I came across a thought-provoking report recently, titled “Technology for Aging in Place 2016,” by Laurie Orlov, a market analyst for aging technology. The report seems to be an update to her 2014 report on aging and technology, which I commented on in this post.
As always, I’m interested in how business people conceive of needs and approaches to solutions, and how that compares to our view of the needs and issues as aging health professionals.
A striking fact which I hadn’t previously appreciated is that many older adults remain in their homes while aging because they can’t afford to move elsewhere. Per Orlov:
Median net worth of the 75+ age range is now $156,000, inclusive of home equity (see Figure 1). This is deferring moves to assisted living – its move-in age now a mid-80’s and frailer demographic. But boomers are right behind them – and even less able to move in. They have simply not saved enough – holding an average retirement savings portfolio of only $136,000 – enough for just two years of a private assisted living community like Brookdale.
Orlov also cites this AoA data summary, which reports that
- About 28% (12.5 million) of noninstitutionalized older persons live alone (8.8 million women, 3.8 million men).
- Almost half of older women (46%) age 75+ live alone.
In short, we have a growing population of older adults, many of whom have limited financial resources, and many of whom live alone in the community.
What percentage of older adults are living in their own homes was unclear to me; Orlov states “Eighty percent of older adults today live in their own homes,” however the reference provided does not address this particular statistic.
To me, “living in your own home” means you own the home. I did find a very good report on aging and housing from Harvard’s Joint Center on Housing Studies, which notes:
Among those aged 80 and older in 2011, fully 60 percent had lived in the same residence for 20 or more years. Another 18 percent had occupied their homes between 10 and 20 years.
However this data is from the American Housing Survey, so presumably it is referring to older adults who are already in community housing, as opposed to all older adults.
The NIA report “Growing Older in America” does provide data on living situations and says 79% of older Americans live in their own homes, however this report is based on Health and Retirement Study data from 2002, and 2002 is starting to feel like a long time ago. Hence, I am still left wondering just where older adults are living, and it would be nice to see updated data addressing this issue.
The most important questions to ask, to address aging-in-place
If you are approaching this from an aging public health perspective, the place to start is with “What do older adults need to ‘age in place‘”?
Whether wearables or tech-enabled home care are going to be successful are questions to consider much later, after we’ve identified the most important problems that need solving.
To figure out how to help a growing older population age in place, we need up-to-date information on:
- Where older adults — segmented by age/health status — are living, and more about their living situations
- What types of difficulties are they encountering, in their current living situations (these are invariably related to health problems and functional limitations)
- Outcomes such as how many people relocate, where they relocate to, and the reasons for relocation
In other words, we need to start with questions that help us understand the specific problems that make aging-in-place difficult, and that force people to relocate. And we don’t just want to aim for people to stay in their homes as they get older. We also want them to thrive, or at least to have the best health, well-being, and quality of life possible as they are getting older and remaining at home.
Again, this means providing interested problem-solvers with the means to understand the problems as they are experienced by older adults and families. This also means providing the best-available knowledge on what helps older adults surmount these problems. This you cannot obtain simply by focus-grouping the older adults; people often do not know what will help them short-term or long-term, although their opinions and interests are certainly very important.
Orlov’s report is pretty weak on this front, as are most reports created by those focused on business and market opportunities. Whether this seriously impairs the ability of innovators and tech companies to succeed as businesses — which is their top priority — I can’t really say. Obviously, we can think of many businesses and business models that have been successful — especially in healthcare — despite doing a poor job overall of helping individuals and society with core needs.
A few resources to get useful information
Here are few relevant articles and reports that I came across while writing this post:
- “Housing America’s Older Adults: Meeting the needs of an aging population” from the Joint Center for Housing Studies of Harvard University (2014).
- Includes a good graphic illustrating the share of older adults facing difficulties with “cognition, self-care, independent living, mobility, living alone, and housing cost burden”
- “Advanced life events (ALEs) that impede aging-in-place among seniors,” by Lindquist et al, Archives of Gerontology & Geriatrics (2016).
- From the Highlights: “Seniors identified five advanced life events (ALEs) would impact their ability to remain successfully at home. The ALES were hospitalizations, falls, dementia, spousal loss, and home upkeep issues. Many seniors perceived that these ALEs would not happen to them and had not planned for them.”
- A few quotes from the full article:
- “Throughout the focus groups, seniors exhibited unrealistic expectations about their future.”
- “While they plan for their end of life, older adults do not consider their “Fourth Quarter”—the time period from 65 to 80 plus years that involves increasing disability, hospitalizations, and/or progressive cognitive impairment.”
- What Assisted Living and Other Residential Care Looks Like, by Howard Gleckman (2016)
- Gleckman’s article is based on this hot-of-the-press CDC report: “Residential Care Communities and Their Residents in 2010: A National Portrait.”
- Those wanting to serve seniors aging-in-place should make sure they can address the needs of people currently in assisted-living. Aging-in-place can only be a viable alternative if most of those needs can be affordably met in the home.
- I also recommend Gleckman’s 2014 article on trends in assisted-living residents and evidence that their health needs are often not met
- “5 Ways to Help Someone Age in Place,” by yours truly, written for my Geriatrics for Caregivers blog in 2014.
Next Steps on Aging in Place?
As always, I believe new technologies have a lot of potential to help people live better during the later part of their lives. But for them to do so, I think we need to do a better job of clarifying the most important problem points, when it comes to aging in place, or just living better while aging no matter where you are living.
I’d be particularly interested in any resources you can share regarding more data on actual “advanced life events” that cause people to move. I assume there are some recent prospective cohort studies that could shed light on this, but I didn’t find much while writing this article today.
We could also learn a lot from stories about why people had to move. I can think of one patient who lived alone with dementia, and caused a lot of trouble because she kept inappropriately calling the police. Others move because they need a lot of help with ADLs. Others need a lot of medical care and it’s too hard to go to see doctors all the time, so instead they move into a facility that’s made an arrangement for doctors to do housecalls at the facility.
And of course, there’s the classic falling, breaking a hip, and never returning home again.
We can do better, to help older adults and families manage these situations, or even avoid these situations.
Last but not least, let’s not forget to consider whether aging in place is the right goal. Although we know that most older adults voice a preference to age in their long-time residences, this may or may not be a good idea. Gerontologist Stephen Golant published a book titled “Aging in the Right Place” last year, arguing that the aging-in-place model has been oversold and that most older adults are not envisioning the life of confinement that awaits some of those who remain at home.
Presumably, the primary goal we are working towards is best-possible health, well-being, and quality of life, even as one develops chronic limitations of the body or mind. At a price individuals and society can afford.
The “advanced life events” that push people out of their homes are also issues that affect people in residential care. So let’s keep clarifying what they are, and let’s keep inviting older adults to be part of planning for that “Fourth Quarter”. That way we can better develop solutions that help people navigate the challenges of aging.
I notice that the issue of family or friends as caregivers to allow the person to live in their home was not mentioned – either in Orlov’s article or in this blogpost. It is ironic that the one factor that can promote safety, and quality of life is not technology, but a friend or family member who is able to fill in those gaps by living with the elder. Caregivers are also under appreciated when discussing technology for elders – but using family as the interface for technology and EMR’s benefits the medical home and the needs of the elder, especially those who are are in the last quarter of their lives. I hope you will expound on this – many seniors do not own their own homes, and it is possible that in the future more seniors will be renters – they will still view their abode as their home, so technology and innovation needs to be mindful of the fact that they are not dealing with cash rich clients who are willing to alter their surroundings.
Thanks for bring up family caregivers, I agree they are an essential aspect of long-term support for older adults. Sorry I was not clearer about that in this particular post. In my own experience, many older adults who live alone are still benefiting from the support and involvement of family caregivers; sometimes they are nearby, and other times they are quite far away.
Also agree that the question of whether older adults own their homes or not is pretty important. Ownership often — but not always — means having a certain equity that can be leveraged, and also may mean greater control/responsibility for adapting the space to support certain needs as one ages. But I suspect many older adults rent, and it’s probably more common than it was in 2002.
Great discussion. I agree with the points made in the article about “Aging in the Right Place”, e.g., the problem is with the lack of alternatives to staying in a place that no longer meet’s one’s needs. I have just helped my mother through the wrenching process of moving from her own (owned but still mortgaged) home, to a rented independent living apartment in a “Continuing Care Community”, to the Community “short term Rehab” Skilled Nursing Care that turned (after the fully-paid Medicare time was up) to “required” long-term care in the (older, less private, less care) wing of the Community, finally to the one nursing home that had a private room available, where she eventually died 18months after her first hospitalization following a fall in the “independent living” apartment building. Each move was more confining, and less supportive of the simple things that would have helped–moving around more, keeping body and mind engaged. As my Mom said, “the treatment is debilitating.” We also learned, too late, that there is a huge lack of respiratory therapy available, even where facilities claim to provide it.
In short, when you give up control of the premises where you live, you lose control of what services/care you get. When someone says they want to age in place, I read that as saying they DON’T want to move to any place they have learned about so far.
How frustrating that you and your family weren’t able to find better options for your mother, and that she died after feeling she’d undergone a series of worsening confinements. (And feeling that “the treatment is debilitating”!)
Thanks for sharing your story.
Surveying the technology solutions I see two important issues that are of concern.
1) Most of the tech products seem to be designed from a “guard/send alarm/rescue” view of benefits offered, which is certainly important for the occupants and caregivers, but one that leaves aside attention to the quality of life as the “guarded” person experiences it.
Sending alarms to caregivers so that the cared-for person can be rescued when they get into “trouble” or do something unwanted, or locking up trouble-causing technologies does not support the personal autonomy of the cared-for person.
I think much more should be done with a design focus on the wants, needs, experiences and capabilities of the person who will be living with the technology. Does it make their experience better? Are their lives better, richer? Does it extend or restore activities of daily life that matter to them?
2) I’d strongly second the call for more and up-to-date demographic and technical information about the abodes of older North Americans (US & Canada), owned or rented, including assisted living accommodations.
Most of the technologies I have seen proposed or offered presuppose their installation in a “Smart” or “smart-ish” house that can support their internet-based connected technology. I suspect a good fraction, perhaps most, of the abodes we are discussing are older “dumb” units offering only electricity and a land-line phone plug – no WiFi, no Internet, quite possibly no cable TV connections.
Thanks for raising these interesting points. Let’s hope that we soon get some more up-to-date data on how older adults are living.
Re designing for the wants and needs of older adults and those who use the technology, in principle I agree. However on a practical level, I would like to see us all zeroing on the most substantial problems that force people to move when they don’t want to. To do this, we will need more information so that we can create and (roughly) prioritize such a list.