RED BAY, Ala. 鈥 At 72, her gray hair closely shorn, her days occupied by sewing and television, Wanda Chism seems every bit a typical nursing home patient 鈥 but for her size.
Chism is severely obese, unable to leave her bed without a mechanical lift and a team of nurses. She has not walked in years. Her life is circumscribed by the walls of her room.
Obesity is redrawing the common imagery of old age: The slight nursing home resident is giving way to the obese senior, hampered by diabetes, disability and other weight-related ailments. Facilities that have long cared for older adults are increasingly 鈥 and unprepared 鈥 to care for this new group of morbidly heavy patients.
鈥淭he population is shifting faster than the ability of nursing homes to deal with them,鈥 said Cheryl Phillips, a senior vice president at , an association of nonprofit providers of services for older adults. 鈥淲e don鈥檛 have adequate staff. We don鈥檛 have adequate equipment. We don鈥檛 have adequate knowledge.鈥
The percentage of those entering American nursing homes who are moderate and severely obese 鈥 with a body mass index of 35 or greater 鈥 has risen sharply, to nearly 25 percent in 2010 from 14.7 percent in 2000, and many signs suggest the upward trend is continuing.
But as demand from severely obese patients surges, nursing home administrators say they cannot afford to care for them, because Medicaid, which covers more than 60 percent of all nursing home residents, does not reimburse them for the specialized equipment required: motorized lifts; larger wheelchairs, bedside commodes and shower chairs; and longer intramuscular needles and blood pressure cuffs. The devices are expensive: $10,000 for a mechanical lift, for instance, and $5,000 for an extra-wide bed.
鈥淚t鈥檚 really not a moneymaker,鈥 said Aundrea Fuller, co-owner of Generations of Red Bay, the private, for-profit facility that cares for Chism in a specially outfitted wing that can accommodate 10 obese patients. Fuller鈥檚 decision to open the unit, which frequently has a waiting list, fulfills her personal mission to aid obese people, who are often ostracized and forgotten. But it makes little business sense.
鈥淵ou鈥檝e got to do it because you have a heart for it,鈥 she said.
Wanda Chism, left, talking to Pam Bates, an administrator at Generations of Red Bay. Ms. Chism cannot walk on her own, and patients like her need to be repositioned every few hours to avoid dangerous pressure ulcers. (Photo by Joe Buglewicz for The New York Times)
There is no national census of available beds in American nursing homes for those weighing more than 350 pounds, the maximum weight a standard hospital bed can handle. But industry groups and researchers say facilities rarely accept more than a few markedly obese patients.
Genesis HealthCare, one of the nation鈥檚 largest nursing-home chains, recently closed its . Nursing experts considered it a model for safe handling of obese patients.
鈥淥ne or two places that have tried to do it recognize the economics just don鈥檛 work,鈥 said Dr. David Gifford, the senior vice president of quality and regulatory affairs at the , an industry trade group.
As a result, nursing homes across the country are routinely declining referrals from hospitals seeking to transfer obese patients, creating dilemmas for hospital staff members tasked with safely discharging those ready to leave.
The problem is especially acute in the South, where obesity rates first skyrocketed decades ago and extreme obesity 鈥 a 40 B.M.I. and above 鈥 continues to rise.
鈥淭his is definitely not my grandmother鈥檚 elderly population,鈥 said , a medical sociologist at the University of Alabama at Birmingham. 鈥淭his is a totally different cohort that is aging now.鈥
Heather Dooley talking with Ms. Chism. Experts warn that the aging of obese Americans will exacerbate the problem of caring for them. (Photo by Joe Buglewicz for The New York Times)
In neighboring Mississippi, , nursing homes that accept heavy residents are few and far between, said Sandra Terra, an administrator at the in Jackson. Ninety percent of the nursing facilities her hospital routinely discharges patients to 鈥渨on鈥檛 have anything to do with鈥 obese patients, she said.
The delays are exasperating and commonplace. 鈥淚t鈥檚 not uncommon to make 30 or 40 referrals to finally find a placement,鈥 said Barbara Miller, the director of case management at the , an academic health center with a hospital and clinics in Little Rock.
Whether these routine denials violate antidiscrimination laws is unclear, especially since the degree to which obesity is a legally protected disability remains unsettled. Industry specialists argue the law is unambiguous.
鈥淣ursing homes aren鈥檛 required, like emergency rooms, to admit patients, so they have a lot of latitude,鈥 said , a professor of health care policy at Harvard Medical School.
But some experts argue that severely obese patients with significant physical impairments could challenge their denials.
鈥淭hat鈥檚 what the is meant to protect against,鈥 said Eric Carlson, a lawyer for , a legal advocacy group.
Legal experts say the question is far from settled, but in at least one instance, a severely obese patient who was denied admission to a nursing home filed a discrimination complaint through the federal . To resolve the issue, the nursing home, the GlenShire Nursing and Rehabilitation Center in Illinois, admitted the patient and provided an extra-wide dialysis chair.
The reluctance to accept hospital referrals, especially when physical therapy or wound care is needed, comes down to practical matters: How many staff members will it take to turn the patient? Where is the wound? How long will physical therapy take?
鈥淲e ask them, 鈥榃hat is the barrier?,鈥欌 said Akofa Bonsi-Wallace, the former director of discharge planning at the University of Alabama at Birmingham hospital, who often reached out to nursing homes in Georgia, Florida and Tennessee. 鈥淢ost of the time it鈥檚 staffing. We鈥檝e heard, 鈥業 already have a morbidly obese patient, and they are eating away at my staffing hours.鈥欌
But it鈥檚 not only the size of nursing home patients that is changing.
Lee Nalls talking with Kathy McCurry, a nurse. Medicaid does not reimburse nursing homes for the specialized equipment needed to care for severely obese patients. (Photo by Joe Buglewicz for The New York Times)
Nursing home administrators say some of their extremely obese residents are young adults or middle-aged men and women stricken by congestive heart failure, stroke or facing complications from surgery or an accident. They can鈥檛 return home or to an assisted living facility because the requirements to safely care for them are too great.
Lee Nalls, 28, awoke during the night at his mother鈥檚 house in North Port, Alabama and noticed his face felt weak. As he made his way to the bathroom, he fell and remembers hearing his mother call the paramedics. A diabetic and severely obese since childhood, Nalls had suffered a stroke that left his right side paralyzed.
鈥淚 can barely move,鈥 he said, his speech slurred and his eyes listless.
With a lunch tray of beef enchiladas and salsa salad in front of him, Nalls slouched in a wheelchair in his room at Generations of Red Bay in Alabama. Like his fellow residents in the special unit for obese residents, Nalls opts to eat alone instead of the cafeteria.
鈥淚鈥檓 not really comfortable around other people,鈥 Nalls said, his Southern politesse unhardened by the gravity of his situation. His classmates in grade school ridiculed him about his weight: 鈥淜ids would stick notes on my back pack as I walked past, and it made me feel sad,鈥 he recalled. Coming under the gaze of other residents is 鈥渏ust something I don鈥檛 want to deal with.鈥
After lunch, a nurse rolls a mechanical lift into Nalls鈥 room. Four aides gently slide a sling underneath him and lift him into bed in a well-rehearsed routine.
Physical ailments are often compounded by obesity鈥檚 emotional toll. 鈥淪tigma, self-image and isolation,鈥 said Dr. Michael Yao, chief medical officer at Golden Living, a national nursing home chain. Residents who are withdrawn or feel shunned need to be reassured, Yao said so they 鈥渄on鈥檛 feel like they鈥檙e alone.鈥
At the Generations of Red Bay facility, nurses reposition obese residents like Nalls, who are unable to move on their own, every few hours to avoid dangerous pressure ulcers. Daily personal needs require monumental coordination. One nurse can help a resident of normal weight dress and sit in a chair within 15 minutes, said Kathy McCurry, head treatment nurse. 鈥淲ith a bariatric patient, that takes an hour with two certified nursing assistants.鈥
There are other reasons nursing homes are wary, including the inability to transport such patients to the emergency room, the possibility of staff injuries and higher workers鈥 compensation costs, and the infeasibility of remodeling older buildings with wider door frames and special plumbing to accommodate sturdier toilets.
The paucity of available beds has meant heavy patients can languish in hospitals, at great expense to Medicare, private insurance companies and the hospitals.
鈥淲e鈥檝e had patients in the hospital for several months,鈥 said Dr. Lynn Crawford, the medical director of the University of Alabama at Birmingham Hospital-Highlands geriatrics unit 鈥 an observation echoed by other hospitals and national industry groups.
Martin Bayne, 65, who has Parkinson鈥檚 disease and weighs 370 pounds, found himself stuck in a hospital in Pennsylvania after episodes of congestive heart failure and the flu. 鈥淚t was hell for me,鈥 he said, lamenting the helplessness and humiliation he felt awaiting placement in a skilled nursing facility.
鈥淭here鈥檚 a terrible feeling that goes along with knowing that you鈥檙e not wanted,鈥 said Bayne, an advocate and blogger on issues of aging. He now lives in a personal care home in Center Valley, Pa.
Patients can end up in nursing homes hours away, and across state lines, from their families, compounding a difficult period of their lives. 鈥淭hey are already ill and feeling compromised,鈥 Terra said. 鈥淏ut at some point, we have to say, 鈥業t has to do with your weight. I can鈥檛 find a place for you to go.鈥欌
, twice as many as in 2000. Adult obesity has continued to increase 鈥 38 percent of Americans 60 and older are obese 鈥 and .
As tens of millions of these obese Americans age, Crawford said, 鈥渋t鈥檚 going to be exponentially worse.鈥
Hospitals have become increasingly inventive, with some offering donations of specialized beds, mattresses and lifts to nursing homes considering admission of an obese patient. 鈥淲e step in to try to help with that transition,鈥 Bonsi-Wallace said.
The prospect of losing weight is neither realistic nor advisable for these patients, doctors say.
鈥淭he expectation has been that we鈥檙e going to get them back up on their feet and get them home again,鈥 said Phillips of LeadingAge. 鈥淏ut there is a group of them that is not going to happen. And losing weight at this point in their life is not a viable option.鈥
Indeed, weight loss can be dangerous for obese patients who, despite their size, lose muscle mass and can become frail, placing them at risk for fractures.
For Wanda Chism, her golden years have played out far differently than she imagined. 鈥淚 always pictured my retirement: I wanted a tricycle and be on my way.鈥
Instead, she seems resigned that she will be in her small room and oversize bed at the obesity wing at Generations of Red Bay until the end.
She surveyed the odds and ends of fabric spilling out of her plastic sewing bins and the call buzzer and TV remote she uses to summon the outside world.
鈥淚t鈥檚 home,鈥 she said, nodding. 鈥淚t鈥檚 home.鈥