Imagine you are in your seventies, and cooking and cleaning are difficult. You have trouble walking to the mailbox or getting from your car to the store. You start out by using selection and optimization. You focus on your most essential activities. You spend more time on each important life task. You are determined to live independently for as long as possible. But you know that the time is coming when you will enter Baltes’s full-fledged compensation mode. You will need to depend on other people for your daily needs. Where can you turn?

For most of human history, older people would never confront this challenge. Families lived in multigenerational households. When the oldest generation needed help, caregivers were right on the scene.

Today, however, this support network is fraying in some of the collectivist countries historically most committed to family care (Qu, 2014). In affluent Japan, nursing home care is becoming common. In China, young people have rapidly adopted Western individualistic lifestyles, as they move from the villages to the cities to find work. The government’s one child policy in particular has left Chinese elderly fearful of what will happen when they need old-age help (Gustafson & Baofeng, 2014). So, the East is turning to the West for models of societal elderly care.

The Scandinavian countries offer some of our best examples of the elder care advanced Western societies can provide (Rodrigues & Schmidt, 2010). In Sweden, Norway, and Denmark, government-funded home health services swing into operation to help impaired older people “age in place”—meaning stay in their own homes. Innovative elderly housing alternatives dot the countryside—from multigenerational villages with a central community center providing health care to small nursing facilities with attractive private rooms (Johri, Beland, & Bergman, 2003). Because their care is free and government funded, Scandinavian older adults don’t need to face that anxiety-ridden question of “can I afford to get help?”

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In the United States, we do have these worries. The reason is that Medicare, the U.S. health insurance system for the elderly, pays only for services defined as cure-oriented. It does not cover help with activities of daily living—the very services such as cooking or cleaning or bathing that might keep people out of a nursing home when they are having trouble functioning in life.

What choices do older people in the United States and other developed nations have instead of going to a nursing home? Here are the main alternatives to institutionalization that exist today:

With their enriching activities and services and social contacts, assisted-living and continuing-care facilities can be marvelous settings in which to spend the final years of your life. (“It’s like permanently living on a cruise ship,” gushed a friend). However, older people must sometimes be unwillingly pushed by family members to move to these places (Koenig and others, 2014). Why?

One reason is that leaving home means shedding one’s prized possessions, robbing people of the identity and memories attached to “real life” (Wiles and others, 2012). Moving can activate fears of losing privacy (Crisp and others, 2013). Yes, you won’t have the scary experience of struggling to make it all alone, but you still can feel lonely, especially since you may confront the same poisonous group-status hierarchies you had to deal with during your preteen years (Ayalon & Green, 2013; Schafer, 2013). (Unfortunately, human nature doesn’t change!)

Most important, in the United States, older people only have the option of moving to continuing care if they are wealthy—not even middle class (see Coe & Boyle, 2013). Can’t we devise innovative, low-cost frail-elder-care alternatives that don’t involve moving and help people who have some ADL problems but don’t require that ultimate setting—the nursing home?

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Nursing homes, or long-term-care facilities, provide shelter and services to people with basic ADL problems—individuals who do require 24-hour caregiving help. Although adults of every age live in nursing homes, it should come as no surprise that the main risk factor for entering these institutions is being very old. The average nursing home resident is in his—or, I should say, her—late eighties and nineties. Because, as we know, females live sicker into advanced old age, women make up the vast majority of residents in long-term-care (Belsky, 2001).

What causes people to enter nursing homes? Often, a person arrives after some incapacitating event, such as breaking a hip. Given that these diseases require such daunting 24/7 care, roughly half of the nursing home population has some neurocognitive disorder such as Alzheimer’s disease.

In predicting who ends up in a nursing home, both nature and nurture forces are involved. Yes, the person’s biology (or physical state) does matter. But so does the environment: specifically, whether a network of attachment figures is available to provide care. Does the older adult have several family members and/or a friend willing to take the person in? The more places (and people) a frail person has “in reserve” to provide help, the lower the risk of that individual’s landing in long-term care (Kasper, Pezzin, & Rice, 2010).

Just as the routes by which people arrive differ, residents take different paths once they enter nursing homes. Sometimes, a nursing home is a short stop before returning home. Or it may be a short interlude before death. Some residents live for years in long-term care.

You might be surprised to learn who is paying for these residents’ care in the United States. Because people start out paying the costs out of their own pockets and “spend down” until they are impoverished, Medicaid, the U.S. health-care system specifically for the poor, finances our nation’s nursing homes.

Evaluating Nursing Homes

Nursing homes are often viewed as dumping grounds where residents are abused or left to languish unattended until they die. How accurate are these stereotypes?

Many times, the generalizations are unfair. Nursing homes may offer perks from beauty parlors to private rooms. Residents often appreciate their newfound feelings of safety after moving (Nakrem and others, 2013). A strong movement is afoot to make nursing homes homey and “person centered,” just as any other retirement home (Bishop & Stone, 2014).

We still have far to go. In one poll, more than one-half of industry experts ranked the quality of U.S. nursing homes as “fair” or “poor” (Miller, Mor, & Clark, 2010). In an alarming Michigan survey, 1 out of 5 family members reported that, yes, their impaired relative had suffered some nursing home abuse (Conner and others, 2011). (As you might imagine, “difficult” residents—that is, those with behavior problems and/or the totally physically incapacitated—are most at risk here.)

It’s also difficult to erase the efficacy-eroding liabilities intrinsic to institutional life. Imagine sharing a small room with a stranger and needing to eat the food the facility serves at predetermined hours (Kane, 1995–1996). Nursing home residents can’t just decide to lie in bed or refuse to take a medicine. Their every action—from sitting in a chair to being taken to the toilet—is dependent on the workers providing care. As one frustrated new resident named Luis put it: “I would say to my friends, don’t go there. Go to jail instead” (quoted in Johnson & Bibbo, 2014, p. 60).

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My discussion brings up the front-line nursing home caregivers—the certified nurse assistant or aide. Just as during life’s early years, caregiving at the upper end of the lifespan is low-status work. Nursing home aides, like their counterparts in day-care centers, make poverty-level wages. Facilities are chronically understaffed (Teeri and others, 2008). So, even when an aide loves what she does, the job conditions can make it difficult to provide adequate care. Having worked in long-term care, I can testify that residents are sometimes left lying in urine for hours. They wait inordinately long for help getting fed. One reason is that it can take hours to feed the eight or so people in your care when dinner arrives!

Still, even some highly experienced nurses gravitate to this “low status” work. As one Swedish nurse explained: “Your relationship with the patients is completely different when you see them for years. . . . As a new nurse, your focus is on medical and technical skills. But, elderly care is so much more” (adapted from Carlson and others, 2014, pp. 764–765). Read what Jayson, a mellow, 6-foot-tall, 200-pound giant had to say about his job at a Philadelphia nursing home:

At first I was put off by the smells. . . . Then I got moved to the Alzheimer’s unit . . . and I found this to be like . . . the best task I ever had. . . . If you just come in here and say, “Okay, I got a job to do and I’m just doing my job,” . . . then you’re in the wrong field. . . . When somebody here dies, we all talk, we say how much we miss the person. . . . Some of them cry. . . . Some of them go to their funerals. . . . I actually spoke at some of the funerals. . . . I say how much this person meant to me.

(quoted in Black & Rubinstein, 2005, pp. S-4–6)

For Jayson, who—after being shot and lingering near death—reported seeing an angel visit him in the form of a little old man, his career is a calling from God. He is flourishing in this consummately generative job. What about nursing-home residents? Can people get it together within this most unlikely setting? For uplifting answers, check out the Experiencing the Lifespan box.

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Dealing with ADL impairments is a vital social challenge facing our rapidly aging world. As you now know, we can’t count on science to magically cure the disabilities inherent to surviving beyond our “expiration date.” We need to prepare for our looming baby-boomer ADL crisis right now!

Our personal challenge, as you learned in these later-life chapters, is to live fully as long as we are alive. The Experiencing the Lifespan box you just read highlights the fact—again—that yes, it is possible to flourish even in a nursing home. It underlines the importance of close attachments in promoting a meaningful life. Plus, the story of this woman who got it together in the nursing home enriches Erikson’s masterful ideas that have guided our lifespan tour: It’s never too late to accomplish developmental tasks that we may have missed. People can find their real identity (or authentic self), fulfill their generativity, and so reach integrity in their final months of life!

In the next chapter, I’ll continue this theme of inner development and also stress the crucial importance of making connections with loved ones as I focus directly on life’s endpoint—death.

Question 14.13

1. is affluent, worried about living alone, and has no ADL problems.

2. has ADL impairments and is living with her family—who want to continue to care for her at home.

3. has instrumental ADL impairments (but can perform basic self-care activities), can no longer live alone, and has a good amount of money.

4. has basic ADL impairments.

5. is beginning to have ADL impairments, lives alone, and has very little money (but does not qualify for Medicaid).

   1. a continuing-care retirement facility

   2. an assisted-living facility

   3. a day-care program

   4. a nursing home

   5. There are no good alternatives you can suggest; people in this situation must struggle to cope at home.

a, 1; b, 3; c, 2; d, 4; e, 5

Question 14.14

1. No one in the family is available to take their mom in.

2. Medicare will completely cover their mom’s expenses.

3. The quality of the facilities to which their mom will go may vary greatly.

4. The staff at their mom’s nursing home will almost always hate their jobs.

a and c

Question 14.15

Here, you can use your own creativity. My suggestions: (1) Institute a program whereby people get cash incentives to care for frail elders in their homes. (2) Build small, intergenerational living communities, with a centrally located home option specifically for the frail elderly. Residents who buy houses here would commit to taking care of the older adults in their midst. (3) Set up a Craigslist-type Web site, matching older people with a room to spare with area college students in need. Young people would live rent-free in exchange for helping the older person with cooking and shopping. (4) Establish a national scholarship program (perhaps called the “Belsky Grant”!) that would pay your tuition and living expenses if you commit to caring for frail elders in the community.