Caring for the Elderly in America

Published in: 2023

By: Wienclaw, Ruth A.

Subject Terms

Caring for the Elderly in America

Abstract

Although the care of older adults has historically been provided either by the individuals themselves or by the family or community, in twenty-first century America, there are a number of other options available to supplement or substitute for this care when necessary. Approximately two-thirds of older Americans remain in their own home or that of their children. However, the other third needs the care of a long-term facility. Even most of those remaining at home need additional care and services from time to time as their health deteriorates. Improved longevity and declining birth rates, combined with increasing costs of care, make paying for elder care an issue of increasing concern. More work is needed to develop plans that can help all Americans receive the care they need and deserve as they age.

Overview

The truth is that most of us will need some kind of assistance in our later years. In some cases, people need nothing more than occasional visits from a home nurse, some light housekeeping, meals, and visitors willing to talk and run errands. In many ways, such aging in place is the ideal situation, with research having found that older adults who live independently rather than in nursing homes tend to live longer lives. While there is a movement to make aging in place possible for more people, it is not always an option. Dementia and other debilitating illnesses can require around-the-clock medical care and monitoring, things often more easily given in a professional facility than at home. Even in cases where taking care of an elder is theoretically possible through constant (or even partial) care by a family member, the realities of twenty-first-century society are not necessarily conducive to this type of care from the family, particularly when the adult children of the aging parent work. The "sandwich generation" often feels caught in between concerns for their children and concerns for aging parents and is often left with the feeling of putting their own lives on hold.

The realities of old age bring with them many concerns for aging adults, ranging from the inability to be able to physically continue to take care of oneself and one's property as was possible earlier, fears of loss of cognitive abilities or the onset of dementia, and the need for long-term care. These are questions that virtually every adult needs to face as they continue to age. The fact that capabilities will decline in old age is accepted by most people. How they will accommodate such changes and how their care will be provided in such an eventuality, however, is a more difficult question. As discussed above, members of the sandwich generation often find it difficult to balance the demands of children, careers, and aging parents without feeling overstressed. In many cases, this means that other arrangements need to be made for the care of one's aging parents. In some cases, this is minor: eating together, doing grocery shopping for both households, and running the occasional errand. Local area agencies on aging can often provide additional support services to take some of the burden off family members, such as finding adult daycare programs or finding help for the instrumental activities of daily living. But in other cases, long-term care requirements are more extensive, and arrangements need to be made for other caregivers and services to support the aging adult. This is a major concern for many elders.

Aging in Place. According to the Centers for Disease Control and Prevention, aging in place is the "ability to live in one's own home and community safely, independently, and comfortably, regardless of age, income, and ability level" (2013). A 2014 national survey by the Pew Research Center found that 69 percent of Americans aged sixty-five or older strongly agreed that they prefer to age in place (Stepler, 2016). Following the COVID-19 pandemic, this number rose to 77 percent, according to the American Association for Retired People (Davis, 2021). Advocates of aging in place say that aging in place is ideal for older adults who own their own homes and have the means to make them accessible, low-maintenance, and safe. The benefits of aging in place include living in a familiar home and neighborhood and the independence of living on one's own. There is even a trend in technology and industry to accommodate the growing population of adults over sixty-five who wish to live independently, with advances in senior-friendly tablets, smartphones, and robotic aids. The challenges of living in place include individual issues such as emotional isolation, difficulty detecting changes in nutrition, hygiene, and health, and vulnerability to abuse, as well as community issues, such as a lack of public transportation, supportive infrastructure, and home modification and maintenance programs for older residents. And, while the population of older individuals is expected to increase through the middle of the twenty-first century, the number of available caretakers is expected to decline significantly, making aging in place more difficult to achieve (Osterman, 2017).

Long-Term Care. Long-term care consists of long-term aid given to individuals with personal or health care needs. The majority of long-term aid consists of non-skilled help with daily activities. Long-term care is intended to help maximize the independence and function of those with a chronic illness or disability. Although the concept of long-term care is often linked with care in a nursing facility, board-and-care facility, assisted-living community, or hospice, approximately two-thirds of the people requiring long-term care receive it in their own homes or in the home of a family member (Beers, 2004; US Department of Health & Human Services, 2017). In the latter cases, the primary caregivers are usually members of the person's family, most often daughters (Grigoryeva, 2017), although healthcare practitioners and other service providers may also visit and provide additional care. Whether long-term care can be performed in the home or if the individual needs to be moved to a facility depends on a combination of what the individual's needs are for medical, functional, social, and emotional care and the individual's preference, finances, and social support for other arrangements.

Outside Care. There are a number of options available for long-term care outside one's own home.

Assisted Living. Assisted-living communities are designed for people that can take care of themselves with a little help. These facilities provide meals, social and recreational activities, and help with daily activities for the older person needing long-term care. Typical living arrangements in assisted-living communities comprise apartments in most cases, although some facilities only provide bedrooms with private baths. Meals are offered either in a communal dining room or in the person's room. Some assisted-living communities also use intercoms and personal emergency response systems to monitor for emergencies or have available the services of nurses, physical therapists, or 24-hour supervision as necessary. Although in some states, Medicare may help pay for the costs of an assisted-living community, funding typically comes from either long-term care insurance or private funds.

Board-and-Care Facilities. Board-and-care facilities (or rest homes) are another option for long-term care. As in assisted-living communities, meals in board-and-care facilities are provided in common dining rooms or the individual's room. Board-and-care facilities also provide transportation to medical appointments or shopping and offer social activities. Board-and-care facilities also offer help with personal care and, in some cases, help with taking medications. The typical living arrangement in a board-and-care facility comprises rooms along a common hallway. Funding for board-and-care facilities typically comes from private funds.

Life-Care Communities. Life-care communities (or continuing care retirement communities) provide as much or as little care as the older individual needs, with care levels changing as the individual's needs change. These facilities are particularly good for those older individuals who want to move only one time rather than from facility to facility as their needs change. For example, within the same community, individuals might be able to live in their own cottage (perhaps with the proviso that they participate in a communal meal once a day to demonstrate that they are still functioning well), then move to an apartment in a central building as they need more help. Typically, life-care communities also have available assisted-living facilities and nursing home facilities all on the same property. Life-care facilities also typically provide transportation and social and recreational activities for their residents.

Although Medicare and Medicaid may pay for skilled nursing care when needed, the costs of life-care facilities are usually paid out of private funds.

Nursing Homes. Although the term "nursing home" is often applied to any long-term care facility, it is more properly applied to those facilities that are specifically designed to support individuals with chronic medical conditions that require skilled health care but do not require in-patient hospitalization. Nursing homes provide skilled care by trained medical practitioners in addition to other care. In addition to meals and help with daily activities, nursing homes provide 24-hour skilled nursing care and physical, occupational, respiratory, and speech therapy as needed. Nursing homes also provide hospice care, including palliative care and services for the emotional, spiritual, social, and other needs of terminally ill patients. Rooms in nursing homes are typically arranged along a common hallway. The cost of a nursing home may be borne in part by Medicaid and Medicare (when there is a need for short-term skilled care after a hospital stay) as well as through private funds.

Applications

Programs Available to Provide Elderly Care. Although many older people are able to stay in their homes with the help of family or outside services, others are not. In either case, the question becomes one of determining not only the level of care needed but who will pay for it. In the United States, there are a number of programs to help older adults receive the care that they need.

The Older Americans Act. The Older Americans Act (OAA) is a federal legislation designed to address the needs of adults aged 60 and older. The OAA creates a body of federal, state, and local agencies that provide and regulate services for elderly individuals. Services covered under the OAA include congregate and home-delivered meals, senior centers, employment programs, supportive services (e.g., transportation, information and referral, legal assistance), in-home services (e.g., homemaker services, personal care, chore services), and health promotion and disease prevention services (e.g., health screenings, exercise programs).

Medicare. Medicare is a federal health insurance program for adults aged 65 and over (as well as for certain disabled persons under the age of 65). Medicare Part A comprises hospital insurance for inpatient care in a hospital or skilled nursing facility following a hospital stay. Medicare Part A also covers some home health care and hospice care. Medicare Part B comprises optional medical insurance covering physicians' services, some out-patient care, home health care, preventative care, and many other services and supplies not covered by hospital insurance. Medicare Part B requires the payment of a monthly premium. Medicare Part C, also known as Medicare Advantage and formerly called Medicare + Choice, allows participants the choice to receive all their healthcare services through a specified provider organization. Participants must live in the service area of the plan that they join and have Medicare Parts A and B. Medicare Part C is not available for individuals with end-stage renal disease (Medicare.gov, n.d.b). Medicare Part D comprises prescription drug coverage (US Social Security Administration, 2013).

Medicaid. Medicaid provides additional medical assistance for low-income individuals. Although Medicaid is open to individuals of all ages, there are income eligibility requirements. A summary of the coverage of senior healthcare benefits is given in Table 1.

Planning for the Future. Although advancements in medical science continue to grow, so do the associated costs of medical care. This, combined with the problems of deteriorating health and reduced income in old age, make a volatile mix. As a result, many older adults (as well as those who are trying to realistically predict and assess their needs for later in life) are understandably concerned about how they will be able to provide for their care should catastrophe strike. Brandon (1989) suggested three general directions that can be taken in providing long-term care for older adults. The first approach is to basically maintain the system as it stands, perhaps with the addition of government support for home care and other programs for elders requiring long-term care. The second option is to establish a compulsory program of social insurance to cover the costs of long-term care facilities. The third option is to develop private insurance for long-term care. None of these options, however, is without its problems. Shoring up the existing system may be difficult, particularly as the number of baby boomers reaching retirement age continues to increase and the declining birth rate continues to provide decreasing numbers of individuals who pay into the system to support it. As for compulsory social insurance, the Patient Protection and Affordable Care Act (ACA) of 2010 did include provisions that aim to ameliorate gaps in the nation's long-term care system. One provision, the Community Living Assistance Services and Support (CLASS) Act, is a self-funded and voluntary long-term care insurance choice. While the CLASS Act remains part of the ACA, the Obama Administration decided not to implement it because it failed to meet its own built-in requirement for actuarial soundness (White House, n.d.; Book, 2012). The ACA, though passed in 2010, remains controversial. Private insurance is costly and may not, therefore, provide adequate coverage for those who most need it. The problem remains, therefore, and will continue to be a topic of conversation in varied venues, from kitchen tables to Capitol Hill, for some time to come.

Conclusion

Throughout most of history, the care of older adults was provided either by the individuals themselves or by the family or community. In twenty-first-century America, however, there are a number of other options available, including private insurance, retirement packages and pension plans, and government programs such as Social Security Income and Medicare. Approximately two-thirds of older Americans remain in their own home or that of their children. However, the other third needs the care of a long-term facility. Even most of those remaining at home need additional care and services from time to time as their health deteriorates. Improved longevity and declining birth rates combined with increasing costs of care make paying for elder care an issue of increasing concern. Much more work is needed to develop plans that can help all Americans receive the care they need and deserve as they age.

Terms & Concepts

Activities of Daily Living (ADLs): Activities that are routinely performed in the course of a day in order for the purposes of self-care (e.g., bathe, dress, groom, eat, use the toilet, transfer to or from the bed or chair, get around the house).

Adult Day Care: Community-based programs that provide a variety of health, social, and other support services to functionally impaired adults in a protective setting.

Area Agency on Aging: City or county agencies funded under the Older Americans Act that plan and coordinate various social and health service programs for adults aged 60 years and older.

Assisted Living: Residences or living arrangements that provide various services (e.g., help for performing activities of daily living, reminders to take medication) on an around-the-clock basis. Assisted living facilities are typically oriented toward helping elders with disabilities. Assisted living arrangements emphasize the privacy and choice of the resident.

Caregiver: (a) A medical or services professional who assists in identifying, preventing, or treating a disability or illness. (b) An individual (e.g., adult child or other family member, friend, or neighbor) who attends to the needs of a child or dependent adult and provides support and assistance. Support may be emotional, financial, or hands-on and may be done in person or long distance.

Cognitive Ability: A skill or aptitude related to perception, learning, memory, understanding, awareness, reasoning, judgment, intuition, or language. Cognitive abilities include all forms of knowing (e.g., perceiving, conceiving, remembering, reasoning, judging, imagining, and problem-solving) and thinking.

Dementia: In the generic sense of the term, dementia is a generalized, pervasive deterioration of a person's cognitive abilities (e.g., memory, language, executive function). The deterioration caused by dementia can be very severe and can significantly impact the ability of the individual to perform on the job, function well within society, or even accomplish the activities of living. Dementia is not a single disease; many diseases can cause dementia, including Alzheimer's disease, stroke, Pick disease, Parkinson's disease, Huntington's disease, and AIDS dementia complex (MedlinePlus, 2013). Brain tumors and other treatable conditions may also cause dementia. Although the onset of dementia may vary, in most cases, it occurs later in life, typically after 65 years of age.

Instrumental Activities of Daily Living: Non-self-care activities necessary for daily life (e.g., going outside the home, light housework, preparing meals, taking medications in the manner prescribed, using the telephone, paying bills, and keeping track of money).

Long-Term Care: Long-term care consists of long-term aid given to individuals with personal or health care needs. The majority of long-term aid consists of non-skilled help with daily activities.

Medicaid: A medical assistance program for low-income individuals. Although Medicaid is open to individuals of all ages, there are income eligibility requirements.

Medicare: A federal health insurance program for adults aged 65 and over (as well as for certain disabled persons under the age of 65). Medicare has four parts: Part A, hospital insurance; Part B, medical insurance; Part C (Medicare Advantage), provider organization coverage; and Part D, prescription drug coverage. Each part comes with different eligibility requirements and restrictions.

Nursing Home: A state-licensed facility that offers residents both personal care and skilled nursing care on an around-the-clock basis. Nursing homes also provide room and board, supervision, medication, therapies, and rehabilitation for their residents. Rooms are typically shared, and dining is often communal.

Older Americans Act (OAA): Federal legislation designed to address the needs of adults aged 60 and older. The OAA creates a structure of federal, state, and local agencies that oversee service programs for older adults. Services covered under the OAA include congregate and home-delivered meals, senior centers, employment programs, supportive services (e.g., transportation, information and referral, legal assistance), in-home services (e.g., homemaker services, personal care, chore services), and health promotion and disease prevention services (e.g., health screenings, exercise programs).

Palliative Care: Medical care or treatment that is intended to relieve, reduce, or soothe the severity of the symptoms of a disease or disorder without curing it. The goal of palliative care is to improve the quality of life for individuals with serious or terminal illnesses.

Sandwich Generation: The generation of adults who must care for both their children as well as their own aging parents.

Bibliography

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Caring for the Elderly in America

On this Page

Subject Terms

Caring for the Elderly in America

Abstract

Overview

Applications

Conclusion

Terms & Concepts

Bibliography

Suggested Reading