Those of us who have been working in the field of aging are experiencing validation of many things we have been predicting for decades now. One area we have been persistently calling attention to is the woefully inadequate housing that is available for low-income elders, and the increasing need for trained caregivers. We’ve been writing about the need for policy makers to address this and other issues, but have not succeeded in making the case. This is at the bottom of an implicit contract about growing old: we take care of our children when they are young, and they take care of us when we are old. But what about those of us who never had children? Or whose children are far away or bailed on the “contract”? What provisions exist for our care?
Some background here is helpful. For generations preceding Boomers, the annual birth rate always exceeded deaths. This meant that there were sufficient numbers of heirs to look after aging parents, who generally died somewhere in their 60s or early 70s. This was the norm until we all started to live longer.
The consequence of having children and living longer resulted in a population boom. Scientists made predictions about whether there would be enough resources to support the growing numbers of people on the planet. One movement that came out of this was Zero Population Growth. This movement enjoyed its heyday back in the late 1960s and
early 1970s. Many of my generation took an oath to not have children in order to address the very real threat to our planet of too many people and too few resources.
Fifty years later, declining birth rates, extension of the lifespan, and the Boomer bump are creating a real conundrum for communities. The contact that was once taken for granted now is showing some loopholes. A very real issue for Boomers who never had children is who is going to take care of them. I fall into this category. There is an implicit contract between parent and child: I take care of you and raise you, and then you take care of me. This is often not made explicit and can be a source of sadness and guilt for children as well as parents.
Many of us are independent minded and are planning on aging in place. This is well and good, until faced with functional impairment that requires care. Who will take me to my doctor’s appointments? Who will be there to pick me up after my hip replacement surgery? What happens after I have my cataracts operated on while I can’t drive? Those who have children or family to do these things, don’t think twice. Those of us without family have to rely on systems of care that frankly, exist mostly on paper.
It remains a source of sadness to me that I was unable to fulfill my mother’s desire to die in her own home. When she could no longer live there safely, I was able to get her into an assisted living facility in her hometown where she stayed for several years before needing a higher level of care. She transitioned into a nursing home that had space, and stayed there until she died, cared for by a wonderful loving staff and many friends. This is the typical journey for most aging adults in the United States. But very few of us have made this contract explicit or have sufficient resources in place to insure this outcome.
What are the implications of this? At the local level, communities need to be focusing on insuring they have the infrastructure to care for larger populations of aging adults who need increasingly complex and intensive care. Specifically, they need to have a health-care delivery system that has sufficient numbers of providers trained in geriatric medicine. They need to have sufficient availability of housing that is elder-friendly, safe, and affordable. They need to have transportation systems that can accommodate wheelchairs, walkers, and have routes that are specifically designed to stop at shopping sites and medical locations so that elders can easily access them.
Medical care is a particularly challenging issue. Fewer and fewer medical students are choosing geriatric medicine as a specialty. This is due primarily to low reimbursement rates and low status within the medical field. Yet elders are among the most medically-challenging patients a primary care or specialty care provider will see in his or her career. Within this field, there are ever fewer physical health care providers or behavioral health care providers with training in geriatrics.
A challenge also exists in how to provide care to individuals who are physically relatively healthy, but who cannot care for themselves due to cognitive deficits. Housing aging adults with dementia is rarely discussed at a policy level, but it will be one of the most pressing issues within the next five years, as skilled nursing facilities and assisted living facilities fill up and elders outlive their savings.
As I have no children of my own, I don’t have family who will care for me. The community I live in is already at capacity for caring for aging adults in the assisted living developments. Our local hospital is closing down its skilled nursing department, leaving three others in town, all of which have waiting lists for their long-term care beds. There is an increasing demand for memory care, but community developers are more intent on low-income housing than long-term care for dementia patients.
Families are feeling an increasing strain both financially and emotionally in how to provide care for each other. Some elders actually outlive their children, leaving them without family support and necessary advocacy. Some families are in such distress that children may be unable or unwilling to care for their aging parent. This leaves the parent vulnerable.
Things are coming to a head. There will be a reckoning. If you are un-partnered and have no children, it pays to start thinking about who will care for you and where you want to spend your old age. The Co-housing movement is a well-developed model that addresses this issue. These are intentional communities organized to provide support and care for members. Other models are being explored. Yet, there is an urgency to this that is not being seen by our elected officials and policy makers. We need more and more creative ways to address the unmet needs of those among us who are most vulnerable. That is a contract we can and must keep.