Family Caregiving.

• Deploy Technology for Safety, Health, and Communication: Technology serves two purposes.  First, technology use supports cognitive health. Second, technology offers solutions to challenges faced when aging in place that otherwise might demand institutionalization. 

• Revocable Living Trusts for Asset Protection: A revocable living trust, as discussed in our recent article “The Dangers of Last-Minute Estate Planning.” ensures assets are managed and distributed per the senior’s wishes, even if they become incapacitated. Unlike wills, trusts are transparent in asset titling (e.g., on deeds or accounts), deterring manipulation and supporting financial independence. Trusts can also fund home care or modifications, avoiding the asset depletion that forces some into long-term care, and protect against guardianships, and abusive guardians.

• General Durable Powers of Attorney (GDPOA): A GDPOA appoints a trusted agent to handle financial and healthcare decisions if a senior becomes incapacitated. This prevents the need for court-ordered conservatorships, which can strip autonomy, as seen in the Autry case. By ensuring a trusted person manages their affairs, seniors maintain control indirectly, aligning with the study’s call for personalized care.  Structuring trusts to prevent third-party guardians access to trust assets disincentivizes guardians, and helps prevent control of assets being wrestled away from trusted advisors and agents.  

• Aging-in-Place Care Coordination:  In-home care, such as nonmedical caregivers or telehealth services, allows seniors to receive support without leaving home. Emerging technologies like tele-dentistry or remote monitoring, noted in LTC News, enhance access to care for mobility-challenged seniors. Coordinating care through family, agencies, or professionals ensures needs are met without the institutional routines criticized in the study.

• Guardianship Protections and Nominations: Nominating a guardian in a GDPOA or trust ensures that, if guardianship is needed, a trusted individual is appointed. Structuring trusts to limit guardian access to assets, as discussed in “The Dangers of Last-Minute Estate Planning,” preserves the senior’s plan. This protects against the loss of control highlighted by the study, as seniors retain influence over their legacy.   Structuring trusts to limit guardian access to assets, as discussed in “The Perils of Last-Minute Estate Planning,” preserves the senior’s plan. This protects against the loss of control highlighted by the study, as seniors retain influence over their legacy.

• Medicaid Planning for Long-Term Care Costs:  Strategic Medicaid planning, using trusts or asset transfers, can preserve resources for in-home care rather than nursing home costs. Unlike the hasty Medicaid attempts in the Autry case (Dangers of Last Minute Estate Planning), a well-crafted trust allows crisis planning without disrupting the estate plan, supporting aging in place. Consideration of and implementation of asset transfers permissible to qualified family members under Medicaid are more certain and less expensive and disruptive than either monolithic irrevocable transfers so common from trust mills, or crisis planning planning.

• Lifestyle Changes: Simple lifestyle changes can support, protect, and improve cognitive and physical health as well as  emotional and psychological well-being, and build a broader community and social safety net thereby removing barriers and creating opportunities for home and community based care. 

These strategies and solutions, regularly featured on this blog, empower seniors to avoid the institutional settings critiqued in the study. By planning proactively, families can create environments where independence thrives, reducing the risk of a “fate worse than death.” 

Dangers of Incomplete and Last-Minute Estate Planning: A Mississippi Case Study

Estate planning is often delayed until the last possible moment, frequently done on an ad hoc basis- addressing issues as they arise without developing a comprehensive plan. A recent Mississippi case illustrates how such delays can leave seniors vulnerable to manipulation and undue influence, potentially unraveling their true intentions for their legacy. Havoc often ensues in the vacuum created by last-minute or incomplete planning. This article explores a real-life example of a will  invalidated due to the undue influence of a testator’s son, and how individuals and  families can protect themselves from similar risks.

The Case: A Will Invalidated Due to Undue Influence

In the case, In re the Matter of the Estate of Autry, the Mississippi Supreme Court affirmed a ruling setting aside several deeds and invalidating a decedent's will due to lack of authentication, lack of  capacity, and undue influence.  The case is an object lesson regarding the benefits of  comprehensive estate planning.

Effie Mae Autry  and her husband made a will within 2014, but he predeceased her.  She had three sons, two of whom also predeceased her, leaving five grandchildren (three from one sone, two from the other). Effie's 2014 will, stipulated that, if her husband predeceased her, 143 acres of real property would be divided equally:  one-third to her surviving son, Steve; one-third to her grandchildren from one deceased son; and one-third to her grandchildren from the other deceased son. Effie also provided for a $1,000 bequest to her church and specific bequests to Steve and each grandchild.

In early 2019, Marcus, one of Effie’s grandchildren, filed a petition for conservatorship after Effie’s bank notified him that Steve and his wife had accompanied Effie to the bank and tried to remove Marcus’s name from her accounts or close the accounts. Steve lacked a power of attorney to act on Effie’s behalf. Marcus later withdrew the petition because the conservatorship confused and upset Effie. Notably, Marcus' name was on Effie's accounts, suggesting that Effie had not executed a power of attorney; otherwise, Marcus would not have needed to file for conservatorship.  This indicates that Effie and her husband relied solely on wills for estate planning.

Later in 2019, Steve called the family’s longtime attorney who had drafted Effie’s 2014 will, to discuss drafting a new will and deeds. After meeting with Effie and Steve, the attorney refused to prepare new documents, citing a significant decline in Effie’s mental capacity and concerns about Steve's potential undue influence. The attorney even warned other attorneys about the situation.

Undeterred, Steve then engaged another attorney to draft a new will and deeds for Effie. Steve drove Effie to this new attorney's office, where the attorney, unaware of the prior attorney's refusal or 2014 will, discussed a new will with Effie. The attorney testified that Effie appeared competent and clear about her intentions. Several days later, Steve drove Effie, Effie’s "caregiver," and the caregiver’s sister to the attorney's office to execute the new will and deeds. Effie signed a will leaving all of her assets to Steve, providing for the grandchildren only if Steve predeceased her and omitting the church bequest. The caregiver’s sister and the attorney's secretary signed as witnesses but failed to include their addresses in a required affidavit. Effie also executed several warranty deeds conveying all real property to Steve, retaining a life estate for herself.

After Effie’s death in 2021, Marcus contested the validity of the 2019 will and the deeds. The court ruled that the will and deeds were invalid because: (1) improper authentication by the witnesses, (2) Effie lack pf testamentary capacity, and (3) Steve undue influence. The Mississippi Supreme Court affirmed the ruling. The case highlights the risks associated with last-minute estate planning and the vulnerabilities seniors face without a comprehensive plan.

What Happens Next?

The case isn't over.  It now proceeds back to the probate court.  The next step is likely to admit the 2014 will, if that will is signed and authenticated properly. However, even a will drafted by an attorney and executed in an attorney's office, as the 2019 will was, can invalidated for technical errors or contested on other grounds.  If no valid will is admitted, he estate will be  administered as intestate. 

In Mississippi, intestate distribution (Miss. Code § 91-1-3 (2024)) mirrors Effie’s 2014 will: one-third to Steve, one-third to the grandchildren of one deceased son (split equally), and one-third to the grandchildren of the other deceased son (split equally). However, certainty is elusive. The grandchildren could argue that Steve’s share be withheld due to his wrongdoing, or Steve might contest Marcus’s share, citing the conservatorship attempt. Other tort claims, such as fraud or breach of fiduciary duty, could arise, though Mississippi does not recognize the tort of intentional interference with an inheritance. 

Additionally, Medicaid estate recovery could complicate matters if Effie qualified for long-term care after transferring assets, now invalidated. While unlikely, this highlights an overlooked risk: Effie’s family likely did not anticipate the full consequences of their reactive decisions. Discord is common even in well-planned estates, but incomplete planning exacerbates conflict.

A Word On Motivations

In my practice, I focus solely on my client's motivations, assuming the worst from others in order protect the client.  Courts evaluate actions based on legality, not intent.  However, considering motivations can illuminate the consequences of poor planning.

It’s tempting to view Steve as selfishly attempting to seize the estate. Yet, the court noted intriguing details: Steve was married but had no children, and the 2019 will, upon Steve’s death, distributed assets to most grandchildren, excluding Marcus and his sister (possibly due to the conservatorship). The will did not benefit Steve’s wife, suggesting alignment with Effie’s broader intentions. Effie’s severe dementia and need for around-the-clock care, partly provided by the caregiver whose sister witnessed the will, further complicate the narrative.

The deeds, retaining a life estate, likely represented a hasty Medicaid planning attempt to protect assets from nursing home costs. Marcus’s dismissal of the conservatorship may reflect a shared family goal to avoid asset loss, as a finding of incompetency would have invalidated transfers. These dynamics underscore how complicated last-minute planning can be, and how a comprehensive estate plan could have prevented conflict and better served the family.

The Weaknesses of Incomplete and Last-Minute Planning

Last-minute estate planning often occurs when seniors are vulnerable— due to illness, cognitive decline, or emotional distress, making them susceptible to manipulation. In Autry, Steve exploited his mother’s weakened condition to influence the will. Rushed decisions, especially without proper legal guidance, often fail to reflect the testator’s true intentions. Courts scrutinize last-minute changes, particularly those deviating from prior plans or disproportionately benefiting one person.

Vulnerabilities Seniors Face Without a Comprehensive Plan

Without a comprehensive estate plan, seniors are exposed to several risks, including, but not limited to:

Lack of Legal Protections: Without powers of attorney or trusts, no trusted individual is authorized to act if the senior becomes incapacitated.

Increased Risk of Manipulation: Seniors without a plan are more likely to be targeted by those seeking to exploit their assets, as there are fewer legal safeguards in place.

Family Conflict: Ambiguous or incomplete estate plans can lead to disputes among family members, causing emotional and financial turmoil.

In Autry, the absence of a robust plan not only made it made it easier for the son to exert influence, but it allowed conflict that could only be resolved by the court.  

How a Complete Estate Plan Would Have Prevented

 and Resolved the Autrey Case

A revocable living trust offers transparency and protection. Unlike a will, which remains private until probate, a trust’s existence is evident in deeds, bank accounts, insurance policies, and other assets. This visibility deters manipulation, as third parties (e.g., new attorneys) are aware of the existing plan. In Autry, a trust would have prevented Steve from engaging an unaware attorney to draft a new will, and the 2019 will’s invalidity due to authentication errors would have been irrelevant.. 

 

In the Autrey case, one person exploited the limitations of a will, to obtain legal counsel to make a new will, that counsel being wholly unaware of the prior estate plan, such as it was.  The son might argue today that the grandchildren also exploited the weaknesses of the will by so easily contesting the second will, which was legally invalid even though it was drafted by an attorney, executed in the attorney's office, and a staff member of that attorney served as a witness.  The court did not need to find undue influence because the will was invalid as executed!  The reason I suspect the court considered and resolved the undue influence claim is to solve the problem of technical invalidity- a will can be invalid as a will for technical reasons, but evidence a clear intention to replace a former will.  That circumstance  results in no will, increasing the cost and complexity of the administration.  Your trust protects you from such exploitation.

Powers of attorney, which accompany every revocable trust, help protect you from conservatorship and guardianship by making them unnecessary, and if drafted properly, protect the trust assets from guardian control.  They even disincentivize third-party guardians (those appointed by a court that are not your family) by limiting what a guardian can manage of your entire estate.  Finally, in states that are required to give preference to agents nominated under a power of attorney when appointing a guardian, they help in getting your most  trusted family or advisors  appointed. 

Ad hoc solutions, like adding Marcus to Effie’s accounts, create uncertainty and risk. Banks rarely document the context of such changes (e.g., whether the account holder was advised or accompanied). Adding a co-owner can inadvertently make the account vulnerable to the co-owner’s creditors, a risk banks may not explain, as they are not legal advisors. Seniors often first learn the consequence of adding a child to an account when they are advised of a garnishment against a child as creditors seek to  remove assets from their account. 

      

If Medicaid planning motivated the deeds, a trust would have been superior. Modern Medicaid rules in many states, including Mississippi, scrutinize life estates, potentially valuing them as assets. A trust not only allows, but encourages crisis Medicaid planning without relying on the grantor’s competence, enabling an agent or trustee to create an irrevocable planning trust that preserves the original distribution plan. This would have avoided the need for questionable transfers and protected Effie’s estate.

Keep in mind that the real world result of the Autrey case is that Steve may ultimately receive nothing.  If he was acting in what he thought was the best interest of his mother and family, this result is tragic.  Comprehensive estate planning might have prevented such a result. 

An Actionable Plan to Protect Your Legacy

To prevent a situation like this from becoming your family’s reality, it’s essential to take proactive steps well before any health crises or vulnerabilities arise. Here’s an actionable list to help safeguard your estate and ensure your wishes are honored:

Create a Trust: A trust allows you to manage your assets during your lifetime and ensures they are distributed according to your wishes after your death. It can also provide protection against undue influence by clearly outlining your intentions in a legally binding document. It can assist in aging in place, reduce the risk of guardianship, and protect assets from third-party guardians.  Additionally, a trust can help avoid probate, reducing the likelihood of costly public disputes.

Establish General Durable Powers of Attorney (GDPOA): A GDPOA allows you to appoint trusted individuals to make financial and medical decisions on your behalf if you become incapacitated. This prevents someone from stepping in and taking control without your consent. Be sure to choose someone you trust implicitly, as this role carries significant responsibility.

Nominate a Guardian: Nominate someone in advance, usually in your GDPOA. This ensures that if a guardian is required, it’s more likely to be someone you’ve chosen, not someone appointed by the court who may not have your best interests at heart.

Incorporate Aging in Place Planning: Aging in place planning involves making arrangements for your care and living situation as you age, ensuring you can stay in your home or a suitable environment. This can include modifications to your home, arrangements for in-home care, or plans for assisted living if needed.

Include Guardianship Protections in Your Trust: Your trust should include provisions that prevent a guardian from easily accessing or altering the trust assets. This adds an extra layer of protection, ensuring that even if a guardian is appointed, your estate remains secure and distributed according to your wishes.

These steps should be taken well in advance, while you are still of sound mind and not under any undue influence. Waiting until the last minute can leave you vulnerable to manipulation, as seen in the Autry case.

The Emotional and Financial Toll of Undue Influence

Cases like this don’t just result in legal battles—they can tear families apart. The emotional toll of fighting over a loved one’s estate, combined with the financial costs of litigation, can be devastating. By taking proactive steps now, you can help protect your family from this kind of heartbreak and ensure your legacy is preserved as you intended.

Conclusion: Don’t Wait—Plan Today

The Autry case serves as a powerful reminder of the dangers of last-minute estate planning and the vulnerabilities seniors face without a comprehensive plan. By creating a trust, establishing powers of attorney, nominating a guardian, and incorporating aging in place and guardianship protections, you can safeguard your estate and ensure your wishes are honored.

If you haven’t already, now is the time to take action. Consult with an experienced elder law attorney to create a plan that protects you and your loved ones from the risks of undue influence and ensures your legacy is secure.

Executive Order Expanding Apprenticeships Could Ease Staffing Shortages in Nursing Homes, Assisted Living Facilities

An executive order to consolidate federal workforce programs could address workforce shortages among senior living and other aging services providers by expanding apprenticeships, according to an article penned by Kimberly Bonvissuto, writing for McKnight's Senior Living. This comes at a critical time given that Biden era staffing mandates have been stuck down by a federal court.

Trump signed an executive order, “Preparing Americans for High-Paying, Skilled Trade Jobs of the Future,” on April 23 with the goal of expanding and improving job training for skilled trades. The order directs the Labor, Education and Commerce departments to streamline and consolidate federal workforce programs, with a focus on expanding registered apprenticeships to more than 1 million annually.

Although the initiative is most directly aimed at the  administration’s goal to revive US manufacturing, LeadingAge Director of Workforce Policy Amanda Mead said in a written announcement that it could help alleviate critical workforce shortages in the aging services sector: 

“While the president’s executive order is widely seen as part of the administration’s push to revitalize US manufacturing, the initiative to expand apprenticeships could also benefit direct care workers — such as nursing assistants and home health aides — by offering enhanced training and alternative educational pathways beyond traditional four-year degrees.” 

Argentum is a national trade association representing senior living communities across the United States. It advocates for policies that benefit the senior living industry and its residents, serving companies that own, operate, and support professionally managed senior living communities. Argentum’s mission includes promoting quality care, operational excellence, and workforce development within the sector.

Back in 2020, Argentum  touted the success of the Healthcare Apprenticeship Expansion Program, which served more than 7,600 incumbent workers through a $6 million Closing the Skills Gap grant from the Department of Labor. The association also petitioned the Centers for Medicare & Medicaid Services (CMS) to include assisted living in an incentive program geared toward attracting registered nurses to skilled nursing facilities.

Since the 2020 grant, staffing challenges in the senior living industry have persisted and intensified, particularly due to the COVID-19 pandemic. In response, several efforts emerged to bolster the workforce:

• Workforce Development Initiatives: Argentum has continued to prioritize workforce development, launching initiatives such as partnerships with educational institutions in 2022. These programs aim to create career pathways, offering training and opportunities for individuals entering the senior living field.

• Legislative Actions: At both state and federal levels, there have been efforts to address staffing shortages in healthcare, including senior living. These include funding for training programs, loan forgiveness for healthcare workers, and incentives for employers to hire and retain staff. For instance, discussions around immigration reform in 2023 have explored allowing more foreign workers to fill caregiving roles, while some states have introduced minimum staffing requirements for nursing homes, potentially influencing senior living practices.

• Improved Compensation and Benefits: To attract and retain staff, many senior living providers have increased wages and enhanced benefits, recognizing the competitive labor market and the need to make these roles more appealing.

• Technological Innovations: The industry has also turned to technology to supplement staffing needs. Solutions like telehealth services and remote monitoring have been adopted to enhance care delivery and reduce the workload on existing staff.

In late 2023, a survey I conducted for an article (I never published) suggested that  38 states and the District of Columbia had established their own minimum staffing standards for nursing homes, but that figure was gleaned from internet searches; I could find no readily available source cataloguing the states and their staffing regulations.  I was surprised that the information wasn't more readily available since federal staffing mandates were then a hot topic.  

An Argentum spokesman told McKnight’s Senior Living:

“There are far too few caregivers to meet the needs of our rapidly aging population, and it will take an across-the-board approach to recruit and retain more than 20 million workers who will be needed across long-term care by 2040.” Three million of that 20 million will be needed in senior living alone, according to Argentum."

The American Seniors Housing Association (ASHA) told McKnight’s Senior Living that  the aging population demands a steady pipeline of workers to serve older adults living in senior living communities and other long-term care settings. ASHA Vice President of Government Relations Jeanne McGlynn Delgado appears optimistic:  

“Identifying and implementing federal training programs that can attract and grow this workforce, whether it be in retooling existing grant programs or expanding apprenticeships specifically for senior living workers, shows much promise,” ASHA ."

The American Health Care Association/National Center for Assisted Living told McKnight’s Senior Living that it continues to support making apprenticeship programs more available and accessible, including supporting the recently introduced American Apprenticeship Act to provide tuition assistance to fund apprenticeship programs:

“We’ve seen the value they can bring through our own apprenticeship partnership with Equus Solutions, who has supported some of our long-term care providers with the process. Apprenticeships are one of the many solutions we need to help recruit and retain more long-term caregivers, and we appreciate this effort to help address the nation’s growing caregiver shortage.”

Despite these efforts, staffing remains a critical and ongoing challenge in senior living. The effectiveness of these measures is under evaluation as needs increase, and the industry and governments continue to seek innovative and sustainable solutions to ensure high-quality care for residents. 

You can help.  Develop a plan to age in place.  To the extent possible, relegate institutional choices to "when and if it is absolutely necessary, and there is no available alternative."  You and your loved ones will likely experience better outcomes, and you will relieve an already burdened system.  

Aging in Place Planning: Groundbreaking Study- Take Charge of Your Cognitive Health with Simple Lifestyle Changes

As we age, the risk of stroke, dementia, and late-life depression threaten our independence, decision-making, and financial health. The consequences of these conditions threaten our families with burden, cost, and concern. These conditions change how we live, make decisions, and plan for the future. But here’s the good news: a groundbreaking new study from Mass General Brigham, widely covered by CNN, The New York Times, and Fox News, suggests that simple everyday steps can lower our risks.

By making small changes now, we can protect our brains, stay independent longer, and make life easier for ourselves and our loved ones. From the perspectives of estate planning, elder law, and aging in place planning, the findings offer critical insights into preventive health strategies that can enhance quality of life, reduce care giving burdens, and inform legal and financial preparations for aging. This article dives into what the study found, why it matters for planning your future, and how you can start today.

What the Study Says

The Mass General Brigham study, looked at tons of research to identify 17  modifiable risk factors shared by stroke, dementia, and late-life depression (LLD), things we can change to lower our chances of suffering from these conditions. These aren’t complicated medical fixes—they’re things like eating better, staying active, or even spending more time with friends. 

High blood pressure and kidney problems have the most profound impact, but staying active and keeping your brain engaged can make a significant difference in cutting your risk. The study found that improving just one of these areas—like going for regular walks—can help protect against all three conditions. They even created a tool called the Brain Care Score to help you track your progress. For example, boosting your score by 5 points could cut your risk by 27% over 13 years. That’s something to get excited about!

The reason that the study is groundbreaking is that these conditions, which contribute significantly to stroke, dementia and depression, share vascular and small vessel pathologies, making their overlapping risk factors critical. The 17 modifiable risk factors common to at least two of the three diseases are: blood pressure, kidney disease, fasting plasma glucose, total cholesterol, alcohol use, diet, hearing loss, pain, physical activity, purpose in life, sleep, smoking, social engagement, stress, body mass index (BMI), leisure time cognitive activity, and depressive symptoms. Among these, high blood pressure (hypertension ≥ 140/90 mm Hg) and severe kidney disease (estimated glomerular filtration rate < 30 mL/min/1.73 m²) had the greatest impact on disease incidence and burden, while physical activity and cognitive leisure activities were associated with the most significant risk reduction. The interconnected nature of these risk factors means that improving one—such as increasing physical activity—can positively impact others, like blood pressure, sleep, and social engagement.

Why This Matters for You and Your Family- Aging in Place, Estate Planning and Elderlaw Implications

As we get older, we want to stay in control of our lives—living in our own homes, making our own choices, and not leaning too heavily on our kids or loved ones. Stroke, dementia, and depression can make that harder, affecting everything from your health to your finances. This study gives us a roadmap to fight back, and it’s especially important if you’re thinking about aging in place, planning your estate, or  protecting your future.

Staying in Your Home (Aging in Place): Most of us want to stay in our own homes as we age,  surrounded by our friends, family, memories, and comfort. This study says you can make that more likely by moving your body, sleeping well, and managing stress. Here’s how to make your home work for you:

• Make It Health-Friendly: Add a place for stretching, a blood pressure cuff, or even smart lights to help you sleep better. These little changes support the habits the study recommends.  

• Fix Hearing Loss Early: Your home should not be a prison. Untreated hearing loss can make you feel isolated and raise your dementia risk. It makes you less likely to leave your home, and more likely to isolate. Get a check-up—it’s a small step with big payoffs.

• Get Family/Friends Involved: Ask your kids or grandkids to join you for walks or game nights. Invite friends over for a sports event or movie. It's fun, keeps you social, and lowers your risk of depression.  

• Use Tech: Set up reminders on your phone for meds or try a sleep-tracking or exercise app to stick with healthy habits.  Schedule Zoom or Facetime calls with families and friends to talk. Consider my article regarding the use of technology to reduce dementia risk and age in place.

Planning for Your Future (Estate Planning): Nobody wants to think about losing the ability to make decisions, but stroke or dementia can make that a reality. By taking steps like managing your blood pressure or quitting smoking, you can keep your mind sharp longer, which means you’re more likely to stay in charge of your money, your home, and your care. Here’s how you can plan smarter:

• Set Up a Routine Healthcare Plan: Work with a doctor, physicians assistant, personal trainer, deploy an online health app, and/or work with family and friends to improve your health, increase activity, and spend more active and engaging time with family and friends.  Design these around things you already enjoy or like.  Set goals, and work towards them to create a routine. 

• Advance Directives: Engage a lawyer to create a healthcare proxy and living will that says what you want if you become sick. Avoid simple minimalist forms, and actually state your intentions regarding long-term care (e.g., "if I need care I want it to be in my home," or "I do not want to burden my children financially, but hope they will provide time and support when needed").  Mention your current routines and plans (e.g., "monitor my blood pressure a few time a day," or "continue my selected supplements as they have demonstrated success" or I might qualify for Aid and Attendance because your father was a wartime vet, talk to the VA if I need help at home"). 

• Pick Someone You Trust: Choose a family member or friend to handle your finances and/or health decisions if you can’t. Make sure they know your goals, like staying healthy to avoid nursing homes and direct them to take advantage of your existing plan (e.g., if my Medicare benefit runs out, use my MA plan's "hospital at home" benefit, or pay for home care using my long-term insurance policy/short- term disability policy).   

• Deploy Trusts: Consider establishing trusts to fund healthcare needs, including home modifications or caregiver support, to facilitate aging in place, and/or to protect assets from long-term care spend down in the worst case.

• Save for Care: Set up a trust or savings to cover things like home modifications (think grab bars, ramps, a hospital bed at home, or a simple blood pressure monitor) so you can live independently longer.

• Financial and Insurance Planning: Consider aging in place planning when making other financial, insurance, or investment decisions. Consider, for example a Medicare Advantage Plan with home health care benefits, or a life insurance policy that is convertible to lifetime long-term care benefits.

Protecting Your Rights (Elder Law):  Elder law is fundamentally about making sure you’re taken care of as you age, whether that’s qualifying for Medicaid or finding community support. This study shows that simple changes—like joining a book club or getting your hearing checked—can keep you healthier, which means less stress on your wallet and your family. Here’s what you can do:  

• Stay Social: Loneliness can lead to depression, so find a local senior center or volunteer opportunity to stay connected. It’s good for your brain and your mood.  More, it protects your decision-making by providing interactions with people who know you and can alert you or your family if there are changes and/or help you if a predator or scammer attempts to take advantage of you.

• Plan for Medicaid: If you’re worried about long-term care costs, talk to an elder law attorney about protecting your savings while staying healthy to delay those costs.  

• Guardianship Protection: Implement a plan to protect you and your assets from guardianship.  Even a simple revocable trust can, in many states, be crafted to remove or frustrate guardianship control of the trust assets.

Easy Steps to Start Today

The study calls these 17 factors a “menu of options,” meaning you don’t have to do everything—just pick what works for you. Here are some ideas to get going: 

1. Check Your Blood Pressure: Get a home monitor and aim for under 120/80. Cut back on salty snacks, eat more fruits, and talk to your doctor if you think you need meds.  
2. Move More: Walk around the block, try chair exercises, or join a local tai chi class. It helps your heart, brain, and even your mood.  
3. Quit Smoking: If you smoke, call a quitline or ask your doctor for help. It’s one of the best things you can do for your brain.  
4. Stay Connected: Call a friend, join a hobby group, or volunteer. Feeling connected keeps depression at bay, and keeps you active.  
5. Challenge Your Brain: Do crosswords, read a new book, or learn a skill like painting or a new technology or device. It’s fun and keeps your mind sharp. 
6. Sleep and De-Stress: Try a bedtime routine or a quick meditation app to relax. Good sleep and less stress are brain boosters.

The Brain Care Score is a great way to see how you’re doing—just answer questions about your habits, and it’ll show you where to focus. The study says they’re working on more ways to use this tool, so keep an eye out!

How They Did the Study (And Why It’s Solid)

The researchers looked at 182 big studies from 2000 to 2023, narrowing it down to 59 that really dug into what causes these conditions. They focused on things you can actually change, like how much you exercise or how you manage stress, and figured out which ones matter most. They then employed a statistical analysis to compare how much each factor affects your risk, so you know where to put your energy.

This approach is strong because it pulls together lots of research, not just one small study. But it’s not perfect—they might’ve missed some things specific to depression, for example, and they can’t say for sure that changing these habits causes less disease (it’s more like a strong hint). Still, it’s a reliable guide for making smart choices.

What Else We Learned (And Why People Are Talking)

This study’s a big deal because it shows you don’t need a magic pill to protect your brain—just small, doable changes. People are excited about it—CNN called it a “hopeful message,” and experts say it’s empowering to know we can take control. It’s also a wake-up call: with dementia cases expected to skyrocket and strokes hitting even younger folks, starting now is key. Plus, things like finding purpose or staying social remind us that aging well isn’t just about your body—it’s about your heart and soul too.

One cool takeaway? The study’s Brain Care Score is like a personal coach for your brain. It’s already helping people, and researchers want to test it more to make it even better. For now, it’s a simple way to see what you’re doing right and where you can improve.

Wrapping It Up

Growing older doesn’t have to mean losing your independence or worrying your family. The Mass General Brigham study shows that by making small changes you can lower your chances of stroke, dementia, and depression. That means more years in your own home, more control over your future, and less stress for everyone. Whether you’re planning your estate, talking to a lawyer, or just want to age on your terms, these steps are a powerful way to take charge and implement a plan. So grab a friend, take a walk, and start building a healthier, happier future today.

Aging in Place: Multigenerational Living as a Strategy to Avoid Institutional Care and Support Family Caregiving

As the U.S. population ages, the desire to age in place—remaining in one’s home and community as one grows older—has become a priority for many older adults. According to a recent AARP survey, 77% of adults aged 50 and older want to stay in their homes for the long term, a trend unchanged for over a decade. However, rising healthcare costs, limited long-term care options, and the financial burden of institutional care (e.g., nursing homes costing over $100,000 annually) pose significant challenges.

A growing solution to these issues is multigenerational living, where families pool resources to care for aging loved ones at home. A recent article from National Mortgage Professional highlights this trend, noting that 17% of homebuyers in 2024 purchased multigenerational homes to reduce costs, care for aging parents, or accommodate adult children. This article explores how multigenerational living supports aging in place, aligns with elder law strategies to avoid institutional care spend-down, and strengthens family caregiving, with insights for Ohio residents.

Multigenerational Living: A Practical Solution for Aging in Place

The National Mortgage Professional article underscores a shift in homebuying trends, driven by economic and caregiving needs. According to the National Association of Realtors’ 2025 Profile of Home Buyers and Sellers, 36% of multigenerational buyers cited cost savings as their top reason, followed by caregiving for aging parents (25%) and supporting adult children (21%). Generation X buyers (36%) and Millennials (28%) are leading this trend, with some Gen Z buyers (44%) motivated by financial support. These homes often include features like mother-in-law suites or accessory dwelling units (ADUs), designed with grab bars, slip-resistant flooring, and zero-step entries to support seniors’ mobility needs.

Multigenerational living aligns with aging in place by allowing older adults to remain in a familiar environment while receiving care from family members. This setup contrasts with institutional care, which can deplete savings and disrupt emotional well-being. For example, the KFF Health News reports that 9 in 10 people find it “impossible or very difficult” to afford nursing home costs without Medicaid, and assisted living facilities average $54,000 annually. By sharing housing costs, families can redirect funds to home modifications (e.g., wider doorways, first-floor bedrooms) or in-home care services, enhancing safety and independence.

Elder Law Strategies: Avoiding Institutional Care Spend-Down

In elder law, a key goal is to avoid asset spend down, where seniors exhaust their assets in order to qualify for Medicaid, which covers long-term care but often requires institutional settings. Multigenerational living offers a financial and legal strategy to preserve assets while meeting care needs. By pooling resources, and aging in place, families can:

• Reduce Housing Costs: The Veterans United survey notes that multigenerational homes help families afford larger properties, lowering per-person expenses compared to separate households or senior living facilities.

• Delay or Avoid Medicaid Eligibility: Keeping seniors at home with family care reduces reliance on costly institutional care, preserving savings and assets for inheritance or other needs.

• Leverage Medicaid Home and Community-Based Services (HCBS): Ohio’s Medicaid program offers HCBS waivers, such as the PASSPORT program, which funds in-home care services (e.g., personal care aides, meal delivery) for eligible seniors, supporting aging in place without institutionalization.

• Eliminate the Inherent risks of Institutional Care: Institutional care comes with some profound inherent risks, such as medical and non-medical mistakes, security risks, infection risks, and guardianship risks, most of which can be eliminated or reduced by aging in place (for a discussion regarding these risks, attend an Aging in Place Planning Workshop).

These strategies are not, however, without complications or risks.  Families should fully consider title, security, and ultimate disposition issues carefully before reflexively doing what comes naturally; how these issues are confronted and resolved have tax and legal implications for all concerned.  Effective elder law, financial and health care planning is critical to maximize these benefits. Families should:

• Consult an Elder Law Attorney: An attorney can structure assets (e.g., through trusts) to protect them from Medicaid spend-down while ensuring eligibility for HCBS.

• Consult a Financial Planner/Insurance Specialist: Effective financial  and insurance planning can help assure that you are maximizing your financial resources to age in place, and provide opportunities for alternative to institutional care or spend down at a time of need (e.g., long-term care insurance, short term disability insurance, home health care policies, or Advantage Plans with robust aging in place benefits such as "hospital at home").

• Draft Powers of Attorney and Healthcare Directives: These documents ensure fiduciaries can manage financial assets, and make health care decisions minimizing the risk of the legal system intruding into what otherwise a family might consider private decisions.

• Plan for Care Costs: The Center for American Progress notes that unpaid family caregiving, common in multigenerational homes, saves families from hiring professional caregivers, but supplemental HCBS can bridge gaps when needs escalate.

Family Caregiving: Benefits and Challenges in Multigenerational Homes

Family caregiving is the backbone of multigenerational living, with 63% of older adults receiving care from family, often in their 20s to 40s. The National Mortgage Professional article emphasizes caregiving as a key motivator for multigenerational buyers, particularly for aging parents. Benefits include:

• Emotional and Social Support: The Institute on Aging highlights that multigenerational homes reduce isolation, a major health risk for seniors, by fostering daily interactions and shared activities like cooking or storytelling.

• Cost-Effective Care: Family caregivers provide unpaid care, saving thousands compared to professional services. The AARP reports that 1 in 5 Americans is a family caregiver, with 40% caring for someone in their home.

• Flexible Care Arrangements: ADUs allow caregivers to monitor seniors closely while maintaining privacy, supporting both independence and safety.

• Preferred Treatment or Protection of Assets: One key Medicaid provision that highlights these benefits is the two-year live-in child caregiver exemption for home transfers, which allows certain family caregivers to receive the home of a Medicaid applicant without triggering penalties or asset recovery.

However, caregiving can strain families, especially women, who face a median wage loss of $24,500 over two years when providing intensive care. Challenges include:

• Emotional and Physical Toll: Caregiver.com notes that caregivers often experience fatigue, irritability, and lack of personal time, particularly in multigenerational households with multiple care recipients (e.g., grandparents and grandchildren).

• Role Negotiation: Families must define responsibilities, as some members may prefer hands-on care while others focus on chores or finances.

• Conflict Risks: Lifestyle differences (e.g., noise levels, guest policies) can spark disputes, requiring open communication.

To address these challenges, families can:

• Involve Capable Children and Grandchildren: Young family members can assist with light tasks (e.g., reading to grandparents), fostering bonds and easing caregiver burdens.

• Seek Respite Care: Ohio’s Area Agencies on Aging offer respite services, allowing caregivers temporary relief.

• Use Technology: Technology can provide surprising solutions and necessary relief for caregiving burdens when employed properly.  More, use of technology can actually support cognitive health, and slow cognitive decline.

Practical Tips for Families

Assess Home Suitability: Use the National Institute on Aging’s Home Safety Checklist to identify modifications (e.g., stair railings, better lighting) for aging in place (make only necessary modifications to avoid unnecessary expenditures depleting funds for what may be alternate future needs).

Discuss Expectations: Hold a family meeting to clarify caregiving roles, financial contributions, and lifestyle preferences.

Incorporate Technology: Use technology where appropriate, and protect its availability and access by completing a Digital Asset Inventory, ensuring fiduciaries can act swiftly as needs arise.

Explore Housing Options: Consider ADUs or multigenerational homes with accessible features, as 59% of caregivers in the AARP survey value such designs.

Seek Legal Guidance: An Ohio elder law attorney can tailor plans to leverage HCBS, protect assets, and age in place.

Conclusion

Multigenerational living is a powerful strategy for aging in place, offering financial savings, emotional support, and caregiving flexibility. By reducing reliance on institutional care, families can avoid spend-down and preserve assets, aligning with elder law goals. However, success requires planning. In Ohio, leveraging programs like PASSPORT makes sense. As the National Mortgage Professional article shows, multigenerational homes are more than a trend—they’re a meaningful solution for families navigating the challenges of aging.

For some insight into the laws, rules and regulations governing ADU's in Ohio, go here and here.

Law Day- Supreme Court of Ohio Honors Judicial Legacy with Melhorn Exhibit

The Melhorn exhibit, Preserving Ohio’s Judicial Legacy, honors Judge Calvin Pease’s courageous 1806 decision asserting judicial independence. Visit the Supreme Court of Ohio’s Law Library to explore this landmark moment in Ohio Law.

Court News of Ohio published the following: 

The Supreme Court of Ohio commemorates Law Day on May 1 with the unveiling of the Melhorn exhibit, “Preserving Ohio’s Judicial Legacy.” This presentation highlights a significant contribution to the state’s legal history with Frank Melhorn’s donation of the historic article, Important Law Intelligence, first published in the Scioto Gazette on December 25, 1806.

The article, attributed to Judge Calvin Pease, captures a pivotal moment in Ohio’s judicial history. Judge Pease, facing considerable political pressure and the threat of impeachment, rendered a groundbreaking decision ruling an act of the Ohio Legislature unconstitutional. This assertion of judicial independence marked the first recorded use of judicial review in the state and laid the foundation for the judiciary's role as a coequal branch of government. Often referred to as Ohio’s Marbury v. Madison, this early case exemplifies the enduring principles of justice and the rule of law in Ohio.

The Supreme Court recognizes Frank Melhorn for his efforts in preserving this historic document for the public’s viewing. Utilizing high-resolution scans provided by the American Antiquarian Society, Melhorn oversaw the creation of two replicas of the article,  now on display publicly, offering greater accessibility for those interested in Ohio's judicial history. Together, this donation honors Judge Pease’s courage while serving as a testament to Ohio’s commitment to preserving its legal heritage.

Law Day, a national observance held annually on May 1, celebrates the rule of law and its role in protecting freedoms and promoting justice. This year’s commemoration underscores the historical contributions of individuals like Judge Pease, whose legacy continues to inspire confidence in the judicial system.

The Supreme Court of Ohio invites the public to reflect on and celebrate these foundational moments of legal history. For more information on the exhibit, visit the Supreme Court’s Law Library.