The Elderly

by Stephen Hynes

The last years of life can present many challenges, both for the aged and their families. Age robs so many of their abilities to deal with daily life, foreclosing opportunities, contacts and perspective. Diminished physical and mental capabilities are the main cause, but for many these diminishments are accelerated and in some cases created by a social system that often generates an astonishing level of stress and disorientation for its elderly, and these issues are made more difficult by the suburban lifestyle that so many of the elderly have lived.

The ideal for most of us is to remain in a consistent and familiar environment as we age. We want to stay at home and "age in place". On the North Shore, as in so many suburban locations, this means a retired couple living alone in their single family home, and maintaining as far as possible an active lifestyle with their friends and family and operating and maintaining their home. This is the ideal, and a lucky few are able to live out their lives with dignity in this way.

The unfortunate fact is that most people face a wide range of increasing difficulties as they age. And efforts to prolong the time spent in their familiar home environment can have the effect of foreclosing later care options due the to admissions standards of many private care facilities. This potentially relegates elderly into state run "old age" homes, offering astonishingly poor levels of service and support.

The transition from being a fully independent, socially engaged older person to a highly dependent suburban shut-in is often surprisingly quick. There are a number of reasons for this. The first is that the social support available at suburban densities is rarely local. Access to activities is primarily by automobile. The ability to drive is critical. And ICBC, which administers licensing issuance in British Columbia, has been adopting an increasingly aggressive standard for the qualification of older drivers. Medical certification of fitness to drive is required past age 75, although doctors are asked to report younger individuals who they think may be unsafe drivers, which advances the requirement for medical certification. Once certification is required, it generally becomes an annual requirement, presaged by the same unsypathetic form letter from ICBC requiring that it be completed within 30 days. If it is not, the licence is revoked.

The fact is that the fatality rate for drivers over 85 is nine times higher than for drivers between 25 and 69, and the vast majority of these fatalities take place during daylight hours in good conditions (US NHTSA, 1997). And fatality rates begin a linear increase to this level starting at around age 69. The fact that so many older drivers limit their driving to good conditions suggests their vastly higher fatality rate may underestimate their driving risk. ICBC's standards are probably justified from a statistical perspective. But this does nothing to allay the fear created in many older drivers when they receive their annual letter.

Getting a driver's license represents a right of passage in North America, creating dramatic freedoms that allow fuller social participation. Losing a driver's license reverses this. And losing it because of age related conditions creates a powerful connection between aging and the breakdown of social relationships. The loss of a driver's license is a dramatic first step in the diminishment of social standing, with which an older person immediately becomes dependent on friends and relatives, to whom they may become a burden - and even if this is not the case, it is natural for them to think of themselves in this way. And often the friends they rely on are themselves in a similar position, their friend's experience portending their own imminent loss of freedom.

Older people who have lost their drivers license may seem to be in generally good health and capable of getting on in the world. But with reduced mobility comes reduced activity, which can compound age-related decreases in vision, cognitive functions, and physical abilities. For some the progression is slow or negligible, but for others it is swift and dramatic. I suspect that a study to compare relative circumstances would find a direct relationship between suburban isolation and rate of decline. I have certainly seen it in my personal experience with older friends and relatives. In one case, the husband of a very independent and outgoing elder couple fell off a stage and broke his leg while performing music for a large Kiwanis group. The vision problem that prevented him from driving obscured the edge of the stage in low light. They had been living entirely on their own in an urban part of Marine Drive in West Vancouver, but were pressed to move in with their concerned suburban children, which both resisted, particulalrly the wife. And despite having the resources to employ caregivers, their decline in energy and attitude was dishearteningly swift. Nothing was walking distance, so they did not walk. The shop-keepers, bank, restaurant and post-office employees who saw them every day were no longer in their lives. Their friends thought they lived in someone else's house, so they visited less frequently, and their natural compassion was drained by the appearance that others were responsible for their care. They have transitioned from dynamic and outgoing people to near agoraphobic shut-in's.

The people I am speaking about left a healthy urban environment at a time when the interaction it offered was most important, and their story underlines the importance of a well functioning social network. This is important for all of us. The only difference I would suggest is the rate of decline when it is withdrawn, with elders more vulnerable to rapid, sometimes astonishing declines.

Most suburban elders' experience is a transition from vehicle supported social interaction to suburban insulation, bravely endured until dramatic health changes create urgent problems that put tremendous stress on friends and family. This also puts them at a disadvantage in seeking institutional accomodation.

The best strategy in securing institutional elder care is to get into the system as a fully functional, independent living older person. Age, health and wealth are subtantial advantages in admission. There are many choices in elder care for the advantaged - well designed buildings with good staff, good food services and a variety of activity programs. The best of these are entirely private, generally with waiting lists for admission, and with an annual cost of between $50,000 and $80,000. Some will accomodate elders as problems develop, providing various levels of assistance, but they do not admit those who require assistance to begin with - leaving out many "age in place" suburban elders.

The second level in elder care is "assisted living", and those who require assistance have a narrower range of choices. There are a mix of private and public facilities, with the cost of the private options between $50,000 and $90,000 annually, with additional fees based on specific, advanced requirements. Even in assisted living, some faclities have a low disability tolerance - requiring individuals who fall below a certain standard to find other accomodation. And private facilities that provide assisted living often do so only for elders who develop such requirements in place.

Public facilities are either funded or operated directly by the Vancouver Coastal Health Authority. Many private facilities are, in fact, only privately managed public facilities - with admissions controlled by the Regional Health Board. Admission requires an assessment by a Health Board "case manager", who makes both a physical and financial assessment of the "applicant". This determines both the facilities for which the applicant is eligible and how much he will be required to pay. The applicant has some choice in where he will go, but in practice the urgency of placement and the length of waiting lists restricts this choice. Waiting lists range between 10 months to two years. Some of these facilities make a limited number of "private pay" beds available, bypassing Health Board admission control, but at a far higher cost.

I have toured many of the facilities on the North Shore, posing as someone looking to find accomodation for my grandparents. I have also interviewed both current and former employees and several elder users, both in the facilities and during trips outside of them. The quality of life in these facilities varies widely. The best facilities are like high quality hotels, with private apartments, nice common areas and friendly staff. The worst are nothing more than geriatric prisons, with four people in a small room, elders languishing in wheel chairs scattered in grey terazzo hallways, a wide variety of odours hanging in the air. Completing the picture is a staff fully reflecting the dour environment. They are hard places to visit, and few do. There is a palpable sense of time running down, a passive acquiescence. It is hard to remember that these are real people who lead real lives building the world around them, with hopes for the future and their children. They changed our diapers.

It is hard to understand elder decline without actually seeing it happen. And I have noticed that even those who watch it up close seem to view it as an abstraction, not thinking about their own future. Many able bodied elders speak of facilities for older people as places for "old farts", definitely not for them. The only explanation I have for this is denial. Accepting the inevitable decline that is part of the human experience is frightening. It is far easier to segregate the afflicted and forget about them. The fact that this is the ultimate reality for many elders makes the prospect more fearful, a terminal diagnosis.

The truth of this is strongly underlined by the perverse fact that the most vigorous opponents to change in the single family suburban landscape of the North Shore are older individuals. Their reasons are often nothing more than that they want to preserve their wonderful suburban way of life and want nothing to change. It is not a great leap to understand this in a more personal sense. They are afraid of their own future. And like so many who cannot bring themselves to write a will, they cannot acknowledge the need for architectural and social change.