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BOOK REVIEW |
Professor Emeritus and Director Long Term Care Resources Program Duke University Center for the Study of Aging and Human Development Durham, NC 27710
Physical Environments and Aging: Critical Contributions of M. Powell Lawton to Theory and Practice, edited by Rick J. Scheidt and Paul G. Windley. The Haworth Press, Binghamton, NY, 2003, 155 pp., $49.95 (paper).
Reinventing Care: Assisted Living in New York City, by David Barton Smith. Vanderbilt University Press, Nashville, TN, 2003, 208 pp., $24.95 (paper).
Residential Choices and Experiences of Older Adults: Pathways to Life Quality, edited by John A. Krout and Elaine Wethington. Springer Publishing Company, New York, 2003, 256 pp., $43.95 (cloth).
The Paradox of Aging in Place in Assisted Living, by Jacquelyn Beth Frank. Bergin & Garvey, Westport, CT, 2002, 222 pp., $66.95 (cloth).
Polly Adler, a celebrated American madam of the last century, famously observed that a house is not a home. Older adults understand the distinction. Beyond being where the heart is, one's home is usually associated with family, shared memories, and comfortable familiarities. A home promises autonomy, a sense of security over the long term, and being able to age in place if one chooses.
A majority of older Americans still reside in and expect to live out their lives in their own homes or some acceptable alternative. When the Duke Longitudinal Studies of Normal Aging were begun a half-century ago, the initial study sample was drawn intentionally from older adults living in the community (rather than in institutions) where, even then, the great majority of older adults lived. Current studies of migration of older adults still confirm that staying put remains their option of choice even though some home improvement now and then may be required as well as help from one's friends and family.
However, there has been a growing awareness over the last four decades of an increasing number of very old adults who have elevated risk for security and supportive services of the sort found in hospitals, nursing homes, and special sheltered settings that are decidedly not like home. Recently, assisted living housing has been enthusiastically promoted as a home away from home for at-risk elders, as shelter that promises reliable availability of appropriate services in the long term with minimum compromise of autonomy as one ages in place. Affordability has not, however, been promised, so where one ages remains tied to socioeconomic status.
Social gerontologists interested in physical environment and aging have expectedly been interested in the housing of older adults. Ecological psychologists over several decades were particularly interested in documenting the effects of placing older persons with defined functional capacity in physical environments with defined characteristics. Some person-environments do appear to fit better than others and consequently to produce a better quality of life. Ecological psychologists with interest in housing were joined by architects who explore the effects of alternative environmental design and by policy analysts who promote the use of public resources to enrich physical environments. Academic interest in research on housing of older adults, however, declined over the past decade although economic research was stimulated by a booming market for assisted living housing, a type of shelter with a distinctive philosophy emphasizing the appearance and feel of a home, maximum feasible autonomy, and reliable availability of appropriate services in the long term (Maddox, 2001).
Four recent volumes illustrate current themes and issues in conversations at the beginning of the new century about the availability of housing and homes in later life. Although the review of them in this essay is particularly focused on assisted living housing, a variety of conceptual and methodological perspectives are also noted.
Reinventing Care
David Smith's Reinventing Care: Assisted Living in New York City tops my list of "must read" books for gerontologists interested in assisted living as the "new thing" over the past decade in research on environment and aging. Smith, a professor in the Department of Risk, Insurance and Healthcare Management at Temple University, approaches caring in the long term variously as a care manager, historian of housing for older adults in New York City, keen observer of financial markets, systems analyst, policy analyst, and proponent of community action for social change. An indication of his distance from the field of gerontology is that there is no reference to ecological psychology and no mention of the work of the late M. Powell Lawton or his numerous colleagues. What the reader gets is nonetheless a very readable, brief history of long-term care experienced in New York City from the Poor Laws through Medicare/Medicaid and naturally occurring retirement communities (NORCs), to nursing homes and the new thing in housing, assisted living. Along the way Smith makes clever observations about how Florida tends to cream off the fittest New Yorkers only to send the sick ones back to be cared for in New York.
The current New York experience with long-term care, Smith observes, reflects the Depression of the 1930s, the social movements of the 1960s, and the economics of the 1990s. Remember the years of "tender love and greed" in the history of nursing home development after Medicare and Medicaid stimulated the rapid development of a nursing home industry, or the boom and bust of the real estate market in assisted living housing in the 1990s? Smith's play-by-play accounts of how in housing "silver was turned into gold" and real estate investors' discovery that "where there is gray there is green" will keep your attention. Ridicule aside, Smith concludes that interest in the potential usefulness of assisted living, however, was real enough; in recent decades needful 85-year-olds were increasingly visible, nursing home use was decreasing, hospital discharges were earlier, and there were buyers for the promised homelike places in which one had expected to grow old with dignity. The blessing and the curse of the assisted living hype, he observes, were that its selling points were only partly true.
The implicit genius of the assisted-living strategy was its initial focus on consumers and its promise to package, and hopefully integrate, a broad range of services that health care and senior services previously offered separately, such as homelike environments with reliably available supportive services as well as privacy, autonomy, and the promise of being able to age in place. This is the sort of combination of responses to needs in later life that Smith calls, using systems language, "killer solutions." Such proposed solutions are illustrated by continuing care retirement communities (CCRCs) and the Programs of All-Inclusive Care for the Elderly (PACEs). But as Smith concedes, such solutions exhibit significant socioeconomic limitations, with CCRCs priced out of the market for most older adults and PACEs dependent on substantial public subsidy.
Taking the long view of a historian aware of New York City's demonstrated adaptive capacity, Smith seems optimistic that some form of assisted living will be part of the reinvention of appropriate supportive care for at-risk older adults. A major handicap will be the reduction of socioeconomic differentials in the capacity of most at-risk older persons to purchase needed care. Rosalie Kane (2003), an astute observer of long-term care housing policy and performance nationally, has recently reached a similar but somewhat more guarded view of the future of assisted living housing. Smith seems equally, if not more, enthusiastic about the potential of NORCs as a form of enriched housing to meet the needs of increasingly at-risk older adults. In any case, the sustained involvement of communities in solving problems of housing at-risk elders will remain a vital part of how the future of long-term care plays out. In creating this future, Smith argues, philosophy and values will matter. Aging in place is both difficult and not cheap. What will work will depend on community involvement, civic leadership, and public will.
Hopes Unrealized, Promises Not Kept
Jacquelyn Frank's The Paradox of Aging in Place in Assisted Living contrasts sharply with Smith's hopeful forecast. Her focus is as narrow as Smith's is broad. Frank's anthropological field report is based on a decade-long investigation of two assisted living facilities in Illinois, supplemented by interviews with a number of facility managers in Chicago. As an academic researcher, she exhibits disappointment, perhaps surprised outrage, at what she observed and heard. Asked about how the promises of assisted living had worked out—home, choice, aging in place—residents reported "not so." Unlike Smith who offers his historical perspective and his experience as an administrator of complex services, Frank reacts to promises apparently unkept with no apparent sense of irony about why this is likely to be the case or why there are likely variations in the experience of different residents in different facilities. The broadness of her generalizations about assisted living certainly requires qualification. And the limits of Frank's experience with long-term care, in contrast with Smith's, provide no basis for optimism about the possible beneficial effects of community involvement that might lead to better outcomes. It should be noted in passing that Frank, like Smith, does not reference Powell Lawton.
Physical Environment and Aging
The work of Powell Lawton expectedly appears in most, though not all, recent books on environment and aging and is remembered affectionately in the compendium edited by Rick Sheidt and Paul Windley, Physical Environments and Aging: Critical Contributions of M. Powell Lawton to Theory and Practice. Friends, colleagues, and students summarize what they consider to be Lawton's many critical contributions to the theory and practice of ecological psychology. In the various chapters the intellectual breadth and depth of the man are celebrated. Unquestionably Lawton was a rare breed of scholar who, always grounded in theory, wanted to know whether and how theory might lead to useful benefits in quality of life for older adults. Lawton was part of the mystique at the Philadelphia Geriatric Center associated with exploring the quality of life of at-risk elders. He loved his students and colleagues as well as older adults and they clearly loved him.
The various chapters of the book mostly cover once again ground that will be familiar to long-time observers of Lawton at work. We are reminded about the centrality of vision, values, and quality of life issues in Lawton's work over his entire career. And we are expectedly reminded of his working relationship with architects and designers of physical space. The relationship between Powell's ecological psychology and notion of person/context "fit" and the Selective Optimization with Compensation model of Paul and Margaret Baltes (Baltes & Baltes, 1990) is a more recent connection worth noting. These practical implications of his work are appropriately celebrated.
Pathways to Quality of Life
The fourth volume discussed in this essay provides an illustration of mainstream population-based academic research on environment and aging. John Krout and Elaine Wethington's edited volume, Residential Choices and Experiences of Older Adults: Pathways to Life Quality, introduces a multidisciplinary, longitudinal project that will warrant following as it unfolds. This volume is the introduction to the collaborative Pathways to Life Quality project of gerontologists at Ithaca College and Cornell University. The first chapter describes succinctly a panel survey of more than 800 older adults in an upstate New York county, aged 55–100, living in many different types of housing arrangements, and it explores their experiences and decisions. Survey participants were selected to represent a variety of housing arrangements—CCRCs, an adult care home, income-subsidized housing, and senior apartments—during the first two waves of the survey in 1997 and 1999. Although two observations do not properly mark longitudinal inquiry, additional waves are promised.
Exploration of how housing and decisions about housing affect quality of life led the investigators to ask how types of housing and communities are related to housing decisions, well-being, health, and social integration. Students will love the design of each chapter that systematically reviews relevant literature, discusses key questions and the methodological issues involved, presents findings, and discusses implications for research, policy, and planning. The rationale for the variety of settings used, the sampling strategy for addressing key questions about residential choice, and the decision to stay put or move are adequately explicated and related to current theory and methodology.
The indebtedness to Lawton's theoretical perspective and commitment to relating good theory to practice is evident. But the influence of the theory and research of Cornell's Urie Bronfenbrenner and of his student Melvin Kohn, and their relevance for research on housing as an environment, is also implicit (see Maddox, 2001). Although neither Bronfenbrenner nor Kohn ever focused on housing older adults, their research is in fact quite relevant. A trademark of Bronfenbrenner, for example, was his focus on developmental dynamics that persistently produce variety as well as consistency in human behavior. He focused persistently on how behavior in specified contexts can and typically does produce and sustain variety over time and in space; this observed variety led him to be a multidisciplinary experimenter and an interventionist. Bronfenbrenner was an advocate of studying human choices up close to observe proximate causes of behavior and to understand why quality of life has many faces. Such observation led him to be a firm believer in human resilience, which in turn fueled his belief that designed psychosocial interventions can be helpful in compensating for experienced deprivation.
Both Bronfenbrenner and Kohn were keen observers of the differential allocation of resources and of related cumulative advantage and disadvantage that are likely outcomes of social class location. Kohn was particularly astute in noting how occupational placement can encourage or discourage autonomy that in turn can produce a more or less confidently autonomous individual who can become more tolerant of and a better manager of change. The themes of resilience, autonomy, and change management are rather obviously key characteristics of outcomes featured in the idealized philosophy and values of designed living environments associated with assisted living housing. This is the hopeful view of the benefits of living in designed housing environments that encourage homelike environment and autonomy linked with reliably available supportive services when needed.
The Pathways to Life Quality investigators are not at this point purposive interventionists. They are currently observers of how individuals make choices about staying put or changing their living environments by choice or necessity. They focus on key variables that have been the focus of Phyllis Moen (2003) such as social roles, role identities, social participation, and social integration. Even at this early phase of the research, however, groundwork is being laid for exploring the long-range effects and consequences of housing choices on health, the utilization of health care, and quality of life. And, predictably, the psychological issues of personal well-being and adjustment as they are affected by housing contexts and decisions are addressed. We can anticipate that the findings will identify older adults who not only are affected for good or ill by their housing environments but who also bring a differential sense of mastery and self-efficacy that permits some individuals to age well in a variety of environments. Successful mastery of one's environment can, as Kohn has suggested, become part of a cumulative advantage that is adaptive and forecasts resilience in the face of even daunting challenges. Even at this early stage of this research, the investigators conclude that, in general, the older individuals in their study tend to be robust and resilient as they age.
Pathways to Life Quality is not alone in announcing an intention to provide evidence relevant for policy and practice. But the intent to offer longitudinal evidence useful to policy makers and designers of effective, affordable long-term care is commendable. In the tradition of Powell Lawton, one might suggest that these investigators, as Lawton did, will not wait for policy and practice advocates to come to them. These investigators will make it a point to be wherever translators of sound ideas into good practice are observed at work.
As a starter, one can imagine a useful conversation particularly between David Smith and longitudinal investigators Krout and Wethington about common issues identified in their work. If this conversation could be arranged, I would pay to be present. In such an exchange they would certainly agree that the cumulative advantage associated with occupation, education, and income presents a daunting, probably the most daunting, challenge to policy makers and service providers in our society. After all, we tend to believe you get what you pay for and that every farsighted mission to do social good always has to face the margin of profit anticipated for the producer. Are there economically and politically viable policy options that promise to alleviate the demonstrated socioeconomic disadvantage in housing options? Unless the answer is affirmative, the theoretically neat philosophy of assisted living has little chance to be translated into realistically available housing that is homelike, provides choice, and allows one to age in place with dignity. And Smith, Krout, and Wethington would probably agree that in housing there is such variability in older populations that no one size is likely to fit all. Maybe this implies that one goal of housing policy is to maximize options and monitor carefully who thrives in what environment. As Smith suggests the likelihood of even this happening will depend on sustained community involvement, civic leadership, and political will.
References
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