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Aging in What Place – Oversold concept or the refuge of denial?

The Washington Post article about aging in place was, uh, provocative.  It provoked me, anyway. The concept of aging in place has been oversold, says Professor Stephen Golant, author of a new book called less provocatively Aging in the Right Place. The Post encapsulation included a few gems from his book, noting that seniors who prefer to age in place have 'residential inertia' --  and paraphrasing their thinking as 'I’d rather rot in my own home.'  The premise that the concept was oversold to the public, however, makes a nice headline, almost sounding like a marketing campaign -- but that simply is not what has happened in the recent past. What else was going on?

Government enablers and incentives emerged to keep seniors out of nursing homes. Aging in place is not only a concept, it was a government strategy and policy for low income elderly, government agencies viewed it as cheaper than Medicaid-reimbursed nursing homes. So over the past twenty years funding programs like PACE and Medicaid Long Term Services and Support specifically focused on keeping people out of nursing homes and thus in their homes (or variants). To make this ‘aging in place’ a reality, nursing home building moratoriums appeared from time to time – and sometimes lasted for a very long time – as in Florida. Pretty soon a waiver system sprang up to use nursing home Medicaid funds for the equivalent of nursing home care – at (some sort of) home. And the Money Follows the Person program had a similar result. By 2000, due to this migration of money, many nursing homes closed.

Some aging in place hype came from notable names. Who could forget Henry Cisneros’ 87-year-old mother staying isolated in her cavernous house, her friends gone and the neighborhood in decline. But she wanted to age there, and he was thus inspired to write a book about independent living and hit the talk circuit. Sadly, she only lived another 3 years, dying at 90, never recovering from a fracture from a fall. Would her time have been safer, more pleasant, and possibly lengthened into another decade in an assisted living community with meals, care and watchful eyes of staff? Yes. Did she stay (rot?) in her home because aging in place was oversold as a concept or was she just stubborn?  By the time aging in place becomes the nightmare that it is for many, seniors are in their mid-80s and beyond – the move to senior housing more of an imperative than a choice.

Then there was that other law of economic unintended consequences.  The economic downturn of 2008 forced many middle class seniors to remain longer in their homes. There was nothing oversold or conceptual about a fragile economy that kept many in the past decade from selling their homes and moving somewhere. Maybe they are the young-old, moving into a 55+ community like the renown Florida cluster known as The Villages, for example, which may turn out to be the equivalent of Aging in Yet Another Place before Yet Another Move. It is intriguing to note that the 80+ population in that setting barely represents 7% of the 107,000 residents. Perhaps those of more advanced age move out. Perhaps they need the full services of pricier senior housing communities that are affordable only if prospective residents sell large assets like homes. Given today’s lengthening life expectancies, these moves must be sequenced to help the money last as long as an individual needs it. That may be the underpinning of so-called 'residential inertia.'


I agree with the comments. However, it is what you do not know that is the problem. Typically, everything goes well until a fall is experieinced and that has a cascading effect. If a house has not been modified for a walker/wheel chair, the default becomes assisted living if it can be afforded. Some folks will take the time and effort to modify a home after a fall but most will not. So what to do? If governments wants folks to age in place, there should be a free home evaluation done at age 60 with modification costs explained and how to contract for the work. Too many older adults get ripped off by unscrupulous contractros.

Yes we all agree that proactive home modifications are only a fraction of where they should be, but to blame it (even partially) on unscrupulous contractors only hurts the cause. I would never say that our seniors don’t get ripped off, but it has been my experience that most contractors are well intentioned, just untrained when it comes to an individual's special needs. Take for instance the CAPS program sponsored by the NAHB & AARP. It is more about how to sell to seniors, than about the physical needs. A lot of contractors that want to do more senior home modifications, still refer to ADAG, thinking that what is good for the masses (commercial application) should be good for Mrs. Jones. Wrong! She has special needs determined by her existing environment and her current abilities. Contractors, like the rest of us, don’t have a crystal ball to say what will be needed in the future. How you prep a house for a Stroke patient will be different than for one with Macular Degeneration. Yes, a physician ordered Home Evaluation, with both an OT & Contractor on site, would be a darn good start.

Thanks Laurie - - I thought the article was entirely simplistic, unhelpful and detrimental to the aging in place industry. it provoked me to write up some thoughts on what i think was right and wrong about this article.


Dr. Golant does have a point–that ‘aging in place’ has been twisted into a pretzel by AARP, some parts of the media and reverse mortgage shills. There’s even an implied slam on we who advocate care technologies. However, he offers, based on this article, no statistics and no solutions beyond what I sense is the forcible–removing those incompetent or unplanful older people from their homes for their own good into ‘retirement communities’. “The United States has so far failed to provide decent alternatives for older people to relocate.” In other words, is he saying that government should ‘nudge’ (that statist word) old people out of their present communities? Who decides? To where?

Here in the Northeast, there are two major incentives–high state/local/property taxes and winter! The dampers? Weak property values in many of those same places. Finances eroded by this grinding recession and zero interest rates. I’m not holding my breath for those affordable model homes and communities to appear like mushrooms after rain because they are not cute and sexy to VCs. The alternative is ghettoes of the aged? Toss me under the M42 bus, please.

I’d bet Dr. Golant is a big fan of Ezekiel Emanuel’s ‘remove personal medical interventions’ policy for those over 75 too. That’s one way to rid ourselves of the old people problem! (s/o)

Considering what Laurie Orlov’s written on the CCRC model, that can be a nightmare, yet I know people who’ve thrived in such communities. Perhaps we should be looking more at NORCs (naturally occurring retirement communities–Ed.) in larger communities and how they work, realizing that we have to bring the support–medical, emotional and physical–where the people are already, and making it attractive to us not-thinking-old-yet people. Yet what gets developed and funded are cute apps and fitness wearables–not a thought in the bunch about making them useful for or accessible to older adults.

The Brits are increasingly calling it technology enabled care support (TECS), a term I really like rather than arguing over what is telehealth, telemedicine etc. We should be looking at what GreatCall does right. That is why I am so cheered by the UnaliWear Kanega and buddi, and so disappointed that Apple is concentrating on the young and wealthy with the Apple Watch. Yes, there’s personal responsibility and planfulness. There is also a right to want to hang on to what is familiar (and the consequences, often devastating, of the emotional wrench when one can’t) and yes, to be cussedly stubborn.

We also have the right to be left alone from ‘make way for tomorrow’ types. At least for now. But ‘Houston, we still have a problem’ with aging, the sheer numbers of Boomers and ‘Silent Generation’, as to where and how we are going to live.

I appreciated the discussion generated by my book, Aging in the Right Place (Health Professions Press, 2016). https://www.healthpropress.com/product/aging-in-the-right-place/

Yes, I am plugging my so-called simplistic book that took me over two years to complete. I am a slow writer but I also took the time (unlike many journalists– although the Washington Post account was extremely thoughtful) to exhaustively examine the pros and cons of older people staying put in their own homes as opposed to downsizing or relocating to such senior housing options as active adult communities, independent living communities, assisted living, or CCRCs. I emphasized the importance of older people being proactive and coping with their inappropriate places and examine a host of options (e.g., family support, smart home technologies, and elder villages) now available to them. Many of these strategies will be successful; others not. Much depends on whether older persons are rich or poor, how serious are their health conditions, their personalities and importantly, the quality of their alternatives. The bottom line of my book was to avoid hyping any options and seriously recognize both the potentials and limitations of strategies designed to help older people age successfully—whether in their homes or elsewhere. And no, I do not want to stop living at age 75. As I frequently emphasize in my book, older persons in poor health, with disabilities, or unfavorable demographics are not precluded from happy lives, if they make the right living choices.



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