Dirk Jarré, European Federation of Older Persons – EURAG – firstname.lastname@example.org
Home Sweet Home
“Why and how do older persons want to age at home?”
(as of 05.08.2016)
Over the last 100 years life expectancy in European countries has, in a general perspective, raised by about 2,0 to 2,5 years per decade. This trend is probably going to continue and perhaps even still accelerating due to progress to be expected in life sciences and in technology. Today people not only live simply longer but they have good chances to age well – provided that all societal possibilities were to be used in the most appropriate manner.
During the same timespan, European society has changed fundamentally with enormous consequences for the ageing populations. Just a few but very important aspects should be mentioned here. High mobility and work related migration patterns have resulted in a remarkable alteration of traditional family structures and solidarity patterns. Strong trends to individualisation and the value of personal choices in life planning as well as rapidly growing female labour market participation have fundamentally changed the willingness and ability to provide long-term care inside the family. Advancement in the medical and social care professions have lead to increased institutional treatment and attention to patients.
In their possibilities to determine where to be during the last phase of their life and how to age, older persons are heavily affected by these developments. In a first reaction to rapid population ageing and the change of family and kinship patterns the welfare state felt the responsibility to create old peoples’ homes and geriatric medical facilities. However these proved to be almost always insufficient in numbers and capacities, very often understaffed or lacking professional competence, frequently of questionable general quality and expertise, very costly for society and/or the individual and predominantly unsatisfactory in terms of respect of older persons’ dignity, their fundamental rights as well as their will and preferences.
During the last decades it became clear that a generalised solution to put older persons into retirement homes, into institutional care facilities or keeping older patients for long-term care in hospitals is neither any longer adequate, nor really affordable, nor corresponding to the needs and preferences of most of the ageing persons. Thus a new “ideology” with connected choices covering personal needs became more and more significant – “Living and ageing at home!” as long as possible and with the logistic as well as the professional support of the community.
Research shows that a very large majority of older persons – around 80% as a European average – do not want to go to “old folks homes” and fear to be treated there “like a vegetable”. This attitude even prevails if their capacities are reduced by age, if they experience functional limitations or infirmity and thus may need specific assistance or long-term care. A study of the American Association of Retired Persons, AARP, has shown that even 89% of persons 50+ prefer to remain in their homes indefinitely as they age. The option “to age in place as long as possible” has consequently become more and more a preferential choice of policy makers, insurance companies, the medical and care professions – and also the families concerned.
However, the term “in place” is not at all precisely defined nor generally understood with all its different connotations by all stakeholders in a non-ambiguous way. An interesting study that had put the question “What is the ideal place to grow older?” into the centre of investigation revealed that ageing persons thought immediately and consistently about functional, symbolic and emotional attachments, connections, experiences and meanings of one’s home, but also including the neighbourhood and even the surrounding community. Ageing in place, in one’s own home placed in a larger societal context, was mainly related to a feeling of personal identity, of autonomy, providing a certain degree of independence, maintaining self-determination, giving better possibilities of choice, but also offering chances for various interactions in terms of connectedness, attention, security, communication, participation, personal recognition, as well as caring relationships and intergenerational contacts.
There is also the trust that one is familiar with the environment, knowing the existing opportunities and, perhaps, has easy access to services of all kinds. Thus the “in place” goes far beyond the concept of the physical and emotional home and has not to be considered simply as a “container” of the person living in it. Home can be seen as a refuge from which one can go out to benefit from the resources and amenities the community is offering. In addition it often is an important focus point for interaction with family members, friends and neighbours. Finally it is felt by many as very important to be near to these persons “towards the end”.
Still, home may also be an uncomfortable, work intensive and even very dangerous place – full of hazardous features and difficult to live in. Statistics show that, for example in Germany, the physical home environment produces more than the double of fatal accidents than does traffic. Most of todays rented or owned flats, apartments and houses are not conceived and equipped in an appropriate manner for older persons, for persons with physical or mental handicaps – and even not sufficiently safe for children. A majority of homes are not at all senior-friendly and rather look like “Peter-Pan-Houses”, designed for people who never grow old. Thus they may require intensive maintenance work and, very importantly, daily living activities may encounter severe obstacles, barriers or complications that make it hard for older persons to lead their life easily.
With advancing age, general and specific individual ailments, incapacities and limitations develop needs that have to be clearly addressed, whatever the individual or collective living arrangements may be. People may be, and mostly are, increasingly considered as “old, frail and forgetful”. But what does this mean in more concrete and practical terms?
To start with, there are physical problems with the ageing body: like the reduction of the muscular tension and strength, balance uncertainties, poorer sight, hearing and smelling, perhaps incontinence difficulties, possible loss of consciousness, etc. Then mental and cognitive problems may render independent living more difficult or even impossible without help: like failing memory, low level of stimulation to become active or to care for oneself, phases of depression, incapacity to get organised, a feeling of insecurity, etc. Also health issues of all kinds normally become more frequent and severe with higher age. Social aspects are important and not to be underestimated: like the feeling of being abandoned, lonely, neglected, disregarded and ensuing sentiments of isolation and loneliness. Finally and in addition, there are often real or imagined financial problems that can haunt older persons.
Society at large and communities have a fundamental interest in responding adequately to demographic changes and to the ensuing consequences – in particular in respect to the needs, aspirations and choices of older persons. When decisions go rather towards predominantly “ageing in place / ageing at home” versus placing older people into institutions, this preference should not solely be a matter of financial considerations but follow a strategy aiming at guaranteeing human rights, maintaining social cohesion and supporting solidarity. But also the families concerned and the ageing population itself are highly interested in seeing the right strategies being implemented.
General and specific needs derive from ailments, incapacities and limitations due to ageing and must be covered by various measures in terms of improving public structures and services, by supporting voluntary organisations in their efforts to help older persons to live with their limitations and benefit from ageing, by adapting the immediate physical living conditions to the new or changing needs of people as they age, through the development of technical and logistical devices to help persons with lower capacities to overcome problems, to be more secure and to feel better connected, by creating or reinforcing adequate personal and home help services arrangements, but also by educational and information measures to motivate people to intelligently prepare themselves for ageing – preferably well before an age-related personal crisis or even catastrophe hits.
Public authorities have the responsibility to strongly take the needs, preferences and choices of older persons into consideration in their planning and the provision of services of general interest – especially in terms of infrastructures like information-, communication-, transport- and ambulant care service systems as well as offers related to educational, cultural and leisure opportunities – in order to create an age-friendly environment in the community. They also have to make sure that appropriate regulations, budgets, provisions of general interest as well as quality monitoring systems are created, interconnected and coordinated to insure the necessary coverage of medical and care services and address other personal assistance needs of the older population. Last but not least, public authorities should actively promote a comprehensive understanding of ageing in a life-course perspective and foster a positive image of older persons, a clear recognition of their past and present contributions to the development of society and promote the understanding of the indispensable mutual responsibilities of solidarity between the generations. Such a constructive approach may also stimulate a meaningful public discourse about the future chances and perspectives of European society – not least in moral and economic terms.
The groundwork for the required strategies and action has been mainly achieved by the Second World Assembly on Ageing of the United Nations that took place in Madrid in April 2002. It adopted the “Madrid International Plan of Action on Ageing” (MIPAA) – a very comprehensive strategic document with some 130 concerns, concepts and action points addressing the changes and the needs of ageing societies and older persons worldwide. This was then followed by a European “Regional Implementation Strategy” (RIS) by which the 56 member states of the United Nations Economic Commission for Europe, UNECE, committed themselves to implement the UN “International Action Plan on Ageing” through a total of 100 specific action points regrouped in 10 chapters. More concrete commitments of the UNECE member states are made in regional “Ministerial Conferences on Ageing” that take place every 5 years and that also assess the progress made during the last five years. On these grounds the individual states develop themselves their policies, strategies and action plans to match the targets set in common. They are motivated, supported and critically monitored by competent civil society organisations representing older persons or advocating for the concerns, interests and demands of the older population. Also inter-governmental organisations like the Council of Europe and special agencies of the United Nations encourage and support national programmes in this area. For example, the World Health Organisation has developed an “Age-Friendly Cities Programme”, after consultation of older persons’ organisations from 33 countries, in which now a considerable number of urban agglomerations worldwide participate. And the European Union sponsors a “European Ambient Assisted Living” programme with partners in 23 countries.
While governments have to deal with the overarching political concepts on how to create an age-friendly society it is largely considered as a reasonable approach to leave the implementation to the regional and, in particular, to the local level. Municipalities administered with a high degree of social responsibility know best what are the needs and wishes of their older population and how to support older persons to age well in the community. Progressively they have understood that the processes of conceiving, planning and implementing measures to provide amenities to facilitate physical activities, mobility and communication, social interaction, cultural engagement and on-going education should be performed “with” older persons rather than “for” them – that older persons should not be treated as objects but as subjects of policy- making and thus be considered as an important societal resource.
Number of municipalities try to act in an age-friendly manner when they plan physical spaces, transportation and infrastructures, including parks and gardens, community centres, clubs and alike – but also the location of shopping areas, community-based social and health centres, and so on. Thus they provide in addition to technical and economic service facilities also accessible social hubs that are so important for people to feel that the community is on the one hand a resource provider and on the other one also “a warm place” to be. It is well known that interconnectedness through social contacts is indispensable for human beings and that it can not only promote individual wellbeing but also significantly contribute to the health status of the person.
The fulfilment of the requirements of the ageing society in general as well as the large variety of very specific individual needs and choices of older persons definitely offer huge market opportunities for private business. It can be safely said that the areas of medical prevention and treatment, of lifestyle science offerings, of permanent health and social care services as well as of household and personal assistance will be among the strongest booming economic sectors in the future and for quite some time – be it in terms of goods, process solutions, services or employment. Totally new conceptual approaches and practical solutions will be required – originating simultaneously from a multitude of drivers like: science and research, a broad range of interested and concerned professions, hardware and software industries, public and private service providers, the construction sector and housing associations, social security organisations and insurance companies, but also from politicians, other decision makers and public administrations.
In contrast to prevailing partial opinions and biased societal attitudes, older persons are not at all a homogeneous category. They are at least as diverse in personalities, needs, preferences and judgements as members of any other age group. However, by their various age-related ailings, possible physical and mental deficiencies and growing limitations of capacities they may require additional multifaceted attention and support. These may be related to self-care tasks like body hygiene, dressing, eating, moving around, etcetera, also called ‘activities of daily living’, or instrumental daily tasks, like meal preparation, household cleaning, or managing money.
In case of disabling conditions long-term care certainly does not cure the underlying illnesses but tries to maintain a reasonable to optimal level of functioning that provides some kind of independence. Thus an important objective is to give to the person the feeling of being still in control of his or her life and wellbeing by “extending the margin of independent living” – recognising that it is very important for them “to live under one’s own rules” and that this is a key reason for staying at one’s own home.
An initial and very important step is to make homes user-friendlier, instead of just having them more beautiful or luxurious. This means to proceed with the necessary modifications of the housing features and apply adaptations according to the needs of the vulnerable and less able individual by making the home safer, easier to maintain and more comfortable, thus helping the person to be longer independent and able to continue to live at home. Even well conceived “little details” can make everyday life much more easy and less hazardous.
Advanced technologies, high-tech products, innovative processes and services of all kinds can be of tremendous importance to insure better and more independent living conditions, improve people’s comfort and quality of life – and even can combat loneliness and sentiments of abandonment. Among them are applications known as home automation, various kinds of functional service robots, inter-active leisure devices, sophisticated communication and information tools, systems of tele-medicine and tele-care, as well as monitoring and supervising sensors connected to remote assistance and intervention centres, but in perspective also artificial intelligence gadgets characterised by self-learning capacities. In the long run investments in these products and applications will certainly extend the longevity of home-residence and probably be much less costly investments than the option of nursing home placement and institutional care.
With the growing individualisation in society and the impressive options created by science and technology – not least by the sequencing of the human DNA – totally new responses are possible to match the varying and multiple support needs and choices of the individual and thus avoid inappropriate ‘one-size-fits-all’ approaches. They can effectively address the desire of people to receive personalised and flexible care that is tailored to their specific needs and respects them as unique individuals. At the same time they may provide to the person the sentiment that he or she is still functioning, maintaining personal skills and social abilities that enable to go on ageing in place.
One of the most important factors to successfully tackle with the challenges of an ageing society is the, so far mostly neglected or underdeveloped, direct involvement of older persons themselves – and this starting with the conceptual phase of the planning of goods, services and processes, going through all the production and implementation or marketing steps to finally reach the monitoring, evaluation and readjustment process. None of these steps is unnecessary – they all deserve the highest degree of combined attention. At the same time issues of personal data protection and respect of individual privacy need to be carefully addressed. It is equally important to develop intense communication and cooperation between the different generations in society in order to promote mutual understanding of the various needs, choices and solutions, but also to facilitate compromises between possible divergent but legitimate interests.
New concepts and configurations of “Extended-Public-Private-Partnerships”, EPPP, with strong inclusion of science, research and civil society organisations will be needed and tested. Among European political and strategic priorities should definitely count intensive efforts to create and develop the best possible “enabling environment” for innovations addressing the needs and opportunities of an ageing European society. Such innovations or further refinements of the existing solutions need to take place in particular in the area of science and research, in the field of technology and operational processes, in social and cultural issues, in medicine and health care, in personal attendance and support – just to mention a few important sectors. They may be of very different nature like the invention of goods and services, the improvement of physical structures and of logistic processes – but even of ethical orientations, philosophical options and action strategies. All possibilities of close interconnection, cooperation and combination of these areas should also constitute a matter of high attention.
The collection, documentation, analysis and dissemination of successful concepts, solutions and practice – especially when conceived and organised at supranational level – will be of particular high importance and may easily lead to helpful “creative imitation” processes to adapt them to regional or local conditions, respectively to particular groups of users and clients. Substantial targeted public investment, by the European Union, should be made in this respect. It certainly will represent very effective expenditure and boost the EU’s global competitive power in this extremely important and future oriented economic sector.
All these considerations lead to the conclusion that we are at the doorstep of a brand new form of society and presently have the enormous chance and responsibility to shape its future through wisely orienting its technical, ethical, cultural and economic developments by benefitting from the available options and by making the right choices for todays populations as well as for generations still to come.
Kronberg, 05 August 2016 Dirk Jarré