Elderly Are Among the Fastest

¶ … elderly are among the fastest growing segments of the population in the United States today. Moreover, this growth is projected to continue well into the mid-21st century as the baby boomer generation reaches retirement age. Although estimates vary, it is also projected that about one in five of this elderly segment of the population will need some level of alternative living arrangement, including residence in a nursing home or long-term care facility. There is a consensus that most elderly people want to remain in their own homes as long as possible, but there comes a time in many people's lives where physical or mental problems force them to move into some type of alternative living arrangement where the daily care they need can be provided. Because there are some inevitable adjustment problems associated with moving from independent living to an institutional setting, it is important for elders or their caregivers to select the least restrictive alternative living arrangements possible. The purpose of this study was to identify what alternatives are available and how many elders are currently relying on these living arrangements in the United States.

Elderly Living Arrangements in the United States

Introduction

On the one hand, the types of living arrangements that are being used by the elderly (those 65 years and older) have become a hot topic in recent years (Goldstein & Damon, 1999). According to Kamo and Zhou (1999), "Living arrangements of elderly persons have been extensively studied in the United States. Particularly at issue has been whether the elderly live in an extended family household, a nuclear family household, live alone, or in an institution" (p. 544). As a result, there is a growing body of evidence concerning what types of living arrangements are needed by the elderly that indicates human capabilities are not predetermined by aging, but are rather a function of the interplay of physical health, behavior, and the environment (Bucher, 2005). On the other hand, though, while the living arrangements themselves have received a great deal of attention in recent years, less attention has been paid to the quality of life issues that surround these alternatives. In this regard, Bucher notes that, "Just as advances in medicine have created possibilities for men and women to experience aging more positively, the ostensibly more mundane physical settings of daily life shape life in ways that are often unexamined" (2005, p. 118).

One of the most important aspects of how the daily life of elders is shaped concerns accessibility to the types of care and services they require. In this regard, Durant and Christian (2007) note that, "It is a well-established fact that the United States is an aging society. Increasing longevity and life expectancy has increased the number of elderly persons with chronic health conditions who are in need of special social services and caregiving" (p. 37). Because the elderly segment of the U.S. population is projected to more than double by 2050, it is important determine what resources are currently available so that steps can be taken to ensure that the elderly have a sufficient amount of appropriate living arrangements available to them in the future, an issue that relates to the problem investigated by this study which is discussed further below.

Problem Statement

At some point in the lives of many older persons, a precipitating event such as a fall causing a broken hip, the death of a spouse, or a combination of factors such as diminished cognitive abilities and increasing frailty compel these elders to make a hard choice about where they should live. In this regard, Cox (1999) emphasizes that, "The overriding desire of most older persons, including the frail, is to remain in their own homes. However, the ability of these individuals to do so is often restricted due to few housing options or alternatives" (p. 101). Moreover, there are a number of environmental factors that can affect the ability of the elderly to remain in their homes. For example, Heumann, McCall & Boldy point out that, "The very location of a home can be an impediment. Homes located in areas with high crime, high pollution, steep topography, no pavements/sidewalks and heavy traffic with no safe way to cross streets, are all examples that can limit mobility and trap the frail elderly person in their homes" (2001, p. 31).

Likewise, there are a number of barriers inside elders' homes such as staircases, insufficient heating and lighting and even the types of furniture and how it is arranged, can all contribute to making life too difficult for elders to remain in their own homes. Even if all of these constraints are addressed, there may be other limitations that prevent the elderly from remaining in their own homes past a given point in their lives. In this regard, Heumann et al. add that, "Certain forms of living arrangements -- be they alone, with family or strangers -- can limit the ability to empower a person with desired support options. Even homes that are adequately furnished and located can be impediments if they are too costly and difficult to manage and keep clean" (2001, p. 31). The alternative living arrangements that are available to elders are can no longer reside in their own homes span the continuum of care from absolutely no care provided to skilled nursing facility and hospice care where the elderly receive intensive healthcare services (Scheve, 2010).

Rationale for the Study

The elderly population in the United States is projected to more than double between the present and mid-21st century to around 80 million. By that year, as many as 1 in 5 Americans could be elderly. Most of this growth should occur between 2010 and 2030, when the "baby boom" generation enters their elderly years. During that period, the number of elderly will grow by an average of 2.8% annually. By comparison, annual growth will average 1.3% during the preceding 20 years and 0.7% during the following 20 years (Sixty-five plus in the United States, 2010). Unfortunately, although there has been an increasing amount of attention paid to just how many older people the United States will have in the future, there has been far less attention paid to the quality of life issues that surround the continuum of care that is offered in the various types of alternative living arrangements that are available for the elderly in this country. There have been some recent political and social trends that have made this type of analysis all the more urgent. For instance, Szinovacz emphasizes that, "The rise in alternative family structures (divorce, children raised by grandparents, stepparenting) and current political pressures to cut programs for the elderly and poor may pose a serious threat to the safety net of future generations of older persons and may place undue burdens on the younger generation, especially those who are single parents" (1999, p. 700). Taken together, the business axiom, "Prior planning prevents poor performance" is highly applicable to the need to plan today for the alternative living arrangements that will be required by the elderly in the United States in the future.

Literature Review

The need for appropriate housing for older adults has become the focus of an increasing amount of attention from the public and private sectors in recent years, and current trends indicate the problem of finding suitable living arrangements for the elderly is going to become particularly acute in the future. Currently, about 10 million people who are 65 years of age or older in the United States rely on care that is provided by family members, and this figure is projected to double by the year 2040 (Future needs for long-term care, 2007). Other current estimates of the elderly population in the United States are as follows:

1. The elderly population, ages 65-74 years represents 7% (18,759,000 people) of the total population;

2. The elderly population, ages 75-84 years, represents 4% (11,145,000 people) of the total population;

3. The elderly 85 and older are 1% (3,625,000 people) of the total population; and,

4. The total elderly population, aged 65 years and older, represents 13% of the total population (Rubin, 2009).

Figure 1. Numbers of elderly in the U.S. By age group as of 2009

Source: Rubins, 2009

Clearly, the tens of millions of elderly must live someone, and while the optimum choice for many is to remain in their homes as long as possible, age-related disabilities and diminished cognitive and physical abilities frequently require alternative living arrangements at some point along the continuum of care that is provided for the elderly in the U.S. According to Sheve (2010, "When older family members are still too independent for full-time nursing-home care, many need a much lesser degree of help with daily tasks. These tasks include bathing, cooking, eating, changing clothes and getting safely into and out of the bathtub" (para. 3).

On the continuum of care for the elderly, assisted living facilities fall in the range between independent living arrangements at home alone or with family members or other caregivers to the other end of the spectrum of the type of care that is provided in nursing homes and hospices. 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 living facilities include: residential care, board and care, congregate care, and personal care (What is assisted living, 2010). 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 various living arrangements and how many facilities are available?

3. What is the continuum of care offered by the various living arrangements available to the elderly in the United States today?

Methodology

This study used a literature review methodology to answer the above-stated research questions with an emphasis on peer-reviewed and scholarly sources, but on locating the most recent resources available as well, which in some cases required consulting governmental and commercial resources. This approach is highly consistent with a number of social researchers who cite the need to review what is known about a given topic in order to formulate opinions or arrive at informed conclusions. For instance, Fraenkel and Wallen (2001) report that, "Researchers usually dig into the literature to find out what has already been written about the topic they are interested in investigating. Both the opinions of experts in the field and other research studies are of interest. Such reading is referred to as a review of the literature" (p. 48). A well-conducted literature review can also help identify any gaps in the relevant body of knowledge. As Gratton and Jones (2003) point out, "A literature review is the background to the research, where it is important to demonstrate a clear understanding of the relevant theories and concepts, the results of past research into the area, the types of methodologies and research designs employed in such research, and areas where the literature is deficient" (p. 51). Therefore, the literature review methodology was deemed well suited for answering the above-stated research questions.

Data Analysis

A summary of the various types of living arrangements that are available to the elderly in the United States today is provided in Table 1 below.