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Social and Physical Environments for the Vulnerable Aged Beth d. Soldo and CharIes F. Longino, dr. NOTIONS OF VULNERABILITY Human aging encompasses much more than physiologic change over the life course. Age-related changes are manifest across all aspects of life including physical, environmental, eco- nomic, and social aspects and mental well-being. Yet change along any dimension is not simply, or irrevocably, correlated with chronological age. The serious Toss or compromise of capacity in one area, how- ever, can accelerate the rate of decline in others. Such interac- tions are often complex. Poor health, for example, can require increased medical expenditures that divert income from other essential areas such as home upkeep or the purchase of food. Over time, such interactions can result in further erosion of functional capacity in the aging. Alternatively, a supportive so- cial or physical environment may retard the rate of functional Toss to some degree. Clinical assessment and care plan protocols for the elderly Beth Soldo is an associate professor in the Department of Demography, George- town University, Washington, D.C. Charles Longino, Jr., is the director of the Center for Social Research in Aging at the University of Miami, Coral Gables, Florida. The research reported in this chapter was supported by National Institute on Aging Grant no. RO1 AG05153, The Commonwealth Fund Grant no. 7405, and Public Health Service Grant no. 507 RR 07136-15. 103

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104 BETH J. SOLDO AND CHARLES F. LONGINO, JR. typically reflect this multidimensional understanding of the hu- man aging process. But the same perspective does not consis- tently guide national planning and policy development. With the exception of a limited number of local-area demonstrations (see, e.g., Carcagno and Kemper, 1983; Hicks et al., 1981; U.S. Comptroller General, 1978), assessments of the care require- ments of a population often take into consideration only the quantitative aspects of aging, such as rapid increases in both the absolute and relative numbers of the elderly and the unprec- edented growth of the oldest old proportion of the population. Demographic analyses also call attention to other important planning variables such as key compositional factors (e.g., the predominance of women in older populations) and the uneven tempo of growth in various segments of the elderly population (Manton and Soldo, l985b). Yet the study of the quantitative features of population aging can provide only limited informa- tion on the status or needs of the elderly. In fact, the diversity of the elderly population undermines the simple logic of extrapo- lating from the observed age structure to estimates of need. Even among those persons aged 85 and older, there is a sub- group of hardy survivors who are physically and mentally in- tact. Recent analyses have also isolated a subgroup of the young old (those aged 65-74) who evidence substantial co-morbidity (Soldo and Manton, 1985c). Effective planning for an aging society clearly requires atten- tion to the qualitative aspects of aging as well as to the quanti- tative features. Such factors largely define the quality of life at any age and include not only health status but also financial status and aspects of both the social and physical environment. For the frail elderly, however, these same factors are also mark- ers of vulnerability. By this we mean that these factors have the innate potential to mediate- positively or negatively the be- havioral and life-style consequences of chronic i]Ll health (Soldo, 19861. When qualitative factors coalesce into natural coping re- sources, they can often blunt the demand for formal services, services that are usually financed by the public sector. But when these same factors are deficient or absent, the demand on socie- tal resources can be exacerbated. Thus, the total volume of re- sources necessary to sustain the elderly depends on the joint distribution of both the quantitative and qualitative features of aged populations.

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SOCIAL AND PHYSICAL ENVIRONMENTS 105 In this paper, we attempt to integrate a qualitative emphasis that follows from biomedical research and service delivery ex- perience with the quantitative insights of demography. We do so in order to broadly assess (1) the vulnerability of the elderly; (2) the supportive quality of the social and physical environment they occupy; (3) the potential for further environmental amelio- ration of disability; and (4) potential changes in the mix and distribution of markers of vulnerability over time. In our discus- sions and analyses, we have restricted our attention to the com- munity-based elderly even while acknowledging the survivor- ship bias that confounds this approach. That is, the elderly who retain their community residences, even in the wake of substan- tial disability, are the select survivors of their initial cohorts from which mortality has claimed the less hardy and institu- tionaTization the most vulnerable. We begin our inquiry by documenting the functional depend- encies of the aged and the extent to which the frail elderly of today are also vulnerable financially, socially, and environmen- tally. Next, we consider service and environmental responses to dependency, distinguishing between formally and naturally or- ganized services. We conclude by identifying some of the specific implications of our analysis for planning efforts for example, the issues involved in creating environments for "successful" aging. THE VULNERABLE AGED Functional Dependency Our point of departure for examining dimensions of vuinera- bility among the aged is to consider the health status of the elderly. This is a difficult task if only because the "health" of even a single older person, assessed at but one point in time, summarizes the operation of multiple age- and time-dependent processes, both physiologic and pathologic, that differ in terms of duration, severity, and trajectory (Soldo and Manton, 1985a). Our main concern, however, is with the health of the popula- tion of individuals aged 65 and older. From this perspective, there are two basic assessment strategies. The first requires an examination of the distribution and mix of diseases within the population. In an older population, this approach focuses primar

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106 BETH J. SOLDO AND CHARLES F. LONGINO, JR. fly on the chronic diseases that affect four out of every five of the elderly in the community and nearly all of those in Tong- term care facilities (Soldo and Manton, 1985b). The disease-spe- cific approach, while offering distinct advantages for epidemio- Togical forecasting, is unwieldy for cross-sectional analysis be- cause neither care needs nor disease severity are uniquely identified with the simple presence or absence of pathology. Of greater utility for our purposes is a functional assessment that examines the behavioral consequences of chronic morbidity. In this approach, deficient functional capacities are viewed as re- lating directly to the need for assistance, usually from another person, in carrying out such basic functions as eating, bathing, and dressing (Becker and Cohen, 1984; Katz, 19831. Data from the 1982 National Long-Term Care Survey (NETCS) offer the opportunity to assess the functional capacity of aged noninstitutionalized persons in considerable detail. This survey, which was sponsored jointly by the Health Care Financing Ad- ministration (HCFA) and the assistant secretary for planning and evaluation, was fielded by the U.S. Bureau of the Census.i Approximately 36,000 persons from a listing of Medicare enroll- ees were screened by phone to identify 6,340 noninstitutional- ized elderly who reported having a limitation in either the "in- strumental activities of daily living" (lADL)2 or the "activities of daily living" (ADL)3 that lasted 3 months or longer. A per- sonal review confirmed the presence of such limitations in 5,582 cases (87 percent of those who qualified on the screener). These 5,582 cases represented approximately 4.6 million persons aged 65 and older who live in the community with either JADE or ADL dependencies. The number of cases corresponds to approx- imately 18.9 percent of all noninstitutionaTized elderly. Table 1 shows estimates of functional dependency by age and sex using two scales of functional disability: the lADL and the ADL. Limitations in the activities of daily living (ADL) are broadly accepted by gerontologists as indexing incapacities for self-care. The 1982 NETCS assesses performance in six activi- ties: eating, toileting, bathing, bed transference, dressing, and continence. Because these activities scale in the order in which they are lost, a simple count of the number of ADI~ limitations is a useful summary index of functional incapacity. The instru- mental activities of daily living (IADL) scale refers to the capac

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SOCIAL AND PHYSICAL ENVIRONMENTS TABLE 1 Percentage of Persons 65 Years of Age and Older Living in the Community with Functional Disabilities, by Age and Sex, 1982 107 Type of Dependency Age and IDA {YLADL Scoreb Sex Limiteda1-2 3-45-6 Total 65-74 4.54.2 1.82.1 12.6 Male 4.23.4 1.72.4 11.7 Female 4.84.7 1.91.9 13.3 75-84 7.99.0 3.64.5 25.0 Male 7.16.5 2.54.6 20.9 Female 8.510.3 4.34.4 27.6 85 + 10.217.4 7.810.4 45.8 Male 9.915.7 7.77.5 40.8 Female 10.318.2 7.911.8 48.2 Total 65+ 6.06.6 2.83.5 18.9 Male 5.45.1 2.33.3 16.0 Female 6.47.7 3.23.6 20.9 aSuch individuals need assistance with the instrumental activities of daily living (IADL): managing money, shopping, light housework, meal preparation, making a phone call, and taking medication. bThe ADL score is the number of activities of daily living with which the respondent requires assistance. SOURCE: Tabulations from the 1982 National Long-Term Care Survey. ity to perform basic but noncare activities, such as managing money or making a phone call. To a large extent the JADE summarize cognitive functioning. Even those elderly individuals with severe physical disability should still be able to use the phone or manage their own money if they are not cognitively limited as well (Manton and Soldo, 1985b). The data in Table 1 indicate that, although rates of functional dependency increase with age and are typically higher for women than for men, functional Toss is not an inevitable conse- quence of aging. Even at age 85 and older, over half of all those who remain in the community have no measurable Toss in their basic capacities. Related analyses of these same data indicate that, among the noninstitutionaTized elderly, the Toss of func- tional capacity at the younger ages (65-74 years of age) is asso- ciated with life-threatening diseases such as malignant neo

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108 BETH J. SOLDO AND CHARLES F. LONGINO, JR. plasms; at the extremes of old age, disability is usually related to the chronic degenerative diseases such as senility or arterio- sclerosis (Soldo and Manton, 1985c). The high rates of functional disability at the extreme ages- coupled with unprecedented and largely unanticipated improve- ments in life expectancy at ages 65 and 85 are often interpreted as implying dramatic increases in the number of the frail elderly (National Center for Health Statistics, 1984; New York State Office for the Aging, 1983; Rice and Feldman, 19831. Although both the existence and magnitude of morbidity-mortaTity link 1 ,200 1 ,000 800 - - c~ ._ - z 0 600 CL o Baseline Alternate - 400 200 o . . . _ co us At: ~ ~ cat ~ ~ . . . _ co u is, . . ~ c c, ~ 1 1 980 CM ~ OCR for page 103
SOCIAL AND PHYSICAL ENVIRONMENTS 1 ,200 1 ,000 - cn c`5 800 cn o i_ ._ - o 600 CL o 400 200 o 1 980 YEAR 109 Am Baseline Alternate CM ~ (D , ~ co ~ _ a,, _ ID ~ ~ us C) J ~ ~1 ~ ~ <: ~ . . ~ Co U) C) Cat _ Ct 2000 2040 FIGURE 2 Baseline and alternate projections for women aged 85 and older, 1980, 2000, and 2040. Note: Baseline and alternate figures for 1980 are the same. ADL = activities of daily living; IADL = instrumental activities of daily living. SOURCE: Reprinted from Manton and Soldo (1985a). ages have been the subject of recent and intense debate, we believe it is reasonable to assume that those same factors that have produced increases in old-age life expectancy have also modified the disease and disability profile of the elderly (Feld- man, 1982; Fries, 1980, 1983; Gruenberg, 1977; Manton, 1982; Manton and Soldo, 1985a, 1985b; Riley and Bond, 1983; Ver- brugge, 1984; and Walford, 19831. This issue is no mere academic debate; as an illustration of this point, consider Figures 1 and 2, reprinted from Manton and Soldo (1985a). These figures show,

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110 BETH J. SOLDO AND CHARLES F. LONGINO, JR. for men and women, respectively, the projected growth in the absolute number of the frail elderly, aged 85 and older, under alternative assumptions. The baseline projections assume no improvements in the rates of disability consequent to modest gains in old-age life expec- tancy; that is, current age-sex specific rates of disability, by type, were superimposed on the age-sex structure implied by projections prepared by the Social Security Administration (19811. These baseline projections can be compared with those prepared under the assumption that age-sex specific disability rates will be reduced in proportion to projected mortality de- cTines. Because of the simple demographic imperative of increas- ingly larger cohorts entering old age, the number of the frail elderly aged 85 and older increases in either scenario. Yet by allowing for the interdependence of morbidity, disability, and mortality, there is a 27 percent reduction for men and a 39 percent reduction for women in disability rates by the year 2040. Assuming perfect interdependence, there would be approxi- mately 1.4 million fewer disabled persons 85 years of age and older in the year 2040 than if rates of disability are assumed to be independent of mortality declines. These two scenarios probably represent the best- and worst- case projections in that additional years of life expectancy are unlikely to translate directly into additional disability-free years of life (Wilkins and Adams, 19831. Thus, the two projections may be thought of as indicating the upper and lower bounds on the number of community-based disabled elderly in the future. These projections also suggest the potential role of health care policy in shaping the disability profile of the elderly in the future. Changes in the health status of the elderly are caused by and, in turn, cause major shifts in both the composition of the U.S. population as a whole and in the needs profile of the older ages. In the long run, however, the health care requirements of an aged population also respond to the amount of resources allo- cated to disease prevention and treatment (Manton and Soldo, 1985a). Yet in the short run as well, the course of disability for individuals and the aggregate volume of demand on the public sector depends, in part, on the "natural" resources available to the disabled elderly, that is, the qualitative aspects of population aging.

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SOCIAL AND PHYSICAL ENVIRONMENTS Disability and Other Markers of Vulnerability 111 With the progression of disability, the social world of the el- derly often contracts. The social world of the most disabled, for example, may be fully defined by the housing space they occupy. Cross-sectional data offer persuasive but not definitive evidence for the changing utility the frail elderly assign to different household structures, particularly the utility of living alone. The presence of a "caring unit" within a household, for example, often allows the functionally impaired to continue to reside in the community (Branch and dette, 1982; Brody et al., 1978; Weis- sert and ScanTon, 19821. Within a community's population of the frail elderly, there also appears to be a natural sorting-out process that operates, through which the disabled elderly associate themselves with TABLE 2 Percentage Distribution of Disability Among Community Long-term Care Elderly by lip e of Living Arrangement Disability Level ADL Score Type of Living Arrangement IADL Only 1-2 3-45-6 Totala Alone 34.4 44.5 14.76.4 100.0 (1,434) With spouses 32.1 30.8 15.721.4 100.0 (1,918) With other relations 28.5 30.6 14.126.7 100.0 (1,175) With nonrelative 22.9 34.5 13.629.0 100.0 (121) Total 31.7 35.1 14.918.3 100.0 (1,472) (1,631) (694)(851) (4,648) NOTE: ADL = activities of daily living; IADL = instrumental activities of daily . . wing. aTotals may reflect rounding. bWeighted base count in thousands. Includes those who live only with a spouse and those who live with a spouse and others. Includes those who live only with relatives (not a spouse) and those who live with both relatives and nonrelatives. SOURCE: Tabulations from the 1982 National Long-Term Care Survey.

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112 BETH J. SOLDO AND CHARLES F. LONGINO, JR. living arrangements consistent with the degree of support they require from their immediate environment Jawton, 19811. Such a gradient of need across types of living arrangements is evident in the data presented in Table 2. Clearly the "luxury of living alone" is reserved for those who can meet the physical demands of household independence (Tissue and McCoy, 19811. Very few of the severely disabled elderly (i.e., those whose functional self-care capacities are limited in five or six areas) live alone. The different types of shared living arrangements, however, vary in their supportive quality, as indicated by the percentage distribution of "unmet" lADL and ADL dependen- cies shown in Table 3. TABLE 3 Percentage Distribution of Unmet Functional Needs Among Community Long-term Care Elderly by lope of Living Arrangement Unmet Functional Dependencies Type of Living No Unmet Unmet IADL Unmet ADL Arrangement Needs Needs Onlya Needsb TotalC Alone 86.8 9.8 3.4 100.0 (1,434)8 With spouses 95.5 3.4 1.1 100.0 (1,918) With other relativesf 93.4 4.1 2.5 100.0 (1,175) With nonrelatives 91.6 5.5 2.9 100.0 (121) Total 92.2 5.6 2.2 100.0 (4,648) Respondents reporting that they need but do not receive help with doing house work/laundry, preparing meals, going grocery shopping, managing money, or man aging medications. bRespondents reporting that they need but do not receive help with eating, bed transference, inside mobility, dressing, bathing, and toileting. This group included those who had unmet activities of daily living (ADL) needs with or without unmet instrumental activities of daily living (IADL) needs. c Totals may reflect rounding. Weighted base counts in thousands. eIncludes those who live only with a spouse and those who live with a spouse and others. f Includes those who live only with relatives (not a spouse) and those who live with both relatives and nonrelatives. SOURCE: Tabulations from the 1982 National Long-Term Care Survey.

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SOCIAL AND PHYSICAL ENVIRONMENTS 113 In this analysis, persons with care needs are those who did not receive assistance with at least one of the lADL or ADL tasks in which they are dependent. Defined in this way, the prevalence of unmet care needs is not substantial, a circumstance that may reflect underreporting as a result of the Tong-standing accom- modations many frail elderly persons make to the gradual Toss of capacity. Nonetheless, approximately 364,000 disabled but noninstitutionaTized elderly report at least one neglected aspect of personal care. Of most interest to the present discussion is not the magnitude of unmet needs as such but rather the systematic differentials in the prevalence of unmet need across types of shared house- holds. The likelihood of unmet care needs varies inversely with the closeness of the bond that relates the disabled elder to other members of the household. Functionally limited elderly persons who live with spouses are the least likely to report areas of unmet need; those living with nonrelatives are the most likely to have unattended areas of care.4 Related analyses have also shown that those who live with nonrelatives, and particularly those whose care needs are not fully satisfied, are the most likely to be on a waiting list for nursing home admission (Soldo and Manton, l985c). The evidence presented in our discussion thus far suggests that the vulnerability of the frail elderly is primarily a refiec- tion of their morbidity and disability and not of inadequate social environments. Apart from obvious measurement prob- ULems, the concept of vulnerability as discussed in the preceding paragraphs directs attention to additional aspects of the social and physical world of the disabled. Thus, to consider vuinerabil- ity, it is necessary to examine evidence that relates disability to multiple aspects of the environment occupied by the frail elderly. For this purpose, a simple quaTity-of-life deficiency index was created by summing respondent reports of deficiencies in five aspects of their social, economic, and physical environments: Financial Monthly personal income is less than the 25th percentile of the income distribution, or about $325 per month (25.2 percent). Service At least one lADL or ADI~ care need is neglected in the current care-giving arrangement (7.S percent). Social Contact is not maintained with family or friends

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SOCIAL AND PHYSICAL ENVIRONMENTS 123 changes in the physical space they occupy. Care-giving house- holds often make less dramatic and permanent changes as when the "sick" room is relocated to the dining room for the conven- ience of both the care provider and the care receiver (Noelker, 1982). Yet changes in the structure or organization of dwelling units do not encompass the vast array of environmental responses to dependency. Often, the environmental context of disability is involuntarily defined in the case in which an older person con- tinues to maintain a Tong-standing and familiar residence even as the social world of the neighborhood deteriorates. In this section, however, we focus more narrowly on the ways in which disability is accommodated through residential relocation. Our knowledge of the prosthetic effect of the immediate hous- ing environment for the frail elderly is informed primarily by studies of"special populations"-for example, elderly persons who relocate to age-segregated buildings, service-saturated dem- onstration projects, or wealthy retirement communities.8 Such individuals are self-selected and hardly represent the vast ma- jority of elderly who age in place or move from one private dwelling to another. Nonetheless, prior research tends to dem- onstrate the positive effects on global or subjective markers of well-being that can result from improved housing environments. For this reason, we examine next the process by which suppor- tive environments are sought out as an accommodation to age- related changes in personal needs. Retirement Communities When the Social Security Administration initially funded the Comparative Study of Midwestern Retirement Communities a decade ago, its focal interest was a comparative evaluation of the costs and benefits of living in age-focused housing (Peterson et al., 19791. Study settings were chosen to represent a range of types of niches or localized living environments whose costs, degrees of service, and natural settings differed considerably. The sites chosen for this study included high-rise, central-city public housing developments for the aged, a large suburban life- care village, and small towns in the Ozarks region of Southern Missouri that had essentially become retirement communities through the in-migration and dense concentration of recently

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124 BE TN J. SOLDO AND CHARLES F. LONGINO, JR. retired people. Each community attracted a different mix of residents. Although the residents of the public housing site had apprecia- bly Tower incomes than the residents of the life-care community, older persons in both of these planned environments were more likely than those who lived in nonstructured communities to describe their health as "good." Such preliminary findings would seem to imply that the residents of housing developments for the elderly are better off than they would be in other environ- ments. Yet almost all voluntary movers evidence higher levels of satisfaction in their new surroundings than at their former address. In addition, retirement communities are specialized liv- ing environments and do not attract a representative cross sec- tion of the older population. The problem of assessing the prosthetic effects of the housing environment occupied by an elderly person independent of the effects of self-selection was addressed by drawing a shadow sam- ple of matching controls from a national opinion survey (Lon- gino et al., 19811. Researchers then administered an instrument to residents of the study sites that contained many of the atti- tudinal items from the national survey. In this way, self-selection (at least on background variables) was controlled for in the anal- ysis of relative benefits. It was possible, therefore, to assess environmental effects with some confidence by comparing the quality of life of residents in the study communities with similar people in the general population. The results of the study indicated that the life-care community provided measurable benefits to residents in the areas of medi- cal care, freedom from the fear of crime, and loneliness and boredom. The cost-of-housing benefit was negative; the same tangible housing and services could have been purchased more cheaply in suburban areas elsewhere. The intangibles of life- care community living, however, seemed to make a substantial difference to the residents. They felt that they were getting a "good deal"; their morale was higher than that of their counter- parts elsewhere. Yet it appeared from the study results that beneficial living environments are not reserved solely for the affluent. People in the shadow sample were far more likely to complain about in- sufficient medical care than were the residents of the public housing site for the elderly. Residents also benefited from a

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SOCIAL AND PHYSICAL ENVIRONMENTS 125 reduced fear of crime. (Many of the residents had moved from high crime areas into the public housing units, whose security guards and exclusively elderly residents made them feel safer.) Similar conclusions were drawn, with one key exception, when rural retired migrants were compared with their shadow sample from the general population. The Ozarks residents, while feeling safer from crime and more socially adequate in every way than their counterparts in the general population, were much more likely to complain about insufficient medical care. Although we might expect those elderly persons who selected more supportive environments to show improved functional ca- pacity, such improvement is not always the case. In comparing several groups of such residents with stationary community con- trols, Lawton (l9SOb) reported a relative and substantial decline in functional capacity among the frail elderly who moved into five different housing projects. Because factors that generally have a positive bearing on health (morale, social behavior, and leisure-time activity) were negatively correlated with functional capacity in the 12-month follow-up assessment, Lawton specu- lates that the net effect of programmatically improved housing may be to "buffer the individual against a decline in health, so that attitudes, affect, and even some forms of social involvement, could remain at relatively favorable levels" (l9SOb). Conse- quently, elderly public housing residents may consider their medical care to be more adequate than that of their community counterparts, but this belief does not necessarily translate into improved functional capacity. However, several other markers of vulnerability are lessened in this type of housing environment. The Comparative Study of Midwestern Retirement Communi- ties indicated that the factors motivating a change of housing environments were predictably related to the likely outcome of a residential move. Resource deficits in the face of declining functional capacity can trigger a change in residential location. Both subsidized and nonsubsidized planned communities are service-enriched living environments, designed with the needs of older residents in mind. The people who move to such places tend to be motivated by perceived deficiencies in their previous housing and community environments; in their reasons for mov- ing, they tend to emphasize those very areas of support that are the strengths of the planned community. Thus, people who are attracted to such communities tend to have characteristics that

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126 BETH J. SOLDO AND CHARLES F. LONGINO, JR. imply greater need and vulnerability. The fit between living environment and individual needs would seem to be reasonably good in such settings. Persons with a greater need for support in the instrumental activities of daily living tend to be attracted to communities built to meet those needs, and support seems to flow from within the community to the persons who move there (Longing, 1986; Longino and Lipman, 1981, 1986, Peterson et al., 1979). Indirect Environmental Influences Preliminary evidence also suggests that aspects of the built environment can influence, both positively and negatively, not only disability itself but also the ease with which care services are provided (Newman, 19851. Noelker (1982), for example, has recently reported on an innovative study of the environmental impediments to care in households shared by the care provider and his or her relative. Both spatial barriers (e.g., inadequate number of bedrooms) and navigational barriers (e.g., interior stairs) were found frequently. Spatial barriers were most highly correlated with tension among household members, perhaps stemming from a lack of privacy; navigational barriers were positively correlated with the number of personal care tasks with which the elderly person required assistance and the care provider's perception of the difficulty in providing such care. Although most home care programs emphasize service deliv- ery, modifications of the built environments in which care is provided may also be effective in preventing or postponing insti- tutional placements. Because housing seems to affect the style, intensity, durability, and tolerability of care giving, it is fair to conclude that, in this context, housing characteristics function as important intermediate variables. The size, condition, and location of the involved households all indirectly affect the de- gree of fit between the elderly person's needs and the available compensating social resources. FUTURE CONSIDERATIONS In this paper, we have presented a wide array of data relating the disability of the elderly to markers of vulnerability in other areas and finally to a range of both service and environmental

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SOCIAL AND PHYSICAL ENVIRONMENTS 127 adaptations. Yet despite the range of information we have as- sembled, it is clear that we lack the detailed data necessary to the simultaneous examination of all of the quantitative and qualitative dimensions of population aging. As a result, many of our comments have been speculative, drawing particular at- tention to the gaps in our knowledge of how different types of people actually live in natural environments and why they func- tion as they do (Parr, 19801. We are impressed by the magnitude of change projected in the number of the frail elderly, even under the most optimistic of scenarios. To respond to this volume of demand, it is clear that our society cannot afford to dismiss out of hand any strategies that have the potential to be both cost effective and efficient. This imperative includes leveraging certain aspects of the social and built environments to enhance their functional capacity. In the past decade, we have seen the development of a wide- spread community awareness of the needs of handicapped per- sons. This awareness derives from and perhaps has contributed to the parking and building regulations that have helped to eliminate barriers to the activities of the handicapped, thereby increasing their independence and productivity. The possibility of adapting our built environment for the disabled is no longer a novel idea. As the U.S. population ages, community awareness and acceptance of environmental modifications are likely to con- tinue and expand. Creating environments that are more supportive of older, func- tionally limited persons is not the exclusive purview of the pub- lic sector, however. Building codes and zoning regulations can obligate builders to add features that make new construction less hostile to persons who are restricted in their mobility. The private sector already is vigorously marketing planned, support- ive housing for the marginally disabled. These efforts are likely to intensify as Tong as the number of old persons who can afford such environments increases. Even under the assumptions of modest economic growth, we can anticipate further increases in at least the absolute number of the future elderly with the financial wherewithal to "buy into" planned communities. Despite the likely improvements in the financial profile of each new cohort, however, there will continue to be sizable num- bers of older persons who will not be able to compete effectively for the prosthetic goods and services they will require. Meeting

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128 BETH J. SOLDO AND CHARLES F. LONGINO, JR. the needs of the low-income elderly will most likely remain the responsibility of the public sector while the private sector pur- sues the more affluent segment. Policymakers and planners con- cerned with the well-being of the elderly thus will be faced with two issues: one old and one new. The perennial question in a pluralistic society such as ours is how to provide for the elderly the poor and wealthy alike in a manner that is "just" and "equitable." Given the rate at which the number of elderly persons and the volume of their needs are increasing, we must put aside any thought of meeting all the needs of all the elderly. Even taking as an objective a level of service far short of that goal, few societies can provide for even the minimal needs of their elderly populations without compro- mising some other social good, such as education, security, trans- portation, or environmental protection, goods that benefit young and old alike. Thus, the overarching issue in planning for an aged population is one of resource allocation, which subsumes, albeit implicitly, concerns for distributive justice. Let us consider the implications of the allocation question even at the service delivery level. As noted earlier, the social and environmental resources available to an impaired older per- son are often reviewed in developing a care plan. It is not clear, however, how this information should be used in assigning serv- ice priorities. Tentative evidence, including some of the data presented earlier in this paper, suggests, for example, that a spouse's commitment to noninstitutional care is more durable than that of adult children, other relatives, or friends. Should other research confirm this finding, equity questions would arise concerning the appropriateness of concentrating public expendi- tures on elderly persons who are cared for by individuals other than spouses that is, the equity of concentrating public monies on elderly persons whose resources for accommodating depend- ency are constrained and whose risk of a nursing home place- ment would appear to be greatest. The TawIsean principle of justice would require that society benefit those who are least advantaged socially or environmen- tally. But other understandings of justice may mandate that all of the frail elderly and their care providers, regardless of in- come, have an equal claim on available resources or an equal claim to a minimum level of assistance. Similar questions may arise around the issue of providing

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SOCIAL AND PHYSICAL ENVIRONMENTS 129 intensive care services to kinTess elderly. Conventional service delivery wisdom is to focus service provision on such indivi- duals. The materials presented earlier in this paper suggest that environmental modifications in the immediate household should also be considered to facilitate the optimal functioning of those with an inadequate support network. It seems clear, however, that the most technically advanced modifications, even in com- bination with intensive home care services, can elevate function ing only so much and sustain it only so Tong. For such indivi- duals, institutionalization may be all but inevitable in the Tong run. This argument suggests that the most efficient and effec- tive strategy of allocation might be to concentrate public re- sources on those whose nexus of private resources are most con- ducive to noninstitutional care. We certainly do not claim to have the answers to these difficult questions. But when resources are finite, difficult choices must be made that may benefit one group at the expense of another. It is clear that, no matter how seemingly objective our attempts to construct the process of choice in formulating a national pol- icy on aging, in the end, we must still confront value questions- and we must confront them directly in an orderly, critical, and reasonable way (Soldo et al., 19851. A relatively new issue on the planning horizon is how to "cre- ate" environments that are conducive to successful aging. The solution to this question is not likely to be found in a unitary master plan generated either by the public or the private sector. It is more likely that a diverse array of "building blocks" wit! be made available to the disabled elderly and their care provi- ders. These components will include increased and varied oppor- tunities for adaptations to existing housing units, home-deliv- ered services, and planned living environments that offer different mixes of ancillary services. Individuals may then choose from among the components of their expanding opportu- nity set the environmental, service, and health care service bun- dIe that best balances needs with resources. We believe that public policy is far less likely to create new environments for the vulnerable elderly in this century than it is to encourage the production of new "building blocks" with which people can create their own customized environments. Whereas this prophecy would seem to be a direct translation of contemporary political attitudes, we maintain that our rationale

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130 BETH J. SOLDO AND CHARLES F. LONGINO, JR. reflects an awareness of the heterogeneity of the elderly popu- lation as a whole and of the frail elderly in particular. Taking account of this heterogeneity in the formulation of public policy may be the hallmark of new initiatives that struggle, in a rela- tively short time, to accommodate the large baby boom cohorts and differing mixes of needs and resources. NOTES 1. The methods and procedures of this survey are described in detail by Macken (1986). 2. The instrumental activities of daily living (IADL) scale measures the perform- ance of the following tasks: managing money, shopping, light housework, laundry, meal preparation, making a phone call, and taking medication. 3. The activities of daily living (ADL) scale measures the unassisted performance of the following tasks: eating, bed/chair transference, indoor and outdoor mobility, dressing, bathing, and toileting. Respondents reporting incontinence problems also qualified for survey participation. 4. Other analyses indicated that the prevalence of unmet need decreases slightly with age and is greater for women than for men at any age or for any type of living arrangement. 5. Although it would be desirable to disaggregate this summary index to show patterns of deficiency, the unweighted sample size was sufficient to support this level of detail. This claim also applies to the statements in the next two paragraphs. 6. Newman (1985) also reports that, although rates of mobility limitations in- crease with age among the elderly, the prevalence of substandard housing conditions (defined in terms of the U.S. Department of Housing and Urban Development's [HUD's] criteria for physically adequate dwelling units) was fairly constant across age groups. 7. The recently released Survey of Income and Program Participation (SIPP), however, will provide data on the benefits individuals receive from a number of publicly financed programs. 8. In 1982 only about 9 percent of all community elderly with functional limita- tions received care at home from a visiting nurse. Approximately 2 percent received a home visit from a physician (Soldo and Manton, 1985c). REFERENCES Becker, P. M., and H. J. Cohen. 1984. "The Functional Approach to the Care of the Elderly: A Conceptual Framework." Journal of the American Geriatric Society 32:923-929. Branch, L. G., and A. M. Jette. 1982. "A Prospective Study of Long-term Care Institutionalization Among the Elderly." American Journal of Public Health 72:1373-1379. Brody, S., S. W. Poulshock, and C. F. Masciocchi. 1978. "The Family Caring Unit: A Major Consideration in the Long-term Care System." Gerontologist 18:556-561. Carcagno, G. J., and P. Kemper. 1983. "The National Long-term Care Demonstra

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