Aging in Place

Older people overwhelmingly prefer to age in place—to stay in their homes or apartments as they age, rather than move to new settings. Most of them do so: fewer than 10 percent live in nursing homes, assisted living or adult foster care facilities, or continuing-care retirement communities. In fact, during the 1990s, the number of people living in nursing homes in the United States declined although the number of people over age seventy-five rose. About 6 million older people who need assistance, including many with complex medical conditions, get help at home. Laws, regulations, and court decisions increasingly ensure the rights of people with disabilities to live in noninstitutional environments, with maximum control over the services they use.

Older people move less frequently than do people in any other age group. A long-time residence is more than just a building; it is the site of memories and a place to welcome friends and family. It represents familiarity—with people and community resources, the location of the light switches, and the local shortcuts—as well as privacy, control, and stability amid life changes such as widowhood or declining health. The longer one lives in a particular place, the harder it may be to leave, despite problems such as hard-to-climb stairs or unmanageable repairs. Moving requires considerable energy. Older homeowners—more than 75 percent of people over sixty-five own their homes free and clear—may find it especially hard to leave a place that not only embodies status and autonomy but also is often their main economic asset. Sometimes the attachment to home is so strong that it "transcends any rational calculation of benefit" (Fogel, p. 20).

Especially as the proportion of people over sixty-five rises, aging in place presents both challenges and opportunities for older individuals and communities. The risk of illness and disability, and associated needs for assistance, rise with age; yet family assistance is increasingly limited due to smaller and more mobile families, a greater number of women in the workforce, and higher divorce rates. Professional assistance, such as nurses or home health aides, may be expensive, unavailable, or of low quality. Factors such as inaccessible housing and transportation add to the challenges. Too often the results are preventable illnesses, disability, and isolation, especially for those who live alone. The expense of aging in place can be daunting, running tens of thousands of dollars a year if round-the-clock care or extensive housing adaptations are needed. Public funding cuts in the 1990s reduced the amount of home care covered by Medicaid and Medicare. Long-term care insurance helps some people, but much of the cost must be paid out of pocket.

At the same time, the "increase in the elderly population will provide new and important economic and social resources to communities that are positioned to attract them" (Retirement Research Foundation 2000, p. 3). Older residents' needs and wants may stimulate new businesses and services. Construction of new elder-oriented housing frees up single-family homes, which are usually older and therefore more affordable for younger families. New construction and the renovations associated with real estate turnover create jobs and prompt spending. Older residents also have some distinct advantages over younger residents:

When retirees move out [and] families with children move in. . .it means more children swelling enrollment at local schools, more garbage to pick up, more cars on the road, more services generally. . . ."If you are not able to retain [seniors], you end up without the values they represent, and with services that are much more expensive than if they stayed." (Peterson, p. S14)

Accordingly, some communities are reducing taxes and enticing retirees with amenities such as free or low-cost transportation, free health screening, reduced tuition for college and adult education courses, and more and bigger senior centers.

The notion of "elder-friendly communities" captures community characteristics that address the challenges and capitalize on the opportunities presented by an aging population. Elder-friendly communities have a range of reasonably priced, high-quality health, social, and supportive services, such as transportation, housekeeping, and meals; affordable and accessible housing and businesses; and opportunities for older people to continue participating meaningfully in community life through volunteer, cultural, and recreational activities. For example,

In Blue Island, Illinois, Metropolitan Family Services has been using an asset-based approach to creating a more caring community for its older residents. . . . The effort began by identifying ways in which the elderly can use their talents to benefit the community and setting up a number of intergenerational service projects. The newly created Blue Island Commission on Successful Aging may bring public transportation and affordable housing options to this community for the first time. (Retirement Research Foundation, p. 4)

Although any urban, suburban, or rural setting can offer the advantage of familiarity or the disadvantage of isolation—an older person with impaired mobility may be as isolated in an urban high-rise as on a remote farm—types of locations differ in their support for aging in place:

• • In urban areas, older people are more likely to be able to walk to stores and services, use public transportation, and access organized health and supportive services. Because of economies of scale, agencies, organizations, and businesses may offer cheaper or more convenient services, more choices, and isolation-fighting activities such as companion programs. On the other hand, the fast pace and rapid rate of neighborhood change and crime (or the fear of crime) can challenge an older person's ability to age in place well.
• • Suburban areas have lower crime rates and lower population density; but because health and other services are more dispersed and public transportation is often in short supply, they are more expensive to deliver and harder to get to.
• • In rural areas, quality-of-life advantages such as a strong sense of community and history may be outweighed by even more dispersed and expensive health, social, and transportation services than in the suburbs, and the lack of a trained labor pool. Rural housing and economic conditions are also worse, on average, than those of suburban or urban areas.

Because desire to age in place may center on the community as much as on the dwelling, some older people would consider moving to a different residence if their community had affordable supportive housing that promoted independence and balanced privacy with social interaction. Formal models include congregate housing, continuing-care retirement communities, and assisted-living and adult foster care facilities. However, supportive housing can also be found or developed in publicly subsidized or private apartments; housing cooperatives (which allow older people to retain their home equity while living in more supportive housing); and even neighborhoods. (Buildings or neighborhoods with a disproportionate number of older people, sometimes called naturally occurring retirement communities, offer many of the advantages of planned senior housing.) When enough older people live near each other, economies of scale or "clustering" services can reduce the costs, improve the efficiency, and enhance the flexibility of services. On-site service or resource coordinators often pull these elements together. They help residents to obtain services they need and want while contributing to creating the accessible environments, healthy communities, and choices that promote safe and dignified aging in place.

In addition to familiar supportive services such as housekeeping, meals, and transportation, a widening array of other services fosters aging in place: creative "low-tech" services (grocery and pharmacy deliveries, errand assistance, house calls by professionals such as podiatrists and hairdressers, assistance with paying bills and balancing checkbooks, and help with arranging multiple services); "high-tech" services (emergency response systems or interactive medication or pacemaker monitoring); assistance with housing adaptations (installing ramps and grab bars, eliminating thresholds, or installing an elevator); adult day care centers (offering meals, medical care, physical and occupational therapy, and social interaction); and community support for caregivers.

Confronting the challenges and capitalizing on the opportunities presented by aging in place will not be easy. Hope exists, however, in the variety and creativity evident in some states and localities.