Living Alone With Cognitive Impairment Can Be as Impactful to Health as Poverty


This social determinant of health could have the same level of negative impact on health as the experience of racism, poverty, or low education.

Approximately 25% of older US adults with age-related cognitive decline are putting themselves at greater risk of health complications by living alone, suggest investigators from the University of California San Francisco (UCSF) who recently published the results of a qualitative study in JAMA Network Open.

Image credit: pikselstock -

Image credit: pikselstock -

The current health system does not subsize care for these older adults, “projected to live longer and often alone," said first author Elena Portacolone, PhD, MBA, MPH, UCSF Institute for Health and Aging and the Philip R. Lee Institute for Health Policy Studies, in the press release. “Effective treatments to reverse the course of cognitive impairment are unavailable.”

UCSF investigators conducted a qualitative study to understand how the current health care infrastructure supports care to patients with cognitive impairment. They interviewed 76 health care providers (HCPs) of varying disciplines who worked in memory clinics, home care, and social services in California, Michigan, and Texas.

The research shows that 1 in 4 older adults in the United States with dementia or mild cognitive impairment lives alone. Isolation causes this population to be at greater risk of missing medical appointments, not responding to doctor’s follow-ups, and/or forgetting their reason for making appointments. This makes them more vulnerable to untreated medical conditions as well as self-neglect, malnutrition, and falling, according to the HCPs interviewed in the study. Even then, the health care system may not have enough resources to allocate extra care for these patients.

"We don't necessarily have the staff to really try to reach out to them," said a physician interviewed in the study.

The findings also suggest that living alone with cognitive decline is a social determinant of health (SDOH) in and of itself, according to Portacolone. Cognitive decline might even have as much of an impact on health as poverty, racism, and low education.

In addition, the current health care system only subsidizes home care aid for the lowest-income patients who suffer from cognitive decline. Further, approximately 79% of patients with cognitive decline are not eligible for long-term home care aides subsidized by Medicaid, Portacolone noted.

When Medicare, which is available to patients aged 65 years and older, subsidizes home care aids, it is also only for a short duration of time, usually following hospitalization or an acute episode. This can pose a problem to patients who need longer term care. As Portacolone explains, cognitive impairment can last decades, and, without subsided care, most patients would need to pay out-of-pocket. Further, Medicaid-trained home care aides are likely not paid well or have not received enough training.

UCSF investigators noted that they want Medicare and Medicaid to provide funding to the health system so that more care can be given to people with dementia and cognitive impairment. Further, countries such as Japan and Canada are much more likely to subsidize home care aides.

"In an era when Medicare is going to spend millions of dollars for newly approved drugs with very marginal benefits, we need to remember that Medicare and other payers refuse to pay far less money to provide necessary supports for vulnerable people with dementia,” said Kenneth Covinsky, MD, MPH, UCSF Division of Geriatrics, in the press release.


Caution: Living alone puts people with cognitive decline at risk. University of California San Francisco. News Release. August 18, 2023. Accessed on August 24, 2023.

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