How Seniors Want to Live Out Their Lives
By Clay Beach, Beach List Direct - 2006

Basically, there are two kinds of senior living choices: assisted living facilities and skilled nursing facilities or nursing homes. The literature on senior living and long term care make it clear that most older adults prefer a third choice: they want to remain in their own homes as they age. As longevity increases, however, many seniors need at least some help by their 80s or 90s. Assistance might be needed for cooking, shopping and bathing. Others will require substantial assistance, which could mean a move to housing where care can be had 24/7. The goal for seniors who can still attend to their everyday needs to some degree, is independence, i.e. as much as is possible given factors such as chronic illnesses and the level of self-care possible.

Assisted living can mean different things to different people depending on their needs. Normally, such a setting works for a senior who is still active and relatively healthy, but still needs more help than he or she could get at their home. Such facilities can give seniors as much, or as little, help as they need, and can offer some nursing care. Residents often live independently in their own units, are offered meals and housecleaning and often can take advantage of “field trips” coordinated by the retirement community.

Some of these facilities are part of continuing care communities that offer graduated care as older people become more frail or less cogent.

Nursing homes have traditionally been reserved for seniors who need 24-hour nursing care or who might wander away without supervision. They generally need far more care than a caregiver can give, and they cannot live alone.

The latest outgrowth of this “declaration of independence,” as noted by AARP, are community-centered concierge services favored by independent seniors who remain in their own homes and have the financial stability to keep it that way. Beacon Hill Village in central Boston, for example, is considered “revolutionary” by AARP for the services it willingly provides for senior residents who want to remain in the tony neighborhood. The village works with its 320 members to help them with virtually any service they need, from around the clock nursing care to twisting the top off of a pickle jar. They get these services, the AARP says, on discounted fee schedules.

Joseph Coughlin, a nationally noted expert on aging at the Massachusetts Institute of Technology (MIT) was impressed enough to declare that this approach could shape the direction of senior living for decades to come. Beacon Hill Village has received more than 200 inquires from interested seniors since the service began three years ago.
“With Beacon Hill Village you have life, you don’t have retirement,” Coughlin told the AARP. Adds village founder and member J. Atwood “Woody” Ives, “Even the places they call active retirement communities tend to be depressing. They’re so artificial – everybody there is old.” His reference point is the mix of different kinds of people he still has in his social milieu and that it contributes to his quality of life. Establishing this concept elsewhere, in suburbs and beyond may actually be easier because the cost of living outside central, urban hubs is lower.

“What we need,” Coughlin says, “are folks with the passion to work these things out. Those folks cold be entrepreneurs “who see an explosion of disposable income and a demand for services that needs to be met.” Interestingly, one of the biggest obstacles to the Beacon Hill concept was the residents themselves. AARP says that of the 13,000 people living in the village, 14 percent are age 60 or older and many of them were the most resistant. Mainly, their protests amounted to a human foible: people hate to admit that they need help, even when they’ve reached their 80s and 90s. The problem with that approach, experts say, is that they actually end up constricting their lives by pretending they don’t need any help, and they then pull away from the social structure that keeps them going.

Despite the viewpoint of village founder Woody Ives, assisted living facilities are not all the same. Planning ahead and doing your homework, with the help of family members or friends, can make all the difference in a satisfying living arrangement.

“Older people generally hold varying, multiple and potentially conflicting preferences for their long term care, and current policies and practices often fail to meet their wishes,” write two aging experts, Robert and Rosalie Kane, in the journal Health Affairs. “Ageism, that is, basing attitudes and treatment of a person on age, has long been recognized as a problem in the care of old people. This ageism is reflected in the differences between how older and young persons are treated in long term care policies and programs.”

The authors note, for example, that while policy on assisted living for younger seniors has shifted toward their receiving services in the “most normal social settings possible,” where they can influence their helpers and the assistance they receive, older seniors have fewer and more restricted options that reflect “paternalism,” or “doing something to or for a person against his or her will for his or her own good.” They note that while the preferences of others can be relevant, they are sometimes given “undue weight.”

“The ultimate way to maximize choice”, the authors say, “is to ensure that people have the cash to purchase the services they prefer. This approach is actively espoused by many spokespersons for young adults with disabilities. It has gathered momentum from the recent Olmstead decision, which ruled that persons with disabilities are entitled to care in the most integrated setting possible. Various coaches, counselors or surrogates are effectively used to promote community living and self-determination for cognitively impaired persons.”

Based on the sporadic research that has been conducted on the living preferences of older adults, experts have found that nursing home residents find certain aspects of care particularly important, including kindness, caring, compatibility and responsiveness. They also value control and choice on aspects of their daily lives, particularly in being able to leave the facility and communicating with other outside the facility by phone or in person.

When older adults need long term care and come to grips with their preferences, they value having private accommodations. Private rooms and baths are rare in nursing homes, but are more common in assisted living. Most residents prefer a smaller private space than a larger shared one and would trade activity programs for that privacy. On the other hand, they consider competent care a “nonnegotiable” necessity.

Older home care consumers value interpersonal qualities, such as the caregiver liking and caring about them, being compatible with the caregiver, reliability, task competence and adequacy in the amount of care and help received.

In a large study, seniors receiving in-home services varied in whether they preferred flexible or fixed routines and whether and how they wanted family members involved in their care. Most placed a high priority on privacy, with that concept varying from bodily privacy, to financial affairs, to being literally alone.

These differences in seniors’ preferences create conflict between safety versus choice, control, individuality and continuity. Families often opt for nursing homes because they fear leaving relatives at home where some accident may occur. When that quandary was put to home care clients themselves, about one-third preferred to be in control of their activities and be less safe; about a third preferred to be safe and protected even with restrictions; and a third were ambivalent, undecided or felt they were entitled to both safety and autonomy.

The Kanes note that research of older persons’ preferences has found that many are actually attracted to congregate settings where services and care are easily found, i.e. they are choosing assisted living that provides a private apartment but also congregate meals, housekeeping, personal care and access to health care.