Craig Klugman, Ph.D.
When I was a child, every Sunday afternoon was dominated by a visit to Grandma in the nursing home. Today, we would call the place a “skilled nursing facility.” For a kid, this was not how I wanted to spend a weekend day. There were lines of people in wheelchairs “parked” against the walls. Those who would talk at all complained about the food, their medications, the staff, or their families. You had to speak quietly and sit still. The better days were when we would help Grandma into the car, put her wheelchair in the trunk and just ride around. As we got older, we wanted to visit less. In fact, a joke in our family was “you can visit Grandma, or you can clean the toilets” (a particularly despised chore in our household). As I passed into my teenage years, we had very clean toilets.
In a recent PBS Frontline Series, journalist AC Thompson reported on assisted living housing. Diane Rehm on NPR also held a program on this presentation this week. Assisted living homes fall in between the skilled nursing facility (where patients often have shared roommates, rigidly scheduled lives, group dining, and are unable to complete activities of daily living without 24 hour skilled care) and independent living (where residents have their own apartments, can participate in activities, can be part of group dining, and can complete most if not all activities of daily living without assistance). In assisted living, a person needs some assistance in daily living such as preparing and eating meals, taking medication, even getting dressed.
Nearly three-quarters of a million people in the U.S. live in these homes. Thompson said that some of the facilities are excellent with beautiful rooms, aesthetically pleasing surroundings and good care. My grandmother said she was happier in her facility than she had ever been at any other time in her life.
Other places have problems such as a lack of staff, lack of training, lack of cleanliness, safety concerns, and medication errors. In a specific dementia facility owned by a national corporation, staff receive only eight hours of training to learn how to take of patients. Part of the concern is that while skilled nursing facilities are regulated by the federal government and must meet standards, there are no national rules regarding assisted living. Instead, assisted living is held to various state laws and in some cases, there are no regulations at all. Public funding systems often will not cover the cost, meaning most families have to pay out of pocket. Rates are quoted as high as $5,000 per month.
As a child and now as an adult, I have wondered about such homes where we “warehouse” our elderly (a term popularized by anthropologist Jules Henry in his 1963 book, Culture Against Men). For much of human history, families lived in multi-generational homes and families took care of their elderly. Yet in modern America, we put our family members in homes that we often to do not want to visit. We put old age and death out of sight, and sometimes out of mind.
Sometimes we simply cannot provide the care that seniors need. In many cases, it is safer for a person to be in a facility than living in a home where the senior may be along for many hours a day. And with busy modern American lives with 12 hour work days, and children with full activity schedules, there often is not time (i.e. convenience) to provide care for an elder at home.
In other cultures, putting elders in a home would be unthinkable. In China, for example, families are expected to care for their elders. If an elder does not have children, then the community or work unit cares for them. Although even this practice is changing to some extent. In Singapore, the law requires children to care for their parents and if they do not, then the cost of care is taken from the children’s paycheck. If that is not sufficient, the state can even sell your house and use the proceeds to pay for your parents’ care.
The over 85 population is largest growing demographic in the United States. And the baby boomers are moving into retirement in droves. Caring for our seniors will become an increasingly large concern for all families and communities.
Innovative models in the U.S. are being developed to provide a more at-home environment such as the Green House Project and programs that enable seniors to age-in-place, providing more home-based services. Multiple innovative approaches will be needed.
The experiences we provide for our seniors should be respectful of them, demonstrate that we value and care for them, and leave us all with the peaceful knowledge that when we are old we will have the kinds of options that fulfill our needs instead of simply getting us out of the way.