(An Introduction and three chapters are included below for your perusal) T H E W I S D O M OF AG I NG
Asking the Right Questions
by Daniel R. SeagrenPREFACE
Aging as a subject is not only for the elderly. It is a phenomenon affecting every man, woman and child. It used to be said that life begins at forty. Aging begins before then. Actually, humans probably peak physically in the mid-twenties but we may not peak in other ways until later. Or earlier. When a person hits 50, the sobering reality of aging begins to dawn.
This study is designed not only for the aging population. It is proposed for everyone, young and old, healthy or otherwise, rich or poor. We should be asking the big questions. More than that, we need to know what is happening, not only in our country, but around the world. This book reflects the author's experiences and is not intended to provide the final, definitive answer. Do seek expert advice on all matters covered in this study to satisfy your needs and interests more fully.
Aging is a worldwide concern. Not only because of increasing numbers involved but because of changes in society. These changes are both obvious and subtle, general and esoteric, natural and atypical. Years ago, most of the elderly died at home; today, this is not nearly as true. The entire panorama of aging is changing, at home and abroad.
Nations, known for their extended families, are also affected. Many diseases, previously fatal to the elderly, have been conquered, prolonging lives while increasing the chance of chronic disability. Nursing homes will meet the needs of some but may be relegated to roles of caring for only the most needy (those with physical and mental disabilities) and/or the most affluent. Families are becoming more and more involved with boomerang kids also getting caught in the squeeze of the sandwich generation.
Since we can learn from others as well as ourselves, an attempt will be made to glean helpful insights from selected nations which share similar challenges and opportunities.
This study is the result of an increasing concern regarding the future of our intergenerational society. Hopefully it will bring attention to some of the challenges facing both the young and the elderly in providing mutual care and support: emotionally, financially, physically, socially and spiritually. When so many grandparents are caring for their grandchildren, when seasoned adults must provide assistance to their elderly parents (young elderly caring for the older elderly) as well as their boomerang kids, when single-parent families continue to swell the ranks, the challenge of aging, putting it mildly, is awesome.
As we look at these questions together, we probably will agree that there are other questions that could have been asked. These are chosen because they are continually calling attention to themselves. It is hoped that this will be a discussion-starter as well as an eye-opener. Welcome to the intriguing wide world of aging as you establish your own tailor-made strategies for today and tomorrow.
INTRODUCTION
The experience of industrialized nations (e.g. Denmark, Japan, the Netherlands, Norway, Sweden, Switzerland and Canada) seems to show a shift in public policy away from large-scale, stand-alone, institutionalized facilities designed for the elderly. The trend now is to encourage older people to remain in their own homes or apartments or in smaller-scale, community-based residential settings such as congregate housing or assisted-living units.
Research focused in one study revealed that Argentina, Canada, the Netherlands, Norway and Sweden view home-care as a stage in the long-term care continuum that precedes or prevents institutional care. Some countries are experimenting with the integration of long-term care services in an open-care or synergistic model where patients may alternate between their homes and a nursing home according to their need. Countries with comprehensive national health insurance programs tend to offer home care services as a basic entitlement usually free of premiums, deductibles or copayments. The trend, however, seems to be moving toward requiring some participation in covering the cost of services through a flat, nominal fee or a sliding scale, or a prepayment fee.
Industrialized nations share a similar concern in both the need for long-term care as well as an increasing elderly population. Sweden claims that about 18 percent of its population is over 65, Norway reveals about l6.5%, the United States shows 12% and Japan statistics claim 11%. In each case, projected figures show an increasing percentage of elderly which presupposes increasinglylarge numbers of older persons in the future. The older elderly are often the fastest growing segment of the population.
Consequently, it seems imperative that the trend to decentralization and deinstitutionalization is inevitable, even in Japan where more than 60% of its elderly reside with their children or in extended families. Compared to the United States, fewer than 10% live this way. One concern is that Japan's lofty 14% savings rate could plummet as the long-lived may be forced to invade their savings. This also must be seen not only as a long-term effect on Japan's economy but also in light of the savings of the American population which is paltry by comparison.
Speaking of comparisons, this same report revealed that the average length of a hospital stay for a person over 70 years of age in Japan is 95 days compared to 8.5 days in the United States. This suggests that the hospital in Japan fulfills some of the role played by nursing homes in the United States. It also points up the difficulty in making comparisons between nations but does suggest that industrialized nations must face reality in budgeting for the elderly in the next generations.
How nations should cope with their elderly populations in the light of earlier retirement, often reluctantly managed by both employer and employee, continues its nagging process, especially in light of an increasing longevity coupled with failing health among the older elderly. Consideration should be given to keeping the elderly in the work force for a longer period of time. As long ago as 1967, the National Association of Manufacturers (NAM) declared: Employers are urged to observe voluntary hiring practices that give consideration to skill and abilities rather than to any arbitrary age factor.
The NAM submitted reports showing that pension plan costs are not markedly increased when older workers are hired; mature workers generally maintain better attendance records than younger employees and are superior in their attitude toward work; new job opportunities were opening up with the growth of service industries and other developments that reduce the need for physical strength. In 1990, Senator John Heinz, ranking minority member and former chairman of the Senate Special Committee on Aging decried the following misconceptions:
It may be that Japan and the United States lead the way in implementing employment and training policies specifically for older workers. In Japan, legislative actions have already been taken and in the United States, programs such as The Senior Community Service Employment Program and the Job Training Partnership Act have functioned effectively. In Japan, cash awards are given to employers whose work force contains over 6% of older workers (i.e., 50+). Cash subsidies to the employer cover one-fourth to one-third of the wage of older workers hired through a public employment agency who remain on the job for at least a 12-month period. Beyond this, some employers are reimbursed at a higher rate (1/3 to 1/2) than the costs to younger trainees or retrainees.Myth One: Performance Declines With AgeMyth Two: Older Workers Take More Time Off
Myth Three: Older Workers Have More Accidents
Myth Four: Older Workers Will Leave Their Jobs Sooner
Myth Five: Older People Are Less Adaptable
Myth Six: Older Workers Are Just Waiting To Retire
Myth Seven: Older Workers Take Away Jobs From Younger workers
Myth Eight: Older Workers Don't Learn
Among reasons given for this include (1), economic security (2), a widespread belief that working is good for one's health and well-being and (3), the practice of a post-retirement contract under which a new retiree works with the same or a new employer.The International Labour Organization (ILO) commenced a research project on "Training and retraining of older workers and retired individuals in industrialized countries" which produced Training of Older Workers in Industrialized Countries by Peter C. Plett (1990) producing facts on Belgium, Canada, Denmark, France, the Federal Republic of Germany, Japan, the Netherlands, Sweden, Switzerland, the United Kingdom, the United States and the former USSR.
Until recently, it was the over-60 crowd that was faced with layoffs, often not because of aging factors but due to companies streamlining, downsizing, mergers and cost-reduction tactics. Today it is affecting 40 and 50 year-olds and even those 30-40 no longer can count on job security as enjoyed in the past. Coupled with fears of diminishing reserves in Social Security, pension fund fraud, assaults on the balance sheet of Medicare, even those 39 and younger have a right to be concerned. Long-term care (LTC) of the elderly is one of the fastest-growing segments of health care and health-care costs in industrialized societies. Reasons for this are many including a general decline in health among the older elderly, loss of sensory perception, an increase in falls and accidents in the living place, nutritional deficiencies and increased susceptibility to disease.
Now that the industrialized world has tamed many of the adult-killing diseases, the elderly are living longer but face debilitating diseases that longevity begets. Both cardiac and vascular diseases are often forestalled by prompt and efficient medical detection and prevention, and pneumonia is not as fatal as it once was. Even so, the quality of the life of the frail elderly who survive the formerly killing diseases is not always a pleasant anticipation. The specter for many is often a source of terror. It has been said that if we live long enough, we will all be acquainted firsthand with Alzheimer's Disease or other forms of dementia. Coupled with other debilitating diseases, physical and mental, emotional and spiritual, the future will not want for challenge. We may remember when a cry went forth from an independent politician to dismantle Medicare, start all over again, and assign the task, starting from scratch, to technicians under 40. In all likelihood, this is a task that needs to be undertaken not only by the young but by the elderly as well so that enthusiasm and experience can balance each other.
Of the many studies on health problems of the elderly, one which is esoteric to the United States, but undoubtedly reflects the fate of the elderly worldwide, should be noticed. The Second Fifty Years takes its title from the second half of a 100-year human life span. It, according to its panel of experts, pegs 50 as the age when most adults begin to give more attention to aging matters and health concerns. It also stresses the need for medicine to go beyond the traditional goals: curing and preventing disease. It insists that tomorrow's physicians and nurses must preserve and improve the quality of life in the older person. These 13 risks are not necessarily applicable only to the elderly, but these primary risks are also threats for those 39 going on 89.
In concluding this introduction, a brief mention should be made of how the health and life of the elderly will be maintained. As mentioned above, some societies have a cradle-to-the-grave economic system which may or may not be adequate for a burgeoning elderly population. This could be offset by some kind of a co-payment system, a redistribution of tax bases, other sources of additional revenue; by building fewer institutions for the elderly, paying family members to do the work of caregivers, and possibly by increased volunteerism.
The United States on the other hand does have its social security benefits for the elderly with its medicare and medicaid programs which may be supplemented by pensions, earnings, investments and other income. An arresting study suggests that income declines with a median income of nearly $45,000 at age 45 to about $12,000 at age 75. The U.S. Census Bureau charts it this as follows:
MEDIAN HOUSEHOLD INCOME OF THOSE 65 AND OLDER
$100,000 2.1%
80,000 - 100,000 1.7%
60,000 - 80,000 3.3%
40,000 - 60,000 8.4%
20,000 - 40,000 26.9%
10,000 - 20,000 29.6%
Under 10,000 28.0%CHANGES IN SOURCES OF INCOME FOR PERSONS OF 65
1990 1980
37.5 Social Security 42.3%
15.5% Earnings 17.5%
16.9% Pensions 14.7%
24.7% Investments 21.8%
5.1% Other 3.7%Although Social Security was never intended to be the major source of income for the elderly, 13% had no other source of income in 1990. Most if not all industrialized countries, regardless of the type of government, will be facing challenges posed by the elderly who are rapidly increasing in numbers but also face critical health and economic challenges. As we move into these subjects each posed by a leading question, it seems fitting to begin with questions of health. These health risks not only affect those over 50; they also impact the lives of those under 50. Although it may seem too late for those up in years to take heed, it is never too late. On the other hand, it is never too early to think of our health and the opportunities and challenges that lie ahead of us. How unfortunate it would be to enter our golden years unprepared when, had we paid a little more attention and were better informed, we could have improved our situation immeasurably.
Share these ideas with those closest to you. Do not be afraid to question, argue, reconsider and evaluate. Each of us face situations differently. What may be fitting for one may not be as appropriate for another. Welcome to the wonderful, demanding, challenging and exciting world of strategic aging.
(A copy of The Wisdom of Aging is available on disk for $10.00 prepaid from Padre Enterprises)
CHAPTER ONE WHAT ARE THE GREATEST HEALTH RISKS?
This chapter will deal with health risks faced by adults in or nearing the second half of life based on the studies revealed in The Second 50 Years: Promoting Health and Preventing Disability.
Let's face it. Poor health is better than no health but good health, our goal, is so much better than poor health. Although this study is based upon health factors in the United States, the assumption will be made that the findings are generally in keeping with the overall population of the industrialized world. The thirteen risks specifically mentioned in the above volume are not all of the threats facing the elderly. These risks, which could be supplemented by other threats to the elderly such as Alzheimer's Disease and other forms of dementia, arthritic conditions, strokes and heart disorders, are intentionally limited to thirteen. Why?
The limitation is threefold: (1) only those risks/threats that cause or play a major role in the disabling of older personswere included. For instance, high blood pressure (or hypertension) is not only a disease but a significant causative factor for strokes and coronary artery disease which cause impairment.Since high blood pressure is a causal factor of heart disorders and strokes, it is listed as one of the primary risks.
Another criterion is this: (2) the risks had to affect appreciable numbers of adults over 50; (3) interventions to modify these risks or threats had to be available, although not necessarily fully developed. While some of these threats are in early stages of research, establishing standards and procedures, others are more fully developed. Research, particularly among the elderly, needs considerably more attention although much can be inferred from studies of other age groups.
The book, The Second 50 Years stresses the need to get beyond the treating of symptoms by looking for causes. Striving to improve the quality of life among the elderly rather than simply detecting and treating maladies is paramount. While not demeaning prevention, this study strives to go beyond prevention stressing an improved quality of life for the elderly which in effect is preventative -- only more so. Furthermore, some say that much if not most of our current health problem is caused by unwise behavior associated with eating, drinking, driving, sex, alcohol, drugs, violence and smoking rather than epidemics, viruses and the aging process itself. It is estimated that 75% of all hospital patients suffer from illnesses due to negative lifestyles, that over 50% of all deaths are premature and lifestyle related.It is at this point where the spiritual aspects of life enter the picture. If the elderly have little perception of the meaning of life, living could be less important than it might be. If it makes no difference how attitudes and life styles affect others, if one can do as one pleases with little concern for a loftyself-esteem, it is likely there may be a lack of an incentive for the elderly who have maintained a mediocre lifestyle for decades. However, if they believe that improving might decrease the risk of a premature death or lessen a disability, the will to change could be enhanced if there were also a desire to become a better role model. It is not always wise to attempt to improve one's health strictly on physical, emotional or mental disciplines. Self incentive may not be sufficient without a personal concern including a willingness to be a role model.
With this in mind, let us look carefully at the 13 risks confronting all of us in light of their potential to debilitate.If an ounce of prevention is worth a pound of cure, and if a good quality of life (physical, emotional, mental, social and spiritual) will enhance aging, reducing risks should be a high priority. These risks are developed thoroughly in The Second 50 Years.
HIGH BLOOD PRESSURE Blood pressures vary from person to person as well as from day to day. The best way to know one's blood pressure is to take it (or have it taken) regularly and average it over a period of time. Since high blood pressure can trigger many undesired effects such as hypertension, stroke, congestive heart failure and myocardial infarction (heart attack), every effort should be made to treat it. This may be done through diet, weight control, sodium restriction, exercise and relaxation therapy. More severe problems may need a pharmacologic treatment which in turn may create a another risk.
MEDICATION MANAGEMENT Proper medication can be very beneficial; improper medication can be disabling, even deadly. One must ask if the results outweigh the risks. Health professionals (often mature adults will have several physicians) must know what medications, over-the-counter as well as prescriptive, the individual is taking. Medications can be difficult to administer and may create unwanted or unforeseen side-effects. A pill memory bank, which will jog the memory and keep track of medications, can be very useful for many of us.
Some drugs are absorbed more quickly than others and their half-life varies (the length of time a drug remains in the system -- which is usually longer among the elderly). "If one pill is good, then three or four ought to be better" is often erroneous thinking. Some medications are extremely powerful, even more so among the elderly. A frail elderly person may need less than a typical adult dosage.
The cost for some medications is extremely high which often must be borne by the elderly. Again, the question should be asked whether or not the cost and the risk are commensurate to the result. Patients can pay dearly for medications, sometimes to alleviate pain, reduce blood pressure, calm the stomach and help defeat insomnia. It is often easier to depend more on pharmacology and less on diet and exercise. At best, a regular review of all medications taken should be made with one's primary physician lest a needless impairment inhibit the second 50 years. There is probably much truth in the statement that many elderly are over-medicated and that pills are at times an easy way out. Both physicians and caregivers (and the individual) should routinely guard against this.
INFECTIOUS DISEASES Three major types of infectious diseases affect the elderly: (1) Pneumococcal disease. This category includes pneumonia, bronchitis, bacteremia and meningitis accounting for up to 60% of cases among the elderly, more than three times the rate of the younger generation. The costs can be great because the disease often results in hospitalization and can cause complications. The death rate varies from 20-80%, increasing with age and complications. Antibiotics can cause a decline in the use of a vaccine but antibiotics have their limitations. In the 1970s the pneumococcal polysaccharide vaccine was reintroduced with some excellent results at a modest cost.The recommendation that 23-valent vaccine be given to all elderly persons including those over 50 seems to be sound and is cost-efficient. Unfortunately, this vaccine is not too widely used.
The next type of infectious disease is: (2) Influenza. Caused by any of the strains of influenza A and B viruses, it is another of the major risk factors among the elderly. Usually it occurs in the winter and leads all other illness categories in terms of restricted activity and bed days resulting in too high a death rate. Vaccines created especially for the predicted strain of virus are available but must be taken annually (unlike the long-lasting vaccine for pneumonia). Generally they are safe and relatively inexpensive and both influenza and pneumococcal vaccines could be taken simultaneously.
There is one more type of infection to be noted: (3) Nosocomial infections. These are infections of any type that could develop during a hospital stay and constitute a risk for the patient, showing up in urinary tract infections, infected surgical wounds, and nosocomial pneumonia and bacteremia (bacteria appearing in the blood). Rigorous infection control must be made in hospitals and long-term care facilities including isolation practices, infection surveillance, and careful sterilization techniques. Early detection of infectious disease is important to ward offfevers often of unknown origin, diarrhea, endocarditis, meningitis, urosepsis and pressure sores. Other possible infectious incursions such as acquired immune deficiency syndrome (AIDS) also require vigilance as the elderly population and their caregivers will not automatically be immune.
OSTEOPOROSIS Bone loss leads to reduced bone strength which can lead to fractures at various skeletal sites: hip, spine, wrist, arm and leg. Since this disease may progress over decades, often in spite of preventative measures, cures may be unlikely but interventions can reduce some of the adverse consequences. Since many elderly apparently do not receive sufficient calcium, or the body steals calcium intended for the skeletal structure, the process of bones weakening often goes undetected.
Recovery, particularly after a hip fracture, can be traumatic but can be successful allowing eventual independence. Complications can arise (pressure sores, pneumonia, urinary tract infections, arrhythmias, depression) that may involve rather lengthy rehabilitation. Usually there are no symptoms until a break occurs. Even though bone mineral density can be accurately assessed, apparently it is not widely done. There is a relationship between the peak bone mass during youth which helps explain why some are more prone to osteoporosis ("porous bone") later on.
In addition to ascertaining bone density, care can be given to avoiding environmental hazards that could induce a fall (loose carpets, exposed wiring, clutter, poor lighting, etc.). Observing family history, diet (high in calcium and vitamin D), exercise, avoidance of tobacco, estrogen supplements, judicious use of drugs designed to combat bone loss, building up of muscles and increasing activity may all help alleviate osteoporosis-induced difficulties.
SENSORY LOSS Of all the senses: sight, hearing, taste, touch and smell, all affect, in part or collectively, most of the elderly. The two most prevalent among seniors are sight and hearing which are often linked to limitations in physical, emotional and social functioning. As the elderly withdraw, the spectrum of disability increases. The loss of smell could fail to alert an elderly person of a fire nearby and the loss of touch could cause one to get burned (or stumble because a fold in a rug was not felt).
The most common visual impairments include cataracts, glaucoma, macular degeneration, and diabetic retinopathy. Hearing loss among the elderly is caused primarily by presbycusis (an increased threshold for high-frequency sounds). When it becomes more and more difficult to hear and clarify sounds, the result is a reduction of speech comprehension, particularly with complex, rapid patterns of speech resulting in "please talk lower and slower, not necessarily louder."Screening for hearing and vision loss on a regular basis is highly recommended. In some cases, restoration is possible at least to a degree (e.g. hearing aids and eye glasses). Sometimes there will be diminishing but not total loss. For the rest, little or no hope may be inevitable. However, compensatory mechanisms can do wonders and the remaining senses are often heightened. For some, sensory loss is traumatic and leads to a severe disability or handicap, social withdrawal, physical inactivity, depression or loss of self-esteem. Fortunately, there are many kinds of help for those with sensory diminution, even for those with a total loss.
ORAL HEALTH PROBLEMS When oral health is compromised, the overall quality of life may be impaired. The elderly of today have not enjoyed the dental preventative programs the younger generations are experiencing. Fluoridated water systems coupled with enhanced tooth paste has made a difference. Oral hygiene practices among the elderly have improved but there is still room for improvement. The consequential costs and potential social ills facing the over 50s can be momentous.
The health of the oral cavity (teeth, underlying bone, neurosensory apparatus, soft tissues, immune system and glandular mechanisms) are critical to tasting, swallowing, speech, facial esthetics and nutrition. Oral problems can and do lead to social isolation, infection and lower self-esteem. Seniors are at risk for multiple oral problems including dysfunction, periodontal diseases, pain, halitosis, oral cancer as well as the results of falls and accidents. Social and economic factors complicate the equation of good oral health. Unusually expensive procedures late in life may benefit the profession more than the individual.
SCREENING FOR CANCER Age is the most consistent predictor of risk for cancer, so much so that mortality rates increase exponentially with age starting with age 50. Cancer screening is a form of secondary prevention and should be differentiated from primary cancer prevention (e.g., reduction in smoking, chemotherapy, radiation and other treatments). Since cancer is no respecter of persons, it can show up anytime. When it does become detectable, it might be too far advanced for a cure. Consequently, screening, especially after the age of 50 and continually thereafter, is important. Unfortunately, this can be expensive, painful or intolerable (some find it impossible to submit to either a screening test or surgery -- quite related to an earlier reluctance to visit a doctor or dentist). However, the results of early detection are rewarding especially when coupled with risk factors which predispose a person to cancer (e.g., cancer in the family; persistent, nagging discomfort or pain; unaccountable skin blemishes). There are constantly new innovations in both primary and secondary screening of cancer with some important ones relatively painless and cost efficient, especially for those who do not procrastinate.
NUTRITION Good nutrition early in life can be beneficial in later years. This is clearly shown when life expectancy in 1900 was about 47 years compared to a life span of 74+ today. With the advent of an improved food supply, dietary consciousness and safety measures, undernutrition and malnutrition have diminished, even among the elderly who are eating better. At the same time, our diet has changed in the other direction as well including risk factors for chronic degenerative diseases including certain cancers, coronary heart disease, high blood pressure and stroke. These now cause @ 75% of all deaths and half of all bed-confinement days among the elderly. Attention to nutrition can significantly increase the quality of life. In 1985, more than 5 million people over 65 needed special care to remain independent and the oldest old, those over 85, will likely need even more help in planning diets, purchasing and preparing food, and eating. Many in differing eating situations may face a lack of variety, unattractively displayed or a poor quality of food which may be rather unappetizing. Others may have excellent meals but lack the energy, skill or desire to participate. Consequently, nutritional concerns for the elderly will probably increase rather than decrease as years go by.
Ways and means to maintain independent functioning are imperative, not only for the enrichment of the elderly, but because of the benefits derived from good nutrition in fighting debilitating diseases such as atherosclerosis, high blood pressure, diabetes and osteoporosis. In some instances, the will to live can be enhanced by participation in nutritional projects (limited baking and cooking experiences) and congregate dining.
CIGARETTE SMOKING It has been said that smoking is the perfect vice because it never leaves one satisfied. Although the volume, The Second 50 Years, titles its chapter as above, it might be made broader to include all forms of tobacco and substance abuse. What is said about cigarette smoking could have relevance to many forms of substance abuse (i.e., a reduction or elimination of use has beneficial health factors whereas the use and/or abuse has negative consequences).
In 1985, about 30% of adults were smokers but the rate dropped significantly among the seniors slipping to only 8.5% of those over 75 years old. Reasons for this include a later age for beginning smoking (among today's elderly, regrettably, smoking seems to be beginning at an earlier age today), fewer women who smoked earlier, deliberate cessation, plus an increased survivorship of nonsmokers (smokers die earlier). Current estimates reveal that much of coronary heart disease, chronic obstructive lung disease, and cancer are linked to smoking.
The good news is that cessation of smoking brings about some dramatic improvement in some areas (risk of heart disease) and lesser improvement in other situations (cancer). Studies are now revealing concerns from passive smoking (e.g. non-smoking wives of smoking husbands). With any addiction, quitting is not always easy; although smokers may claim some benefits, the liabilities are sobering. With incessant cigarette advertising (in spite of warnings on labeling), smoking remains a risk for seniors who should be encouraged to quit. Years, even decades of smoking, can be nullified, at least in part and sometimes in whole.
DEPRESSION Depression is seriously under-diagnosed and often missed. The relationship between health problems and depression is significant. Among the elderly, there is a decrease of major depression but an increase in depression-like symptoms. Therefore, care must be given to ascertain whether a person is depressed or exhibiting depression-like symptoms (e.g., mood change, fatigue, social isolation, illness, alcoholism, grief, stress, social withdrawal). Many life situations create an upward or downward mood which may not be clinical depression.
Depression, and pseudo-depression, is a specialty health risk but there are numerous ways to deal with it thereby reducing its threat to the elderly. Drug intervention, psychiatric care, electroconvulsive therapy demand skilled execution by trained personnel who must determine if a medical illness and/or a psychiatric disorder is involved. Other means of treating depression include diet, treatment of illness, counseling, and dealing with fear, loss of control, a forced dependency and reduced self-esteem. Some depression is undoubtedly due to spiritual factors caused by inner doubts, guilt, remorse, anger, loneliness, poverty and disillusionment (a grandchild's divorce, an inability to
believe any longer in a Deity, life after death or forgiveness). Depression is a complicated phenomenon and cannot always be alleviated by pharmacology or psychoanalysis, or religion. Often several approaches need to work together.
PHYSICAL ACTIVITY Social isolation, physical weakness/disability, sedentary living and lack of exercise are all precursors of disease and disability. Sedentariness is defined as either little or no physical activity (i.e., fewer than three times per week with fewer than 20 minutes per occasion). One survey indicated that approximately 55% of 25,221 elderly respondents were classified as sedentary. Being sedentary is more common among women, and increases with age. Other studies point out that there has been a decline in sedentariness in later decades.
Spontaneous programs of activity are less likely to be maintained than supervised programs. Simply encouraging a person to exercise is not enough; programs should prompt, reinforce, and remove barriers to maintaining physical activity. There are some excellent results from the promotion of physical activity. Benefits include reduced medical and hospital costs, a zest for life, elevated moods, better attitudes, increased life expectancy, physical fitness, better breathing, less risk of heart disease, weight control, muscle and joint improvement, better circulation and improved elimination.
Walking, swimming, aerobics, and sports are necessary to replace former working roles with special attention given to age, lifestyle, physical limitations, handicaps (e.g., vision, hearing, arthritic and heart conditions), diet (nourishment, weight control), impediments (stairways, smoking) and indolence (apathy, pessimism, lack of incentive).
SOCIAL ISOLATION Closely akin to physical inactivity, the elder- ly here face a risk factor that can result in disability, disease and/or depression. It is a risk that can be overcome but there are obstacles that must be removed. Social isolation may be defined as the absence of social interactions between family and friends, neighbors and "society at large". Social support is the net result of social interaction resulting in emotional, financial, mental, physical, social and spiritual enrichment. Maintaining a social network is important. Social isolation can result in various forms of dysfunction.
Social needs vary from cultural to individual. Some sense a greater need for social interactions than others, and for many elderly, socialization can be severely limited or difficult: health factors in existence; living quarters that are inaccessible, remote, uninviting, dangerous; lack of mobility (of self or peers, family, friends); cognitive factors (an inability to recognize social needs or respond to suggestions or directions).
Caregivers and providers, conservators and family members often are unaware of the need for the elderly to socialize. They can be short circuited by the elderly themselves: "I have all I need; besides, I don't want to be a bother." Deep down, it seems that the elderly know that a social support network is important but often must be gently nudged (or pushed) into social interaction, continually informed, and programmed. Identifying those who are at high risk because of social isolation and/or physical inactivity is important for family members, caregivers and providers. If a new TV set is in order, an exercise bicycle perhaps ought to go with it.
FALLS IN OLDER PERSONS Falls diminish function by causing injury, fear (of falling), activity limitations or curtailment, reduction of mobility resulting in a wide array of disabilities ranging from emotional/psychological to physical. Falls should be considered as unintentional events resulting in fractures (hip, forearm, pelvis, humerus), lacerations and trauma. Falls are sometimes caused by carelessness, muscle and/or bone weakness, unstable joints, physical activity (walking, playing, reaching), failure of balance system, poor coordination, sensory losses, loss of consciousness, an overwhelming external force (such as a moving vehicle), an obstacle or a slick surface.
In 1986, there were 8,313 recorded deaths from falls reported in the United States for persons 65 and over. Falls gained the dubious distinction of being the major cause of death from injury. The rate of fall-related deaths rises with age and is more likely to occur among men. However, improved medical attention has increased the survival rate of fracture patients. Each year in the United States there are 220,000 each of hip and wrist fractures (some occur simultaneously) and several times as many other fractures for those over 65.
Other injuries resulting from falls include hematoma, joint dislocation, severe laceration, sprain, and soft tissue injury with women victimized more than men. Even so, most falls do not cause sufficient injury to receive medical attention (fewer than 1% of falls result in hip fractures). Estimates, however, suggest that in 1986 alone, nearly eight million acute injuries of all types occurred resulting in almost 60 million days of restricted activity and 19 million bed days.
Prevention of this risk is difficult as the causes of falling are many. Chronic medical conditions, medications, impaired mobility, behavioral, cognitive and psychological factors, high-risk activities, environmental hazards, haste, demands exceeding ability all tend to make prevention of falls difficult.Focused exercise and strength training regimes, physical therapy, comprehensive medical diagnosis, careful use of drugs, modification of environment, improved vision care, better understanding the risk factors and effects of injury will all aid in the reduction of falls with their subsequent injuries and treatment.
Having said all this, The Second 50 Years asks via Arthur Caplan several questions of significant interest to all concerned with the health and welfare of seniors. Among these questions this one raises an eyebrow: If You Are Not Sick, Are You Healthy? We fight disease and repair injury (If it's broke, fix it).
But is our industrialized democratic society concerned enough about maintaining good health, and if so, can it be afforded, and if so, by whom? If values play a key role in the definitions of both health and disease, which ones are important? Is it more important to preserve (lengthen) life than deal with chronic illness and the quality of life -- if we are forced to choose? Ultimately, caregivers, politicians, economists, clergy, children and the elderly themselves should be concerned not only with disease and accident prevention but with promoting wellness which includes the demoting of health risks.
In all likelihood, "promoting health is a task that will require much broader social commitment and accountability." An extensive social commitment must include a spiritual commitment as well. The promotion of good health among the aging and frail elderly involves ethical matters, value systems, moral dimensions, meanings in life and religious beliefs as well as physical, emotional and economic concerns, at home and abroad.
STRATEGY
1. Lifestyle improvement is possible and recommended.
2. Learn to recognize risks that cause illness and accidents.
3. Treat the cause, not the effect, whenever possible.
4. It may be late but never too late to change.
5. Wellness should precede prevention and medical care.Corollary Although the above is prescribed by the medical profession, and because wellness is such an important and broad topic, it is important to indicate that socalled alternative medicine such as acupuncture, chiropractic, herbal medicine, osteopathy, etc. can also be beneficial in reducing the risks facing the adult population in their later years.
Working together, as individuals and professionals, young and those not so young, public and private endeavors, can be most beneficial to all concerned with health risks at any age.
CHAPTER TWO WHERE WILL THE ELDERLY LIVE?
With the world constantly changing, the demography of the elderly is also in flux. Therefore, it is difficult if not impossible to predict where the elderly will reside either in ten years or a century hence. Since much of the industrialized world has moved from rural to urban within this century, we can expect that this trend will continue although not accelerate appreciably. Many of the elderly will continue to live in big cities and will not join en masse the procession to the suburbs or rural areas.
Worldwide, the trend is away from proliferation of special hous-ing for the elderly while encouraging the elderly to live longer in their own homes. Those over eighty years of age constitute one of the most rapidly increasing age groups, even outdistancing baby boomers and teenagers but living alone poses major problems.
In 1776, a child born in America could expect to live to be 35 years of age. By 1900 the average tenure was about 47 and in 2,000 life expectancy will be roughly 75. Except for declining fertility rates, the numbers would be even higher. Many of the diseases that prematurely took lives have been sharply curtailed resulting in sizeable populations of senior adults, often becoming nations within nations.
The 25 nations with the highest longevity (according to the U.S. Bureau of Census, International Data Base, 1987) are listed as follows:
Percent of Population over 65
As the elderly retire earlier and live longer, the pool enlarges. This places more pressure on the kind of living quarters needed by the elderly which encourages if not demands a more adaptable housing than that which is available for a younger population. In some instances, the frail elderly could live at home indefinitely except for stairways, lack of adequate public transportation, changing neighborhoods and other concerns (noise, pollution, vandalism, yard work, snow shoveling, maintenance).1. Sweden 18 %
2. Norway 16
3. United Kingdom 15
4. Denmark 15
5.West Germany 15
6. Switzerland 15
7. Austria 15
8. Belgium 14
9. Italy 14
10. Greece 14
11. Luxembourg 14
12. France 13
13. East Germany 13
14. Finland 13
15. Hungary 13
16. Netherlands 12
17. Spain 12
18. United States 12
19. Ireland 12
20. Bulgaria 12
21. Portugal 12
22. Faroe Islands 12
23. Uruguay 11
24. Czechoslovakia 11
25. Canada 11Some homes are now being designed for the elderly which are not noticeably different but have built-in features that would serve both the elderly and the handicapped (as well as the handicapped elderly). Door knobs, for instance, would give way to handles, stairs would be non-existent, and there would be no high shelves.
The Gallup Organization polled 1,500 noninstitutionalized people 55 and over regarding areas where they might anticipate help in order to remain self-sufficient and feel comfortable in their homes as they grow older. They identified the following areas of likely concern:
The urge to retire in the proverbial sunbelt (or maintain two residences) still exists but seems to be diminishing in favor of living closer to home in spite of flocks of sunbirds migrating South and West in the winter months. Home, in today's setting, is probably the most recent (or earliest) domicile rather than the proverbial lifelong setting of home, sweet home. Career mobility probably is on the downswing as companies are finding it to be costly and at times counterproductive to relocate its employees. Double-paycheck families are also discovering how difficult relocating is and at times will stay put risking a demotion rather than a disruption.1. Opening medicine packages
2. Reading product labels
3. Reaching high things
4. Fastening buttons, snaps or zippers
5. Vacuuming and dusting
6. Going up and down stairs
7. Cleaning bathtubs and sinks
8. Washing and waxing floors
9. Putting on clothes over one's head
10. Putting on socks (stockings) and shoes
11. Carrying purchases home
12. Using tools
13. Being helpless if something happened at home, since no one would know
14. Using the shower or bathtub
15. Tying shoelaces, bows, and neckties
16. Moving around the house without slipping or fallingParents, willing previously to relocate to be closer to their children are also finding this to be quite impractical. The same is true with children who wish to relocate closer to home. However, an emerging generation of boomerang kids are returning home when a job is lost or a marriage fails, often finding solace and a place to nest. The sandwich generation has also emerged wherein parents are caught between caring for their frail elderly parents and their own boomerang kids. Some households are discovering that they are not large enough (in room and/or spirit) for three or more generations. Moving from a nuclear family to an extended family is not as easy as it sounds.
In spite of this, a matrix family is emerging. In the shift from an agrarian society to an industrial lifestyle, the patriarchal became the nuclear family (parents and children under one roof). Ken Dychtwald in Age Wave explores this concept showing that the cultural center of gravity has shifted with several forces at work. Interpersonal relationships often involving several generations have created a "matrix" (that which gives origin or form to something) family. The sandwich generation and boomerang kids play a vital role in the matrix family.
In 1900 there were 13.6 adults between 18 and 64 for each person over 65. By 1990 the ratio was about 4.8 to 1. Put another way, about 10% of today's senior citizens have children who are also senior citizens. As a result, parents and adult children often become peers and younger children are parented by both parents and grandparents (or only grandparents). One grandmother at 74 was reported to say that she can be a parent to her estranged daughter's four-year old but wonders how she'll manage a teenager when she's 84. The intergenerational family, matrix or extended, may well be part the wave of the future and will greatly affect where people will live as well as how.
With an upsurge of single-parent families coupled with absentee fathers, women are forced to play an increasingly large role in the rearing of children as well as being caregivers for elderly parents and in-laws. It is estimated that up to 90% of adult and child caregivers are women, one-third of whom are over 65. In all likelihood, a woman could spend more time caring for her parents than she did her children.
However, women have moved into the marketplace in droves during the past twenty years moving from 40% to 60% or more of adult women now at work. The two-paycheck family is a reality and probably will continue because of the lucrative lifestyle it begets.
An interesting study was released in 1992 which disclosed that 1.3 million more women owned and ran businesses than shown in the 1987 US Census of Business. It revealed that 5.4 million businesses are owned by women which is 28% of all American firms. These employ some 11,000,000 workers (just shy of the 12,300,000 employed by the Fortune 500 firms). Some 40% of these firms had been in business 12 years or more. Further, it has been said that there is about an equal number of men and women between 40 and 60 years of age in the US work force. If 90% of all caregivers are women, and if caregivers are vital to the care of the elderly, what will be the source of caregivers in the years ahead? Since only about 4-5% of the elderly live in continuing care retirement communities, a large amount of care must be given at home: the domicile of the elderly themselves, the home of a caregiver (often an adult child), or in a matrix or extended family setting. If the working wife and mother along with single women were employed in a relatively non-demanding 8-5 job, some time and energy could be left for caregiving.
But if substantial numbers of women are engaged in entrepreneurial endeavors involving long hours and take-home portfolios, what will happen to the pool of caregivers, paid or volunteer, essential to caring for the frail elderly at home? Both finding, then training and caring for the caregiver, could become critical tasks if the elderly are to be cared for at home.
All of this is antecedent to two primary concerns: where will the frail, elderly live and who will care for them? Since the number of women entering the working place has risen some 50% in the last 20 years, about 60% of adult women of working age now work. A whole new family structure is emerging. The shift from a nuclear child-centered family (parents and children living together) to an adult-centered matrix or extended family spanning three or even more generations is occuring. The single-family including the single-parent model may be giving way by necessity to an extended family type of living.
To many individuals, the matrix and extended family is the same. However, the matrix family is transgenerational and may or not involve relatives. Matrix family members could be bound together by friendship, lifestyle, economic concerns, value systems, ethnic or other common denominators rather than bloodline. The extended family would normally be considered bloodline and could include grandparents and grandchildren, parents and siblings, uncles and aunts, nephews and nieces and cousins living together. Communal living would be similar but held together more by cultural, sociological or religious bonding and may not be intergenerational or involve a common bloodline.
Not only are adult children caring for their aging parents but the young elderly often care for the frail older elderly as well as grandchildren. The role of the grandparent is taking on a multi-faceted dimension as the family is being reinvented.
Although not totally inclusive, the following is a listing of various types of housing options available to the elderly. In all likelihood, innovations, modifications, additions and deletions will soon render any such list partially obsolete. Still, looking at these options helps us see the broader picture and which options may be available when they are needed:
Accessory Apartments (in-law units within family houses)It becomes quite apparent that the habitation of the general population is varied. The same is true of the elderly. Some live on the streets as homeless while others reside in mansions. Many prefer to remain at home as long as possible while others seek the solace of a retirement community. Some elderly move in with relatives and others have relatives move in with them.
Adult Foster Homes Apartment Living (see Condo, Cooperative)
Bed 'n Breakfast (Inns, Country Inns)
Cohousing Cooperative Housing (see Condo, Apartment, Town House)
Communal Living Condominiums (Cooperatives, Town Houses)
Continuing Care Retirement Communities (CCRC)
Convalescent Hospitals (Long Term Care Centers)
Estate (see Mansion, Villa)
Echo Housing (Granny Flats)
Group Homes (see Cohousing, Communal Living)
Half-way Houses Highrise Buildings (Senior Apartments)
Hospice Hotel (Motel, Boatel)
Hut (Hovel, Shed, Shack, Shanty) House (Detached, Row, Bungalow, Cottage)
Inn (see Bed 'n Breakfast) Mansion (see Estate, Villa)
Manufactured Housing (Mobile Home, Motor Home, Trailer)
Motel (see Hotel) Nursing Home (see Convalescent Hospital, CCRC)
Old Folks Home (see Retirement Housing, CCRC)
Poor Farm Prison (Asylum, Jail, Work Farm, Reformatory)
Public House Retirement Housing (see Apartments, Senior Housing)
Rooming House (see Bed 'n Breakfast)
Rural (farm, ranch, village)
Senior Housing (specially designed for the elderly)
Street Living (homeless, mission, skid row, transients)
Suburban Living Town House (see Condominium, Highrise)
Trailer Park (see Manufactured Housing, Mobile Home)
Villas (see Estate, Mansion)Ironically, many of the elderly live in homes that are presently too large for them, cannot maintain them very easily, and sometimes find them unaffordable even though paid for with a sizeable equity. Various forms of equity loans have made it possible for some to linger longer with little or no financial worry when properly executed. Others share their home with compatible others. The whole issue of elderly housing is complex and some of these issues will be addressed later. Meanwhile, let's briefly explore some of the ramifications involved in elderly housing in order to get a bearing on future needs.
APARTMENT LIVING. With the demands of home ownership falling on a landlord, apartment life often is only as good as the landlord. An absentee owner can at times be inconspicuous, inconsiderate, incompetent or incorrigible but some of them are neighborly, negotiable or nonpareil (having no equal). An apartment building can be a stunning highrise or a dingy tenement. It can cost a fortune or constitute a bargain. Often apartment buildings are conveniently located but their convenience can also be detrimental (noise, vandalism, mugging, crowded conditions, lack of open space or a greenbelt). When exercising care, apartment living can be a viable (practical) option for many and could have many more virtues than vices. There are advantages for the elderly, particularly the frail elderly, in not having the pressures of home ownership although giving up a house is not always easy nor pleasant, and in some cases, unlikely.
COHOUSING is an innovative if not contemporary option. It is a form of a cooperative whereby a group of persons band together, buy property and build a cluster of single-family homes around a "common house". This is where they gather for meals, child care and recreation with facilities for laundry and overnight guests. Security and neighborliness is similar to 19th Century Europe and today in places like Denmark, California and New England. (For more information on cohousing look at Cohousing by Charles Durrett, 10-Speed Press, 1989).
Understanding the disadvantages as well as advantages of communal living are important. Communal, cooperative living is not for everyone but for those who find it suitable, it can have many advantages. Day care centers can be arranged for the elderly as well as children. Costs can be kept to a minimum, travel can be reduced considerably and the social benefits can be very satisfying. Even so, care must be given to read the fine print. Association laws can be cumbersome as well as inadequate. Emergencies, distress, incompetency and incorrigibility are facts of life and cooperative paradises can suddenly or gradually fade.
With any cooperative, the time may come when dissatisfaction or disinterest settles in, when rules and regulations are ignored, when the ill or the elderly need more care than the cohousing unit or cooperative can or will give. Eviction can be unpleasant although necessary at times. Even though there are many kinds of communal, cooperative cohousing styles of shared living, they are not for everyone and should be entered advisedly.
Even the matrix or extended family, which has not been a lifetime phenomenon in many industrialized cultures, can be difficult to establish and/or maintain. Families that have grown apart find it awkward to reassemble under one roof. Parents who have enjoyed an empty nest can find it frustrating when the nest fills again. Love, compassion, and caregiving can be longsuffering but are often taxed beyond endurance.
Some societies make it financially worthwhile for adult children to add a room or an apartment for their elderly parents. Granny flats is a novel innovation for elderly housing. Also known as "echo housing," this kind of housing is a one or two person-living unit separate from the main home but sharing the same utilities (see Granny Flats as Housing for the Elderly:
International Perspectives, edited by N. Michael Lazarowich, The Hayworth Press, 1991). This monograph describes granny flats in New Zealand, Canada, Great Britain and the United States. This kind of feature is also a viable option in Scandinavia and other countries where the elderly can live alone but with close proximity to other family members or friends.
Others find it advantageous to move in with elderly parents blessed with a large empty house and provide them with tender loving care (TLC) and meals without wheels. Houses with large equities can also provide resources for the elderly with reverse mortgage and/or equity-sharing possibilities.
CONTINUING CARE RETIREMENT COMMUNITIES (CCRC) vary from exotic, expensive, luxury living to rundown boarding houses. To qualify, a CCRC should live up to its name: a continuing care facility. It provides care from the time a person enters until s/he departs from this world. There could be three or four levels of living, from independent through assisted living (and/or an intermediate level) to skilled nursing. Some include separate quarters for Alzheimer-type elderly which is becoming increasingly important in long-term care consideration. These can be financed on a monthly basis or with an entrance fee plus monthly fees. In the latter, the monthly charge is usually less with a break even point converging somewhere down the road. There are many financial arrangements for CCRC admission meriting intensive study, not only for an entrance fee, monthly costs and amenities but fiscal responsibility as well.
Even though seriously considering a CCRC, some elderly try to remain at home as long as possible. When the time comes to make a move, it could be into a CCRC at the assisted living level or directly into the skilled nursing facility. Some will become ill while living at home, become hospitalized and move into a convalescent or nursing home, within or apart from a CCRC. Even though a small per centage of the elderly will spend a year or more in a nursing home, a larger number of frail elderly will spend their last days, weeks or months in a skilled nursing facility. This parallels the fact that the last year of one's life is the most expensive medically, but not everyone knows when the last fifty-two weeks will occur. Some may be given a terminal target but at best it is often a calculated guess. Many of the elderly are amazed how long they have lived, often outliving a normal life expectancy even by a decade or two.
ECHO HOUSING may also be known as Granny Flats or Elder Cottages, a form of elderly housing which facilitates both community and family-based assistance, popular in Australia, New Zealand, Denmark (Kangaroo Houses) and to a lesser degree, the USA. In time, this kind of housing could become popular if economically sound. At times, the government may subsidize this housing which may be a permanent or temporary solution.
HOME is where you hang your hat and feel free to raid the icebox (even if hats and iceboxes are obsolete). Homes come in all shapes and sizes, and for a large number of the elderly, this is where they want to be as long as possible. In the olden days, home was where the elderly were born and where they lived and died. Living at home has its advantages. Things are familiar, even cozy (though perhaps a bit rundown). Moving is usually rather unpleasant and difficult, physically and emotionally. So, home becomes more and more important whether its a cottage or a mansion, an apartment or a condo.
Some elderly can hardly wait until retirement so they can move on but others, probably a majority, want to stay put. Home, sweet home is sentimental but it is also quite basic. Most industrialized societies are realizing how difficult it is to provide a new home for their elderly, not only economically but in many other ways. As a result, considerable effort is being expended on how to keep the elderly at home as long as possible.
MANUFACTURED HOUSING for the elderly is quite widespread, particularly in the sunbelt. To fail to differentiate between the various kinds of manufactured housing invites misunderstanding. There can be a big difference between a mobile home, a house trailer and a motor home. Some manufactured homes are prefabricated in a factory, installed on a slab or foundation and may be barely discernible from a house built from scratch. Some live in a mobile home, owning or paying rent for the space, and although technically mobile, rarely go anywhere. Others consider this kind of living temporary and are transients (sunbirds) while others take their home with them (and some actually live for years in a trailer or a motor home).
In California and elsewhere, there have been major problems between owners of coaches and the owners of the parks. In some instances, manufactured houses depreciate while the land under them appreciates. Cooperatives may resolve some problems only to create others. This is true with all cooperative housing where associations are necessary, and at times, costly. Even so, manufactured housing, with wheels or without, when well-located, well-built and properly managed, can serve the elderly well and often relatively less expensively.
MOTELS and HOTELS can also meet the needs of the elderly. Daily rates could be prohibitive for long term but weekly, monthly and annual rates can be attractive. The downside is living in one room or a suite even with a kitchenette for any length of time. Hotel or motel-style units have been converted to senior housing with varying degrees of adequacy. How many elderly spend their latter years in some kind of hotel living is difficult to measure. And every major city has its reclusive elderly population living on the streets, in tenements, rescue missions and flop houses where anonymity protects as well as obscures.
OLD FOLKS HOMES or Homes for the Aged and Poor Farms are nomenclatures of the nostalgic past. These facilities still exist with a local flavor, usually operated by a district, county or city, public or private. In some cases (for instance, church-related facilities), district homes have become regional or national with increasing sophistication and expertise. Accompanying this is a change in terminology which is more appealing such as Pleasant Hills, Evergreen Terrace, Glenwood Manor, The Victorian and Homestead Acres with subtitles such as A Home for Retired Teachers, Elegant Living for the Active Senior and Gracious Living for the Retiree.
With an increasing senior population, large corporations are moving into the area of retirement living. Knowledgeable in matters of housing with creative flair, this kind of living could be attractive for many but beyond the means of some.
If it is true that the senior population in the USA currently is enjoying a golden age of retirement, there may some ominous clouds appearing on the horizon. The affluence of today's senior may be relatively short-lived. The dramatic increase of the value of real estate for many approaching retirement or already there may slow to match or even fail to keep up with normal inflation. If this is the case, the future may not be a repeat of the recent past. This rather recent rapid increase of home values, for those living in the right place at the right time, has often provided a tidy nest egg for retirement. The net effect of this might linger awhile as inheritances have also been quite generous in many instances which, if not squandered, could benefit the next generation of retirees.
PUBLIC HOUSING includes community efforts to provide housing for various segments of society including the elderly. These range from the proverbial Poor Farm (when America was much more rural than it is today) to low-cost affordable housing. These are well-intentioned but not always ideally located or managed. The objective is to reduce housing costs for a segment of the elderly population which would benefit them considerably. Rigid requirements are often imposed eliminating a potentially healthy economic mix of residents. On the other hand, a first-time home ownership for non-frail retirees, could greatly increase their sense of well being and higher self-esteem as it helps alleviate a shortage in elderly housing.
Society has an uncanny way of meeting the needs of its people; even preexisting prejudices can be overcome when one considers what the alternative might be. Tender loving care can be found at all levels, from a posh CCRC skilled nursing facility to a nursing home catering to the indigent. And, even though the per centage of elderly living in some kind of penal institution in their elder years may be small, there are those who will be incarcerated until the time of their demise.
Where the retired live and where they will live in the future is a concern. As we have seen, it is not an easy task because of enormous needs and demands, differing value systems and econmic levels, personal preferences and individual proclivities. Knowing how the senior population will cope with an increasingly long retirement tenure will be somewhat dependent upon where they live, how costs will be met, and when caregivers are needed, who will provide the care, and even more, who will actually care?
In short, retired persons will live in small towns and on farms, in the heart of our great cities and out in suburbia. They will live in charity wards on a shoestring and in luxury skilled nursing facilities. They will live in high-rises and in one-story buildings. Some will have money to burn but others will not know how they will pay the next month's rent. They will live within security gates and behind doors that won't keep the snow out. They will cruise from North to South in posh motor homes or flee the wrath of winter in their pop-top tent-trailers. They will share their house with their children and they will move in with their offspring. They will live in granny flats, coops and condos, cohousing and matrix/extended family units. A few will live off nature, some in penal institutions, others in sanitariums and asylums, hospices and hospitals. Some will be stubbornly independent but others will be fiercely dependent. An unbelievable number of them will live alone. When they are gone, some will be sorely missed and long-remembered; others will soon be forgotten. Unfortunately, some will not be missed at all.
More often than we care to admit, we clergy have been summoned by a mortician to officiate at a service attended by only the minister and the mortician and possibly an organist. The fear (and embarrassment) of a closing ceremony unattended is a real fear for some.
The challenge of where the elderly will live and die is more than demographics and economics, politics and semantics. It is also a moral and spiritual concern between all concerned parties, especially family members. When a son or daughter reaches thirty-nine, and mom and dad are healthy, enjoying their retirement, what happens when the younger generation gets laid off at forty and grandmother, in her nineties, can no longer live in her home? Who is responsible? Ideally, the whole family. But if that breaks down, hopefully neighbors, friends and society will kick in.
STRATEGY
1. List possible places to live in retirement.
2. List the pros and cons of the above.
3. Determine both desirability and feasibility.
4. Make your home "elderly proof".
5. Discuss thoroughly with family and friends.
CHAPTER THREE WHO WILL CARE FOR THE ELDERLY?
As we have seen in Chapter Two, the care of the elderly, particularly the frail, handicapped elderly of modest or little means, is intricately related to where they will live. If they live in Continuing Care Retirement Communities (CCRCs) or in nursing homes, their care is much less their concern than that of the providing institution.
However, if the frail elderly live alone at home, caregiving takes on a different dimension. Those who work with the elderly in a CCRC will often attest to the difficulty of caring for those who may be less than cooperative, plagued with memory loss and frustrating limitations. Adult children, pressed into caregiving for their frail elderly folk, are probably at best novices but the job often must be done, with or without finesse.
It might be well to redefine what is meant by elderly since both the young and the not so young will find room for debate. Besides, some cringe at many of the synonyms used to describe those who have been around awhile: old, elderly, seasoned or senior citizen, oldtimer, primetimer . . . but it could be orse. Consider: antique, antiquated, archaic, a has been or primeval. Ah yes, what do we call ourselves? True, some are old in body but young in spirit; others are only old in spirit while others are young in body and mind;others deny their age and some refuse to look at the handwriting on the wall (or the mirror down the hall).
For practical purposes, let's try to categorize the venerable: ELDERLY This could be as young as 50 or as old as 100. Let's simply say 65 and over since oldness varies considerably among this age group.
YOUNG ELDERLY This could be those in good health, physically and mentally, quite able to live alone and care for themselves adequately. Maybe 65-75 or even 80.
MID ELDERLY This might include those who are finding it more and more difficult to do certain things, go places with ease but are not yet feeble or handicapped severely. They can manage alone but will begin to let things slide. These perhaps are 70-85 years old.
OLD ELDERLY Mostly in their 80s and 90s with more and more difficulty managing everyday affairs. Often one spouse is a caregiver for the other until something traumatic happens, physically, economically or mentally.
FRAIL ELDERLY This can happen early in the aging process and could affect a person as early as in their 50s or 60s, even prior to retirement but usually refers to the older persons. There might be excellent mentation but a very weak, fragile body. Or the reverse might be true. Or a combination of both.
INFIRM ELDERLY Again, this is no respecter of age but some where, somehow, the person has become dependent upon others and may be confined to a room, a bed or possibly a wheelchair either at home or in an institution.
Therefore, when we are talking about home, home care, caregivers and homes for the elderly, we need to know more of the nature of the elderly than their chronological age. When this is known, we can then think of caregiving and caregivers, at home or wherever.
Caring for the elderly is anything but easy. Is it the task of the state, of society at-large, or the community in which they reside? Is it the responsibility of the family: the able spouse, adult children, younger brothers and sisters, grandchildren, siblings or others? Should Mom and Dad take care of Aunt Tilly (on Mom's side of the family) and Uncle Frank (on Dad's side) because they are single and alone, frail and poor? Or is this the responsibility of others in the family? If so, whom?
Is it the function of society? Local or national? Is it a combination of these?
Rather than getting involved in an argument of who is or is not responsible, let's look at it from another perspective. What are the alternatives for caring for the needy elderly? In order to do this, we should consider the ideal as well as the second-best, the practical as well as the impractical, the real and the unreal.
THE FIRST ALTERNATIVE is for the elderly to take care of themselves, singly or as a couple, for as long as possible. This is probably what most individuals want and usually everything should be done, generally, to encourage this. This can be accomplished in their own home, in an extended family setting (or matrix or communal living), or in an institution designed for the care of the aging, capable or infirm.
ALTERNATIVE TWO is similar to above except it calls for one of the spouses to become a caregiver for an infirm spouse, or in the case of a single infirm senior adult, a caregiver who moves into the dwelling enabling the person to remain at home. This caregiver could be a family member, a friend or someone appointed or hired. This situation is quite common, and seems to be the preferred way for many if it can be managed, particularly becausethe task is not yet overwhelming although essential.
One of the difficulties in this arrangement is finding a caregiver when needed. When a spouse finds it difficult to perform alone, a supplemental caregiver must be found, and often alternate part time caregivers are needed to give the caregiver respite. A non-spouse caregiver in this situation either lives-in full time or comes in on a regular basis.
ALTERNATIVE THREE involves a caregiving role of something less than a full day. Frail elderly, including couples, could often remain at home with a minimal amount of help. This would not only increase the duration they could remain at home but also their quality of life. The difference between no help at all and a few hours of minimum of assistance could be significant.
With so many adults now employed in the labor market, caregivers can be difficult to find. When there is little or no choice, incompatibilities can occur. Strangers sometimes never cease to be strangers; language barriers can be frustrating, particularly to the elderly whose senses may be diminishing (sight, hearing).
Home care, worldwide, is becoming increasingly an important although difficult part of health care for the frail elderly. Norway has been in the forefront of home care development with a comprehensive system of health and social services covering a range of nutritional, health, social and recreational services.
Yet the problem of finding competent caregivers is acute. To meet the growing needs of its elderly, Norway is engaged in a decentralization and a deinstitutionalism policy and program. High priority is given to the modification of the senior's own family home or apartment with emphasis on meeting changes in health status and physical disability. To fulfill the ever increasing need of caregivers, Norway has embarked on a unique program.
It encourages relatives to be paid as home caregivers. Family members, often the daughter or daughter-in-law, are hired part-time to provide home-help services for an elderly or disabled relative. Some provide care for other elders and become employed full time. About 25% of all home caregivers in Norway are relatives or neighbors. Because many are paid, they are able to supplement family incomes with convenient working conditions plus first-hand knowledge of the situation.
Because these jobs are on the low end of the pay scale and often physically and emotionally demanding, recruitment and retention is difficult. While this part-time salary is quite modest, it often is enough to allow a family member to supplement the family paycheck and give aid where and when needed as well, particularly in out-lying and rural areas.
For some there is a natural abhorrence in being paid to give care to a relative; for others the modest pay is just enough to make it possible to personally care for a relative. Neighboring Sweden, similar in its social structure to Norway, also has seen a shrinking proportionately of its elderly living in institutions. This is due to its expansion of home-nursing and home-help services. These services have expanded as numbers and ages of the elderly have increased while the number of institutional beds has remained the same. Since the 1960s, the number of handicapped and elderly receiving home care has more than tripled. In 1989, 17% of Sweden's old-age pensioners received some form of home help and more than 43% of those over 80 used this service which includes meals-on-wheels, chiropody, occupational therapy, personal care services, snow-shoveling, home maintenance and other assistance designed to keep the elderly at home longer. Some of this attention is given at steadily growing day care centers of which some are run by the elderly themselves.
Again, where can these caregivers (home-help) be found? Swedish policy is clear that the government (national and municipal) has an obligation but it is not clear about statutory requirementscompelling the family to care for its elderly. Finding caregivers is becoming increasingly difficult, both here and abroad. And mandating families to provide care for their elderly kin is usually politically repugnant.
The U.S. is continually struggling with the question of time off from work to care for a newborn. If and when this becomes a common procedure, it is conceivable that this could be expanded to include time off for short term care of elderly and incapacitated relatives as well, with or without pay.
As an example, Germany requires 14 to 19 weeks of fully paid sick leave for a working parent and Italian law mandates five months of paid leave at 80% of the wage with an additional six months off at 30%. The US presently relies on a few scattered state laws plus the good will of employers for child care. Perhaps this could be a foot in the door for an inclusion of leave for elderly care.
ALTERNATIVE FOUR is another option to be considered. Day Care Centers are not only suitable for children but also serve the elderly. These adult centers are often connected with existing institutions within a community such as churches, schools and other existing facilities (hospitals, nursing homes, youth centers unused in the middle of the day, etc.) which reduces capital outlay and start up time for autonomous centers.
These senior day care centers are often maintained by volunteers, including young elderly in conjunction with paid supervision. They create a respite for the elderly person as well as the caregiver (spouse or other family member) enabling the elderly to live in the community easier and longer. Many are ecumenical, economical and non-ethnic in scope appealing to a wide cross-section of society. However, those with physical or mentation problems may not function as well, or not at all, in this kind of environment. Still it is often worth a try.
Similar to a day care center is Respite Care which can be differentiated from the above in that existing CCRCs and nursing homes may allow caregivers respite by providing a place and a program for temporary care: overnight, a weekend, a week or longer stay. These arrangements can often be made in advance or in an emergency. The caregiver may need respite to travel, undergo surgery, or simply for rest and relaxation.
Hospice Care is another means whereby the terminally ill may stay at home with nursing care given a few hours a day or around-the-clock. Generally, this care is provided only for those with a relatively brief life expectancy and the care is given, not in hopes of affecting a cure but in providing comfort, medication and nursing care. Nowadays, much of the physical pain caused by a terminal illness can be reduced significantly although in some instances, consciousness may be diminished and death either hastened or delayed. Hospice care can be a blessing in many ways and should not be considered as either a passive or active form of euthanasia. There is a distinct dissimilarity between striving for a pain-free, dignified closure of life and mercy-killing.
ALTERNATIVE FIVE Although there are doubtless other possible options for remaining at home, we now move away from the home setting into Institutional Living. This usually is a first resort, an option often taken carefully, selectively and deliberately before disability forces a move. This could mean moving into a Continuing Care Retirement Community (CCRC) or an apartment complex for senior citizens where amenities are geared toward the elderly.
In non-CCRC-type senior housing units, caregiving ultimately can become a problem and should be considered seriously well in advance. Most senior housing facilities without continuing care can serve the elderly well as long as they can remain independent. It may possibly be easier than living at home because of the conveniences: upkeep and maintenance provided, transportation amenities and convenient shopping. In some situations there may be a nurse on duty and a physician on call. Caregiving at best is postponed but not necessarily eliminated.
A continuing care facility on the other hand is designed to provide care as needed ranging from independent to assisted living and skilled nursing residents. The costs for this range widely with various options.
The art of choosing a CCRC is complicated because of the various kinds of facilities and philosophies. Each has its own merit; the advantages and disadvantages should be carefully considered
before any commitment. Although not exclusive, here is a list of questions you may wish to raise in considering a CCRC:
1. Is the CCRC (or another type housing facility) well-located? Is it in a good neighborhood, close to cultural activities, hospital(s), shopping, churches, recreation and public transportation?
2. Is the facility well-endowed, financially secure, with a good track record? What is the sponsorship or is it strictly independent? Are the financial records available? Is it accredited? How long has it been in existence?
3. Are you able to spend a few days as a guest to get a personal feel for the facility? What do the residents say? Staff persons? Note: each facility has its own personality, its own character, uniqueness, individuality. Comparative shopping could be invaluable.
4. Is the cost within your budget? Does it have an entrance fee with a monthly fee or no fee? Who pays for intra-facility moves? Since assisted living and skilled nursing costs usually are more expensive, who pays the difference? Is insurance available or included? Can you upgrade or downgrade easily? What do you forfeit if you change your mind, if you lose your spouse, if your assets are depleted, if you cnange your mind?
5. Is a portion of your entrance fee left to your heirs or estate? Can you exchange your assets for perpetual care? Should you? Is your entrance fee refundable on a pro-rated basis? Have you read the fine print? Has your family and your attorney gone over all the details?
6. Have you taken extra precaution for promised amenities not yet available (e.g. swimming pool, a skilled nursing facility, a bus for private transportation, aircondi- tioning to be installed etc.). Economic austerity, unforeseen emergencies, acts of God, civil requirements, civic resistance, low census, overestimation or poor management can forestall the best of promises.
7. What is the resource pool for hiring future employees? Is the community large enough with adequate resources to provide custodial care, nursing aides and gardeners as well as professional, administrative and managerial personnel?
These, and other questions must be asked before decisions can be made. At times knowing the right questions is more important than getting answers. A gorgeous, hidden or remote paradise might be a wonderful place to retire until something goes awry. We cannot choose too carefully even though we may never find the perfect place to retire. The next to perfect may have to suffice.
ALTERNATIVE SIX creates the possibility of finding caregivers within a structured family-type setting such as cohousing, cooperatives, communes and other forms of communal living. Some of these housing arrangements are structured more toward the young family and children than the elderly. Care for children is now more prevalent than care for older adults. Actually, this kind of living arrangement is suitable for the able elderly but not always for the infirm or frail. The day may come when these cooperatives and cohousing units will be designed for a cradle-to-the-grave lifestyle but this is not yet achieved.
Health concerns and other regulations (city, county, state and federal) impact the care of the very young as well as the elderly. In a cohousing settlement, for instance, a cluster of single homes centered around a "common house" can function nicely for dining, play areas, laundry facilities and guest rooms but it is another matter to provide day care and/or around the clock licensed (approved) care for the infirm elderly. Cohousing is hardly suitable for aging-in-place at the present time.
It could be tempting for an elderly couple to buy into a cooperative hoping that when they'll need care it will be available. If anything, the proliferation of rules and regulations for custodial care often causes a much higher technical and professional requirement than realized. Idealism often collides with realism with unfortunate results especially for those least able to do anything about it: the very young and the infirm.
Cohousing and other cooperatives must protect themselves not only against petty (and not so petty) regulations that tend to frustrate even the most superior motives. When the time comes, and the infirm can no longer meet the demands of the cooperative, the health department, the fire marshall and other regulatory agencies, an eviction is inevitable unless alternative caregiving arrangements can be made.
In short, the question of who will be caregivers for the elderly is not answered easily. For awhile, the elderly will care for themselves as long as possible. Eventually, a spouse may act as a caregiver, often quite competently. When the time comes, a caregiver may not be able to perform effectively and another form of caregiving is necessitated. This could be a family member, a day care center or another institution, a visiting caregiver or even hospice care in the case of a terminal illness. For single persons without a caregiving spouse, the burden shifts to the family, a social agency, the church or temple, a fraternal organization or the government.
Am I my brother's keeper? Spiritually, we can learn from the wisdom of yesterday which often is the wisdom of tomorrow. We remember the cartoon of a young boy carrying a child who answers a poignant question, No, he ain't heavy. He's my brother. When all other recourse fails and no caregiver is available, when retirement funds erode or evaporate, where shall we turn? In a way, we tend to put the cart ahead of the horse. We should exhaust all possible means of caring for the elderly before turning to charity or government, benevolence or coercion (encouraging haves to pay for the have nots). Or urging or forcing irresponsible or evasive relatives to provide for their hurting or destitute elderly kinfolk.
If we are our brother's keeper (using brother as generic for kinfolk and even broader, humankind), and if we lived up to this decree, a great portion of the elderly will not be neglected.
First of all, if families cared for families, most elderly would find caregiving assured. Next, we would look to organized religion with its imposing membership. Each church, temple and synagogue would not have to save the world, only accept responsibility for its own constituency. Where the needs of the elderly are met by the elderly themselves or by their families, religion would play a supportive role. However, where there is neglect or abuse, religion would assume a caregiving role. Where the burden on one congregation is onerous, sister congregations could assist. The results would be amazing. Let's continue.
Fraternal organizations and service clubs could also play a role. The comradery is already built-in. If the Chi Omegas and Shriners, Rotarians and Lions took inventory of their aging alumni, those missed by family and religion might well be picked up by their fraternal friends. The same could be true of labor and credit unions, professional organizations, the military, law enforcement, fire associations and the like.
Academically, by discipline as well as by institution, a search through alumni associations of professional/social clubs could uncover hardship cases of elderly professors, librarians, researchers and administrative personnel. In addition, ethnic common denominators, neighborhood surveillance teams and old-fashioned neighborliness would also uncover neglected elderly.
We could continue but the point is established. If we truly were our brother's keeper, there would be almost no elderly abuse or neglect, no abject poverty. Those who might escape the above humanitarian nets of brotherliness could then be taken care of by local, state and national agencies as a last resort, not a first.
Furthermore, if this spirit of being our brother's keeper were to be taken seriously, by the elderly themselves as well as others, the haves would not hoard but would naturally share their means, particularly if they felt it were not a hopeless or thankless task.
The bottom line seems to be this: our concern for caregivers for the elderly should have a dual focus: caregiving should involve both caring for as well as working with the aging. If a frail person can polish his/her shoes but cannot tie the laces, caregivers should tie the laces but not polish the shoes. Helping those who help themselves goes beyond charity into a noble form of caregiving.
When a well-heeled philanthropist was ushered through the Pearly Gates by St. Peter, he had visions of a crown loaded with sparkling gems ceremoniously placed on his head. Instead, he felt a firm, moist palm caress his brow. "Welcome to Paradise," were the only words he heard. Mystified, he looked up and addresed St. Peter, "Sir, I gave millions. Is this all I get, a pat on my forehead?" Peter paused for a moment, then spoke softly, "I'm not sure, but I think it wasn't how much you gave but how much you kept for yourself." Even the elderly, some of whom have far more than they can ever spend (time, wisdom, experience, maturity, resources), also share an obligation in the whole matter of elderly caregiving. Caregiving is sharing, and sharing has no limits.
STRATEGY
1. Assume that you will be a caregiver at some time in your life as well as a recipient.
2. If something happens to you or a loved one, plan your alternative strategies early.
3. Identify your potential "brother's keepers"?
4. Give thought now to alternate plans for possible incapacitation sometime in the future.
5. Develop another ALTERNATIVE of your own.