Tag: Aging-in-Place

Originally published at Forbes.com on June 11, 2022.

Aging-in-Place — most of us think of this as the decision, as we get older, to stay in our longtime family homes, even as increasing infirmity or cognitive decline makes this harder. We know there are support programs available, providing home health aides, assistance with yardwork or a wheelchair ramp, a “senior freeze” to keep property tax increases at bay, and so on. And our homes hold so many memories and are a source of affirmation of the success we’ve had in our lives.

But is aging-in-place really the right decision? Or, put another way, does it “work”? Is it the right path for us all to take as we age, or would we be better off if we moved somewhere more suitable — a single-level house, or a condo in an elevator building, or a home near public transportation, or any of the communities designed for older adults? Would we miss our neighbors in our old communities, or quickly adapt and be glad we’d gotten past our hesitancy?

In the book Aging in the Right Place from 2015, author Stephen Golant provides a number of reasons why that “right place” might be the longtime family home:

•The advantages of a familiar neighborhood: the individual knows the shops and services and can navigate the area well even after physical or cognitive decline.

•The advantages of a familiar home: spatial competence (finding your way when the power goes out, navigating steps out of familiarity)

•Preserving familiar relationships – friendships and service providers.

•The attachment to possessions and pets is not disrupted (e.g., vs. moving to no-pets home); the home not only contains memories of the past but also reminders of past successes.

•The home affirms one’s self-worth; one fears (whether rightly or wrongly) that others will consider the person a “retirement failure” upon moving.

•Maintaining privacy, vs. moving from a single-family home to an apartment, or to Assisted Living, shared housing, or living with family.

At the same time, there are many quite considerable costs incurred in Aging in Place, not just direct financial costs, for which we can argue about whether the government should shoulder these, but less tangible costs:

•Financial costs: the cost burden of maintaining large older home with yard vs. smaller but newer space with maintenance covered by association/landlord

•Physical costs: the steps/stairs and narrow doorways can make home a prison for the physically-impaired or place the individual at risk of falls.

•Social costs: the idealized neighborhood relationships might not be real, and turnover in the neighborhood may mean that there is more likelihood of social connection with the intentional social opportunities of a senior community.

•Health costs: isolation can mean lacking help for medical emergency – even to the point of dying unnoticed. More mundanely, homebound seniors have less ability to cook healthy food, travel to doctors, etc.

•Finally, there are particular challenges for those experiencing cognitive decline, especially when there is no family member to notice or when decline is hard-to-notice.

Golant doesn’t beat around the bush, but writes that

“Older adults are now bombarded with a singular and unrelenting message: They should cope with their age-related health problems and impairments in their familiar dwellings. . . . Older people cannot turn on a TV, search n the Internet, read books about old age, or pick up a newspaper without getting this persistent stay-at-home message” (p. 63).

In a somewhat older article, in 2009, William H. Thomas and Janice M. Blanchard offered a sharp critique of the Aging in Place model, in “Moving Beyond Place: Aging in Community.” They acknowledge the fear of nursing homes but write:

“The bitter truth is that an older person can succeed at remaining in her or his own home and still live a life as empty and difficult as that experienced by nursing home residents. Feeling compelled to stay in one’s home, no matter what, can result in dwindling choices and mounting levels of loneliness, helplessness, and boredom.”

This is a stark message. But here’s an even more discouraging problem: in my research on the issue, I encountered one repeated refrain. There is no solid scholarly research which asks the question: “which choice is the better one, in terms of future quality of life, to stay or to move?” It’s not an easy question, to be sure: simply looking at the quality of life of the elderly and comparing those who live in single-family homes vs. various kinds of “elder-friendly” housing would not adequately distinguish between those who moved due to some sort of health problem and those who moved with the aim of preventing future health problems, for example. But there’s a data source that scholars have mined creatively to answer all manner of questions about retirement and aging, the Health and Retirement Study, and economists and similar researchers have been very creative in identifying “quasi-experiments” to answer this sort of question.

Discouragingly, though, given the relentless policy advocacy of supports for “aging-in-place,” it seems rather likely that this advocacy has discouraged researchers from considering that question in their research, depriving us all of what would otherwise be rather important information.

 

Author’s note: the terms of my affiliation with Forbes enable me to republish materials on other sites, so I am updating my personal website by duplicating a selected portion of my Forbes writing here.

Originally published at Forbes.com on June 5, 2022.

Americans, we’re told, want to “age in place,” as proven by repeated survey data.

And most of us probably think we know what it means — staying put in the home we raised our children in as we age: “the only way I’ll leave this house is feet first,” as my own father used to say.

But it turns out, it hasn’t always meant this, there is no single official definition, and not all experts even use what we might think is its straightforward meaning.

The CDC definition

At first glance, the term looks obvious: a google search turns up repeated references (for example, at the Rural Health Information Hub, Harvard Health Publishing, and the AARP) to a definition by the Centers for Disease Control:

“The ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level.”

But it’s not that simple.

This definition was not a part of some sort of Aging-in-Place research project at the CDC. It does not come out of a larger discussion of the topic. Instead, that definition comes from a web page called Healthy Places Terminology, and, what’s more, the page itself is stated by the CDC to be inactive, part of the Healthy Community Design Initiative, “no longer a funded program.” In fact, the page was last reviewed on October 15, 2009, and, according to the Internet Archive/Wayback Machine, that page first appeared in 2004, but the Aging in Place definition was not added until the end of 2008, and a broader review of the Healthy Places initiate indicates that the project was concerned not with aging but with community design to encourage physical activity, for example, encouraging sidewalks so that it’s easier to walk to get to places.

And, in fact, if you think about it, this definition of “aging in place” doesn’t really make much sense: what defines being in your “own home” vs. some other living arrangement? If you move to an apartment or a retirement community or an assisted living facility, is your unit still your “own home”? And why does the definition state that “aging in place” is about living “safely, independently, and comfortably”? Don’t plenty of people “age in place,” that is, live in their longtime homes by themselves, without safety, independence, or comfort, when they are homebound and dependent on others?

The AARP

The AARP, on the other hand, has conducted a number of surveys in which a definition of Aging in Place is implied, if not directly stated: to stay in one’s current home forever, or for as long as possible. The first survey, “Beyond 50.05; A Report to the Nation Livable Communities: Creating Environments for Successful Aging,” dates to 2005 (seemingly; it is undated) based on 2004 survey data, and reports that 84% of those 50 and older, and 91% of those 65 – 74 and 95% of those older than 75, somewhat or strongly agree that they want “to stay in my current residence for as long as possible.” In December 2011, they sponsored a similar survey, “Aging in Place: A State Survey of Livability Policies and Practices,” which addressed a variety of issues related to housing and aging, similarly reports that “According to a 2010 AARP survey, nearly 90 percent of those over age 65 want to stay in their residence for as long as possible, and 80 percent believe their current residence is where they will always live.” In 2018, AARP updated their survey, reporting that 76% of those aged 50 and older and 86% of those 65 or older wanted to stay in their own home. And in another survey in 2021, they asked similar questions, though with fewer age bands, and less detail in reporting, stating again only that over 75% of those over age 50 wanted to stay in their current home.

In all these cases, the AARP makes it clear that to age in place is to remain in one’s home, with the title of the webpage featuring the latest data proclaiming, “Despite Pandemic, Percentage of Older Adults Who Want to Age in Place Stays Steady.” And in all these cases, the reports offer an explicit agenda: government agencies, nonprofits, and adults planning for future aging should all direct their efforts towards making this possible and providing more support for in-place agers.

A generation ago

It also turns out that, going back further (though early studies are hard to find), “aging in place” did not have this meaning at all. For example, in “Changing Concentrations of Older Americans,” an October 1978 article by Thomas O. Graff and Robert F. Wiseman at The Geographical Review, “aging-in-place” was used to describe not a housing decision but the process, at a broader, regional level, that caused a disproportionate share of older persons in certain regions of the country due to the out-migration of younger people for economic opportunity while their parents stayed put, as opposed to regions where the share of older adults was disproportionately large due to their in-migration.

And when Aging in Place was used specifically of housing choices, it did not have the positive framing of the CDC, but was considered to be a negative.

For example, a 1982 dissertation, “Aging in Place: An Investigation of the Housing Consumption and Residential Mobility of the Elderly,” by James David Reschovsky, considers the stability of the elderly, that is, their tendency not to move even when it would be beneficial for them, to be a problem that reduces welfare, or at least an economic puzzle that requires modeling and empirical explanation. Unlike current proposals in support of Aging in Place, Reschovsky’s policy proposals include assistance to elderly households to ease their search for more appropriate housing. Strikingly, he writes, “It may well be that what has been assumed to be a strong attachment for the current home by elderly homeowners is in fact more of a strong attachment to homeownership, and the pride and security attached to it,” and continues,

“The other area where individual counseling and assistance may be appropriate is in helping the elderly household decide whether a move is in its best interests. Many households may need some encouragement and support to make a move, particularly those mentally or physically frail” (p. 175 – 176).

The scholarly literature

Finally, in current academic journals, “aging in place” gets a pretty expansive re-definition.

For example, in “The quality of life of older people aging in place: a literature review,” in 2017, authors Patricia Vanleerberghe et al., write that

“Aging in place used to refer to individuals growing old in their own homes, but lately the idea has broadened to remaining in the current community and living in the residence of one’s choice. Indeed . . . the World Health Organization Centre for Health Development defines the concept broader as: ‘Meeting the desire and ability of people, through the provision of appropriate services and assistance, to remain living relatively independently in the community in his or her current home or an appropriate level of housing. Aging in place is designed to prevent or delay more traumatic moves to a dependent facility, such as a nursing home.’”

Indeed, the authors later claim that Aging in Place is so broad as to include assisted living facilities, which they identify as “a type of supportive senior housing.” As it turns out, these facilities are actually classified by the US federal government as a type of nursing home, or at any rate they have the same “long-term care facility” classification that meant that they had the same Covid lockdowns for their residents every bit as much as for actual nursing homes.

And what’s the point of this redefinition into meaninglessness?

My best guess is that Aging in Place has been determined by the AARP and other “aging experts” to be the right, acceptable way of living as one ages, and has become the unquestioned national or international policy objective. As a result, anyone who might wish to discuss alternatives that are not the very clear “stay in the family home” meaning, feels obliged to stretch the meaning of that term so that they can claim that their alternative is also a form of “aging in place.”

But this clever redefinition has not actually helped experts or government officials figure out the best sort of policies or programs to help the elderly as they begin to have physical or cognitive impairments. In fact (stay tuned . . . ), it’s probably made it harder because “aging in place” has become a party-line that one contradicts at one’s peril!

 

Author’s note: the terms of my affiliation with Forbes enable me to republish materials on other sites, so I am updating my personal website by duplicating a selected portion of my Forbes writing here