Introduction

Dr. Regina Koepp 0:00
Some of the folks that I've worked with in my career will struggle to find Senior Living communities because of having a mental health condition. And so this is where I would love to hear your thoughts and experiences and helping families who do have mental health concerns and conditions and have looked for senior living communities.

Candy Cohn 0:21
It is a problem I, you know, it definitely comes up a lot. And recently, it's come up for me, I don't know if it's because of COVID I, just, in the last six months, I've had so many cases like this. And the trick is that these people have a mental health condition, but they live a normal life. And we're not looking for a mental health, senior living community. For them, we're looking for how to mainstream them, it's important to prepare them and their family, so that when they do move, they will be successful. And so that the community that they're moving to knows all the details and knows what they're getting, so that they can help and they can partner with the family is really how I look at it.

About the Psychology of Aging Podcast

Dr. Regina Koepp 1:10

I'm Dr. Regina Koepp. I'm a board certified clinical psychologist and I specialize with older adults and families. I created the psychology of aging podcast to include older adults in conversations about mental health and wellness. And here's why this is important. When we're all a little more informed about mental health for older adults, we reduce suffering and improve quality of life. And who doesn't want that? So join me, it's simple. All you have to do is listen, be willing to learn, and then share what you learn with others so that they can be included in this conversation, too. Alright, let's get started.

THE INTERVIEW

Well, Candy Cohn, thank you so much for joining me on the psychology of aging podcast. I'm thrilled that you're here. Can you share a little bit about who you are and what you do?

Candy Cohn 2:07
Yes. Hi, thank you so much for having me here today, Regina, it's really an honor to be on your podcast. I've been listening to it for a while now and learning a lot from it. And it's very friendly, and it's something people would want to listen to. So I really am honored to be here. So, I'm a certified senior advisor and the owner of Oasis Senior Advisor, South Florida, I help people find Senior Living communities. And that includes independent and assisted living as well as memory care. And I own a franchise, so I'm part of a national company. And so it's a free service that we offer, we get paid a commission by the senior living community when we place someone, so I can, because it's a franchise, I can actually help people all over the country, because I can refer them to my colleagues and other places. And I am passionate about what I do, because I got into this business because of my own parents. And that was about 10 years ago, I had to find senior living for my parents, and I was lucky enough to be referred to a senior placement advisor to help us. And at the end of the whole process, I had been doing some freelance marketing at that time, mostly in healthcare. So I asked the senior placement advisor if he needed help with his marketing. And he said, "Actually, I'm interested in training someone to do senior placement. Would you like to do that?" And I said, "Absolutely." So, that's how I found this career. And it turns out it's my life calling, I am absolutely positive of that.

Dr. Regina Koepp 3:46
Oh, so that's such a great journey.

Candy Cohn 3:49
Yeah, so I worked with him as an independent contractor for a while. And then three and a half years ago, the opportunity presented itself to purchase this franchise. And I bedded the company and looked into it and Oasis senior advisors just had so much to offer, especially for me, I had never really owned my own business, I had been a freelancer, but not like owned a whole business. So, I love the support they provide. And we also have a proprietary software system that helps match the senior to the senior living community. And that's really terrific because it takes me out of the picture as far as the initial matching, and then, you know, so it's objective just based on the parameters, but then I use my judgment and my experience to narrow it down with the client.

What are the Different Types of Senior Living Communities?

Dr. Regina Koepp 4:40
Can you give us an overview of the different types of senior living communities that older adults can live in?

Candy Cohn 4:46
Yes, so there is independent living, which is when people just want to move into a community maybe their house has become overwhelming caring for it, the maintenance. Maybe they stopped driving, that's often a time I get a call or the children, adult children calling me to say my parents shouldn't be driving anymore, and I don't want to have them just stuck at home. Oftentimes loneliness is a really big issue. So sometimes when they just lost a spouse, or they just all their friends are starting to pass away, and they just can't have much of a social life anymore. That's a great reason to move to independent living. So in independent living, you have your own apartment, and you're part of a community, you might have a studio, one bedroom, two bedroom, and you have a kitchen, it's a full apartment. And you are part of a community where you get dining... there's communal dining and a dining room, you get two meals a day in most Independent Living communities.

In assisted living, you get three meals a day, and a lot of communities have independent and assisted living on the same campus. Most of them do, I only know of a couple communities here that are just independent living. So when there's independent living and assisted living on the same campus, they're often similar. At some, they're totally different. Some places, it's a separate section for assisted living. And some places the independent and assisted living apartments are kind of integrated. So either way independent or assisted, you get your own apartment, and you have the opportunity to eat in the dining room. With COVID, the dining has changed. It's been mostly that they're delivering the meals to the apartments, although I'm happy to say here in South Florida, they are starting to resume communal dining, as long as the community has been COVID, free for 14 days. So that's been a really big deal here and everywhere, you know, but it's different in every state and every location.

Dr. Regina Koepp 6:56
Are they testing the residents there regularly?

Candy Cohn 6:59
They are not testing them regularly at every community. It's not a state regulation. They were testing them for a while they are taking temperatures at most communities. And they are taking staff temperatures on a regular basis at all the communities that I deal with. Yeah. So COVID has definitely changed the face of senior living. But it's still a wonderful option. And I'm really pleased with the way the senior living communities I deal with have handled it. In the beginning, we were all petrified. And you know, business just stopped for a while the only people I was moving were people in crisis. But now people are back to wanting to move a lot of them are really lonely because they've been stuck inside. You know, I have this one client, she's so desperate to move. Unfortunately, her son and her doctor won't let her move yet. But she calls me crying all the time. She's like, I don't care if I get COVID I am so lonely. Her husband passed away a year ago. And she was all set to move in March. And her son won't let her. So it's really sad. But I am happy to see that most seniors are open to it now and are looking forward to moving.

Candy Cohn 8:14
So besides the dining, they have activities that these communities, whether you're in independent or assisted living, they have you know, people say especially at the nicer communities, it's like being on a cruise ship that's docked in port, you know, you get up, you check your calendar, you know, you're going to go to breakfast, and then you're going to maybe go to morning exercises, and then go to the book club and you know, current events and it's great. They make friends. And even people that don't want to participate in a ton of activities. They just... the meals alone are the social activities. So like for my parents, they weren't Card Players. They didn't do all those other activities. But just going to the meals was a really big deal on my mother before moving my parents to assisted living. I would go visit them sometimes and they'd still be in their pajamas, housecoat, you know sitting around reading, cooking, like not cooking, eating canned soup and tuna fish. And my mother used to be an amazing cook. So it was really kind of depressing. As soon as I moved them, whenever I would go over there, my mom was all dressed, she had her makeup on. She even started wearing a wig, which I convinced her to do because she was so upset that her hair was getting really thin. And she got dressed and felt good every day. And that was so important. So I think that routine is so important. Because when people retire, that's often a big thing that happens, they just fall apart. They have no routine and they have no reason to wake up in the morning. They don't know what they're gonna do. Some of my clients sit around and watch TV all day and, you know, and they used to be active and vibrant. So I love seeing people move to senior living, I think it really is a healthy situation for them. So just to go back to independent and Assisted Living, you are free to come and go when it's not COVID. Okay. COVID has, you know, put a damper on that there are different rules and regulations in place. But you're, you're still free. It's like having your own apartment in a community you have, you can keep your car if everybody says that's safe to do. And you have this wonderful community, they provide transportation, though to doctors and like some shopping within 10 to 15 miles or so. And they have housekeeping once a week. They do your laundry of your linens in independent living, if you're in assisted living, they do all your laundry. And you can usually pay like if you're an independent, you want to have them do all your laundry. And there's other amenities that are provided.

Candy Cohn 10:48
Memory Care is the next level after assisted living. So that would be for people that have dementia, that is advanced enough that they need constant attention and care. And they might be an elopement risk, you know, they might be one to wander off. So the memory care community is either a whole community in itself separate or it's a separate part of a bigger community that has independent and assisted living. The Memory Care section is locked, is secure, we call it secure. And words are really important. I want to say that, you know, I call these communities. These are not facilities, a skilled nursing facility is a facility. It looks and smells and feels like a facility, it feels like a hospital. These are not, these are really communities. And it's important with my clients, I tell them when you're talking to your loved one about it, call it a community. They all say I don't want to go to those. I don't want to go to the home, the home, that's what they used to call the nursing home, I don't want to go to that facility, you know, so words are, as you know, really important.

Dr. Regina Koepp 11:54
Yeah, because it creates this sense of institutionalization. And nobody wants to be institutionalized or incarcerated or, I mean, that feels like stripped of rights and access and life and vitality. And of course, I really appreciate you saying that words are important and how we talk about Senior Living communities matters. And even the small little things we say to older adults who require assistance outside of living matters, like adult briefs instead of diapers or, you know, and that's something simple or an adult day program rather than adult daycare, because that's very infantilizing. And so the words that we're using talking about communities rather than institutions or facilities, or...

Candy Cohn 12:45
...even what we call seniors, I don't think we've come up with a good word, yet. Do you have a good word?

Dr. Regina Koepp 12:49
No. You know, Ashton Applewhite, who I interviewed a few months ago calls older adults "olders."

Candy Cohn 12:55
Oh, yeah, I like that.

Dr. Regina Koepp 12:57
But I agree with seniors is not a great term, older adults are cumbersome. And everybody ages at different rates and has a different process of aging. And so it's hard to classify, you know, just put everybody in one category. And it's such a long, long span of age too, so adolescence, it's like, you know, 13 to 19. To be a teen, that's six years, that's not very long, older adults are, can be older from 65 to 122. Right. And so that's decades and decades, that's not really fair to put everybody in one of those, you know, in one category, but, but I digress. So, okay, so back to senior living. So, words matter. And you've described independent living in a community, assisted living in a community and memory care in a community. Sometimes those communities are continuous care retirement communities, is that...

Candy Cohn 13:58
....That's correct. So there are the CCRCs, the continuing care retirement communities, and those are what they call buy in. So you buy in you put down anywhere from like 150,000 to 600,000, upfront, and then you still have a monthly fee, they call it a maintenance fee or something like that. And it's high. I mean, you know, it's like 5000 a month or 3000 a month, depending on the community. Then there are the ones that are strictly rentals, and that's what I deal with mostly, but I do deal with the ccrcs it's just not the right fit for a lot of my clients, not just because they don't have the money but because once you're like you know 85, older than 85... I'm not sure that it's the best fit, you know, people at the ccrc tell me otherwise and I'm still learning a little more from some of them but I typically recommend a rental to people in their late 80s or older and that's what most clients want and with the rental you sign a, what they call a one year lease, but you can give 30 days notice and move out. And if someone passes away, you, as soon as you move, remove their belongings, the family removes their belongings, you know, you start paying rent and you get back, they prorate the month if the loved one is already there, so I just think the rentals have more flexibility with the buy ins that money that you put down. If you live there for, you know, number of years, five years or more, your state doesn't necessarily get back much of that money. So it's not necessarily the best way and some of these rentals now, especially near me, my in South Florida are just gorgeous, you know, as beautiful as the buy in communities. So that is something that is different.

And then one other type of assisted living I didn't mention is a residential care home. It's a group home that has an assisted living license. And my mother lives in one. And it's been wonderful for her. So they have usually six beds in Florida anyway. And and there's a lot of them here. But I hear from other Oasis franchise owners that that's not true in every location, you know. So I'm not sure where you are, they have a lot of these. They're in neighborhoods, so you wouldn't know they're there. They don't have a big sign out front, where my mother lives there. It's owned by a nurse, that senior living community has an extended congregate care license. So that's another thing in Florida, that is not true everywhere else. It's probably in some states, there's different levels of licensure for assisted living. So there's a standard license, an lns limited nursing service, and then ECC extended congregate care. So with extended congregate care, they can handle a colostomy, which my mother has, they can handle oxygen, they can give injections, they can do a two person transfer if someone requires two people to transfer them from the wheelchair to the bed. So there's lots of complications, or complexities I should say, which is a reason that someone should work with a professional like myself, a senior placement advisor, so you don't spin your wheels. And so you don't move your loved one into a place that's just not going to work for them. And then you have to start all over again. So those are a lot of the different types.

Dr. Regina Koepp 17:20
Yes. And you're really just in the personal care home or the residential boarding care home or residential care homes... different names. Yes, Georgia has personal care homes and a lot of my patients lived in personal care homes, they tended to be more affordable for my patients than assisted living communities or ccrcs. Is that true, though, Candy? I don't know much about the cost of personal care homes. Is that true or are communities like the ones your mom lives in where there's more... is it nursing care?

Candy Cohn 17:53
No, it's owned by a nurse but it is an assisted living. She does get nursing care. That is true because it is owned by a nurse. But the residential care homes are still assisted living. They're not a skilled nursing facility. But they are a really good way to keep people out of skilled nursing facilities. So I get calls sometimes from clients or a physician that says you know, "my parent or my patient needs to move to a skilled nursing facility, can you help?" And after talking to the family, I realized that they might be able to prevent, we might be able to avoid the skilled nursing facility and move them to a residential care home. Most people don't know about the homes so they, on their own, wouldn't do that. My mother, my parents were actually in a big traditional assisted living community for years. That's how I started this journey. And then my dad passed away a few years later, and then two and a half years ago, my mother started needing more care. She can hardly hear. She's totally deaf in one ear. She has dementia, which has progressed. She has moderate cognitive impairment. And it was getting difficult for her and then she actually hurt... she she didn't fall, but she was bending over in the shower and snapped the vertebrae. So, she uses a walker and she has a heart condition, now, that is making her lightheaded and she started falling. So I realized I either had to hire 24 hour home care aides and keep her at a big assisted living or move her to a residential care home. So that's when I decided to move her and it's been wonderful. You know she gets... there's someone always in the next room. So when she stands up they know and if she you know they get to her before she stands up and she won't fall. She they can take care of her colostomy because of the licensure that they have. And she doesn't have to deal with large crowds in the dining room. It was getting really difficult for her at the other place, she couldn't hear and the dementia... and she started getting paranoid. She thought people were talking about her. So, for someone like my mom, the residential care home is great. And where she lives is pretty affordable. So some of them are priced, they're priced at all different levels, but they can be more affordable. And most of them accept Medicaid. So that's another thing you know, with the larger communities, only some of them accept Medicaid, and Medicaid in Florida will pay up to $1400 a month for the care, not the rent, but the care. But at a residential care home is just one total price. So that 1400 is applied towards her total, rather than where she used to live. We still had to pay her rent, or she did and you know, we had a supplement, and then the 1400 could only be applied to her care. Residential care homes can offer more flexibility...

Why work with a Senior Living Advisor?

Dr. Regina Koepp 20:48
...financially for families. Yeah. Oh, thank you for sharing those options. It's so helpful for families to get a picture of that. And then just to touch back on what you mentioned earlier, so in your role, the family doesn't pay you directly you get paid by getting a commission from wherever the family ends up. Is that right?

Candy Cohn 21:06
That's right. Yeah, I tell people, I'm kind of like a cross between a social worker and a realtor. I'm not, I am a certified Senior Advisor, I do have a certification. But that's just my analogy. So, the Social Work pieces, I go in person, I do an assessment, find out what's going on with them, then the realtor hat I put on and take them on tour with the communities. And then, like a realtor, I get paid a commission by the community.

Dr. Regina Koepp 21:31
Oh, that makes sense. And that's a helpful analogy. Yeah, you're a liaison and an advocate.

Candy Cohn 21:38
Yeah, I am an advocate. That's huge. Because each place I take the client to the salesperson is doing the tour. I'm just there as the advocate. So that salesperson is going to try to sell my client on that community. And I'm not, I'm there to help them compare and contrast and figure out I usually take them to like three places. And I'm trying to help them figure out okay, out of these three, which is going to be the right fit. And I'm not telling them, you know, it's up to them, but I guide them along the way.

Dr. Regina Koepp 22:07
And what would you say to families that this is maybe where that assessment comes in that you do at the beginning? That's objective? Because then the question that comes up for me is if you're getting a commission, does that mean you're only showing the high end communities? And so does that, how do you safeguard against that so that you're helping families where they can afford it?

Candy Cohn 22:28
Well, first of all, I wouldn't take them to a place they couldn't afford, there's no reason to do that. And because I'm a certified Senior Advisor, I have ethical standards, high ethical standards I adhere to, I couldn't sleep, I couldn't wake up and look at myself in the morning, if I was doing something unnecessary. That's just how I am. But I mean, it wouldn't benefit... my job is to help the client figure out, okay, your mom is 93 years old, she gets this amount of money, and we need to make it last. I mean, that is my job. So I would never take them to places they couldn't afford so that I could get paid more. There's no reason for me to do that. And almost all the senior living communities work with me. And even more so now. Because of COVID. A lot of them are hurting. And some that were refusing to work with senior placement advisors in the past are now saying, Hey...

Dr. Regina Koepp 23:17
...we need it. And I think, one you have a moral code and an ethical structure with your CSA, certification or license. And then second is your own lived experience with your own parents and understanding that your parents could start in one place and needs could change and money can change over time and so being open to switching too. So you switched your mom when her needs changed, and then you moved her to a different community that would be more accommodating for her... less stimulating it sounds like she was overstimulated the community... assisted living community, and just said it better meets her needs, financially and physically and hopefully emotionally too...

Candy Cohn 24:08
Right. And I make an effort to keep in touch with my clients periodically because they might need something different at some point as well.

Finding a Senior Living Community for a loved one with a mental health condition

Dr. Regina Koepp 24:16
Right. Yeah. Now, can you share a little bit about, since this is the psychology of aging, I do want to talk about one of the things that's come up frequently in my own practice around older adults with significant mental health concerns like bipolar disorder or schizophrenia or significant depression that recurs throughout an older adult's life, and then they become an older adult and continue to have recurrent depression, or anxiety or post traumatic stress disorder. Some of the folks that I've worked with in my career will struggle to find Senior Living communities because of having a mental health condition. And so this is where I would love to hear thoughts and experiences in helping families who do have mental health concerns and conditions, kind of look for senior living communities.

Candy Cohn 25:10
It is a problem I, you know, it definitely comes up a lot. And recently it's come up for me, I don't know if it's the cause of COVID. I, just in the last six months, I've had so many cases like this. And the trick is that these people have a mental health condition, but they live a normal life. And we're not looking for a mental health senior living community. For them, we're looking for how to mainstream them, it's important to prepare them and their family so that when they do move, they will be successful. And so that the community that they're moving to knows all the details and knows what they're getting, so that they can help and they can partner with the family is really how I look at it.

Candy shares her personal experience with her father who had a bipolar disorder looking for senior living

So I, my first experience with this was my own father. So my dad had bipolar depression. And he had been treated for it for many years and was usually stable, but about, like every eight or nine years, he would have an episode, for whatever reason. And in his... when I like... 10 years ago, he had an episode he was in his late 80s. And it was an episode like I had never seen before. Before this, he was either usually depressed or manic, he wasn't both. This time, he was both. So you know, in a period of a couple hours, he would go up and down and he was so angry. And then he was depressed, and he was lethargic. And then he was hyper. What had happened was he stopped taking his meds, he didn't stop, he ran out of his meds. And he was so embarrassed because he thought he did something wrong. He didn't think it was time to get the refill. He was on an HMO. And he said he was afraid to call them. He didn't tell me and I, you know, at the time I lived five minutes away from him and he was managing their life. I wasn't managing their life. But he, I would have been the closest person to tell him he didn't tell me. And then all of a sudden, his behavior started getting erratic. And we found out that he hadn't slept in a week because that was how he responded to depression. And turns out he had run out of his meds. So he was out of control. I tried and my mother, my poor little mother a really small, tiny woman, and he was strong. My dad used to be a bodybuilder. And he was older and kind of, you know, a little frail, but still, that strength just came out and like he didn't hurt her. He never did anything physical. But he was like, block the doorway, and you couldn't move him if he didn't want me to go out. So I started trying to get him into a mental health hospital. And I couldn't get... there was no bed available at the local place. I called every day. And I was making all kinds of calls trying to figure out what to do. Finally, I called a hospital where he had been, like 10 years prior to that, he actually had ECG treatments, 10 years prior to that, and they really helped him. So I called to see could we get him into the mental health facility there and they did have beds, you know, they said they do have beds, I said, "Well, how do I get him in?" They said, "Just bring them to the ER, and we'll get him in." So I brought him to the ER and it was a horrible experience. It was just my mom and me it was late at night. And like I said, when he did that whole thing, I had to move them and get them in the car. And it was really scary. But we got him there. And while we were in the waiting room for the ER, he started having chest pain. So my dad had a condition they called it an... I forget what they called it. He had an athletic heart, but they had something else that gave him these chest pains, but it was never anything. He had had it his whole life. So I knew it was probably nothing. But they ended up admitting him to the cardiac unit because he was having chest pain. So they got that under control, found out nothing was wrong. And then they we're going to discharge them. And I was at the hospital talking to the case manager. I'm like, "No, I brought him here to get him into the mental health unit." And I had to fight and be his advocate to get them to put him into the mental health unit. So they did finally get him in there. While he was there was when I was introduced to the senior placement advisor. My mother and I went to look at Senior Living communities while he was in the hospital. And my mom was great about it. I mean, she knew she had to do something. And I had shown her senior living communities like a year prior to that just, you know, like, what the heck, let's go look. And she said, "no, I couldn't ever live there. I can't live with all those old people." And I hear that a lot. You know, people think they don't see themselves but my mother and father truly were a young, you know, young for their age, young looking, really good looking and athletic and all that. But this time, my mom was different because it was a crisis. And she knew she had to do something, had to make a decision and move to one of these places. And then the other piece was, we were with the senior placement advisor. So she respected him. And she, it was so interesting to watch her deal with him and interact with him. She wouldn't listen to me that way. And, and granted, I wasn't knowledgeable at the time, but still, just having a third party there is really important. You know, they don't want to be... older people don't want to listen to their adult children.

Dr. Regina Koepp 30:35
Yeah, they want it to be their decision. It's their life.

Candy Cohn 30:39
And we made it her decision. And I do this with clients, we brought her to three places. And it was totally up to her, which of those three, they all fit her budget. You know, they all were places that could handle the care that my dad needed. And, you know, so she made the decision. And so my dad ended up in the hospital for a couple of weeks. During that time, we packed up my parents and found a mover and then we applied for Medicaid. That was another thing. So the senior placement advisor referred me to a consultant and an attorney to help us apply for long term care, Medicaid, and also to a consultant to apply for VA aid and attendance. My dad was a veteran, thank goodness, because I don't think they could have afforded... not think they could not have afforded to move without both of these sources of money. So we, in five weeks, we made it all happen. I mean, it would have taken me five weeks just to start touring places by myself, I think because it's so overwhelming. So thank goodness, my dad was stable, we were able to move him in, when he was assessed by the nurse, you know, she knew she had his whole medical history. So she knew about the bipolar depression, she knew he had been in the hospital, but he was stable by the time he moved in, and it was fine for him to move there. So that was a success. And my parents did quite well there, you know, socially and in other ways. And my dad ended up getting ill other types of illnesses and ended up in a skilled nursing facility the last year or so of his life. But the mental health was stable. He never had another episode The rest of the time that he was alive, which was a few more years.

Medication Management in Assisted Living Communities

Dr. Regina Koepp 32:20
And he stayed on his medications.

Candy Cohn 32:22
Yeah. Okay, so that's another piece. So when he moved in, he was... his medications were being managed by the assisted living community. So the director of nursing would order the meds, you know, she knew when the refills were due, he didn't, that piece was taken out of his control. So that was really, really important. And what I've seen, you know, thinking about this, this morning, knowing that, you know, we were going to talk about this, and I thought about all my clients that have had these issues, they all have gone off their meds, every single one of them for whatever reason. And so I would say that it's really, really important to get people, you know, medication management under control. If you have an elderly parent or, you know, a loved one, and you're not sure if they're taking their meds, you need to find out, you know, that needs to be taken care of, and maybe you can prevent some of these kinds of things from happening.

Dr. Regina Koepp 33:18
The regressions and the relapses into illness.

Candy Cohn 33:22
Yeah. So I have a client right now who, that's a big issue. And he's kind of, he's a little bit younger, and has severe bipolar, but he's been treated. He was taken to the hospital because he fell, and his family called me. And I was trying to get the hospital to discharge him to a mental health facility, you know, an inpatient facility program so that we could get him stable before trying to find assisted living for him. While he was in that hospital, there was no psychiatrist there. They have only one psychiatrist on staff, and a psychiatrist... that psychiatrist wasn't available the whole time he was there. So my client was off his meds for two weeks this is the guy with severe bipolar. And they discharged him to a regular rehab, skilled nursing facility rehab... not have a mental health license or emphasis or anything. So they were not addressed. They were addressing the fact that he fell, but they weren't addressing the underlying causes behind any of it. And it was really frustrating. So finally, he did get into a mental health hospital and I was able to help him find senior living. He's younger. And this is another challenge. A lot of people with mental health issues and sometimes substance abuse and sometimes both together, are a little younger, but their brain has aged more rapidly and they don't want to live with really old people. So they want to be within an independent living community, or at least the Independent Living portion of a community. And then I get that socially, that might be the best thing for them. But if they're in that situation, we need to make sure their care and their medication management is taken care of. So this man, his family, after looking at assisted living with me, did not want him there. And then I took them to a place that only has independence, because it met a lot of the other needs that he wanted, and they loved it right away. And that is where he moved. But I then referred them to a geriatric care manager. So she's overseeing his care. And I am so grateful that I can, because this would have been a disaster without that. She has someone coming in to manage his meds, they fill his medication box, a problem he was having, he's so obsessed with his meds, when he's feeling good, he gets like, I don't need these meds and he throws them out. So, they were setting the box up, and then he would get a hold of it and dump it. So now they had to take it a step further, someone actually comes in gives him his meds, the meds are totally out of his reach and out of sight. And the care manager said to me, You know, I think when he sees the meds, he might hear like a voice in his head coming from that medication box. You know, she said to me, I don't know exactly how his brain works. Of course, we don't know that. But she gets that feeling from things he said to her...

Dr. Regina Koepp 36:21
Oh, interesting. Yeah, well, it can be so helpful, especially for families where you know, like an instance of your mom and your dad, if your dad was a bodybuilder and he's manic or rapid cycling, how you were describing, he was rapid cycling. And one moment he would be agitated and aggressive, not posturing to harm her, but blocking and which is a little bit threatening. And then the next minute depressed or lethargic or withdrawn, or I don't know what his symptoms were. So this rapid cycling is so unpredictable and scary, and then it can be hard for the person in your mom's shoes to be the one to say, "Well, no, you have to take your medicine," and then your dad posturing and saying, "no, I'm not going to take my medicine." And or if your mom's even questioning, I could imagine if your dad is in this agitated state, that he wouldn't be able to hear her. Right. And what's so helpful, then about having a third party also help to manage the medications is that it takes that responsibility away from the family. And so the family can focus on other things like their relationship and not the clinical pieces, like managing mental health, a serious mental health condition, with medications, right, then there's a nurse to help with that. And, and so then it kind of removes that stress and stressors from the family system, which is so helpful, because I could imagine this tug of war between your parents if that kept up if there wasn't somebody else, or I see the tug of war with other families, not just about mental health meds really, but a lot of times about diabetes and diabetes management and you know, you can't eat that food because your blood sugar is gonna spike and did you prick your finger today? You know, all of that. And so it just kind of removes that level of struggle when there's already a lot of other stuff going on. So it can be so helpful to have somebody assisting with medication.

Candy Cohn 38:19
Right. It really is important.

Barriers for folks with mental health concerns moving into assisted living communities

Dr. Regina Koepp 38:21
Now, have you seen any barriers for folks with mental health concerns moving into assisted living communities or personal care homes board, room and board? Is it room and board?

Candy Cohn 38:33
There are different names for them, we sometimes just call them a six bed because they usually have six beds. But I call it a residential care home assisted living. If there's a really active behavior issue, the residential care homes are not the best place. There's only six people living there. And if someone gets out of control, it's really not good. So I don't usually refer to those places if it's an act of behavior condition. And also if they are a low elopement risk that wants to sneak out, their homes aren't the best place. So, but the bigger places? Yes, there are barriers. You know, I try to get my clients to tell me everything. And that doesn't always happen. Sometimes. It's like the last five minutes of a meeting. Oh, did I mentioned my mom was baker acted a few times like Oh, no.

Dr. Regina Koepp 39:25
And just tell us what Baker Act is. So our listeners know.

Candy Cohn 39:28
...Florida, I guess, term and it's called something different in every other state where they are... I don't want to say forcefully, but I guess it is that you have to make, it's not a voluntary admission, to a site. They have to be... you are making them go to a cycle.

Dr. Regina Koepp 39:44
That's right. It's an involuntary hold for a psychiatric reason or the person could be gravely disabled in terms of not being able to care for themselves or potential for neglect and harm and or having thoughts of harming yourself or others. Other sorts of things, but the right... so, it's an involuntary hold in a psychiatric unit, typically.

Candy Cohn 40:06
Okay, thank you for wording that so well. But yeah, I had this client and she didn't tell me till like the last five minutes like did, I tell you that I'm like no, you didn't tell me though. So I have to tell the communities all of this and then I say do you think you can handle this so their nurse does an assessment before someone moves into assisted living, they have to have a form filled out in Florida, it's called the 1823 form, their doctor fills that out with all their medical, not their whole medical history, but their current conditions and you know, especially their mental state of mind, and can they take care of their own meds or do suggest that we manage them all of that kind of thing. So they get the 1823 form from the doctor. And then the nurse does an assessment from the assisted living community. So during COVID, that's been a real challenge. This client I was just talking about, his assessment was done virtually because they wouldn't let anyone come in to the skilled nursing facility to do the assessment or the hospital, it was actually mental health hospital where he was. So, but they did it. And they agreed that they could take him and some places won't, you know, so that's the bottom line. So I have another client today that I'm trying, I'm going to be meeting with the wife, his wife, to take her to see places. And I had to reiterate, you know, I sent the client information to three places. And then I did a follow up email. And I said, I just want to make sure you read all my notes, because sometimes they'll just glance, they don't see everything. This guy is refusing to take his meds again, same thing. And it's a different client. And he's been combative, non compliant. And I want to make sure you saw that. And please let me know if you're, if you think your memory care... and he has dementia. Okay, so this is another complication. So I'm looking for memory care for this new client who has bipolar, and also has dementia. And he's non compliant, not taking his meds. And he's gotten a little combative physically. So I had to let you know, I'm asking can... do you think you might be able to take it? So one of them already said no, no way. And the other two said, we will assess him and see if we can. So, that's an issue. That's absolutely an issue.

Dr. Regina Koepp 42:18
Right. Because we know, at least I know the statistics for depression and PTSD, that it increases the risk for dementia disorder. And so my guess is that also bipolar disorder would also increase because there's a depressive component. I don't, I don't know for sure. But I do know for sure, around PTSD, chronic PTSD increases the risk for depression by two times, two fold increased risk. And depression also increases the risk for dementia. And so yeah, it would behoove Senior Living communities with assisted living licenses to figure out how to navigate or even memory care units to figure out how to navigate mental health concerns. And we know even with dementia disorders, even when people don't have a history of bipolar or schizophrenia, or combative behavior, that most people living with an Alzheimer's disease at some point become agitated. That doesn't have to necessarily include physical violence, but it can include like pacing, and restlessness and irritability and all sorts of physical behaviors that are, you know, unusual or atypical? Because the brain is changing and... And so I think it would really behoove Senior Living communities to, to kind of figure out how to navigate that, because it's, it's important.

Candy Cohn 43:44
Right, and some are better at it than others. And they know usually what they can handle. And they'll tell so that the really important thing is that everybody's open and honest, you know, that the family is open with me, and then with the senior living community, and that there's communication going and they figure out if they think they can manage this.

Dr. Regina Koepp 44:05
Yeah, and even the the honesty from the senior living community back to you and the family, because it could also cause a lot of distress to move multiple times. So if the senior living community says, "no, we really, we're not sure if we can handle this internally," they might say that to each other, and then they don't give you that feedback. They say, "Yes, we'll give it a try." And then the family that the older adult's with, maybe a mental health concern or agitation with a dementia, show up and move in and a month later, "no, we can't handle this. You have to go." I've seen that happen. And then, and then they're cycling through Senior Living communities because they're not equipped necessarily all the time. You know, all of them are not equipped, but are maybe not honest about what they can and can't do. And so yeah, honesty from both sides, so.

Stigma Surrounding Mental Health Concerns for Older Adults

Dr. Regina Koepp

So now one of the things for older adults and families that I've worked with that makes it hard to be honest, all the time is stigma. So there's a lot of stigma around living with mental health. And of course, when we start to talk about even, you know, I'm a mental health provider and I have to work through my own stigma and shame, right, with my own mental health history with my family having some like postpartum depression, I felt a lot of shame and stigma around that. And so and I'm in the business, you know, and I'm like an advocate for people and still, I'm afflicted by the stigma and the shame. And so I really have to work hard to, like, create a new narrative for myself that this is human, there's nothing wrong with me, I have a condition or a situation that I need to manage. And, and so I'm wondering if you could speak a little bit to the stigma, and your experience associated with some mental health concerns for folks that you work with or in your life?

Candy Cohn 45:50
Sure, yeah. This is an important issue to me personally. As I mentioned, my dad had severe bipolar depression, I have dealt with depression myself. And I certainly, years ago, had a horrible experience about stigma. I was seeing a psychiatrist at the time. And I was living in a small town in Florida. My husband at the time was a physician. And the psychiatrist went to write my prescription. He said, "I'm going to write this in your maiden name, because this is a small town, you don't want the pharmacists knowing that Dr. so and so's wife was getting psychiatric medicine." And I said, "No, don't you dare to do that." And I was in a depression at the time, and I went to get my meds and they didn't have them. I asked for it in my married name. And then I'm sitting there and I'm feeling, you know, agitated. Like I said, I was in a depression, and I'm going crazy. And then I'm like, I wonder if that guy... that doctor did what he said he was going to do. And I asked for it in my main name, they said, "Oh, yeah, we have it." I was furious. And like, you're my doctor, my psychiatrist, and you're trying to tell me, I should be ashamed that I have a mental health issue. Ugh...

Dr. Regina Koepp 47:09
... And to hide it. And that I need to hide it from a pharmacist who is also bound by HIPAA.

Candy Cohn 47:15
And I just was so beside myself. And I thought, you know, if I ever take up a cause in my life, helping to reduce the stigma for mental health is going to be that cause. Yeah.

Dr. Regina Koepp 47:26
Wow. Thank you for sharing that. I'm sure. There are 1000s of people who could relate to that story, that even a mental health provider is perpetuating the stigma and the shame.

Candy Cohn 47:38
Right. I don't see it was seniors, like, you know, adult children don't seem embarrassed that their parents might have depression. But they might think it's normal. "Oh, well, she's older, of course, she's gonna be depressed." But there's not as much stigma, I don't think, the only stigma might be talking to a therapist, and that stigma comes from the senior themselves, because they're not used to it. You know, like, my generation. there's not as much of a stigma talking to a therapist. Not even about medications anymore. That was like 20 years ago, but a lot of seniors add on to that. "Why do I need to talk to her?"

Dr. Regina Koepp 48:17
"I'm not crazy." Yeah, I definitely would get that my average age patient was 86. For years and years, and I would get that quite often. I don't think I need to see a therapist I'll ask what's going on, and the person is in total despair and despondent and withdrawn and, and need some, some TLC, and therapy and an antidepressant. And, and we work on it. And then at the end of it, they'll say, "Oh, I guess I did need, I guess I did need this." But yeah, there is a lot of misinformation. And then the point that you're making about adult children saying, "well, it's normal, because my loved one is older, and isn't that normal as people get older?" That's, that's such an important myth to bust. Because, of course, depression is not a normal part of aging. And also, when we think that it is and older adults don't get care that they need to alleviate the depression. And so I do wonder, though, if, in your experience, it's not as much around the stigma for the adult child like the baby boomer generation to the greatest generation, like the world war two generation, it's more your experiences, that it's more lack of information about what is typical with aging and mental health. Is that right?

Candy Cohn 49:42
Or that they can't get their parent to go to a therapist or things that might even be more prevalent. I'm thinking about it.

Dr. Regina Koepp 49:50
Yeah. that makes sense.

Candy Cohn 49:52
Where the kids adult children say I would love to get my mother to a therapist, but she won't go

Dr. Regina Koepp 49:57
yes. I hear that regularly. And spouses, so even older spouses I've tried for years and they won't go home. And children as well. And actually my most visited podcast and blog is, "my aging parent refuses to go to the doctor now what?"

Candy Cohn 50:21
Oh, I have to look for that one.

Dr. Regina Koepp 50:23
Yeah. So that's that gets 100 views a day on my website just from Google or something. So yeah, that is a huge issue around, "how do I kind of build a bridge for accessing these services?"

Candy Cohn 50:37
Right. And that's an issue with moving your parents to senior living to that I know, my parents should move, but she they won't do it or she won't do it. That is a huge issue. And when there's a mental health concern as well, or even dementia, sometimes a guardian, you know, sometimes you need to appoint a guardian. That is a huge issue.

Dr. Regina Koepp 50:58
Oh, yeah. And it's so difficult for families. And that is a topic, I think we should do it. I need to do another episode about because guardianship and conservatorship is so complicated. And even if you do have legal authority over your older loved one, it doesn't make things easier. It just gives you authority. But it doesn't mean everything gets fixed. Oh, it's really challenging on families. And so now what recommendations would you give to families who are living with mental health conditions who are looking for senior living community, so one recommendation was total honesty, so that you could really find a good fit.

What recommendations would you give to families who are living with mental health conditions who are looking for senior living community

Candy Cohn 51:38
Right. First, is get the medications under control. And this is like way before you're looking for senior living, if you know that your parent is not taking their meds, I don't care what the meds are for, but especially mental health, you know, make sure you get that under control in whatever way you need to, you might need to hire a professional who comes in and sets up the meds or gives them the meds, that kind of thing. So that would be the first and the second would be to seek professional guidance. See a mental health counselor or psychiatrist, senior placement advisor. Because this is a tricky time to play someone, you don't want to just get out there on your own doing it, you'll spin your wheels, and possibly a care manager. So like with my client that I just placed, having that care manager has been critical, he would not have been successful without the care manager. And then consider inpatient admission into a mental health facility hospital rehab, before moving them to senior living. And an advisor like myself can help you figure all of that out. That's what I've done with clients. Second, you said about being open and honest. Then I would say to get follow up care afterwards, you want to make sure that senior stays in therapy, stays or starts therapy, if they're not in it, and with telehealth, it's so easy now to get that to happen. And then also that a psychiatrist is managing their meds, or at least if it's an internist, someone that knows how to do this. And to just stay on top of it, you know, no matter where, when you move someone to senior living, you have to stay on top of it. No place is perfect. I tell my clients that all the time, the children or loved ones must stay on top of it.

Dr. Regina Koepp 53:26
What does that mean to stay on top of it? Stay on top of the managing the mental healthcare? Stay on top of what exactly?

Candy Cohn 53:33
Keep in touch with the community. There's a director of Nursing at the community, there's residential management people, whoever it is, find out who... that's the first thing find out who it is your... who's your key person point of contact there. And, you know, check in with them maybe a couple times a month, if it's nothing, if things are just good and smooth, but maybe more out, you know, definitely more often, if there's complications, call them whatever, find out the best way, ask "Who do I keep in touch with? How do I keep in touch" and do it?

Dr. Regina Koepp 54:05
Yeah. Okay, so now I'm just thinking of another scenario where families might... one scenario, for example, a few adult children who are helping their older loved one, and maybe they only have one remaining parent living, right. And so maybe one person sort of.... one of the adult children helps and then two or three other adult children are around in different states. And I recommend typically that families kind of assign a point person in the family to do the communicating with medical providers and senior Senior Living communities, and so on because if four family members start calling one doctor or one director of nursing, it becomes overwhelming for the system for that director of nursing or the physician or the mental health provider, you know, to constantly be returning family phone calls for the same person for the same client or resident. And so do you recommend that he's kind of also designated point person in the family to be the one to do the communicating and then share what they learn with other family members.

Candy Cohn 55:07
Yes, that is definitely a good piece of advice. And I often give that to families, a lot of families have that already kind of, I'll hear from someone saying, okay, there's four of us. And you know, I'm the one that does all the legwork and kind of makes most of the decisions my sister does takes care of all the insurance, medical insurance isn't that my brother handles the finances? And then there's that other sister Oh, she doesn't do anything? Yeah, kind of goes. But yeah, if they don't have that in place, either I suggested or the senior living community. I know, for my parents that was suggested to us, I have two brothers, who live up north, and they got tired of hearing, the community got tired of hearing from all of us, and said, Okay, we'll pick one of you on, we're only gonna talk to one employees that were that we're

What recommendations do you have for senior living communities about working with or including folks with mental health concerns?

Dr. Regina Koepp 55:56
now what recommendations do you have for senior living communities about working with or including folks with mental health concerns?

Candy Cohn 56:05
I'd say first and foremost is to recognize if you can handle that type of behavior and condition. And that should be an ongoing kind of conversation you have with your staff and your management. And to treat the person with dignity to keep them safe. while also being adaptable and creative, you often have to get really creative. And then make sure your staff is trained, if you are going to accept people with can with behaviors that make sure your staff is adequately trained and understands various mental health and dementia conditions. And that it needs to be there has to be some regular regularity to it consistency. So the same people are dealing with that resident on a regular basis, you know, you might have two or three different people, because there's different shifts in different days off, I get that, but there has to be some consistency, and that they need to get to know the person. And that the medication management, of course needs to be really well handled, some places are doing it electronically, where you have to enter it into a computer system, everybody that deals with that patient, whether it's for med management or care, they have to log in and say they've done it. And I love that I think that there's no question like the family can say you weren't even in there. And some places have a key fob, that they can actually look up and see who went in there. Because it's identifiable. Mm hmm. And then the ongoing mental health therapy make sure that a client has it. I would I like when communities have a therapist that comes into the community to see a variety of resonance that's always easier and helpful, but with telehealth, it's getting easier to and then communicate communicate with the family. Well, that's a huge complaint. I hear from families with any resident, you know, and during COVID. You know, if there was not really good communication by the families were very, very upset.

Dr. Regina Koepp 58:10
Yeah, I'm sure. Everything is so uncertain. The best is information. The most helpful is information, even if it's the same as yesterday.

Candy Cohn 58:20
Right, right.

Dr. Regina Koepp 58:21
Yeah. Well, Candy, thank you so much for all of this great information, just kind of breaking down what Senior Living looks like, the different types of communities older adults can live in, the different types of communities that can accommodate different conditions like mental health conditions, I will say mental health is as human as physical health. And, and just as our bodies change, and we might become more susceptible to physical illness, our minds and psyches can shift and change, and we can be vulnerable to mental health conditions. And so the more we're paying attention to that, and providing support and resources and help for that, and then you're really serving as a liaison between older adults who are living with conditions and mental health conditions. And then in physical health conditions, for that matter, or no conditions and, and senior living communities. And so I really appreciate that. And it means so much to me that you shared your own personal story about your dad and about yourself. And just this shared mission of destigmatizing mental health for everyone and for this podcast, especially older adults who are often left out of the mental health system. And so I just thank you, thank you for the work that you're doing. And I'm so delighted to have you on the podcast today.

Candy Cohn 59:46
Well, thank you. It's been a pleasure and I love supporting your mission. I have the same mission. Thank you.

Subscribe on your favorite podcast platform and leave a review

Dr. Regina Koepp 59:55
Now, it's your turn. Join the movement to include older adults in conversations, mental health and wellness. It's simple. All you have to do is subscribe, leave a review and share this episode with others so that they can be part of the conversation, too. One last thing, a special thanks to Jhazzmyn Joiner, our psychology of aging podcast intern, for all you do. Lots of love to you and your family. Bye for now.