This year, the oldest of the baby boomers turns 70. America is swiftly graying, and by 2030 the U.S. population will include close to 73 million people over 65. This milestone shift ushers in a new chapter in American domestic life as a large number of older Americans are choosing to remain in their houses. “Most of my patients live in their homes,” says Samuel Durso, a geriatrician at Johns Hopkins Bayview Medical Center who gears part of his practice toward helping patients age healthfully at home. “It’s clearly a desire that people have now.”
It’s a desire that the AARP has heard from its members with growing resolve over the last few years. According to a 2014 study by AARP, 80 percent of people said that they planned or wanted to age in their homes rather than move to continued care or assisted living facilities. In fact, recent U.S. census data show the percentage of older Americans residing in skilled nursing facilities has dipped in recent years, along with the number of new nursing homes being built.
Unfortunately, our houses—and the cities and the suburbs around them—haven’t always been designed with the needs of older people, even those who are still relatively healthy, in mind. The lack of infrastructure and services available to support us as we age, whether it’s convenient public transportation or easily navigable sidewalks, has prompted organizations like AARP and the World Health Organization to make the design of age-friendly communities a priority, pushing cities in particular to improve everything from roadway design to health care policies.
In the meantime, if you’re one of the millions of people planning to stay in your home as you age—or if you’re helping a friend or family member who is—where do you begin? We asked health care professionals, some of whom are pioneering new programs for independent living, what people who are getting older (but who are still reasonably healthy) should be thinking about. They offered advice on the design of a home, how to function in it, and how to plan for care.
When the AARP asked people why they wanted to age in place, nearly two-thirds cited community as their primary reason. They wanted to stay in a place that’s familiar, where they’ve already established relationships and services.
Unlike a retirement community, where the residents are of a similar age, neighborhoods have greater age diversity and that can enhance the experience of aging at home, says Durso. “Evidence supports that people who have social networks age better, and those who tend to be the most successful are those who have family and friends, including young friends, with whom they interact.”
New research from the Johns Hopkins Bloomberg School of Public Health supports the idea that civic engagement and interacting with younger people can help keep a brain healthier as it ages. The study, published last year, looked at people who volunteered as mentors to children through national programs like Experience Corps, which places retired seniors in schools. Principal investigator Michelle Carlson and her colleagues found that brain biomarkers of memory improved in volunteers, particularly in men, after participating in the program, suggesting that the social and mental stimulation of volunteering and engaging with younger people may actually reverse part of the brain’s aging process.
"Evidence supports that people who have social networks age better, and those who tend to be the most successful are those who have family and friends, including young friends, with whom they interact."
Alicia Arbaje, a geriatrician at Johns Hopkins Bayview, agrees that multigenerational interaction is one of the keys to healthy aging at home. Arbaje chose geriatric medicine in part because she grew up with her grandmother in her childhood home in Kansas. Now that generations don’t live together as they did in the past, intergenerational community connections can help replace those multigenerational homes of yore, she says. “Older adults are looking for more ways they can thrive at home and in their communities.”
Arbaje says doctors should help older patients think about how they use their home to support overall health. You may go to a hospital or doctor’s office to receive medical care, but your home should be the epicenter of daily healthy living. “If you want to look at the top three things people can do to live in a healthy way as they age—socialization, adequate nutrition, and lifestyle, including exercise—all of those things have a significant component in the home,” she says. “The home is where the health care plan gets enacted.”
She warns, however, that while there are health benefits to aging in place, there are also hazards. Most homes were not designed with aging in mind. Staircases, hard-to-reach storage, and threshold levels that change from room to room are among the many standard features that can cause accidents. AARP is one of a growing number of organizations, along with some architecture and design professionals, advocating for new buildings and local building ordinances to follow the principles of universal design—the idea that everything from the building to the light switches should be created for all users, from the very young to the very old, the disabled to the able-bodied. A wide staircase, for example, can benefit a toddler as well as any person with mobility limitations. Easy-to-use door handles can be helpful for an older person with arthritis or a young person who is mastering fine-motor skills.
You may go to a hospital or doctor’s office to receive medical care, but your home should be the epicenter of daily healthy living.
Few homes are currently outfitted with universal design, however, so in the meantime, you can make improvements that lessen the risks. “Better lighting is huge,” Arbaje says. Vision problems, such as cataracts, can predispose people to falls. Falls send more than 2.5 million older Americans to hospital emergency departments each year. Fall prevention and improving mobility in the home should be the twin goals of home improvement, she says. “People don’t move [around their homes] because they are scared [of falling]. Anything we can do to increase their ability to move is good.”
Johns Hopkins occupational therapist Ally Evelyn-Gustave, who specializes in helping people age in place, suggests a number of measures to age-proof a home. “If you can, do some preplanning and some prevention, like making changes and adaptations to your environment and lifestyle before you are forced to.”
She suggests contacting a professional occupational therapist, who can help a person understand how he or she uses a home and offer advice on better ways to make dinner, bathe, or do laundry. “We focus on how people function,” Evelyn-Gustave says. Many of the changes she recommends to her patients cost nothing, like de-cluttering to create clear paths for walking. Others are inexpensive, like installing pull chain extenders to ceiling fans so they can be switched on and off easily. A slightly more costly improvement she often recommends is adding a second railing to a staircase to help with balance. She also suggests investing in adaptive equipment that can help with daily activities, such as a higher toilet seat that’s easier to sit on.
For larger renovations, Evelyn-Gustave recommends contacting a certified aging-in-place specialist—or CAPS—a certification developed by AARP and the National Association of Home Builders for designers and contractors who can help retrofit a home and make it safer.
Instead of identifying and treating only a patient’s medical condition, CAPABLE looks at the person’s entire life.
Evelyn-Gustave has applied many of these fixes through a Johns Hopkins program called CAPABLE (Community Aging in Place, Advancing Better Living for Elders), which pairs nurses, occupational therapists, and handymen with older people living at home. The team helps identify daily functions that could stand improvement, then works with the person over four months to find the best ways to upgrade their home. A nurse helps patients identify the way that pain, mood, strength, balance, and medications might inhibit ?their activities; an occupational therapist works on the functional needs identified as problematic, like the best way to get up from a chair; and the home maintenance worker makes improvements, like adding guardrails or repairing unsteady flooring.
Sarah Szanton, the nurse practitioner at Johns Hopkins School of Nursing who created the CAPABLE program, says that what sets it apart is its focus on quality of life and on nonmedical issues—regular activities like eating, going to the bathroom, and walking around the house. Instead of identifying and treating only a patient’s medical condition, CAPABLE looks at the person’s entire life. So it’s not just about how to treat arthritis with medication but also how to show a person with arthritis how to keep chopping vegetables. It’s a critical shift, says Szanton, “because there has been such an emphasis on fixing symptoms.”
She emphasizes that the role of the nurse or occupational therapist in CAPABLE is not to be prescriptive—the homeowner, not the professionals, chooses what to work on. “It’s patient-directed and based around function,” she says, because improving daily function can help prevent falls and other accidents. “Those are the kinds of things that put you in the hospital, but they are not things that are asked about in a doctor’s visit.”
"When doctors see patients in the home, I think we act a little differently. My observation is that it forces you to be a better doctor. It changes the power structure. I am a little bit more thoughtful about developing management plans that are truly patient-centered because I am in their home. I am also more successful in educating patients because I am a guest. I think it brings out the best in doctors and health care providers."
The results from a trial project of the CAPABLE program funded by the Centers for Medicare and Medicaid Services show that daily living activities improved for 79 of 100 participants, and the number of activities participants had difficulty with dropped by 50 percent. CAPABLE is currently in use only among low-income seniors in Baltimore City, but Szanton would like to see it become a Medicaid benefit. “The program’s successes are applicable to a broad group of people,” she says.
As Americans’ lifespans increase, so do their health care challenges. About half of people over 65 have one or two chronic health conditions, such as diabetes or heart disease, and nearly 40 percent have some kind of a disability resulting in complications such as difficulty walking, according to a U.S. census report.
Receiving care at home may help people age in place longer, even as major medical concerns arise. “I think we are going to see more and more redefining of the home as a place where care is delivered by professionals,” says Arbaje.
The Johns Hopkins Elder House Call Program does just that by bringing doctors and other health care workers to the homes of people who may otherwise struggle or are simply unable to get to a medical office. “Home-based medical care still exists, and it is emerging as a really effective way of taking care of sick older people who have a hard time getting to the doctor,” says Jennifer Hayashi, a geriatrics specialist at Johns Hopkins Bayview and the program’s director. “The philosophy of the program is that as people get older, if they also get sicker and more medically complicated, it gets harder and harder for them to go to the doctor. Delivering good primary care can keep them out of trouble.” House calls may sound quaint, she says, “but what we are doing is highly technical, home-based medical care.”
Receiving care at home may help people age in place longer, even as major medical concerns arise.
To find a similar program in another city, Hayashi recommends visiting the American Academy of Home Care Medicine’s website, which lists practices throughout the country that make home visits. She also recommends finding a practice that includes members from different disciplines, such as physical therapists and social workers. “We use an interdisciplinary team and community resources to help keep people at home,” she says.
Bringing health care to the home can also rewrite the script of how doctors and patients interact. Bruce Leff, a geriatrician at Johns Hopkins Bayview, has witnessed how health care delivery changes when it happens in the home. In the 1990s, Leff helped establish Hospital at Home, a program that sends doctors into the homes of people over 65 who face one of four acute health crises, such as pneumonia and a worsening of chronic heart disease, that would otherwise result in being admitted to the hospital. Hospital at Home focuses on delivering acute hospital-level care in a person’s home—using oxygen and X-ray machines for acute challenges—with doctors and nurses coming to the home for routine visits to administer intravenous medications, perform necessary tests, and provide proper supervision of care. The program is now being used by veterans hospitals across the country, and a related model is being piloted at Mount Sinai Hospital in New York City.
Leff says he has noticed a shift in the traditional doctor/patient relationship when health care happens outside the typical clinical setting. “When doctors see patients in the home, I think we act a little differently,” he says. “My observation is that it forces you to be a better doctor. It changes the power structure. I am a little bit more thoughtful about developing management plans that are truly patient-centered because I am in their home. I am also more successful in educating patients because I am a guest. I think it brings out the best in doctors and health care providers.”
Shifts in the way we traditionally design houses, cities, and health care are likely to continue at a rapid clip as America, and the world, continues to gray. A decade from now, the number of U.S. households headed by someone 70 years or older will have nearly doubled. This is going to offer challenges—and opportunities—for redefining what it means to live well, and age well, at home.
According to a 2014 study by AARP, 80 percent of people said that they planned or wanted to age in their homes rather than move to continued care or assisted living facilities.