The case against 'aging in place': the author, an architect, proposes design criteria for a more aging-resident-friendly level of care

Nursing Homes, Oct, 2005 by Drew H. Kepley

I don't like to move. It seems as though a lot of people I know don't like to move, either. Packing, leaving behind a familiar place, dismantling years of memories to start over again--it's a painful process even for those in the best of health. For those who are older and perhaps in need of some assistance, the situation can be especially traumatic and fraught with apprehension.

In CCRCs across the country, more and more residents are resisting the move to a more intensive level of care. This leads to "aging in place," and that can be a problem.

As time passes and their health begins to deteriorate, residents begin needing day-to-day assistance--help with laundry, meals, bathing, dressing, or other activities of daily living. Other developing problems might include lack of personal mobility, difficulty driving, and/or the onset of early stages of dementia. The loss of a spouse, a devastating event at any stage of life, can take on added significance when the deceased was responsible for a good deal of the surviving spouse's care.

For CCRC residents who are completely aware of their surroundings but just might need some physical assistance, the "medical model" environments (i.e., based on a typical hospital floor) of assisted living and skilled nursing were and remain places to be avoided at all costs. Subsequently, many residents suffer through long periods occupying an independent living unit with reduced capacity, declining health, dwindling social contact, increased depression, and other problems. While caregivers can visit the home or unit to provide assistance, and residents have the media to keep them abreast of day-to-day events, the situation becomes one of increasing dependency and inefficient, costly care. Many of these residents decline quite rapidly and often go straight to a skilled nursing facility, although the right program and environment for them might have prolonged their independence.

One of our goals, therefore, should be to provide accommodations that allow a resident or couple to move from a large independent living unit to a place that, while smaller and more easily staffed, is large enough and has the right mix of amenities to be an acceptable option. While it is true that many CCRCs allow their cottage residents to move into their independent living apartments as they require more care, and this is better than aging in place in a detached cottage, the caregiving situation remains difficult. These larger apartments, in some cases well over 1,500 square feet, can be as much as 60 feet from front door to front door and far away from dining and activity spaces. These distances, because of the mobility challenges they pose, make caregiving inefficient and socialization difficult. Moreover, these intracommunity independent living moves can delay or prevent new residents from coming into these communities.

What is the answer then? What can we provide that promotes independence, good health, and community; is efficient for staff; is attractive to residents and their families; and meets their needs?

Social Model Assisted Living

A "social model" assisted living environment that promotes socialization and community might be the answer. Based on the experience of several CCRCs in the mid-Atlantic region, the right environment has been found to provide an attractive alternative to the problems associated with "aging in place" in the wrong place. Such a facility might include the following features:

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* short travel distances from resident units to dining and other amenity spaces;

* a household-type arrangement involving a limited number of residents and with rooms opening directly into common spaces;

* larger individual units--ideally two-room minimum size apartments;

* food storage and preparation space in resident units;

* fewer units per floor (in larger facilities);

* residential character and ambience; and

* adequate storage space in each resident unit and throughout the building.

Other features that make social-model assisted living more appealing include:

* access to independent living common spaces and wellness services;

* convenient parking and transportation; and

* technologic conveniences and service features, such as a computer with Internet access as a standard feature in each unit, unobtrusive resident monitoring devices that allow staff to track mobility, activities, and sleep patterns, etc.

Some further explanation: In a household-style facility of 8 to 12 units, a large, single room with a private bathroom and shower may suffice--especially when common spaces and other amenities are directly outside residents' doors, in an arrangement similar to their homes. If a household model is inappropriate, large studios or preferably two-room apartments with a small kitchen or kitchenette should be provided. The rooms should have a minimum dimension of 12 feet, in part because the larger rooms allow residents to furnish their apartments with their own furniture. To maximize space, consideration should be given during the design process to how possible furniture layouts will work with door swings, circulation paths, etc. A higher ceiling (9 feet or more) in the living areas and large windows both contribute to an increased sense of space.