In this regard, Sheve adds that, "For these people, assisted living may be the answer. Assisted living facilities fill a gap between complete independence and around-the-clock care. It's an option for those who are 'mostly abled' and who still want (and can safely live with) a high degree of freedom and independence" (para. 4). Not surprisingly, the continuum of care required for the elderly is closely associated with the age, with older individuals requiring higher levels of care as shown in Figure 2 below. Figure 2. Percentage of elderly in the U.S. requiring assistance with everyday activities by age group

Source: Based on data from U.S. Census Bureau, Population Division at http://www.med carelifts.com/65plus.htm

In response to the growing elderly population, there are currently more than 23,000 long-term care facilities of some type in the United States that deliver care for more than a million-and-a-half elderly residents, and the number of long-term care facility residents is projected to increase by more than 50% during the period 1989 to 2020 (Osgood, Brant & Lipman, 1999). The implications of these alternative living arrangements for the elderly, though, are profound. Besides the fundamental adjustment problems that many elderly experience when moving into an institution of some type, Nishtala, McLachlan, Bell and Chen (2008) also emphasize that, "Mental and behavioral disorders are highly prevalent among long-term care facility residents and pose a major challenge to behavioral management in this setting. The estimates of the prevalence of dementia and other psychiatric disorders among long-term care facility residents range from 30% to 62%" (p. 621).

It is reasonable to suggest that many elderly residents of long-term care facilities would have opted for a less institutionalized setting, including most preferably their own homes, but the key issue involved is the amount of resources that are available for housing and requisite care. In this regard, Kamo and Zhou (1999) advise that, "In order to sustain independent living, an elderly person has to secure sufficient resources. Resources of an elderly person may be measured by labor force status and income. Previous studies have shown that elderly living arrangements are affected by income and other economic resources, such as home ownership" (p. 545). This point is also made by Szinovacz (1999) who notes that, "Limited economic resources constrain both adult children's and parents' choices of alternative living arrangements, such as formal help or placement in retirement homes. Consequently, coresidence appears to be more prevalent among lower socioeconomic status groups" (p. 700). Most authorities appear to agree that the significant increase in the numbers of elderly living alone is primarily attributable to concomitant increases in their economic independence (Phua, Kaufman & Park, 2001). As a result, "Today's elderly and their children prefer a modified extended family, whereby even though parental elderly and their children live apart, they keep close contact. However, independent living is more common among elderly whites than among elderly minorities. Elderly minorities' extended living arrangements are often argued as culturally desirable" (Phua et al., 2001, p. 263).

When an elderly individual becomes too disabled or incapacitated to remain in the home, the next level on the continuum is care is most likely an assisted living facility where they may or may not require the full range of services the facility offers. Assisted living facilities provide living arrangements for the elderly who may require assistance with daily living needs such as dressing, bathing, eating, and toileting; however, the continuum of care is still less than that provided by the more intensive medical and nursing care that is delivered in nursing homes (Assisted living, 2010). According to Chesser, Harrison and Barry (2002), "Assisted-living facilities include small homes to large apartment-style complexes that offer a way for older adults to maintain an independent lifestyle in a residential atmosphere that provides them with some assistance and support" (p. 53). Depending on the cost, these facilities can also range from the bare minimums to the luxurious and plush, but they are characterized by certain commonalities in the types of services they provide. In this regard, Chesser et al. note that, "While the types and sizes of the facilities can vary, all provide meals and social activities and are staffed with people who can help residents with activities of daily living, such as bathing and dressing" (2002, p. 54).

Assisted living facilities can be stand-alone operations, or they form part of a larger complex such as a nursing home, retirement community, or senior housing complex (What is assisted living?, 2010). The terms used to describe these facilities and the licensure requirement for them differ from state to state, but some of the more common terms that are used to describe assisted...

The elderly who reside in assisted living facilities typically live in their own residence which may be a unit or an apartment (What is assisted living, 2010). Other commonalities of assisted living facilities include having a support staff on-site and providing a certain number of meals each day; besides the foregoing commonalities, a majority of assisted living facilities also provide some of the following services as well:
1. Health care management and monitoring

2. Help with activities of daily living such as bathing, dressing, and eating

3. Housekeeping and laundry

4. Medication reminders and/or help with medications

5. Recreational activities

6. Security

7. Transportation (What is assisted living?, 2010, para. 3).

The next level in the continuum of care can be represented by so-called "foster homes" for the elderly that have emerged in recent years. According to Cox (1999), "Foster homes differ from board and care homes in that they generally house no more than six elderly residents and frequently have only one resident. Moreover, unlike board and care homes, they provide supportive services and have close linkages with rehabilitation programs and social services. The foster care home is also a family setting with care provided by nonprofessionals" (1999, p. 101). Although this alternative living arrangement for the elderly remains in the developmental and formative stages in many parts of the country, this option may represent the best approach for the growing numbers of elderly who are projected to require assistance with their day-to-day living needs but not at the level provided by assisted living facilities, nursing homes or hospices. In this regard, Cox emphasizes that, "Foster care programs offer another alternative in living arrangements for the frail elderly. But, as with other programs, they remain fragmented, being offered through varying systems with differing eligibility" (1999, p. 101). At present, foster homes for the elderly represent a viable alternative for many elders, but due in part to their recent innovation, the care they are able to provide is fragmented and underfunded. As Cox concludes, "Foster homes also suffer from a lack of resources. Funding of caregivers comes from the resident's resources, SSI benefits, VA pensions, and in some cases Medicaid. In order to be truly effective as a housing option for the frail, such programs need to be more highly coordinated, administered, and supported" (1999, p. 101).

The next level of the continuum of care is perhaps best represented by nursing homes. According to Osgood, Bryant and Lipman (1999), nursing homes represent a type of "total institution" for elders that involves a far more restrictive lifestyle than independent or assisted living facilities provide. "Privacy is at a minimum," Osgood and his associates note and add that, "Residents living in total institutions are told when to eat, when to sleep, and when to bathe by staff members who exert control over their lives. In such a situation, personal freedom and autonomy are greatly reduced" (1999, p. 8). Residents in nursing homes are also "plagued by loneliness, depression, and alcoholism. However, nursing home residents also face a multitude of other losses, stresses, and problems associated with living in an institution, including loss of home and possessions, personal freedom, privacy, and independence" (Osgood et al., 1999, p. 8).

Conceptual Framework

It was the conceptual framework of this study that the optimum living arrangement for the elderly is to remain in their own home until they are no longer able to care for themselves, at which point an appropriate alternative living arrangement will be required based on individual needs. The selection of the alternative living arrangement should provide the elderly with the best mix of care provided using the least restrictive environment possible. The continuum of care involved in the alternative living arrangements for the elderly in the United States can be conceptualized as shown in Figure 1 below, ranging from the least restrictive to the most intensive.

Least Restrictive -( Most restrictive

At home -- alone

At home -- with family member(s)

Retirement home/center or foster home with limited assisted living offerings

Assisted living facility/Skilled nursing facility

Nursing home

Hospice-level care

Figure 3. Continuum of care needs in alternative living arrangements for the elderly

Research Questions

This study was guided by the following research questions:

1. What living arrangements are available for the elderly in the United States today?

2. What is known about the numbers of elders living in the…