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Summit INTRODUCTION Among the challenges posed by our aging or "graying" society is the relationship of the elderly to the social and "built" or physical environment. The changes that have already affected the growing elderly population in the United States point to a number of continuing trends: a majority of the aged increasingly will be female, older, better educated, and probably better off financially, although there will continue to be a "hard-core" group of poor older persons. Demographic projections also esti- mate that, as longevity continues to increase, there may be more very disabled people, as a function both of the changed age distribution in the population and of lifesaving medical technol- ogy. What changes must be made in our social and physical methods of organizing the environment to accommodate the needs of these citizens? What policies should be formulated to effect these changes, and what more do we need to know to carry out our plans effectively? To address these issues, the Committee on an Aging Society convened a symposium in Washington, D.C., in December 1985. The Summary and the Proposals for Policy and Further Research are based on contributions from a number of committee members and symposium participants. We wish to acknowledge particularly William Bell, M. Powell Lawton, George Myers, and Michael Rodgers. 1
2 COMMITTEE ONAN AGING SOCIETY The symposium focused on selected aspects of the social and built environment and on new ways in which the environment might be restructured to achieve two essential goals: (1) enhance the social productivity of aging persons and (2) prolong the resi- dence of older persons in the community in a manner that en- hances the quality of their lives and fosters ties with formal and informal support systems. In selecting the symposium topic, the committee recognized that policies influencing the social and built environment have been largely value driven, often reflecting goals and standards of decision makers, in both the public and private sectors, that have remained undefined. PREVIOUS STUDIES Although domiciliary and institutional living for the elderly have been favorite topics from the beginnings of gerontology as a field of study, their first consolidation in a more scientific form came in the chapters of the handbooks of gerontology published almost 30 years ago (Birren, 1959; Tibbitts, 19601. Vivrett (1960) provided a chapter summarizing much of the service-, policy-, and design-relevant information of the day; similarly, Klee- meier's (1959) chapter was the first attempt to formulate an environmental psychology of later life. Subsequent writings by Carp (1966), Rosow (1967), Pastalan and Carson (1970), and Law- ton and Nahemow (1973) developed the issues further in a period that saw the emergence of a national housing program, the redefinition of the home for the aged, and the stimulation and facilitation of nursing home development by the federal government. The first and perhaps most influential project of research, policy, programming, and education in the aging-related envi- ronmental area was that of the Gerontological Society (later to become the Gerontological Society of America or GSA) from 1971 to 197S, which was supported by the U.S. Administration on Aging and directed by the late Thomas O. Byerts. This mul- tifaceted project treated many of the topics presented in this volume and resulted in a series of conferences, books, policy statements, and teaching materials on aging persons and the built environment. The project succeeded in engaging the atten- tion of many scientists and professionals who had not previously
SUMMARY 3 been involved in the field of aging, and it also contributed to an enrichment of the general methodology of studying person-en- vironment relations specifically focused on older people. (For example, throughout its history, meetings and publications of the Environment Design Research Association have featured gerontological material in substantial quantity, much of it at- tributable to the Gerontological Society's project.J In 1981, GSA provided the U.S. Department of Housing and Urban Development with a research agenda and annotated bib- liography (Taylor, 1981; Taylor et al., 1981, 19821. Other relevant projects funded by the Administration on Aging dealt with transportation (Cantilli and SchmeIzer, 1971; Institute of Public Administration, 1975) and gave financial support to help estab- lish the National Center on Housing and Living Arrangements for Older Americans at the University of Michigan, a project that is now continuing with university support. Other organizations have also begun to address the issue of the elderly and their environment. In revising its standards for facilities for the physically handicapped, the American National Standards Institute (ANST, 1980) engaged a gerontologist-archi- tect, Edward Steinfeld, who succeeded in stimulating the think- ing of design practitioners and administrators. Most recently, the American Institute of Architects mobilized some of its re- sources to encourage architects to be increasingly sensitive to the housing needs of older persons. Unfortunately, the ATA proj- ect appears to have been terminated after the publication of a single book (American Institute of Architects, 19851. THE CURRENT FRAMEWORK The current framework of research on the social and built environment of an aging society acknowledges a basic tenet that has been suggested by Howell (among others): to understand and address the interaction between the environment and an aging population, one must take into account concepts from and the knowledge bases of diverse fields (Howell, 19801. The design of the symposium reported in this volume reflects that stance in that the-eight papers commissioned for it were prepared by authors from such fields as sociology, economics, psychology, medicine, planning, and architecture.
4 COMMITTEE ON AN AGING SOCIETY The Demography of Current and Future Aging Cohorts The demographic changes in the elderly population of the United States are central to addressing the social and built environment of an aging society. In a review of current demo- graphic trends and projections, William d. Serow and David F. Sly (in this volume) suggest the need for a basic understanding of the characteristics of the various subpopulations of older per- sons and how the elderly population as a whole evolves within the larger aggregate of the general population. The authors emphasize that neither of the two aggregates can be viewed in isolation: .. . the needs of this subpopulation (of the aging) and its resulting demands are going to be strongly influenced by its size. In this sense, it is important for us to know much more about patterns of mortality and longevity and how these are changing. This may sound simple, but the complexity of such knowledge is evident when we consider that the size of this population is influenced by historical patterns of fertility and mortality to the point at which persons enter old age, as well as by patterns of mortality throughout the older years of life-to say nothing about the patterns of immigration and emigration over the whole course of life. Similarly, the structure of the processes that are responsible for growth in the elderly population (fertility, mortality, and migration) and the changes that are likely to occur in that struc- ture will influence the demand for "needs" and even influence what these needs are and will be. For example, temporal patterns of child- bearing (when combined with increased longevity) across generations influence how old children are when their parents reach old age and may have profound influences on the physical, economic, and social ability of children to care for their aging parents. Similarly, changing patterns of mortality may not only influence the number of people who reach old age but may also affect how many people survive for longer periods after reaching old age. In addition, changes in mortality may have an impact on the physical, economic, and social abilities of this subpopulation's members to care for themselves (in old age). The period examined by these two researchers comprised 1940- 1980, and it is apparent from their findings that the composition of the population of those aged 65 years or older has changed sharply. Two features stand out, both of which are associated with a distinct increase in the educational level of older persons. First, in general, the economic status of the elderly has im
SUMMARY 5 proved, although, according to Serow and Sly (in this volume), "different cohorts have quite different savings and labor force opportunity patterns, which can have quite different conse- quences for the financial abilities of the population during the early years of old age" (emphasis added). The second feature is increased longevity: older people are living longer after reaching age 65. Regarding the interaction of these trends, Serow and Sly (in this volume) commented: "increased longevity among the aged will have important consequences for how long savings and retirement income will have to last, which in turn may have important consequences for how the elderly dispose of income and savings through old age." The level of disposable income and the extent of savings on the part of elderly persons will also dictate the size of the dependent population to be supported publicly, the period and scope of support to be provided, and the nature of the private sector's response to the changed economic position of the elderly. Yet none of the recent indications of improved economic posi- tion of the elderly should obscure the continued presence of a "hard core" of poor older persons, which was estimated in 1980 to be about 12.5 percent of all those aged 65 and older in the United States. In general, poor older persons are women drawn from many different minority groups, but most of them are black, without spouses, and with limited educational achieve- ment. Higher Social Security benefit levels have helped to lift a proportion of the elderly out of poverty but not by much. It is estimated that approximately 40 percent of older persons on Social Security must survive financially on their monthly pay- ment, a function that Social Security was not designed to per- form when it was begun in 1935. A substantial group of poor elderly persons, combined with the increased longevity of the subpopulations of all older people is a factor that must be reckoned with in planning social services and housing for the elderly. Other recent demographic trends that are also likely to affect the social and built environment of older persons include changes in labor force participation (in particular, the increased numbers of women working) and deci- sions about when to retire; divorce among couples with substan- tial years of marriage, often on the threshold of old age; the diminishing number of family members available to provide so- cial support of a family's elders as more married women enter
6 COMMITTEE ONANAGING SOCIETY the labor force; and changes in mortality differentials by sex. Collectively, these changes suggest an expanded role for formal services to the aging and their families. One segment of the aging population in particular-those 85 years and older, the oldest of the old, frequently characterized as the frail or vulnerable elderly has grown at a dramatic rate over the past four decades and is likely to exercise a strong influence on the social and built environment of the future. Between the census periods of 1940 and 1980, the population aged 85 and older expanded by more than 500 percent from 364,752 to 2,240,067. The growth of 85-and-older persons in this period was almost two to one in favor of women. There is little known about this age group, largely because of the paucity of tabulations from published U.S. census data, and the marked growth in their numbers appears to have surprised some U.S. policy analysts, despite signs of this potential growth as early as 1950. (Serow and Sly point out that in the census periods 1940 through 1970, the population aged 90 and older increased by 6S, 90, and 75 percent, respectively, before tapering off to an in- crease of 45 percent in the census period 1970-1980.) The future "old old" may differ in important ways from the current elderly cohort. For example, Serow and Sly (in this vol- ume) argue that the 1980 group aged 55-64 represents the cut- ting edge of critical differences between the elderly of yesterday and the elderly of tomorrow in the composition of the population and their life-course experiences. The new old are better edu- cated and have higher incomes, although such economic better- ment may be offset by other trends. Men may retire earlier, and women will probably have considerably more labor force experi- ence. Smaller families portend fewer familial resources to care for the future old old. Furthermore, despite a better economic outlook for many of the future oldest old, a substantial group will still fall under the poverty line. To summarize briefly, three new factors of importance in the design of social and physical environments for community-based elderly persons have become apparent. First, the survivorship of elderly persons in the upper ranges of the age scale appears to be increasing. Second is a major demographic trend that will greatly influence the social and built environment: the emerg- ing cohort differences by composition and life-course experiences that suggest the future old old may differ in important ways
SUMMARY 7 from the current elderly cohort. Finally, we may note the sub- stantial growth of an elderly subpopulation whose members are potentially susceptible to decrements in health and related con- ditions that may accompany advanced age, suggesting an in- creasing vulnerability among elderly persons who choose to maintain their independent residences. The Concept of Vulnerability Among the OIclest 01d With increased longevity, vulnerability among the elderly has assumed growing importance. As a result, the changes associ . ated with the normal process of aging are being subject to in- creasing scrutiny. Beth d. Soldo and Charles F. Longino, dr. (in this volume), for example, have proposed the following: · Changes among elderly persons are not correlated with chronological age but exhibit variance. · Changes among older people are not manifest as a simple linear decline but show a variety of rates; change may even be arrested. · Changes in function may produce different effects in the same person, and the variance among older persons tends to increase with age. · The rate of change can proceed along some dimensions rel- atively independently of change in others, but the serious loss or compromise of functional capacity in one area can accelerate the rate of decline in others. · A supportive social or physical environment or positive change can retard the rate of functional loss to some degree. These findings, which were derived from research by Soldo and Longino and others, suggest not only that changes associ- ated with the aging process are multidimensional but that vul- nerability among aging persons should be conceptualized simi- larly because it includes physical, environmental, economic, social, and mental health factors. Indeed, Soldo and Longino suggest that the assessment of vulnerability among older per- sons calls for an integration of qualitative information (derived from biomedical research and service delivery experiences) and quantitative data gleaned from demographic analyses. Soldo and Longino (in this volume) measured vulnerability
8 COMMITTEE ON AN AGING SOCIETY according to five specific areas: (1) income, (2) the existence of care services, (3) social contact, (4) an unmet but perceived need for special housing, and (5) satisfaction with one's neighborhood. Using such a quality-of-life deficiency index to discover vuIner- ability in disabled elderly persons living with or without a spouse and living with or without relatives, the authors found that "nearly 90 percent of the frail are not simply disabled but also socially, economically, or environmentally impoverished as well. Nearly two-thirds are deficient in at least two areas, and slightly more than one-fifth have problems in three or more areas." The authors concluded that the gradient of need on the part of the vulnerable elderly is matched imperfectly with the gradient of available community-based services offered to them. Citing the work of Glick (1979), the authors suggest that the demand for community Tong-term care may far outrace the growth in members of the disabled portion of the elderly. Bar- ring changes in service delivery approaches, Glick's projections also suggest that the proportion of the elderly with an unmet need for Tong-term care and the proportion with multiple social and environmental deficiencies may increase over time. To un- derstand better why this mismatch of need and service exists, it is necessary to examine recent federal housing policies and what current policies portend. Federal Housing Policies Over the years, federal policy on housing for the elderly has been directed toward two elderly groups. The first, and by far the largest in monetary terms, comprises moderate and upper income groups. Tax expenditures, in the form of mortgage inter- est and property tax deductions, have been extremely successful in promoting and subsidizing home ownership for elderly per- sons. By 1986, over 76 percent of the elderly owned their own homes, and 80 percent of those owned their homes outright. The second track of federal policy has been directed toward providing housing and adequate shelter for low-income indivi- duals. Initiated during the Great Depression as part of the Roo- sevelt New Deal, federal involvement in housing for the poor of all ages has a 50-year history. In 1949, Congress adopted a national policy aimed at ensuring a decent home and suitable living environment for every American family. Over the years,
SUMMARY 9 the federal government has developed a number of mechanisms to achieve this goal including the direct provision of housing through new construction, rental assistance, mortgage interest subsidies, and other financing arrangements with local govern- ments and housing development agencies. Currently, these pro- grams account for well over 3.5 million units, some 1.5 million of which are occupied by older persons. Although the low-income housing created under the Housing Act of 1937 was not initially intended to provide special assis- tance to the elderly, it has evolved into one of the principal forms of housing assistance for this age group. As a result of legisla- tive changes enacted in the late l950s, the proportion of housing units occupied by people over age 65 jumped from 10 percent in 1956 to 46 percent in 1984 (U.S. Senate, Special Committee on Aging, 19861. The first program specifically designed for the elderly Sec- tion 202 of the Federal Housing Act of 1964 was initiated in 1959. It has become the centerpiece of federal housing policy for the elderly, providing low-interest loans to private, nonprofit sponsors for the construction of subsidized rental units. As of 1985, it had provided an estimated 18S,000 units of assisted housing for this age group. Yet despite this construction, one estimate is that approxi- mately 2 million of the 3.2 million Tow-income elderly who are eligible for federal housing assistance currently are not served by federal programs (U.S. Senate, Special Committee on Aging, 19841. Recent congressional studies show that, today, over a quarter million older persons are waiting to gain entrance to Section 202 projects nationwide. With the continued "graying" of the population, this demand is expected to grow. Although the federal response to assisted housing has been the major source of Tow-income housing in this country, critics maintain that the current approach has been deficient in several areas. First, unlike health and income security programs, hous- ing has never been seen as an entitlement. Some housing spe- ciaTists fee! that this narrow vision has exacerbated the prob- lems of existing substandard housing and resulted in Tong waiting lists for housing assistance. Second, the government's response to assisted housing has been predominantly production oriented. This "bricks and mor- tar" approach has failed to address the support service needs of
10 COMMITTEE ON AN AGING SOCIETY those requiring help. As indicated by several of the authors whose papers are presented later in this volume, programs of nutrition, health, day care, and other social services have not been fully integrated into assisted housing, which results in a fragmented and confusing array of service initiatives and con- siderable unmet needs. Third, economic concerns in the l980s, fueled by inflation and changes in federal spending priorities, forced shifts in public policy on many domestic programs. Although much of the con- sequent budget-cutting attention was directed toward health and income transfer programs, federally assisted housing also came under scrutiny. Administrative and legislative initiatives in the early l980s substantially reduced assisted housing programs, resulting in a 70 percent loss of budget authority since 1981. In light of these economic and political changes, many observ- ers believe that federal housing programs are undergoing a gradual evolution that may alter the future of housing policy for the aging. Three major trends are likely to have an impact on these developments. First, a renewed emphasis on federalism in the early l980s produced a shift to state and local governments of the responsi- bility to provide for the shelter needs of Tow-income persons. State governments have experimented with a variety of creative financing arrangements. Tax-exempt bonds, the integration of state funds with existing federal dollars from such sources as community development block grants or urban development ac- tion grants, and the allocation of a portion of state revenues for Tow-income housing have all produced promising results. Seven states now have substantial congregate housing programs for the elderly, and at least one local community has promulgated zoning laws requiring developers to earmark a portion of new developments to Tow- and moderate-income housing. Second, the federal government has moved away from its his- toric role in the direct provision of housing and now promotes private sector and philanthropic initiatives. Rather than build- ing new public housing units, the Reagan administration has emphasized stabilizing existing housing programs for the el- derly. Additionally, the private sector, which has traditionally been motivated by economic returns, has been encouraged to adopt new marketing strategies in conjunction with the human
SUMMARY 11 service agencies to ensure older citizens continued opportunities for independent living. In recent years, a number of national and regional organizations have been formed to foster such new partnerships. Finally, the economic pressures of rapidly escalating health care costs, especially among the elderly, are driving the move toward the development of a comprehensive approach to com- munity-based Tong-term care services. (Only recently, however, have the shelter needs of the elderly been recognized as a vital component in such a system.) Research on congregate housing demonstration programs at both the federal and state levels has shown that a mix of support services tailored to individual needs in an assisted housing environment can reduce more costly in- stitutional alternatives (U.S. House of Representatives, Select Committee on Aging, Subcommittee on Housing and Consumer Interests, 19871. The hope of the advocates of comprehensive services is that substantial savings in both Medicare and Medi- caid may be possible through programs designed to provide in- home support services; yet even if savings are not realized, the programs may succeed in enhancing the quality of life and pro- Tonging community residence for older people. In short, the federal government's 50-year commitment to housing for the elderly is likely to continue, although probably in a changed form to meet new needs. Public sentiment and the congressional priorities that have been established during the last several decades will ensure that these needs receive the attention of policymakers. As our society becomes progressively older and. changes occur in the social and economic environment, housing policy must keep pace to address these new and varied challenges. Public Intervention in Housing Programs for the Aging Raymond J. Strnyk's review (in this volume) affirms the rela- tionship between housing and long-term care and endorses the role of community-based housing as a major environmental ele- ment in a multidimensional response to vulnerability among the aging. Viewing housing programs provided by the public sector as a form of public intervention, Struyk asserts:
12 COMMITTEE ON AN AGING SOCIETY The dominant issue in the debate surrounding the housing environ- ment of the elderly is how to construct public assistance to support those housing transitions that are necessary to allow community-hous- ing to become an active and integral element in the overall long-term care system. His view of the needs of older persons for a social and built environment include the following propositions: · changes in health, in the availability of social supports, and in income level accompany persons moving into old age; · the intact elderly differ among themselves in basic health condition, level of household income, and preferences for renting or owning a home; and · the elderly are prime candidates for long-term care, a sys- tem that ought to transcend the traditional institutional solu- tion and include the provision of supportive services to help the vulnerable elderly with the normal tasks of daily living while they retain residence in community-based housing. What is required but is currently absent as part of an effective social and built environment is a set of national policies and practical, flexible options to respond to the elderly, whose hous- ing demands may change as subjective conditions change in the course of the process of aging. In analyzing the extent to which older persons in need of supportive services should remain at home, Struyk (in this volL- ume) distinguished between two types of housing problems: the difficulties associated with the more traditional issue of housing condition and the deficiencies of the dwelling itself are referred to as dwelling specific, whereas problems associated with activ- ity limitations of the housing occupant in the use of the dwelling are termed dwelling-use problems. The former category of issues tends to be related to income level rather than age and can be addressed by paying to have repairs made or having repairs provided by volunteers. The latter set of problems may be attrib- uted to advanced age exacerbated by physical impairment and may be offset by assistance from family or others or by modifi- cations in the design features of the dwelling. Struyk found that about 12 percent of persons aged 65 and older need some form of supportive service in the home 7 per- cent of those aged 65-74 and 21 percent of those aged 75 and older, totaling an estimated 28 percent of all elderly households.
SUMMARY 13 A more conservative approach to estimating the elderly in households with functional limitations receiving formal suppor- tive services calculates that 25 percent of the elderly are in receipt of such services, paid for either by themselves or by an agency. The estimates of the number of elderly with housing- specific problems tend to be more accurate and exceed the num- ber of elderly with housing-use problems. Approximately 10 per- cent to 17 percent of the elderly are said to have both types of problems. Two strategies are available for tailoring housing to a person's needs as health conditions change: one is the modification of the dwelling, and the other is the person's relocation to alternative housing more suited to his or her physical status. The intent of housing modification is to enable the older per- son to continue to live as independently as possible while re- maining in the same dwelling, thereby diminishing actual or potential dependence on others. The cost of modification is a major consideration, however, although some of the costs are one-time expenditures and some changes may not require the outlay of funds. For example, one possible solution for a person with heart disease residing in a home in which the bedroom is on the second floor is to convert one of the downstairs rooms to a bedroom. Yet despite the rationality of a strategy of housing modification, Struyk (in this volume) reports that a 1982 study showed that only 10 percent of the elderly who resided in house- holds with at least one member with health and mobility prob- lems carried out any modification of the dwelling. The second strategy, relocation to alternative housing, may include moving to a smaller home, entering a shared housing arrangement, or moving into one of several forms of residential congregate housing. According to Struyk, Heumann (1985) cal- culated that congregate facilities were about one-third less ex- pensive overall than institutional Tong-term facilities for the same care services. But most older people, whether impaired or not, tend to resist relocation. In many instances the older person is intuitively correct for it may not be possible to replicate his or her current housing, despite its limitations, with an equiva- lent dwelling. Some older people may not be aware of available alternatives. Relocation need not be threatening if the decision is made voluntarily, but the social costs of relocation should be considered.
14 COMMITTEE ON AN AGING SOCIETY The security of familiar surroundings is valued by most older persons. Sweden, among other countries, exercises what it calls a "first line of defense" against moving older pensioners from familiar environments. This policy includes making improve- ments in the housing unit and providing a program of home help (SPRT, 19791. The Swedish system of home help is worth exam- ining as one way of addressing services to the vulnerable elderly. The service is national in scope; in 1979 it employed some 70,000 paid workers throughout the country. The provision of home help, as of other social services, is the financial responsibility of municipal authorities and is usually paid for out of tax funds. It is offered without cost to the recipient. Home help services are provided by a combination of paid staff and volunteers, prefera- bly neighbors and friends. The tasks are divided: those tasks requiring specialized knowledge and skill are performed by the paid staff, and those tasks that are routine and easily manage- able are performed by the volunteers. It is not unusual for the home helper to undertake minor health care such as help with medications, but full nursing service is not provided by this individual. It is not unusual, therefore, to have a consortium of helpers working collaboratively under a case manager, drawing on the varied contributions of a family member, a neighbor in the area, a nurse, and a home helper to provide the range of support services necessary to get the older person through the day's routine. Struyk (in this volume) concludes that making the current housing program in the United States more responsive to the frail or vulnerable elderly will require enlarging housing alter- natives for older people. Also needed is an evaluation of the effects of the housing options now being tested. He argues that the federal government should expand the array of residential solutions to meet various levels of vulnerability among the elderly. The prospects of any change in national policy to incorporate the provision of supportive services in community-based housing as part of a modernized Tong-term care system appear to be slim. Resistance on the part of the current and previous national administrations to any expansion of Tong-term care program- ming beyond the present institutional solution is deeply rooted. Nor are the prospects made better by current shifts in budgetary priorities for social programs.
SUMMARY Mobility and Social Integration of the Aging 15 As the number of elderly persons surviving into their eighties and nineties increases, the issue of mobility takes on an added priority. Mobility, which can be defined as the capacity to travel from home to essential destinations at reasonable cost, is inter- dependent with housing location. The opportunity for older per- sons to maintain a reasonable level of mobility, regardless of the choice of residential location, contributes to the continued inde- pendence of the aging. Yet the role of transportation in connect- ing people to places seems to have received insufficient attention by policy planners. Wachs (in this volume) has noted that, for the elderly, housing choice often involves a trade-off in mobility: If one chooses a low-density suburban living environment, far from friends, relatives, and services, it may entail high mobility costs for the individual and society, especially in old age. High-dersity inner- city environments may impose high housing costs and less aestheti- cally pleasing environments on their residents, but it may cost indivi- duals and society much less to provide access to services at such loca- tions. Although we recognize these principles, we know less than we would like to know about the economic, social, and cultural trade-offs between housing and mobility. Therefore, any investigation of the re- lationships between housing and mobility in old age must include atti- tudinal and social dimensions as well as physical and economic ones. Planning for the mobility of older people should be incorpo- rated into environmental planning for the intact as well as for the vulnerable elderly. As Wachs suggests, the absence of trans- portation may be the means by which our environment con- spires to isolate the elderly; the presence of transportation may be one of the keys to an active and healthy old age. Access to transportation services, whether self-provided or pro- vided by public resources, is particularly important for vuiner- able persons, regardless of age. Such persons should be assisted by all reasonable means to maintain a pattern of living that approximates the norm in a given society if they are to perform appropriately and effectively in that society. The mobility problems of inner-city elderly illustrate the com- plexity and importance of understanding the transportation needs of older persons. Many urban elderly have never driven and, being economically limited to infrequent taxi use, must rely on public transit or relatives and friends who drive. Depend
16 COMMITTEE ONAN AGING SOCIETY ing on friends and relatives fosters a sense of dependency and obligation in a group already prone to such feelings. And unfor- tunately, public transit is not always a good alternative because its use may involve substantial physical barriers such as Tong walks, high steps, narrow doorways, and exposure to the ele- ments. Although attention has been directed toward the removal of such physical barriers, Wachs found a distressing lack of security for persons using public transit (incidence rates of crime perpetrated on older people are 30 times the crime victimization cases reported by local transit police). Greater attention to se- curity- for example, such inexpensive changes as relocating bus stops and better street lighting might be one of the most im- portant initiatives by which public policymakers may better tailor transportation to the needs of the elderly. Older Americans in this decade are different in demographic terms compared with their counterparts in the 1970s. It may be helpful to review some of these major changes and to extract their transportation implications: · Older people are living longer, thereby swelling the ranks of the elderly in the upper ranges of the age span. · The women-to-men ratio has become even more pronounced than in prior decades, with the disparity between the two sexes widening with increasing age. · As measured by the proportion of elderly persons with a high school diploma, educational achievement has risen steadily, thus improving the income, health status, and well-being of older people. · The percentage of older persons voluntarily leaving the la- bor force has increased for both sexes. · Although a smaller proportion of older persons are now be- low the poverty line, at least one older person in eight can still be classified as poor. · Minorities have increased as a proportion of the aging pop- ulation, and all projections indicate they will continue to gain on the white majority. According to Bell and Revis (1983), the transportation impli- cations of these changes appear to be the following: · Car ownership will be maintained by many older persons, and the private automobile will continue to be the preferred and
SUMMARY 17 main source of transportation both for disabled and for intact older persons. · Specialized transportation, estimated by one study to be used by less than 10 percent of all elderly persons, will have to serve an older group of riders who are mostly female, less phys- ically able, and drawn heavily from minorities. · Work-oriented trips will decrease as a trend toward early retirement continues and as elderly riders seek trips to other destinations. In keeping with the phenomenon of a more heterogeneous older population, Wachs (in this volume) states that the travel patterns and mobility requirements of the elderly are a function of life-style. He argues that it is not possible to predict the travel patterns of older people without a grasp of the variations in activity that reflect differences in life-style. The concept of life-style is a useful analytic tool in dealing with the residential location and mobility patterns among the elderly living in a diversified urban setting (Wachs, 19791. Life- style takes into account socioeconomic and demographic varia- bles that singly or collectively affect the elderly differentially. For example, in a study carried out in the Los Angeles area, Wachs identified and subdivided the elderly in the region ac- cording to six life-styTe groups: the central-city dwellers, the financially secure, the new suburbanites, the early suburban- ites, the blacks, and the Spanish-Americans. A different set of life-style groupings could be devised for geographic regions other than Los Angeles. The utility of the life-style concept, in terms of mobility among elderly persons, is that it raises the possibility of differentiating among their travel patterns according to variations in housing location, car ownership, reliance on public transportation, and degree of vulnerability. The Swedish Perspective on Housing and Social Environments for the Elderly The pattern of growth of the elderly population in industrial countries tends to be similar, but the cultural interpretation of independence in old age differs among countries. All industrial- ized nations have exhibited a change in the age pyramid as a
18 COMMITTEE ON AN AGING SOCIETY result of a falling birth rate and the increased longevity of the population. in the short run, urbanization and industrialization minimize cultural and social differences and may appear to form a tendency toward increasingly uniform life patterns for older people. In the long run, the demands of industrialization are likely to become dominant in shaping residential arrangements among older parents and their adult children, even in cases in which such arrangements conflict with existing cultural pat- terns. Sven Thiberg, a research architect from Sweden (in this volume), cites the cases of Japan and Sweden, two countries that are similar in living standards, education, and methods of pro- duction but quite dissimilar in their cultural norms regarding the care of parents in old age: It is not merely that 7 percent of the elderly in Sweden and 60 percent in Japan live with relatives. The declared social goals of the two nations differ just as much. In Sweden, the national policy is that an independ- ent life is desirable and that it can only be attained if older people live in their own homes; in Japan, the state advocates that the elderly shall live with their relatives. Great efforts are made in Sweden to support old people living on their own; in Japan, no reason is seen to develop such support because it is considered to conflict with the desirable social pattern. Thiberg concludes, however, that "everything indicates that a growing degree of industrialization leads to increased mobility, the splitting up of households, and less stable families. In the Tong run, these trends have the effect of separating the young and the old even more than they are at present, and in general, cultural ties do not appear to be strong enough to prevent this development." Cultural influences may become subordinate to the forces of industrialization, and older people increasingly may tend to live near but not with adult children, in most instances by mutual agreement. Rosenmayr and Kockeis (1962) have termed this expression of independence in living arrangements on the part of older people in most modernized countries "inti- macy at a distance." To keep older people out of institutions or delay their entry into that form of living arrangement, Sweden has experimented with several types of specialized housing for the elderly. These include pensioners' flats in normal housing, which are usually one- or two-room apartments dispersed within a residential area; temporary pensioner flats, which are located mostly in sparsely
SUMMARY 19 populated areas; old-age homes for the elderly who could not look after themselves because of deficiencies in their prior hous- ing or who require considerable social assistance from paid staff; and flats in service blocks. Originating in the early 1970s, serv- ice blocks are apartment buildings that are designed to comple- ment housing in the normal market for older people and in old- age homes. About 40 apartments per service block is common, but some local councils (which sponsor service blocks) prefer a smaller number-10 to 15 flats to avoid segregating large num- bers of the elderly in service-oriented buildings. The primary purpose of the service block is to provide housing and support services for its elderly residents. The internal serv- ices offered in the blocks vary but are likely to include a central dining room, hobby shops, social services, podiatry services on a scheduled basis, and limited medical supervision. Some blocks incorporate a child care center on the premises or build a chil- dren's playground on open space owned by the service block thus allowing elderly residents to serve as volunteers in the chil- dren's programs. Frequently, the physical location of the service b]Lock advances its integration with other resources and other generations. For example, a block is often located so as to take advantage either of adjacent health resources or to encourage the interaction of the service block with neighborhood social life. Some local councils have built service blocks that are linked by covered passageways to a contiguous nursing home or health clinic. In such instances, the service block is located in close proximity to a local shopping center. To encourage the use of the service block by area residents and shoppers, it may include services for the public such as a cafeteria, a post office, a library, and a social insurance office. The policy thus encourages elderly residents to remain in their own dwellings, aided when neces- sary by publicly provided forms of social support and informal care by relatives offered voluntarily, in that order of priority. Thiberg (in this volume) indicates that housing programs for older people are sustained both by the general aims of housing policy and housing provision, which are listed below. The aims of Swedish housing policy are as follows: · to guarantee an abundant supply of forms of housing for all ages and types of household; · to make forms of housing economically and technically
20 COMMITTEE ON AN AGING SOCIETY available through government financing and distribution poli- cies; and · to give the elderly their choice of dwelling according to need and desire and not move them to special forms of residence as Tong as adequate care can be provided in their own home. The aims of housing provision are as follows: · to convert the existing housing stock by such methods and such financing as to make it easier for the elderly to remain in their homes, modernization comprising the external environ- ment, service establishments, and communications; · to ensure that new housing is directed toward strategic ad- ditions to the existing housing stock (especially important is the provision of new forms of living environments that are difficult to realize in existing housing); and · to plan reconstruction and new construction so that medical care for the elderly occurs to an increasing extent in their own homes, ensuring that administration, maintenance, and care of the residential environment shall be of good quality and take place in consultation with the residents in order to increase well- being and security and reduce the risks of accidents. What lessons can be learned from Swedish policy on designing appropriate environments for the aging? First, elders are en- couraged to "age in place" as long as it is feasible to remain in one's home. Second, housing is viewed as an integral part of a holistic approach to publicly provided social services for all of the elderly, thus reducing the need for recurring problems of shelter. For aging persons to pursue an independent life in old age requires economic, social, and cultural measures in support of the goal of normalization. New Technology and the Productivity and Indepenclence of the Elderly With increased longevity and, in general, a more affluent old age for the elderly in the United States, the possibilities for enhancing the productivity and independence of older persons have attracted considerable interest. A number of authors have examined new technologies relevant to the social and built en
SUMMARY 21 vironment that might allow the elderly to lead lives of greater productivity and independence. Robert L. Kane (in this volume) has focused on the role of technology and its effect on individual well-being. He views the growth of new technology as a given that we must assess mainly in terms of how to establish priorities and how to finance what is chosen. He holds that there are collective (societal) benefits as well as individual benefits from the new technology that must be evaluated and reminds us that the people who will be affected by the technology of the future will differ from the aged of today. Kane offers some insight into the assessment of various types of technological achievements in medicine, preventive health, and communications. For example, in communications, he fore- sees the use of personal computers in ways that will not only increase the pleasure of learning and entertainment but that will also reshape traditional patterns of social contact. Kane (in this volume) notes: "The ability to interact with machines as well as with other people may provide the elderly with a much more patient, reinforcing set of social patterns than they have experienced before." Victor Regnier's contribution (in this volume) focuses on the more traditional aspects of how housing for the elderly, particu- larly for the frail elderly, can emphasize "user-friendly" housing designs. Regnier maintains that to achieve a complete, behavior- ally based design, all of the desirable goals must be specified beforehand (e.g., social mix, identity, unobtrusive care, etc.) and specifically addressed by certain physical design features. Reg- nier also emphasizes that housing designs must be evaluated empirically in a formal postoccupancy study. Thus, the design model that he proposes for the built physical environment must be carefully integrated with considerations about the intended social environment. Moreover, the physiological and sensory as- pects of design must be evaluated within a behavioral context. Regnier also discusses a number of other considerations in designing housing for the elderly including the neighborhood setting, together with appropriate accessibility to varied serv- ices, and more knowledgeable management of facilities. In the case studies of congregate residence that Regnier presents, an assessment is offered of how these two factors are taken into account in housing design. Both the Kane and Regnier papers call attention to the cir
22 COMMITTEE ON AN AGING SOCIETY cumstance that regulatory design requirements often militate against desirable outcomes. Yet often, these regulations are in- tended to ensure the implementation of new technologies and products to replace old materials and practices (e.g., using poly- plastics instead of wood) and are further examples of innova- tions in the built and social environment that may produce un- intended consequences. Working within a somewhat visionary framework, Tames N. Morgan's thesis (in this volume) calls for a radical reshaping of the physical and social environments of elderly persons. His concern is to seek suitable accommodations for older persons in their passage from welIness to infirmity. He believes this may best be achieved by exploring the potential for productivity in older persons. Already in American society, most elderly persons live long enough to experience an extended period of postretire- ment; increasing longevity also carries the increased likelihood that many older persons will spend a large part of those remain- ing years with functional disabilities that require assistance from others. Considering the growing costs of long-term care, Morgan proposes harnessing the productive capacity of older persons to handle some of the burdens of such care. To do so, however, requires the removal of barriers economic, legal, so- cial-organizational, and environmental. He proposes mega-ex- periments: large-scale demonstrations or trials that involve cre- ating new, flexible, self-regulated communities of older persons operating with a system of nonmonetary currency to facilitate the exchange of services among people who help one another. Such communities presumably would be self-supporting (i.e., un- subsidized), more efficient, and equitable as well as encouraging an increase in productive activity. What would be the essential features of such new communi- ties? Morgan believes they would have to be newly constructed, with homelike living quarters and shared facilities. The com- munities would be compact with a maximum of several hundred units so as to encourage close contact and interaction among the residents. The age composition would be adjusted to maintain a spread of persons 55 years of age and older, but the residence would be viewed as permanent for the remaining years of one's life. For Morgan, tile "glue" that could hold such a community together would be the mode of exchange: a resident would be
SUMMARY 23 able to help others in the community who are disabled and thus earn exchange credits that would be claimed when he or she needed help. Unlike currently planned old-age communities and most congregate housing arrangements, the case services in such a community would be provided mainly by neighbors rather than by professionals. The design of the symposium and of similar efforts to address systematically a major social issue relevant to the aging illus- trate a basic principle that is recognized especially, but not ex- clusively, by researchers and planners in social gerontology. One way of conceptualizing this principle is to characterize it as the vertical-horizontal dilemma in the social problem-solving proc- ess. That is, given the scope and breadth of knowledge in many areas of social life, it is deemed more efficient and appropriate to slice that knowledge into vertical segments, thus creating areas of specialization or disciplines. Yet the problems of the elderly, among others, frequently fait to confine themselves to these arbitrarily created divisions of knowledge but rather tran- scend and cut across separate disciplines, requiring the coliabo- ration of specialists from several disciplines for problem-solving purposes. To that end, the eight commissioned papers presented in the volume are largely specialized analyses of aspects of the general subject of this symposium. The remainder of this first part in- cludes a brief discussion of previous studies and a summary of the current framework of thought in a number of areas covered by the symposium. The next section represents the committee's views on a feasible policy and research agenda for the future. ideas in the agenda for the future were drawn from the positions articulated in the commissioned papers, modified by the discus- sion held at the symposium as well as the perspective of some committee members. REFERENCES American Institute of Architects. 1985. Design for Aging: An Architect's Guide. Washington, D.C.: American Institute of Architects Press. ANSI (American National Standards Institute). 1980. "Specifications for Making Buildings and Facilities Accessible To and Usable By Physically Handicapped People." ANSI 117.1. New York: ANSI. Bell, W. G., and J. S. Revis. 1983. Transportation for Older Americans: Issues and
24 COMMITTEE ON AN AGING SOCIETY Options for the Decade of the 1980s. Office of Technology and Planning Assistance, Office of the Secretary of Transportation. DOT 1-83-42. Washington, D.C. Birren, J. E. 1959. Handbook of Aging and the Individual. Chicago: University of Chicago Press. Cantilli, E. J., and J. L. Shmelzer, eds. 1971. IS ansportation and Aging Washington, D.C.: U.S. Administration on Aging. Carp, F. M. 1966. A Future for the Aged. Austin: University of Texas Press. Glick, P. C. 1979. "The Future Marital Status and Living Arrangements of the Elderly." The Gerontologist 19:301-309. Heumann, L. 1985. A Cost Comparison of Congregate Housing and LongTerm Care Facilities in the Mid-West. Urbana: University of Illinois, Housing Research and Development Program. Howell, S. S. 1980. "Environments and the Aging." Pp. 237-260 in Annual Review of Gerontology and Geriatrics, vol. 1, C. Eisdorfer, ed. New York: Springer. Institute of Public Administration. 1975. Planning Handbook: Transportation Serv- ices for the Elderly. Washington, D.C.: Government Printing Office. Kleemeier, R. W. 1959. "Behavior and the Organization of the Bodily and the Exter- nal Environment." Pp. 400-451 in Handbook of Aging and the Individual, J. E. Birren, ed. Chicago: University of Chicago Press. Lawton, M. P., and L. Nahemow. 1973. "Ecology and the Aging Process." Pp. 619- 674 in Psychology of Ad ult Development and Aging, C. Eisdorfer and M. P. Lawton, eds. Washington, D.C.: American Psychological Association. Pastalan, L. A., and D. H. Carson, eds. 1970. The Spatial Behavior of Older People. Ann Arbor: Institute of Gerontology, University of Michigan. Rosenmayr, L., and E. Kockeis. 1962. "Family Relations and Social Contacts of the Aged in Vienna." In Social and Psychological Aspects of Aging, C. Tibbitts and W. Donahue, eds. New York: Columbia University Press. Rosow, I. 1967. Social Integration of the Aged. New York: Free Press. SPRI. 1979. Primary Care and Care of the Elderly. Special Publication S100-107. Stockholm: SPRI, Fack, 102 50. Taylor, P. S. 1981. "Long Range Research Agenda for Elderly Housing and Related Services." Report prepared for the U.S. Department of Housing and Urban Devel- opment. Gerontological Society of America, Washington, D.C. Taylor, P. S., E. D. Sclar, and B. Soldo. 1981. "Research on Housing and Related Services for the Elderly. An Annotated Bibliography." Report prepared for the U.S. Department of Housing and Urban Development. Gerontological Society of Amer- ica, Washington, D.C. Taylor, P. S., E. D. Sclar, and B. Soldo. 1982. "Research on Housing and Related Services for the Elderly. An Annotated Bibliography." Report no. 2 prepared for the U.S. Department of Housing and Urban Development. Gerontological Society of America, Washington, D.C. Tibbitts, C., ed. 1960. Handbook of Social Gerontology. Chicago: University of Chi cago Press. U.S. House of Representatives, Select Committee on Aging, Subcommittee on Hous- ing and Consumer Interests. 1987. Evaluating the Congregate Housing Services Program. Staff report. Washington, D.C.: Government Printing Office. U.S. Senate, Special Committee on Aging. 1984. Section 202 Housing for the Elderly and Handicappe~ A National Survey. Staff Report 98-257. Washington, D.C.: Government Printing Office. U.S. Senate, Special Committee on Aging. 1986. Developments in Aging: 1985, vol. 1. Staff Report 99-242. Washington, D.C.: Government Printing Office.
SUMMARY 25 Vivrett, W. K. 1960. "Housing and Community Settings for Older People." Pp. 549- 623 in Handbook of Social Gerontology, C. Tibbitts, ed. Chicago: University of Chicago Press. Wachs, M. 1979. Transportation for the Aging: Changing Lifestyles, Changing Needs. Berkeley and Los Angeles: University of California Press.