The Social and Built Environment in an Older Society (1988) / Chapter Skim
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SOCIAL AND PHYSICAL ENVIRONMENTS
SOCIAL AND PHYSICAL ENVIRONMENTS
Pages 103-133
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From page 103... ...
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.
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From page 104... ...
When qualitative factors coalesce into natural coping resources, 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 societal resources can be exacerbated.
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From page 105... ...
We begin our inquiry by documenting the functional dependencies of the aged and the extent to which the frail elderly of today are also vulnerable financially, socially, and environmentally. Next, we consider service and environmental responses to dependency, distinguishing between formally and naturally organized services.
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From page 106... ...
Bureau of the Census.i Approximately 36,000 persons from a listing of Medicare enrollees were screened by phone to identify 6,340 noninstitutionalized elderly who reported having a limitation in either the "instrumental activities of daily living" (lADL) 2 or the "activities of daily living" (ADL)
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From page 107... ...
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.
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From page 108... ...
Note: Baseline and alternate figures for 1980 are the same. ADL = activities of daily living; IADL = instrumental activities of daily living.
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From page 109... ...
Note: Baseline and alternate figures for 1980 are the same. ADL = activities of daily living; IADL = instrumental activities of daily living.
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From page 110... ...
The baseline projections assume no improvements in the rates of disability consequent to modest gains in old-age life expectancy; 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 decTines.
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From page 111... ...
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)
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From page 112... ...
The different types of shared living arrangements, however, vary in their supportive quality, as indicated by the percentage distribution of "unmet" lADL and ADL dependencies 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)
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From page 113... ...
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)
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From page 114... ...
. · Housing There is a perceived but unmet need for special housing modifications such as ramps, grab bars, raised toilets, hand rails, an elevator, or a stair lift (32.9 percent)
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From page 115... ...
NOTE: ADL = activities of daily living; {ADL = instrumental activities of daily .
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From page 116... ...
In contrast, the distribution of the quaTity-of-life deficiency index by living arrangements, shown in Table 5, can be used to identify the most vulnerable segments within the older, frail population. These data indicate that the disabled elderly who live with relatives or nonrelatives have the greatest chance of having at least one environmental deficiency and also are the most likely to have multiple deficiencies in their immediate environment.
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From page 117... ...
(4,648) NOTE: ADL = activities of daily living; IADL = instrumental activities of daily living.
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From page 118... ...
The NETCS is not sufficiently detailed to determine whether this pattern reflects financial constraints operating in multigenerational households or a less durable commitment of nonspousal care givers to home care (Hess and Soldo, 19851. Nonetheless, these data suggest that modifications to the built environment may be an important strategy for reducing the care-giving burden, particularly in dwelling units in which a relative is the primary care giver.
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From page 119... ...
Contrasts between the long-term care populations in the community and those in the nursing home have demonstrated significant differences between the two groups in terms of social support networks and prior living arrangements (see, e.g., Weissert and ScanTon, 19821. Nevertheless, such findings cannot be allowed to overshadow the need for incorporating notions of heterogeneity into national planning efforts for the noninstitutionaTized but frail elderly.
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From page 120... ...
The degree of functional capacity is seen as being jointly determined by individual characteristics and the multidimensional nature of the social and physical environment. Although it would be desirable to parallel our discussion of multidimensional vulnerability with an examination of response clusters, existing data bases provide little opportunity for each analysis.6 Hence, in the following discussion, we confine our attention to responses to personal care dependencies.
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From page 121... ...
Perhaps of most interest for anticipating the service requirements of aged populations are the differences in the probability of formal service receipt by type of living arrangement. At any level of need, the probability TABLE 7 Percentage of Functionally Limited Elderly with Housing Modifications Differentiated by Whether or Not Such Modifications Would Make Life Easier Percentage with Housing Modificationsa Disability Level Would Be Easier Would Not Be Easier IADL limit only 15.3 14.2 ADL 1-2 28.6 35.1 ADL 3-4 41.8 47.5 ADL 5-6 37.8 42.5 Total 30.9 30 0 (1,482)
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From page 122... ...
These findings, in conjunction with the data presented in Table 5, suggest that the volume of demand for publicly financed services will be greatly influenced by the distribution of the disabled elderly across different types of living arrangements. In anticipating future service demands, a number of other factors must be considered as well: changes in intergenerational attitudes, the increasing incidence of divorce, and the course of sex differentials in old-age mortality.
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From page 123... ...
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 lifecare 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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From page 124... ...
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 sample of matching controls from a national opinion survey (Longino et al., 19811. Researchers then administered an instrument to residents of the study sites that contained many of the attitudinal items from the national survey.
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From page 125... ...
Although we might expect those elderly persons who selected more supportive environments to show improved functional capacity, such improvement is not always the case. In comparing several groups of such residents with stationary community controls, Lawton (l9SOb)
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From page 126... ...
Although most home care programs emphasize service delivery, modifications of the built environments in which care is provided may also be effective in preventing or postponing institutional 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.
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From page 127... ...
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.
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From page 128... ...
Should other research confirm this finding, equity questions would arise concerning the appropriateness of concentrating public expenditures 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 dependency are constrained and whose risk of a nursing home placement would appear to be greatest. The TawIsean principle of justice would require that society benefit those who are least advantaged socially or environmentally.
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From page 129... ...
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 combination with intensive home care services, can elevate function ing only so much and sustain it only so Tong.
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From page 130... ...
2. The instrumental activities of daily living (IADL)
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From page 131... ...
1983. "Assessing Self-Maintenance: Activities of Daily Living, Mobility, and Instrumental Activities of Daily Living." Journal of the American Geriatric Society 31:721-727.
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From page 132... ...
1985b. "Health Status and Service Needs of the Oldest Old: Current Patterns and Future Trends." Milbank Memorial Fund Quarterly/Health and Society 63:286-319.
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From page 133... ...
1981. "Income and Living Arrangements Among Poor Aged Singles." Social Security Bulletin 44:3-31.
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