One of the most difficult decisions individuals and families have to make is where an older member should live. Such decisions are never easy, and can be quite wrenching. Figuring out the optimal “fit” where the individual’s competence and the envi­ronmental press are in the best balance rests on the ability of all concerned to be objective about the indi­vidual’s competence and on the ability of the lived-in environment to provide the level of support neces­sary. It requires a degree of honesty in communica­tion with oneself and one’s family that is sometimes challenging.

There are several key decision points in address­ing the issue of the optimal environment. First, it must be determined whether the individual has significant cognitive or physical impairment requir­ing intervention. If so, then a determination of the severity of the impairment is needed. Next, an assessment of the ability of family members or friends to provide support or care must be made. Once that information is understood, a series of decisions can be made about the best way to provide

159 the necessary environmental supports to create the optimal “fit" Assuming that all information points to the need for some sort of intervention, the next critical decision is deciding whether there is an option for providing that intervention in the cur­rent home situation or whether other options need to be pursued. Later, we will consider several living options for individuals needing support ranging from minor modifications of one’s present home to skilled care nursing homes.

Throughout this process, the individual in ques­tion needs to be an integral part of the decision making to the extent possible. This is especially important when the outcome is likely to be a place­ment that involves moving from the person’s cur­rent residence. The degree to which the person actually understands the options, why the options are being pursued, and the long-term meaning of the decision being considered is an integral part of the person’s right to determine his or her own life outcome (a point considered in more detail later).

Individuals and families facing these decisions should at least consult with the person’s physician after a thorough diagnostic evaluation. Additionally, objective information about available options can be obtained from local senior centers, offices on aging, and other nonprofit service providers.