New Year; New Attitudes
In recent weeks I’ve been working in a nursing home rehabilitation setting surrounded by several adults in their late thirties and early forties. On numerous occasions, a number have referred to themselves as being “old.” Each and every time they referred to themselves in this manner I voiced ideas to the contrary; each and every time there was consistent pushback. In one instance agal approaching her 40th year said her own father referred to her as getting “old”.
What must we do to dispel these ageist attitudes? When and how shall we begin? Where did they originate?
Shall we be determined that in 2022, knowing that we are now two years into what the United Nations has declared “the decade of healthy aging”, that we embark on a course to dispel the notion of “oldness”
defined by the Free Dictionary defines as:
a. Having lived, or existed, for a relatively long time; far advanced in years or life.
b. Relatively advanced in age
c. Of or relating to a long life or to people who have had long lives. Certainly, 30’s and 40’s, even 50’s, 60s, and possibly the early years of the 70s most likely do not fall into any of the definitions of oldness.
During Shakespeare’s times, the life expectancy of an average person was approximately 40 years of age, one who lived longer was thought to defy all odds which was related to ravages of the plague, striking every few years, as well as malaria, smallpox, and syphilis. Those who these ills were considered lucky and “old.”
Though the words and phrases Shakespeare used to describe or refer to aging have been studied by scholars over the course of centuries, it is thought that those words and ideas have permeated the general public’s and influenced attitudes towards aging. It is likely that Shakespeare writing for his time, or many of us today, would have imagined that his words would affect present day notions about growing older.
One of my favorites among the works of Shakespeare’s is Hamlet. I’m particularly fond of a line that aptly states that perceptions and attitudes can be changed. This of course can to refer to any situation, but certainly can be applied to our attitudes towards older adults and aging in general. “There is nothing either good or bad; but thinking makes it so.”
Beyond Shakespeare's words, what has permeated our thinking towards aging and older adults? Is it based on the history of the Almshouses which was based on an English concept and first introduced into the Americas by William Penn, who founded the Commonwealth of Pennsylvania. Almshouses were originally intended to be charitable, providing food and shelter to older people unable to work any longer and who were without the means, family or help to care for them. however, they lost often targeted the indigent, handicapped, elderly or widows of the poorest segments of society. One description offers an image of a dire situation: The elderly oftentimes had to reside alongside "insane, inebriated or homeless" regardless of age. These places came to be known as poorhouses, though being "placed" there was not necessarily associated with a person's financial situation.
Churches and women's groups rose to the occasion. They established what was known as the first houses of the elderly, primarily for widows and single women with limited financial means. Amongst the first homes were the Widows Single Women's Society in Philadelphia (1823) and the Home for the Aged Women in Boston (1850). However, these homes were not open to all in need. There were considerable entrance fees, and in some cases, women had to supply references attesting to their good character. This left many who were in dire need relegated to the almshouses.
One could see these homes perpetuated a kind of elitism that reinforced the social inequality and injustices of the times. The founder's concern was that "worthy individuals of their own ethnic or religious background might end their days alongside the most despised." According to the founds of the Boston House for Aged Women, "a haven for those who were bone of our bone and flesh of our flesh...and expressed disdain for foreigners who.....have taken possession of the public charities....as they have of the houses where our less privileged classes formerly resided." Thus, there was a stark contrast between these 2 institutions: benevolent and charitable care on the one hand associated with church and women's groups versus the deplorable conditions associated with the Almshouses.
Almshouses were the primary residences that cared for the elderly throughout the nineteenth century. Individual states also had a program called "outdoor relief" were meager provisions of money, clothing or wood were supplied as a means of survival allowing a person to live independently. However, this "relief" could be revoked at any tie, forcing the person back into the Almshouse.
Due in part to other organizations or institutional-type settings that targeted younger people as years passed, (i.e., orphanages, work homes, hospitals, or insane asylums) there was a demographic shift in the makeup of the almshouse population. According to statistics, in 1880, 33 percent of the population in the almshouses were comprised of the elderly but by 1923, that percentage had risen to 67 percent. In 1903 the term almshouse no longer seemed to be appropriate, thus the Charity Board of the City of New York changed the name to the Home for the Aged and Infirmed. Accordingly, in 1913 Charleston changed the name of its almshouse to the Charleston Home.
Due in part to other organizations or institutional-type settings that targeted younger people as years passed, (i.e., orphanages, work homes, hospitals, or insane asylums) there was a demographic shift in the makeup of the almshouse population. According to statistics, in 1880, 33 percent of the population in the almshouses were comprised of the elderly but by 1923, that percentage had risen to 67 percent. In 1903 the term almshouse no longer seemed to be appropriate, thus the Charity Board of the City of New York changed the name to the Home for the Aged and Infirmed. Accordingly, in 1913 Charleston changed the name of its almshouse to the Charleston Home.
The early part of the nineteenth century saw an increase in social consciousness regarding almshouses. The stigma of the almshouse as a poorhouse continued as Harry C. Evans, a noted social analyst of that time, described the environment, "a war;ed pf hate and loathing for it includes the composite horrors of poverty, disgrace, loneliness, humiliation, abandonment and degradation. It became obvious that as the aged-the word often used to describe elderly adults-could not longer work or care for themselves, they also became increasingly dependent upon the system for care. In 1929, Abraham Epstein, a well-respected advocate of pensions fo the old, wrote that the almshouse "stands as a threatening symbol of the deepest humiliation and degradation before all wage earners after the prime of life.
The vacuum created by eliminating almshouses gave rise to a different dilemma, those receiving pension payments who were in continued need of long-term care had to seek alternative places to reside in their final days. Many entered privately owned institutions that were underregulated. In many cases, these were the same almshouse-type institutions with the names changed but consisting of the same players. the residents of these institutions were not under the auspices of a private-care system, thereby allowing the inhabitants monthly pensions to be diverted to the institution. Though there were homes that were unwilling to admit people who had children, according to the 1923 Massachusetts Commission on Pensions, of those people in the almshouses who were allowed to enter despite having children, 89.93 per cent reported that their sons or daughters were financially unable to support them.
In 1972 this outcry finally led to increased government regulation to oversee the quality of long-term care through the Office of Nursing Home Affairs. This office was responsible for oversight, and it established standards of practice. Along with those reforms, there was also reform that applied to facilities receiving Medicare and Medicaid dollars. Other legislation followed.
In 1987, 26 years after he initially criticized providing Medicare coverage to older adults, President Ronald Reagan signed into law the first major revision of the federal standards for nursing home care since 1965. He signed the Omnibus Budget Reconciliation Act, also known as OBRA’87 or the Nursing Home Reform Act. It was intended to set minimum standards for nursing homes that receive funding from Medicare and Medicaid programs, to ensure quality of care and protect residents from physical, emotional, social abuse and neglect. It also outlined a list of Residents Rights.
In 2018, number of individuals eight-five years and older in the United States was 6.5 million, this figure is expected to jump by 123% to increase to 14.4 million by 2040. [viii]The U.S. Census Bureau estimates that by 2035, the population 65 years and above will outnumber the population 18 and under.[ix]
As one can see, there has been much in our history that has contributed to the attitude towards, care and treatment of older adults.
However, not all persons in need of long-term care are elderly. Approximately 63 percent are persons aged sixty-five and older, the remaining 37 percent are sixty-four years and younger. A Rand Corporation 2017 article reported that 56.6% of adults age 57-61 will spend at least 1 day in a nursing home, a higher number than previously thought.[x] It is also estimated that 42% of Americans who live to 70 years of age will spend at least some time in a nursing home or skilled nursing facility.[xi] As families continue to be more dispersed, there is a stark possibility that many older adults will have to move into a nursing homes- a reality older adults nor their families want to face. However, beyond moving into a nursing home, with an increasing number of adults living to advanced ages there is a concomitant reality that there is an increased frailty that comes with those years. Increased care needs accompanies increased frailty; is it that frailty and increased care need which contributes to our attitudes about aging?
As the population of older adults continues to grow, and especially those living to advanced age, so must our attitudes towards older adults change and grow.
This must start with our young people, much younger than thirties and forties, but children at the earliest ages who should develop an understanding that they are emerging or evolving elders. Something to aspire to, because despite the potential for frailty they will become the wisdom elders of our families, our communities, and our society at large.
[i] Encyclopedia of Aging Online, s.v. “Nursing Homes History” https://ww.encyclopedia.com/education/encyclopedias-almanacs-transcripts- and-maps-nursing-home-history [ii] C. Haber and B. Gratton, Old Age and the Search for Security: An American Social History (Bloomington: Indiana University Press, 1994) 130 (hereafter cited as Old Age and the Search for Security) [iii] Old Age and the Search for Security [iv] A. Epstein, The Challenge of the Aged (New York: Alfred A. Knopf, 1929) 218 (hereafter referred to as The Challenge of the Aged) [v] The Challenge of the Aged, 128 [vi] A. Epstein, The Challenge of the Aged (New York: Alfred A. Knopf, 1929) 218 (hereafter referred to as The Challenge of the Aged) [vii] The Challenge of the Aged, 128 [viii] Administration for Community Living 2019 Profile of Older Americans Publication Date May 2020 https://acl.gov/aging-and-disability-in-america/data-and-research/profile-older-americans [ix] “The Graying of America” More Older Adults Than Kids by 2035”A 2017 https://www.census.gov/library/stories/2018/03/graying-america.html [x] The Rand Corporation Average American’ s Risk of Needing Nursing Home Care Higher Than Previously Estimated. August 28, 2017 https://www.rand.org/news/press/2017/08/28/index1.html [xi] J.R. Knickman and E.K. Snell The 2030 Problem: Caring for Aging Baby Boomers Health Services Res 2002 Aug : 37 (4): 849-884 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464018/#