The Ecology of Aging

DEVICES SUCH AS GRIP BARS IN BATH- ROOMS, WIDER DOORWAYS, RAMPS

5.2 The Ecology of Aging

LEARNING OBJECTIVES What is aging in place?

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How do people decide the best option?

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How can a home be modifi ed to provide a

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supportive environment?

What options and services are provided in adult day

• care?

What is congregate housing?

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What are the characteristics of assisted living?

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M

ark was diagnosed as having vascular demen- tia about six months ago. Because he now has diffi culty in remembering to turn off his gas stove, his daughter and son-in-law think that it may be best for him to move into an assisted living facility. Th ey have had Mark evaluated by his physician, who indicates that she thinks it is a good idea for safety reasons, especially because Mark’s family lives several hundred miles away.

Most people go through young adulthood, mid- dle age, and into later life performing routine daily tasks without much thought. As we grow older, though, the normative changes that occur oft en result in more challenges in dealing with environ- ments that were once not a problem at all. Even our homes, formerly a comfortable supportive place, can present diffi cult challenges; for example, the walk up the stairs to a bedroom may become an equivalent of climbing a mountain.

Mark is typical of a growing number of older adults in the United States and other countries—he is experiencing a signifi cant decline in functioning, lives alone, and his adult child and family live in another city some distance away. As a result, he, like many other older adults, needs a diff erent liv- ing situation. He does not need full-time nursing care at this point, but does need a more supportive environment.

Changes in functional status and how these changes are helped or hurt by the environments in which we live are an important aspect of the experience of growing older for many people. Th ese changes are studied in a fi eld called the ecology of aging or environmental psychology, which seeks to understand the dynamic relations between older

adults and the environments they inhabit (Scheidt &

Schwarz, in press). It is important to understand how even seemingly small changes in a person’s environment can result in major changes in behav- ior, changes that can make the diff erence between a person being able to live independently or needing a more supportive situation.

In this section, we will consider options for older adults that help them maintain as much inde- pendence as possible. First, we will consider the concept of aging in place. Th en we will consider three approaches to helping people live in the com- munity as long as possible: home modifi cation, and two living situations that provide various levels of support—congregate housing and assisted living.

Aging in Place

Imagine you are an older adult who has diffi culty cooking meals and getting around. If you had a choice of where you wanted to live, where would it be? Maybe some of your family members are urg- ing you to move to a place where your meals are provided and you can be driven where you need to go, while others are urging you to stay in your own place even though there will be challenges. What do you do?

Based on the competence–environmental press model described earlier, older adults have options (Scheidt & Schwarz, in press). As the environment in which one lives becomes more restrictive, many older adults engage in selection and compensation to cope. Th ey may select a diff erent place to live. Or they may adapt their behaviors in order to compen- sate for their limitations, such as using microwave- able prepared foods instead of cooking meals from scratch. Using a cane or other device to assist in walking is another example of compensation.

Th e idea of aging in place refl ects a balancing of environmental press and competence through selection and compensation. Being able to main- tain one’s independence in the community is oft en important for people, especially in terms of their self-esteem and ability to continue engaging in meaningful ways with friends, family, and others.

Th is is very important psychologically (Rowles,

Oswald, & Hunter, 2004). Older adults who age in place form strong emotional and cognitive bonds with their residences that help transform a “house”

into a “home.” Having a “home” provides a strong source of self-identity.

Th roughout adulthood, people adapt to changes in the places where they live, sometimes even having to sever connections with past settings (Rowles &

Watkins, 2003). Making a change in where one lives, and having to psychologically disconnect with a place where one may have lived for many decades, can be diffi cult and traumatic. Th ere is no question that people develop attachments to place, deriving a major portion of their identity from it and feeling that they own it.

Rowles (2006) discusses the process of how a place becomes a home. Because of the psychological connections, the sense that one is “at home” becomes a major concern in relocation, especially if the relo- cation involves giving up one’s home. Later in this chapter, we will consider how a nursing home might become a home, but for now the important idea is that a key factor is a sense of belonging.

Feeling that one is “at home” is a major aspect of aging in place. Providing an older adult a place to call one’s own that supports the development of the psychological attachments necessary to convert the place to a home is the basis (Scheidt & Schwarz, in press). Aging in place provides a way for older adults to continue fi nding aspects of self-identity in where they live, and to take advantage of support systems that are established and familiar.

Th e growing understanding of the importance of aging in place has resulted in a rethinking of certain housing options that provide a way for frail older adults to stay in their communities. Such options are important for frail older adults who are poor and cannot aff ord more expensive formal assisted living or nursing home facilities (discussed later).

One alternative is cluster housing, which combines the aging in place philosophy with supportive ser- vices (Golant, 2008).

Golant (2008) describes several types of aff ord- able cluster housing care. A key feature is that ser- vices are provided to the residents by staff hired by the owner or by a service provider under contract.

Th ese services might range from having a service case manager only to actually providing informa- tion, caregiving assistance (e.g., meals, housekeep- ing), transportation, or health care. Th e aging in place philosophy in these settings emphasizes indi- vidual choice on the part of residents in terms of what services to use.

Although cluster housing and other approaches to aging in place make sense as lower-cost alter- natives to nursing homes that help keep people in their communities, funding is oft en diffi cult.

Unlike nursing homes, cluster housing develop- ments are not covered by Medicaid or other insur- ance. Finding solutions to the funding issue will be an important aspect for keeping costs down yet providing supporting environments for older adults who need support. For many, making modifi ca- tions to their existing housing represents a more cost- eff ective option, and provides a research-based way to remain in a familiar environment. We will consider this approach later in this section.

Deciding on the Best Option

One of the most diffi cult decisions individuals and families have to make is where an older member should live. Such decisions are never easy, and can be quite wrenching. Figuring out the optimal “fi t”

where the individual’s competence and the envi- ronmental press are in the best balance rests on the ability of all concerned to be objective about the indi- vidual’s competence and on the ability of the lived-in environment to provide the level of support neces- sary. It requires a degree of honesty in communica- tion with oneself and one’s family that is sometimes challenging.

Th ere are several key decision points in address- ing the issue of the optimal environment. First, it must be determined whether the individual has signifi cant cognitive or physical impairment requir- ing intervention. If so, then a determination of the severity of the impairment is needed. Next, an assessment of the ability of family members or friends to provide support or care must be made.

Once that information is understood, a series of decisions can be made about the best way to provide

the necessary environmental supports to create the optimal “fi t.” Assuming that all information points to the need for some sort of intervention, the next critical decision is deciding whether there is an option for providing that intervention in the cur- rent home situation or whether other options need to be pursued. Later, we will consider several living options for individuals needing support ranging from minor modifi cations of one’s present home to skilled care nursing homes.

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

Individuals and families facing these decisions should at least consult with the person’s physician aft er a thorough diagnostic evaluation. Additionally, objective information about available options can be obtained from local senior centers, offi ces on aging, and other nonprofi t service providers.

Home Modifi cation

Th e discussion of the competence–environmental press model earlier provided two options for people who experience diffi culties dealing with the tasks of daily life. On the one hand, people can increase their competency in order to develop better or new skills for handling the tasks. For example, to remember better where you put your car keys, you can learn a new memory strategy. On the other hand, people can also modify the environment to make the task easier. For example, you can put a hook for the car keys next to the door you exit so that you see them on your way out.

Th ese two options represent applications of the- ory to real-world settings that also apply to helping people deal with the challenges they face in handling tasks of daily living in their homes. When it comes

to these kinds of issues, the most frequent solution involves modifying one’s home (i.e., changing the environment) in order to create a new optimal bal- ance or better “fi t” between competence and envi- ronmental press (Scheidt & Schwarz, 2009).

Many strategies are available for modifying one’s home to help a person accommodate to changing competencies. Minor structural changes, such as installing assistive devices like hand rails in bath- rooms and door handles that are easier to grip, are common strategies. In other cases, more extensive modifi cations may be needed to make a home fully accessible, such as widening doorways, lowering countertops, and constructing wheelchair ramps.

Although minor alterations can oft en be done at low cost, more extensive modifi cations needed by people with more extensive limitations may be unaff ordable for low-income individuals. Even though the cost of such interventions is signifi cantly lower than placement in nursing homes or even assisted living, funding is lacking. As a result, many older adults with functional impairments experi- ence a mismatch between their competency and their environment (Wahl, Fänge, Oswald, Gitlin, &

Iwarsson, in press).

Research indicates that home modifi cations that are done to address diffi culties with accomplishing activities of daily living (ADLs) typically reduce disability-related outcomes (Wahl et al., in press).

Whether these modifi cations also help older adults who are prone to falling remains inconclusive.

Adult Day Care

In some cases, older adults need more support than is possible with just home modifi cation, but still do not need it on a full-time basis. For them, one pos- sible option may be adult day care. Adult day care is designed to provide support, companionship, and certain services during the day. Th is situation arises most oft en when the primary caregiver is employed or has other obligations and is unavailable during the day.

Th e primary goal of adult day care is to delay placement into a more formal care setting. It achieves this goal by providing alternative care that enhances

the client’s self-esteem and encourages socialization.

Th ree general types of adult day care are available (National Adult Day Services Association, 2008). Th e fi rst provides only social activities, meals, and recre- ation, with only minimal health services. Th e second type is adult day health care that provides more intensive health and therapy intervention and social services for people who have more serious medical problems or who require more intensive nursing care for a specifi c medical condition. Th e third provides specialized care to particular populations, such as people with dementia or developmental disabilities.

Adult day care centers can be independent or spon- sored by a profi t (22%) or nonprofi t (78%) organ- ization. Th ey may provide transportation to and from the center. Depending on the services received, Medicaid or other insurance may cover some of the expenses (Medicare does not). Because some states do not license adult day care centers, careful screen- ing of a particular center is advised.

About 35% of adult day care clients live with an adult child, and 20% with a spouse or partner. Th e average age of clients is 72, with about two-thirds being women (National Adult Day Services Association, 2008). Family members who choose adult day care (and can aff ord it) typically do so because they need

Adult day care centers provide a way for adult child and spousal caregivers to continue being employed and provide care to their loved one.

occasional assistance with caregiving, have safety concerns about the care recipient when the caregiver is not around, take increasing amounts of time off from work for caregiving, are experiencing problems in their relationship with the care recipient, or the care recipient could benefi t from more contact with other older adults (MetLife, 2006).

For people with cognitive impairment, changes in routine can result in confusion or disruptive behavior. It is especially important for them, as it is for all older adults who may become adult day care clients, to inform them of this choice. A good strat- egy is to engage in a few trials to fi nd out how well the person acclimates to the diff erent surroundings and activities.

Research demonstrates that adult day care is a viable and important option for caregivers. Th ey are interested in the kinds of programs that meet the needs of their loved ones, and are generally satisfi ed with the services provided (Madeo, Feld, & Spencer, 2008). Family members clearly seek what is best for their loved one in searching for and helping make the transition to adult day care centers (Bull & McShane, 2008). Evidence is clear that, compared with keeping relatives with cognitive impairment at home, good adult day care programs can reduce problematic

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behaviors and lower the need for psychotropic medi- cation in clients, and result in lower reports of caregiving burden among caregivers (Mosello et al., 2008). However, a key factor in the success of day care programs is having culturally appropriate pro- grams in interventions, as demonstrated in a study of Korean clients who benefi tted most when programs took their background into account (Park, 2008).

Congregate Housing

Congregate housing includes a range of living options. Th e most common form is an apartment complex of older adults that provides a level of sup- port, such as shared meals. Congregate housing is oft en the least expensive form of supported living for older adults, as the cost is typically subsidized by various government agencies and nonprofi t orga- nizations. Because of its aff ordability, it is an espe- cially important option for low-income older adults who need some support to remain out of a nursing home. However, there is a shortage of congregate housing in the United States.

Traditional congregate housing diff ers from assisted living in terms of the level of services pro- vided. Although many traditional congregate hous- ing complexes do not include individual kitchens and provide shared meals, the level of medical assis- tance, for example, is lower than in assisted living.

Congregate housing facilities do not provide 24-hour medical services on site. However, newer congre- gate housing complexes are including higher levels of other service, so the distinction with assisted liv- ing is being blurred.

Th e service coordination that is provided in con- gregate living accomplishes several things: interface with housing offi cials, individual service plans for residents, coordination of shared activities (e.g., cleaning common spaces), and mediation of resi- dent confl icts. Most congregate housing complexes require that residents be capable of independent living and not require continual medical care, be medically stable, know where they are and ori- ented to time (e.g., know today’s date and other key time-related information), show no evidence of disruptive behavior, be able to make independent

decisions, and be able to follow any specifi c service plan developed for them. If at some point a resident no longer meets one of the criteria, he or she is usu- ally required to move out.

Th e decision to move into congregate housing is usually done in conjunction with one’s family, and is typically a response to a signifi cant decline in functioning or other health-related problem (Sergeant & Ekerdt, 2008). Families are generally satisfi ed with the outcomes following the move (Williams et al., 2008).

Assisted Living

Given that maintaining a sense of place, a home, is very important to older adults, it should not come as a surprise that they would prefer living options that help foster that desire. Th at is how the option of assisted living came into being (Scheidt & Schwarz, in press). Assisted living facilities are housing options for older adults that provide a supportive liv- ing arrangement for people who need assistance with personal care (such as bathing or taking medications) but who are not so impaired physically or cognitively that they need 24-hour care.

An ideal assisted living situation has three essen- tial attributes (Scheidt & Schwarz, in press). First, the physical environment where a person lives is designed to be as much like a single-family house as possible. Th at way, the setting has a residential appearance, a small scale, and personal privacy that includes at a minimum a private room and a full bath that is not shared with other residents unless the resident explicitly wishes. Th e public spaces in the facility are designed to provide indoor and out- door access, which enhances a resident’s autonomy and independence.

Second, the philosophy of care at an ideal assisted living facility emphasizes personal control, choice, dignity, and autonomy, and promotes a preferred lifestyle that residents and their families consider to be a “normal,” good quality of life. Th is philosophy is implemented by understanding residents’ personal preferences and priorities, and allowing residents to exert control over their lives, their schedules, and their private dwellings.