|
We often have a dismal image of old age in our society: decline, followed by depression, ending with death. Shakespeare, parading the seven ages of humans across the world's stage, declares the "Last scene of all,/That ends this strange eventful history,/Is second childishness and mere oblivion;/Sans teeth, sans eyes, sans taste, sans everything."
The myth of aging is everywhere. We are all affected by it, even if at one level we understand that it's simply a story we have created and may not necessarily correspond to the reality we experience. The myth of aging is a powerful, destructive one that profoundly affects the community we create and the extent to which we involve the old in it. Since (if we are lucky enough) we will all be old someday, it's in our own best interest to address this myth so that we can remain an active and valued part of community as we age.
The fact is that older adults today are better educated, healthier, and more financially secure than any other previous generation. They are also more engaged in learning and interested in contributing to their communities. Keeping older people involved in their community can substantially reduce the anticipated drain on financial, health care, and nursing home resources associated with an aging population. A key issue in aging is social integration, the extent to which a person is actively connected and engaged with their family and community. Cross-cultural evidence shows that older adults are able to maintain a fairly high level of physical and emotional well-being when they have something considered valuable by others in their society, whether it be customs, skills, knowledge, or economic resources.
Today's older adults want more than to simply "keep busy." They need activities with meaning. Meaning has to do with feeling that your life still matters (to yourself, at the very least) and that what you do makes sense. It has to do with the conviction that your life is about something more than simply surviving. Volunteer activities, in particular, have been found to bring new meaning to the lives of men and women at midlife and beyond by allowing them not only to perform useful services but also to function as mentors for those who are younger. Older adults can also participate by helping to care for the young, like their grandchildren, and continuing to be involved in paid labor.
But what about older adults with serious health problems, frail older adults, and the oldest old? The life issues faced by older adults who are well include living with loss, a need for meaningful activities, and the desire to be useful members of society and not be isolated. Frail and functionally limited older adults have the same needs, but require some special consideration for losses of physical strength and perhaps cognitive ability.
In recent years, researchers have divided older adulthood into three general groups: "young old" (65-74), "old old" (75-84), and the "oldest old" (85+). The oldest old are largely widowed (70%) and mostly women (70%). This age group is growing faster than any other segment of the population. In 1999, the 65-74 age group (18.2 million) was eight times larger than in 1900; the 75-84 group (12.1 million) was 16 times larger; the 85+ group (4.2 million) was 34 times larger. The oldest old have the highest potential for functional disabilities. Over 70% of the oldest old have some limitations in one or more activities of daily living. Yet, nearly 45% still have relatively good health and need little assistance in preparing meals, shopping, managing money, or doing light housework. 25% do need some help with certain activities of daily living, while 30% need substantial help.
Ensuring that older people can "age in place" is an increasingly important issue. Studies show one of the biggest concerns older adults have is their ability to remain independent, in their own home. Remaining in their life-long home preserves neighborhood-based social relationships. It allows older people to stay connected with their community. Yet, to remain connected to their community, they need the support of their community. They need adequate health care. For many people growing old is defined by, and is a process of adapting to, declines in physical health. They don't feel old unless they are physically ill or depressed. Once their health is adversely affected and a person is unable to receive adequate care, a rapid decline often follows. After health care, daily living supports are important. Even the oldest old can function to their maximum capabilities when the environment provides the context and supports consistent with their abilities. This includes help with items like transportation, home repairs, housework, meals, and personal care activities like bathing. Finding the needed services and paying for them are critical issues for most of the oldest old. When spouses or children are unable or unwilling to provide support, the oldest old look to neighbors and friends. In one study, 30% identified a friend and 13% identified a neighbor as being able to provide the most assistance.
Although most older adults prefer to remain in their own homes, they can become isolated when functional limitations make leaving the house and/or seeking assistance from others difficult. Sometimes help is available, but older adults are hesitant to accept it. In What's Worth Knowing by Wendy Lustbader, 86-year-old Dorothy Bobrow comments on accepting help:
My mother was pushing ninety, but she still wouldn't let us give her a hand with anything. "I'm fine." That's all she'd say, but we knew she wasn't. She had heart problems, breathing problems, you name it, just like I do now. And look at me! I've been pushing everyone away, just like she did. It's my pride. I don't want to have to depend on anyone. I want to stand on my own two feet. But it's hard for me to carry my laundry basket and use my cane at the same time. The other day, I let my granddaughter do a wash for me. You should have seen her face, so proud to be helping her grandma. I know this is the way it should be.
For many of the oldest old, there may come a point where no amount of help allows them to remain in their own home. Residential change of any kind is difficult for older people. It generally involves separation from family and friends, and a loss of personal control. Nursing homes and other assisted living facilities are seen as a last resort.
There are 1.6 million older adults living in about 17,000 nursing homes across the US. Women have historically made up about 75% of residents in nursing homes. The average age for women is about 83 years, while for men it's 76 years.
We approach nursing homes much the same way we approach schools: segregation and isolation. Nursing home residents, like children, are often isolated from their communities because of age and capabilities. Like the grade system in schools that favors administration over education, nursing home administrators sort and group residents with similar problems. Whether we're talking about schools or nursing homes, lives are determined by institutional needs – and we fail in the essential community goals of educating the young and caring for the old. But, as with schools, nursing homes can become models of the larger sense of community we need in our neighborhoods, cities, and nations.
The place we live at the end of a long, full life should be a reward, not a punishment. We can start by putting the "home" back into nursing home. What does "home" mean to you? Comfort? Acceptance? Safety? Personal control? Many of these elements are missing from traditional nursing homes. No matter how old, infirm, or cognitively debilitated a person is, they share the same basic emotional needs as their healthier counterparts. There also remains some part of that person which is still healthy and capable of growth. Some physical decline accompanies aging in even the healthiest of adults. Sensory losses, decreased muscle strength and reflex time, and diminished energy levels are all normal parts of aging. When these declines are coupled with a disease like Alzheimer's, for example, a person becomes even less able to handle the tasks of daily living. But by creatively addressing the physical and social environment, nursing homes can help maximize the strengths, self-respect, and dignity of all older adults, regardless of their capabilities.
Creating community within a nursing home is related to how individuals interact with each other, staff members, their family, and how they contribute to the facility. In traditional nursing homes, people often lose the roles, relationships, and social support that have sustained them over a lifetime. They are disconnected from their own past. The environment is ideal for feelings of isolation and neglect. For many residents, life in a nursing home consists of a repeated daily cycle of predictable activities occasionally punctuated by a specially scheduled social event, a visit from the "outside," or the stress of a health crisis. Over weeks, months, and sometimes years, the repetitive rhythm and routine of each day provides a sense of familiarity and regularity, but also a sense of lifelessness.
Choice can bring back life, and with it meaning. Even functionally limited older adults should be allowed to make decisions, even small ones. Research has shown that involvement or lack of involvement in everyday decisions such as the placement of room furniture, choice of clothing, timing of meals, choice of seating in the dining room, and routine health care greatly affects residents' well-being. Listening to residents, above everyone else, is vital to determining who should make what decisions and why. Different people may have different views of an individual resident's capabilities and needs. A daughter may only come to visit for an hour or so. The nurse only has a shift at a certain time. The social worker only looks at one aspect of care. Everyone has a different perspective. Are decisions reflective of institutional, professional, and personal norms and expectations or of a fully informed understanding of a person's wishes and abilities? Institutionalization can take on a momentum of its own. Even though respect for autonomy is realized and widely acknowledged, action doesn't always reflect the rhetoric. In many cases, it's simply easier to make the decisions for residents.
The approach in nursing homes should be participant-centered. A shift in orientation to a person-centered philosophy allows the experiences and preferences of residents with regard to decisions affecting their lives to be more widely and routinely acknowledged and integrated into the daily life in the nursing home. Even if residents are compromised in some aspects of their self-responsibility and decision-making, they should still have a say about what they wear, where they sit at meals, and how their possessions are arranged in their room. Rather than paternalistic care that reinforces learned dependency, there is a need for a philosophy that focuses on maximizing individual potential. Older adults should also choose how they fill their days. Even in the case of people with significant impairments, choices should be respected as much as possible. For most people, some choices are taken away as they age. You can no longer have children, you are no longer employed, you may have physical limitations. But, the need for autonomy – the right of an individual to govern themselves according to their own reason – remains. Of course, health and safety issues must be considered; but these, sometimes along with ease, are often over-emphasized to the detriment of self-esteem and autonomy. There is a fine line between "careful enough" and "too careful" – but finding that line is important.
The older we get, the less time we have left, making each hour even more precious than the last. Older people need to feel that their time is valuable, and they deserve to fill their days with activities that are enjoyable and fulfilling. A facility for older adults should never resemble a preschool. One of the primary determinants for activities should be meaningfulness. If a person is stringing beads, perhaps it can be as a gift for a grandchild. If they're making a meal, they should know what it's for – lunch, or perhaps to be delivered to a house-bound person. Gardeners can find satisfaction when they see the flowers they helped care for being admired by visitors or decorating meal tables. In many cases, the most successful "activities" are just an extension of everyday life. Allowing people to do what they would do in their own home – make coffee in the morning, sit quietly with the newspaper, chat with friends, work in the garden – is most meaningful and life-giving. The role of staff shifts from telling people what to do to offering a variety of choices and adaptations which allow people to find continued satisfaction in their lives.
In addition to building community within nursing homes, it's also important to connect nursing homes with the surrounding community. One way to do this is through visitors. Never underestimate the power of a visitor. In What's Worth Knowing by Wendy Lustbader, 87-year-old Sue Powers talks about waiting for a knock on the door:
I remember how I thought of old ladies like me years ago – they were cute. In my family, there were lots of great-aunts, shrunken and shriveled ladies living by themselves in tiny apartments, neat as a pin, with pretty teacups. They were so happy to see me when I bothered to drop by on my way somewhere else. That's how it was. I gave them the crumbs of my life, five minutes here and there. It never occurred to me that they were once just like me, that I could pull up a chair and get to know them as people, not just porcelain dolls. Now I'm a shrunken old lady stuck in my apartment, and I know how those aunts of mine waited and hoped for a visitor to brighten their day. My nieces do come over, but it's once in a blue moon. I never know when. A visitor is like gold. It's too bad we can't understand this when we're young and can still do something about it.
There's a misconception that nursing home residents are "abandoned" by relatives. In fact, family members and friends do stay in contact and continue to contribute to the basic care needs of residents. But one recent study showed that contact with family members decreased by approximately half following admission to a nursing home, compared to reported preadmission contact. Many residents do see family members weekly. When family is geographically closer and when a spouse is still living, residents are more likely to get regular visitors. But another study reported that 16% of residents receive no visits by family and 40% receive no visits from friends. Also, those with dementia seem to get fewer visits than those who are simply frail. Loved ones may need more information about dementia in order to increase their comfort level while visiting a cognitively impaired resident.
Visiting programs not only keep older adults connected to their community, but can help young people learn how to build and participate in community. Elementary-aged children, especially those in fourth to seventh grades, are curious and resourceful. They easily and enthusiastically participate in nursing home visitation programs. They are also often eager to help in a nursing home once they become comfortable. They can help by interacting with residents, pushing wheelchairs, operating the elevator, caring for and handling animals and birds. They learn how to interact with people different than themselves and they learn responsibility – because the older people depend on them.
Broader intergenerational programs in nursing homes can also go a long way to creating community and improving the lives of older adults. One study looked at the effects of participation in an intergenerational program on the behavior of nursing home residents with dementia. Analysis showed participation in activities with small children lowered residents' agitation levels. Other studies have shown that residents with dementia appear more alert and active, and smile more when they are around children. They derive benefits from direct interaction, as well as just passively watching children play. As they focus on the children and their needs, older adults tend to forget their own problems and be pulled out of themselves. And children, especially toddlers, enjoy being the center of all the attention.
Even the oldest old in nursing homes can give love. They can also act as mentors. If nothing else, they can teach us how to be old, and how to look past our differences to our commonalities. In Am I Old Yet?, author Leah Komaiko chronicles her relationship with Adele, a 93-year-old living in a nursing home who is in good health but legally blind. Komaiko volunteers to visit with Adele for one hour each week. Why does Komaiko decide to volunteer?
To begin with, I was not aging graciously…
I was forty-four and in the middle and stuck there forever. I didn't know what I was supposed to do with myself… A clear breeze seemed to come through my head and I heard the words, "Volunteer. Go visit someone who really is old and alone. Get over yourself. Be like a Girl Scout. You'll like it." The next day I called a [local] nonprofit organization called the Elder Corps that found companions for the old and lonely.
Komaiko struggles as she gets used to visiting the nursing home:
Twenty years ago I was still young enough to believe those people could never be me. I thought I would never die. Now I knew I was going to die. I just didn't believe it would happen in this lifetime.
The two women get off to a rough start, but a close friendship slowly develops. Toward the end of the book, Adele sums up the relationship:
I was thinking how much I enjoy our visits. I've met a lot of people in my day and after all these years, I've never met a person like you. I hope I never lose you. The tremendous difference in our ages and lives doesn't seem to make any difference at all.
Komaiko replies, "Back at you."
Beyond making nursing homes real homes, encouraging visitors, and implementing intergenerational and even mentoring programs, we should experiment with making nursing homes an actual part of the community. What if we did away with the entire concept of nursing homes, and replaced it instead with places to care for people of all ages? In doing so, we wouldn't marginalize the old in a single cluster of infirmity. We would also connect the old, who are at a stage in life where they experience many losses, with the vitality of the young – connect them with, in the words of one older person, "friends who won't die on you." Unlike institutions, real communities are collections of people of all ages and stages who cooperate voluntarily in different ways for different reasons. Community is defined by a diverse membership bound together and dedicated to the mutual accomplishment of necessary tasks. Social diversity is as important to the nursing home as it is to a true community. Perhaps nursing homes should become places that also care for and educate children, places where food is consumed, places where we gather and play. Why not have a summer camp for children? What about an after-school program? What about a daycare? What about a meeting place for 4-H Clubs, Girl Scouts, Boy Scouts? The possibilities are endless and enticing.
Understanding and connecting with the oldest old does not take exceptional skill – it does require the will to share part of the common and everyday quality of their lives. The holy book of Islam, the Qur'an, clearly prescribes how people are to treat each other – with caring. If parents attain old age, they are to be shown no sign of impatience or reproach, but be spoken to with kind words. When we care for the old, we are being given the opportunity to show our own children how they are to treat us when we grow old, and to learn more about ourselves and our own aging.
Our legacy will in large measure be determined by how we treat each other, our children, and our old – in other words, the community we create.
Click here to view all of the Legacy Project's Across Generations guides and activities. You can also create your own Life Statement.
Be the first to find out when new online resources are added to the Legacy Project website by subscribing to our free quarterly e-mail newsletter.
|
