By the year 2030,
1 in every 5 Americans will be over 65. We tend to have a pretty dismal image of older age in our society: decline, disability, depression, death. Shakespeare, parading the seven ages of humans across the world's stage, declares the "Last scene of all,/That ends this strange eventful history,/Is second childishness and mere oblivion;/Sans teeth, sans eyes, sans taste, sans everything."
Not an especially enticing picture, is it?
The myth of aging is everywhere. We're all affected by it, even if at one level we understand that it's simply a story we've created and may not necessarily correspond to the reality we experience. The myth of aging is a powerful, destructive one that profoundly affects the community we create and the extent to which we involve the old in it. Since (if we're lucky enough) we'll be old someday, it's in our own best interest to address this myth so that we can remain an active and valued part of community as we age.
You can find many media items about the assistance – the "help," well-intentioned but often patronizing – the young give older adults. But there's far less attention paid to what people of all ages receive from the old. It's the experience of life in a complex, interdependent, multigenerational society that, more than anything else, teaches us how to be human.
Boomers Can Prompt Change
The fact is that older adults today, the Boomers, are better educated, healthier, and more financially secure than any other previous generation. They're also more engaged in learning and interested in contributing to their communities. Keeping older people involved in their community can substantially reduce the anticipated drain on financial, health care, and housing resources associated with an aging population.
A key issue in aging is social integration, the extent to which a person is actively connected and engaged with their family and community. Cross-cultural evidence shows that older adults are able to maintain a fairly high level of physical and emotional well-being when they have something considered valuable by others in their society, whether it be customs, skills, knowledge, or economic resources.
Today's older adults want more than to simply "keep busy." They want meaning. Meaning has to do with feeling that your life still matters (to yourself, at the very least) and that what you do makes sense. It has to do with the conviction that your life is about something more than simply surviving.
Volunteer activities, for example, have been found to bring new meaning to the lives of men and women at midlife and beyond by allowing them not only to perform useful services but also to function as mentors for those who are younger. Older adults can also participate by helping to care for the young, like their grandchildren, and continuing to be involved in paid labor.
But what about older adults with serious health problems, frail older adults, and the oldest old? The life issues faced by older adults who are well include living with loss, a need for meaningful activities, and the desire to be useful members of society and not be isolated. Frail and functionally limited older adults have the same needs, but require some special consideration for losses of physical strength and perhaps cognitive ability.
In recent years, researchers have divided older adulthood into three general groups: "young old" (65-74), "old old" (75-84), and the "oldest old" (85+). The oldest old are largely widowed (70%) and mostly women (70%). This age group is growing faster than any other segment of the population. The oldest old have the highest potential for functional disabilities. Over 70% of the oldest old have some limitations in one or more activities of daily living. Yet, nearly 45% still have relatively good health and need little assistance in preparing meals, shopping, managing money, or doing light housework. 25% do need some help with certain activities of daily living, while 30% need substantial help.
Aging in Place
Research tells us the vast majority of older adults want to "age in place," remaining in their own home – even if that home is no longer a comfortable place to live. As many as 8 out of 10 Boomers want to stay in their home for as long as possible.
We humans develop "place attachment," a socioculturally mediated emotional connection to a particular physical location. In the face of instability and physical changes, illness, and other losses, we engage in an ongoing effort to create and preserve meaning through place-centered activity. We give meaning to places like our home, and our home in turn shapes the meaning available to us as we age.
Don't underestimate the power of where and how you live to sustain you, especially in the face of increasing physical and emotional losses that come as we get into our 70s, 80s, 90s. Environments not only place demands on individuals, but they also provide opportunities for growth and adaptation. For example, being in a multigenerational environment with family or friends can foster better functioning, whereas helplessness-inducing contexts like a nursing home have the opposite effect.
What makes a good place to grow old? A community that promotes the physical and psychological well-being of community members throughout the life course.
Answering Psychosocial Needs
Major systems, such as housing and transportation, should be responsive to the changing needs and capabilities of residents as they get older. The community should also provide opportunities for fulfillment with regard to five major psychosocial developmental tasks of later life, as identified by researcher Andrew Scharlach (Generations, journal of the American Society on Aging, Summer, 2009):
Continuity – individuals are able to maintain lifelong relationships, activities, and interests even as they get older and may experience more limitations.
Compensation – services and products exist to ensure that basic health and social needs of individuals with increasing limitations are met.
Connection – relationships become more important as we age. Individuals who have more actual and potential sources of social support have better physical and psychological well-being, and greater resilience in response to illness and other life stressors.
Contribution – opportunities to develop and contribute life wisdom. We need to feel as though our life still has value, that we can add something to the world around us – if only a smile or hug.
Challenge – the need for stimulation and growth remains important through the life course.
As people search for a "good" place to grow old, they are imagining more varied options. For example, transgenerational design is getting more attention. Aging in place is difficult when that "place" hasn't been properly designed. Many homes need to be retrofitted to accommodate functional limitations. New homes should be designed for the entire life course, not just for the young.
Aging in Community
"Aging in community" has become a broader vision of aging in place. More and more of us live alone, without close family members living nearby. The need and the desire to come together with others who are approaching older adulthood is growing. People are making plans to buy a house and live together to take care of each other – intentional communal living. Variations include senior cohousing, shared households, and cooperative urban villages.
The village concept has older adults in a community banding together and paying a monthly fee to obtain services that allow them to remain in their existing home.
Remaining in their life-long home preserves neighborhood-based social relationships. It allows older people to stay connected with their community. Yet, to remain connected to their community, they need the support of their community. They need adequate healthcare. For many people growing old is defined by, and is a process of adapting to, declines in physical health. They don't feel old unless they are physically ill or depressed. Once their health is adversely affected and a person is unable to receive adequate care, a rapid decline often follows. After healthcare, daily living supports are important. Even the oldest old can function to their maximum capabilities when the environment provides the context and supports consistent with their abilities. This includes help with items like transportation, home repairs, housework, meals, and personal care activities like bathing. Finding the needed services and paying for them are critical issues for most of the oldest old. When spouses or children are unable or unwilling to provide support, the oldest old look to neighbors and friends. In one study, 30% identified a friend and 13% identified a neighbor as being able to provide the most assistance. The village concept formalizes the definition of a "neighbor" so that residents can call a single number to tap into the resources in the community and get whatever help they need.
When it is possible to live with family, multigenerational living often answers needs for all generations. A century ago, children, parents, and grandparents commonly shared homes out of economic necessity. As Western society became more affluent and our cultural values shifted toward independence over connection, multigenerational habitation became less common. We lost something. We lost children learning from their elders, parents getting the physical and emotional support of their parents, and elders feeling useful and connected to their families. We also lost the opportunity to use the family as a testing-ground for one of the biggest human challenges we face: how to get along with other people. Multigenerational living can also address the economic realities facing many families today; living together is cheaper than living apart.
Many of the negatives associated with multigenerational co-habitation, like a loss of privacy and independence, are often the fault of poor design. Good multigenerational design supports the positives of living together and minimizes the negatives.
Aging in Intergenerational Community
Even though options like retirement communities offer community living with some supports, they are age-segregated.
San Francisco resident Anne Leitch shared this viewpoint in Generations, the American Society on Aging journal (Summer, 2009):
I live in a gated seniors community with all the amenities one could dream of – workshops, handicrafts, exercise. You name it, we have it. And yet I am longing, longing to walk to the corner coffee shop, to hear the sound of children playing, dogs barking.
I want to see young people in love, watch mothers with their children in the park, young families, teens in the latest wild outfits. Yes, I'm lucky to have what I do, and I never forget that. But I am excluded from the mainstream of life. I am not elderly and never will be; my mother never was and she died at 92. Many of us don't want to be maintained and monitored. We want to belong, not only to each other, with whom we may have only one common denominator, age, but to society in general. We want to be 'just like everyone else.' Think up something daring, something challenging, something creative. Segregation by race has come to an end. Now we can put an end to segregation by age. We need each other at every age.
So many parents and grandparents just want to be with their children and grandchildren, to be a daily part of their lives. A morning hello, snippets of conversation and banter throughout the day, a hug before you head off to sleep, those are the things that make a day rich and comforting, especially as you face your own physical and emotional losses. The little things keep you connected to the spirit of life. Don't underestimate the power of where and how you live to sustain you.
We need homes and communities that are multigenerational. They cannot be fragmented, with youths, adults, and elders going their separate ways. Rather, they should be age-inclusive, with different generations recognizing – and acting upon – their mutual interests in building family and community. They should also be intergenerational, with intentional opportunities for meaningful interaction between generations.
New Nursing Home Models
Older adults living alone in their own home can
become isolated when functional limitations make leaving the house and/or seeking assistance from others difficult. Sometimes help is available, but older adults are hesitant to accept it. In What's Worth Knowing by Wendy Lustbader, 86-year-old Dorothy Bobrow comments on accepting help:
My mother was pushing ninety, but she still wouldn't let us give her a hand with anything. "I'm fine." That's all she'd say, but we knew she wasn't. She had heart problems, breathing problems, you name it, just like I do now. And look at me! I've been pushing everyone away, just like she did. It's my pride. I don't want to have to depend on anyone. I want to stand on my own two feet. But it's hard for me to carry my laundry basket and use my cane at the same time. The other day, I let my granddaughter do a wash for me. You should have seen her face, so proud to be helping her grandma. I know this is the way it should be.
For many of the oldest old, there may come a point where no amount of help allows them to remain in their own home. An assisted living facility or nursing home has traditionally been the next step.
There are real questions about the long-term viability of traditional assisted living and nursing homes. Many of these facilities are old and in need of major renovations. More importantly, they are not providing the type of sanctuary that frail elders need in the last months or years of their lives.
We approach nursing homes much the same way we approach schools: segregation and isolation. Nursing home residents, like children, are often isolated from their communities because of age and capabilities. Like the grade system in schools that favors administration over education, nursing home administrators sort and group residents with similar problems. Whether we're talking about schools or nursing homes, lives are determined by institutional needs – and we fail in the essential community goals of educating the young and caring for the old. But, as with schools, nursing homes can become models of the larger sense of community we need in our neighborhoods, cities, and nations.
The place we live at the end of a long, full life should be a reward, not a punishment. We can start by putting the "home" back into nursing home. What does "home" mean to you? Comfort? Acceptance? Safety? Personal control? Many of these elements are missing from traditional nursing homes. No matter how old, infirm, or cognitively debilitated a person is, they share the same basic emotional needs as their healthier counterparts. There also remains some part of that person which is still healthy and capable of growth. Some physical decline accompanies aging in even the healthiest of adults. Sensory losses, decreased muscle strength and reflex time, and diminished energy levels are all normal parts of aging. When these declines are coupled with a disease like Alzheimer's, for example, a person becomes even less able to handle the tasks of daily living. But by creatively addressing the physical and social environment, nursing homes can help maximize the strengths, self-respect, and dignity of all older adults, regardless of their capabilities.
Creating community within a nursing home is related to how individuals interact with each other, staff members, their family, and how they contribute to the facility. In traditional nursing homes, people often lose the roles, relationships, and social support that have sustained them over a lifetime. They are disconnected from their own past. The environment is ideal for feelings of isolation and neglect. For many residents, life in a nursing home consists of a repeated daily cycle of predictable activities occasionally punctuated by a specially scheduled social event, a visit from the "outside," or the stress of a health crisis. Over weeks, months, and sometimes years, the repetitive rhythm and routine of each day provides a sense of familiarity and regularity, but also a sense of lifelessness.
Choice can bring back life, and with it meaning. Even functionally limited older adults should be allowed to make decisions, even small ones. Research has shown that involvement or lack of involvement in everyday decisions such as the placement of room furniture, choice of clothing, timing of meals, choice of seating in the dining room, and routine health care greatly affects residents' well-being. Listening to residents, above everyone else, is vital to determining who should make what decisions and why. Different people may have different views of an individual resident's capabilities and needs. A daughter may only come to visit for an hour or so. The nurse only has a shift at a certain time. The social worker only looks at one aspect of care. Everyone has a different perspective. Are decisions reflective of institutional, professional, and personal norms and expectations or of a fully informed understanding of a person's wishes and abilities? Institutionalization can take on a momentum of its own. Even though respect for autonomy is realized and widely acknowledged, action doesn't always reflect the rhetoric. In many cases, it's simply easier to make the decisions for residents.
The approach in more nursing homes should be person-centered. A shift in orientation to a person-centered philosophy allows the experiences and preferences of residents with regard to decisions affecting their lives to be more widely and routinely acknowledged and integrated into the daily life in the nursing home. Even if residents are compromised in some aspects of their self-responsibility and decision-making, they should still have a say about what they wear, where they sit at meals, and how their possessions are arranged in their room. Rather than paternalistic care that reinforces learned dependency, there is a need for a philosophy that focuses on maximizing individual potential. Older adults should also choose how they fill their days. Even in the case of people with significant impairments, choices should be respected as much as possible. For most people, some choices are taken away as they age. You can no longer have children, you are no longer employed, you may have physical limitations. But, the need for autonomy – the right of an individual to govern themselves according to their own reason – remains. Of course, health and safety issues must be considered; but these, sometimes along with ease, are often over-emphasized to the detriment of self-esteem and autonomy. There is a fine line between "careful enough" and "too careful" – but finding that line is important.
It Should Mean Something
The older we get, the less time we have left, making each hour even more precious than the last. Older people need to feel that their time is valuable, and they deserve to fill their days with activities that are enjoyable and fulfilling. A facility for older adults should never resemble a preschool. One of the primary determinants for activities should be meaningfulness. If a person is stringing beads, perhaps it can be as a gift for a grandchild. If they're making a meal, they should know what it's for – lunch, or perhaps to be delivered to a house-bound person. Gardeners can find satisfaction when they see the flowers they helped care for being admired by visitors or decorating meal tables. In many cases, the most successful "activities" are just an extension of everyday life. Allowing people to do what they would do in their own home – make coffee in the morning, sit quietly with the newspaper, chat with friends, work in the garden – is most meaningful and life-giving. The role of staff shifts from telling people what to do to offering a variety of choices and adaptations which allow people to find continued satisfaction in their lives.
In addition to building community within nursing homes, it's also important to connect nursing homes with the surrounding community. One way to do this is through visitors. Never underestimate the power of a visitor. In What's Worth Knowing by Wendy Lustbader, 87-year-old Sue Powers talks about waiting for a knock on the door:
I remember how I thought of old ladies like me years ago – they were cute. In my family, there were lots of great-aunts, shrunken and shriveled ladies living by themselves in tiny apartments, neat as a pin, with pretty teacups. They were so happy to see me when I bothered to drop by on my way somewhere else. That's how it was. I gave them the crumbs of my life, five minutes here and there. It never occurred to me that they were once just like me, that I could pull up a chair and get to know them as people, not just porcelain dolls. Now I'm a shrunken old lady stuck in my apartment, and I know how those aunts of mine waited and hoped for a visitor to brighten their day. My nieces do come over, but it's once in a blue moon. I never know when. A visitor is like gold. It's too bad we can't understand this when we're young and can still do something about it.
There's a misconception that nursing home residents are "abandoned" by relatives. In fact, family members and friends do stay in contact and continue to contribute to the basic care needs of residents. But one recent study showed that contact with family members decreased by approximately half following admission to a nursing home, compared to reported preadmission contact. Many residents do see family members weekly. When family is geographically closer and when a spouse is still living, residents are more likely to get regular visitors. But another study reported that 16% of residents receive no visits by family and 40% receive no visits from friends. Also, those with dementia seem to get fewer visits than those who are simply frail. Loved ones may need more information about dementia in order to increase their comfort level while visiting a cognitively impaired resident.
Visiting programs not only keep older adults connected to their community, but can help young people learn how to build and participate in community. Elementary-aged children, especially those in fourth to seventh grades, are curious and resourceful. They easily and enthusiastically participate in nursing home visitation programs. They are also often eager to help in a nursing home once they become comfortable. They can help by interacting with residents, pushing wheelchairs, operating the elevator, caring for and handling animals and birds. They learn how to interact with people different than themselves and they learn responsibility – because the older people depend on them.
Broader intergenerational connections in nursing homes can also go a long way to creating community and improving the lives of older adults. As we look to the future, we may want to ensure that, for example, every nursing home is a shared site with a daycare. Young and old can then interact every day, forming real relationships.
One study looked at the effects of participation in an intergenerational program on the behavior of nursing home residents with dementia. Analysis showed participation in activities with small children lowered residents' agitation levels. Other studies have shown that residents with dementia appear more alert and active, and smile more when they are around children. They derive benefits from direct interaction, as well as just passively watching children play. As they focus on the children and their needs, older adults tend to forget their own problems and be pulled out of themselves. And children, especially toddlers, enjoy being the center of all the attention.
Even the Oldest Old Have Something to Teach
Even the oldest old in nursing homes can give love. They can also act as mentors. If nothing else, they can teach us how to be old, and how to look past our differences to our commonalities. In Am I Old Yet?, author Leah Komaiko chronicles her relationship with Adele, a 93-year-old living in a nursing home who is in good health but legally blind. Komaiko volunteers to visit with Adele for one hour each week. Why does Komaiko decide to volunteer?
To begin with, I was not aging graciously…
I was forty-four and in the middle and stuck there forever. I didn't know what I was supposed to do with myself… A clear breeze seemed to come through my head and I heard the words, "Volunteer. Go visit someone who really is old and alone. Get over yourself. Be like a Girl Scout. You'll like it." The next day I called a [local] nonprofit organization called the Elder Corps that found companions for the old and lonely.
Komaiko struggles as she gets used to visiting the nursing home:
Twenty years ago I was still young enough to believe those people could never be me. I thought I would never die. Now I knew I was going to die. I just didn't believe it would happen in this lifetime.
The two women get off to a rough start, but a close friendship slowly develops. Toward the end of the book, Adele sums up the relationship:
I was thinking how much I enjoy our visits. I've met a lot of people in my day and after all these years, I've never met a person like you. I hope I never lose you. The tremendous difference in our ages and lives doesn't seem to make any difference at all.
Komaiko replies, "Back at you."
It Comes Back to Community
Beyond making nursing homes real homes, encouraging visitors, and fostering intergenerational and mentoring connections, we should experiment with making nursing homes an actual part of the community. What if we did away with the entire concept of nursing homes, and replaced it instead with places to care for people of all ages? In doing so, we wouldn't marginalize the old in a single cluster of infirmity. We would also connect the old, who are at a stage in life where they experience many losses, with the vitality of the young – connect them with, in the words of one older person, "friends who won't die on you."
Unlike institutions, real communities are collections of people of all ages and stages who cooperate voluntarily in different ways for different reasons. Community is defined by a diverse membership bound together and dedicated to the mutual accomplishment of necessary tasks. Social diversity is as important to the nursing home as it is to a true community. Perhaps nursing homes should become places that also care for and educate children, places where food is consumed, places where we gather and play. Why not have a summer camp for children? What about an after-school program? What about a meeting place for 4-H Clubs, Girl Scouts, Boy Scouts? The possibilities are endless and enticing.
In exploring growing old in community, two other options deserve mention here…
Dr. William Thomas is an out-spoken critic of nursing homes and cofounder in 1991 of the Eden Alternative. It was designed to specifically address the boredom, helplessness, and loneliness experienced by nursing home residents, and allow staff more flexibility in care. The Eden Alternative has trained over 17,000 Eden Associates and now claims over 300 registered homes, in the US, Canada, Europe, and Australia. Now Thomas is developing the Green House concept. Each self-contained house is designed to accommodate 7-12 residents and a core group of staff members responsible for multiple tasks, ranging from cooking to personal care. There can be 5 to 10 of these houses clustered together or in a community where they are part of a hub nursing care center that is home to the administrative, nursing, and rehabilitation services used by the houses. The Green House project has certainly garnered the most recent attention.
In amongst the corporate-built assisted living properties are a large number of quiet, anonymous, small board-and-care homes that offer housing and long-term care services to older adults who require a supportive environment. These small homes care for substantial numbers of moderately to seriously impaired people at relatively low cost in neighborhoods all around the country. They have many names: adult foster care, family care, rest home, domiciliary care home, adult care home. Small homes differ in important ways from the larger, assisted living/nursing home environments. These differences relate to the often quasi-familial, interpersonal bonds that form between caregivers and residents, and the environment of interpersonal connectedness.
There is Inherent Meaning in Being Old
Understanding and connecting with the oldest, frailest old does not take exceptional skill. It does require empathy as well as the will to share part of the common and everyday quality of their lives. Many holy books prescribe how people are to treat each other: with caring. If parents attain old age, they are to be shown no sign of impatience or reproach, but be spoken to with kind words.
When we care for the oldest old, we are being given the opportunity to find the best, most compassionate part of ourselves. We can also show our own children how they are to treat us when we grow old, and allow them to learn more about themselves and aging.
Elders have much to offer all ages as we all share in community.