Living alone puts people with cognitive decline a group whose numbers are predicted to swell as the population ages globally at high risk as they forget appointments, mix up medications and have no one to contact in an emergency, according to new research.

For such patients, living alone is a social determinant of health with an impact as profound as poverty and low education, according to the study published in JAMA Network Open.

An estimated 1 in 4 older people with dementia or mild cognitive impairment lives alone and is at risk of practices like unsafe driving, wandering outside the home, mixing up medications and failing to attend medical appointments.

“These findings are an indictment of our health care system, which fails to provide subsidised home care aides for all but the lowest-income patients,” said Elena Portacolone of the University of California-San Francisco (UCSF) Institute for Health and Aging.

In this study, researchers interviewed 76 healthcare providers, including physicians, nurses, social workers, case workers, home care aides and others.

The providers raised concerns about patients missing medical appointments, failing to respond to follow-up phone calls from the doctor’s office and forgetting why appointments were made, leaving them vulnerable to falling off the radar.

“We don’t necessarily have the staff to really try to reach out to them,” said a physician in one interview. Some patients could not assist their doctor with missing information on their chart, leaving the providers uncertain about the pace of their patient’s decline.

Many had no names listed as emergency contacts, “not a family member, not even a friend to rely on in case of a crisis”, according to a case manager. These patients were at risk for untreated medical conditions, self-neglect, malnutrition and falls, according to the providers.

One consequence of the shaky infrastructure supporting these patients was that they were not identified until they were sent to a hospital following a crisis, like a fall or reaction to medication mismanagement, the study noted.

“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 senior author Kenneth E. Covinsky of the UCSF Division of Geriatrics.