New Outlook for the Aged

Throughout history the aged have occupied a precarious position in society. Some primitive peoples like the Eskimos and other nomads respected the elderly but left them to die when they could no longer care for themselves. Natives of some South Seas islands paddled away from their families--to death--when age overtook them. Nor is the idea of abandoning the elderly unique to primitive societies. Marya Mannes' 1968 novel They postulated a world in which everyone over 50 was herded into public institutions and eventually liquidated. A 1966 Rand Corporation study concluded that if the U.S. survived a nuclear war it would be "better off without old and feeble" citizens, and suggested that no provisions be made to care for the surviving elderly.

The U.S. has clearly not taken such advice. Most Americans, whether moved by religion or common decency, still try to follow the Fifth Commandment and "honor" their parents. But despite their concern, and frequently the anguish that marks their hard decisions about the elderly, the position of the aged in the U.S. has grown parlous. A couple of decades ago, most Americans who reached 65, the admittedly arbitrary age for retirement, could look forward to spending their last years in peace and security, respected and cared for by their families and friends. No longer. For an increasing number of Americans, the years after 65 are a time of growing uncertainty and isolation as, cut off from family, beset by illness and impoverished by inflation, they struggle not to enjoy the rest that they have earned but simply to survive.

Their problem is a pervasive, urgent one, both for the old and for their children. America as a society has yet to develop a practical, human policy for dealing with the woes of old age in a modern world. For those elderly Americans who can still manage--both physically and financially--life goes on much as it always has. But for those who cannot manage, the end of life, or at least of life as most people would want to live it, can be an agony. About a million, or 5%, of the nation's elderly already live in nursing homes, too many of which are grim warrens for the unwanted. Tragically, the population of the nursing homes is growing. But so, too, is the public's concern over the plight of the old. Americans have yet to come up with the answers, but more and more are at least asking themselves the question that most must face sooner or later: What do we do with our parents?

There is no easy, single answer. In an earlier time, when most Americans lived on farms, the relatively few who reached old age simply stayed at home, inevitably working less and less but expecting and getting as their rightful due more and more care from their families. Industrialization, urbanization and the automobile have ended that. Most Americans no longer live on farms or in closely knit family groups. Ever more mobile, Americans by the tens of millions do not stay rooted in one place all their lives but pull up stakes, move and move again. Of those who hold on in the old home town, few live out their lives in one house. Married couples rarely stay with parents any more; even young singles are encouraged to strike out on their own. Those who leave frequently lose contact with their parents because of distance or because they are too busy to bother with the old folks, and may even be embarrassed by them. Says Anthropologist Margaret Mead, 73, and a grandmother: "The modern family, in its present form, is not equipped to care for old persons."

The problem is that there are more old people than ever to care for. In 1900 only 3.1 million, or one out of every 25 Americans, were over 65. Now 21.8 million, or one out of every ten, fall into this category. The reason for the rise is twofold. Modern medicine has cut infant mortality rates and increased the average life expectancy from 47 years in 1900 to 71.3 today. Since 1957 the U.S. birth rate has dropped (TIME, Sept. 16), increasing the ratio of elderly to young people. If present population trends continue, those over 65 and those under 15 should each account for 20% of the population by the year 2000.

Except for numbers, the two groups have little in common. For one thing, a disproportionate number of the American aged are women, who outnumber men by a ratio of 143 to 100. The reasons are obvious. Women tend to outlive men by an average of seven years; they also tend to marry men several years older than themselves, a fact that accounts for the high proportion of widows among elderly women. Nor is this the only difference between the young and the old. A significant number of today's elderly are, according to University of Chicago Professor Bernice Neugarten, "disproportionately disadvantaged." Many are foreign born, uneducated and unskilled. Far from all the aged are infirm, but 38% do suffer from some kind of chronic condition that limits their activities. Of these, fully half have serious problems and 5%, or one out of every 20, are homebound. About a third of all aged Americans are also plagued by poverty. Despite pensions, savings and Social Security, which will disburse $72 billion to 33.5 million recipients this year, fully 4.75 million of the nation's aged exist on less than $2,000 a year--well below the Federal Government's poverty line.

Depending on what they can afford and the extent to which they can take care of themselves or count on their families for help, the aged live in a wide variety of arrangements. For most, the accommodations are reassuringly familiar. More than two-thirds of America's elderly remain in the communities that they have known for most of their lives--and in the same homes. Most like the security of the familiar. For many, however, the decision not to pull up roots is economic as well as emotional: nearly 70% of older people own their own homes, humble as they may be. For owners, housing costs--utilities, taxes (often reduced for those over 65) and repairs--have long been relatively low. Now all of those costs are climbing sharply.

Not surprisingly, lots of elderly homeowners live in rural areas (many of them in Kansas, where nearly 12% of the population is over 65, and Nebraska, where the elderly make up as much as 23% of the population of Boyd and Saline counties). Many remain in small towns where they can live cheaply, with good houses going for as little as $10,000. Others settle in out-of-the-way places that are crimefree and friendly. Most have a simpler reason: to them, these hamlets are home.

In Swift Creek Township, near Raleigh, N.C., doctors urged Oscar Maynard, 67, to go to a nursing home after he suffered a stroke several months ago. Maynard refused, saying: "I'll be on my own, and I'll go where I want to go." Where Maynard wanted to go was to the simple brick home that he shares with his wife Essie, 63, on 25 acres of land. Says Maynard: "I'd rather be here than anyplace else in the world."

Many of the elderly with more money prefer plusher living. An estimated 500,000 have bought or leased property in the "adult" or "retirement" communities that have mushroomed round the country, primarily in Florida and the Southwest, where the weather is warm and the cost of living relatively low. Most of these "villages," "cities" and "worlds" follow the lead of Arizona's Sun City (pop. 34,000) and exclude younger people; no one under 50 can buy or lease property there. Some residents like the segregation practiced in the gerontopolises, but the majority are more interested in the amenities. A number of communities boast well-designed cottages or apartments and programs of social activities, such as dancing and crafts; many have swimming pools and offer residents free bus rides to and from shopping centers and entertainment; some even have golf courses. Miami's Park West community bars dogs, for example, and puts a three-week limit on visits by children. Warner Moore, 64, a retired General Motors executive, and his wife Elizabeth, 65, consider Park West an ideal place to live. It may be, for those who can afford it. The cost of a one-bedroom condominium in Park West begins at $27,000, a similar home in Sun City costs $28,000 and one in New York's handsome Heritage Hills $41,500.

Thousands can afford this expensive apartheid; thousands more can bear the costs of living in pleasant apartments in high-rise buildings in New York, Miami or Chicago. But millions of elderly Americans, the majority of them women and widowed, have to make do more modestly. Ella Larson, 73, a retired nurse in Santa Monica, Calif., finds apartment living increasingly expensive. She gets $107.80 a month from Social Security, which goes for food. An additional $147 from old-age assistance pays her rent and utilities, which leaves her almost nothing for clothes and entertainment. Mrs. Larson worries constantly that her rent will go even higher. "I feel very insecure," she says. "I never know if the landlady is going to raise my rent again or tell me they're going to tear the place down to build one of those new apartment buildings. Then we'd all be homeless."

Some elderly Americans cannot afford even the smallest apartment. For them, what passes for independence is a clammy rented room and a hot plate. An estimated 2,000 oldsters cling to life in $15-a-week furnished rooms in Boston's shabby South End. A few others find homes in peeling, decrepit residential hotels like the once elegant Miami resort where Mrs. David Yates, 90, gets a suite of rooms, maid service and two meals a day (no lunch) for $500 a month. People who cannot afford even this much may sometimes find a plain but safe haven in public housing projects specially designed for the elderly, which offer low-rent living to those who are physically, if not financially, able to go it alone. Chicago shelters 9,250 aged tenants at 41 special sites, including the huge Britton I. Budd complex near Lake Front Park. There Martin Smith, 82, pays $55 a month for an apartment that he feels is better than his daughter's $195-a-month place, and complains only about his arthritis.

For some, old age means giving up solitary independence and moving in with their children. Sometimes that works out well. Edna Segar, 74, who plays the piano in a Culver City, Calif., senior citizens' dance band, finds the ar rangement fine. So do her son Donald, 54, and his wife Frances, 59. Says Donald: "You wouldn't throw your kids out, so you don't throw your parents out when they need you."

For others, caring for parents is a serious problem. Many urban Americans simply do not have the room to house an elderly father or mother, especially in New York and other cities where an extra room means paying an enormous increase in rent or buying a larger home than they can afford. Others claim that the presence of a parent in the home strains marital relations and puts tremendous pressures on children. Still others just cannot take the tension involved in caring for senile parents.

Many families also cannot handle the physical aspects of aging. The Jury family, of Clarks Summit, Pa., watched helplessly as "Grandpa" Frank Tugend faded. The Jurys kept the retired coal miner with them, bearing with him as he became confused and forgetful, cleaning up after him as he lost control of his bodily functions. In his lucid moments, the proud 81-year-old Tugend knew what was happening to him. One day he took out his false teeth and refused to eat any more. He had decided to die, and no one--not his doctor, not his family--could do anything to change that. His children and grandchildren cared for him with anguished tenderness until death claimed him three weeks later.

Few children have the devoted patience or endurance of Tugend's family. Each year more and more of them face the problem of deciding what to do when aged parents need more care than they can--or are willing to--give. In some cases, the answer is obvious: put them in a nursing home. The decision is often devastating for parents and children alike, and has ripped many families apart. Whatever happens, guilt hangs in the air like a sulfurous, corrosive fog. Even children who keep their parents at home generally feel remorse about what Paul Kirschner of the University of Southern California calls the "battered senior syndrome," which involves caring for aged parents but excluding them from many family activities. Those who place their parents in nursing homes often feel a still heavier burden of guilt for "abandoning" the old folks.

In many cases, what they have done, for whatever reason, amounts to abandonment. Mary Adelaide Mendelson, of Cleveland, a former community-planning consultant, has spent ten years studying institutions for the aged. Last year, in a book titled Tender Loving Greed, she concluded that U.S. nursing homes are a national scandal. She writes: "There is widespread neglect of patients in nursing homes across the country and evidence that owners are making excessive profits at the expense of patients."

This does not mean that all of the country's 23,000 nursing homes are bad. A number of them scattered throughout the country are, by any standards, excellent. Others provide their patients with at least good, competent care. They come in all sizes, under highly diverse sponsorship. Members of Southern California's Japanese community need have no qualms about placing their parents in Los Angeles' Keiro (which translates as Home for Respected Elders), a 184-bed facility that bespeaks the Oriental tradition that old age should be a time of ease. Keiro's appeal ranges from chaste Japanese decor to good food served from a gleaming stainless-steel kitchen. The home also has a largely bilingual staff that is genuinely interested in the welfare of its patients, and a program that includes everything from physical rehabilitation to concerts on traditional Japanese instruments.

Nor need children feel guilty about putting their parents in some of the smaller, less shiny but equally good homes round the country. Associated with the Christian Missionary Alliance, the Alliance Residence in Minneapolis is a nondescript three-story building minus any lush lobby or manicured grounds. But what it lacks in gilding, it more than makes up for in concern for its patients. Alliance's 100 occupants are in the care of seven nurses and 25 nurse's aides, who work hi three shifts so that the home will be staffed round the clock. Most of Alliance's patients are not only healthy but happy. Elvira Axeen, 82, still goes out every Wednesday to make coffee for her Bible group. "I'm going to be busy as long as I can do it," says she. So are others. "As long as you can complain and be up and around, you're young," says 91-year-old Mrs. Ellen Wicklander as she stitches on a quilt.

The best nursing homes deprive their patients of some independence. The worst deprive them of far more: their resources, rights and, ultimately, their humanity. They are killer institutions. An investigation still under way in New York has dug out evidence of widespread abuse and exploitation of nursing-home patients. Inspectors who have made surprise visits to homes have found in the worst of them incontinent patients wallowing in their own filth, patients shot full of tranquilizers to keep them bovinely docile, others whose requests for help went unanswered and still others who were unfed or given the wrong foods and medication. They have also found many patients--like those at the now closed Towers Nursing Home in New York City--who were unwilling to complain for fear that they would be punished later by the attendants.

The crimes against the weak are not confined to New York. Authorities in Illinois are investigating not only suspected fraud but also the deaths of seven patients in a home in Rockford. California officials have turned up even more disturbing evidence. Los Angeles County investigators reported that a paralyzed woman at the Torrance Medical Convalescent Center, a 212-bed nursing home in Torrance, Calif., died after a nurse tried to feed her orally rather than through a stomach tube, then dismissed her gasping and flailing as an attempt to burn off "excess energy." The victim was not the only patient to die at Torrance, whose license to operate is being challenged. One patient died when he apparently leaped from a second-story window. "He probably jumped because of the conditions inside," said one angry health official.

A few of these substandard homes are public institutions. The majority, however, are private. The reason for the ratio is money--public money, ironically, appropriated to give aid and comfort to the Indigent aged. In 1966 the Federal Government began to pay for nursing-home care through Medicaid, a federal-state program that last year spent $4.4 billion of its $12.7 billion budget on the elderly. The sudden gush of cash set loose a nursing-home boom as many entrepreneurs, many of them interested only in the bottom line, rushed into the business.

It is not difficult to understand how the homes make money. Medicaid pays them from $8.50 to $49.10 per patient per day, but many homes spend far less on care for their patients. Most save money on staffing, hiring only a handful of professionals and then filling their rosters with unskilled, often careless attendants, who are paid rock-bottom minimum wages. Some proprietary homes save by spending next to nothing on their buildings, which may not only be dirty and stink but may also be unsafe. Also, many nursing-home operators save on food. One owner admitted to investigators that he was feeding his patients for 54-c- a day, less than the county jail spent on its prisoners. Given such practices, it is not surprising that some private nursing homes yield an annual return of more than 40% on money invested. Unblinkingly, nursing-home operators defend themselves as performing a necessary service. "The public does not really want to accept the fact that taking care of a sick old person is not a pleasure," says Max Lewko, administrator of New York's Mayflower Nursing Home. "If some of these people had their mother at home for four weeks, they would appreciate what we are doing."

That begs the question. Regardless of their condition, the elderly deserve to be treated like human beings. Fortunately, action to guarantee such treatment has already begun. A special commission in New York has submitted an eleven-bill package that would include unannounced inspections of nursing homes, establish a stiff schedule of fines for violations of state standards and give the state the right to sue nursing homes that failed to provide proper care. The Minnesota state legislature has tightened up certification procedures and passed laws requiring close monitoring of nursing-home operations. Massachusetts authorities have shut down eight substandard homes and plan to close three more unless they are sold to someone who will run them properly.

Congress is also acting. Senator Frank Moss, chairman of a Senate subcommittee on long-term care, has introduced 48 bills that would, among other things, require 24-hr, attendance of a registered nurse, offer financial incentives to nursing-home operators by allowing higher payments for better care, and provide for full disclosure of the identities of all individuals involved in a nursing home's operation.

The enactment of pending legislation--indeed, even the enforcement of existing state and federal regulations --would go a long way toward ending the dehumanization and exploitation of those who can no longer care for themselves. But improving nursing homes will not help 95% of America's elderly. What will help them and those who will one day join their ranks is a realization that the U.S. suffers from what Dr. Robert Butler of Washington, D.C., calls "ageism"--or prejudice against the elderly--and a determination to end this cruel form of discrimination. "The tragedy of old age is not that each of us must grow old and die," writes Butler in his newly published book Why Survive? (Harper & Row; $15), "but that the process of doing so has been made unnecessarily and at times excruciatingly painful, humiliating, debilitating and isolating through insensitivity, ignorance and poverty."

But, says Butler, much of this pain and humiliation can be eliminated. He and his fellow gerontologists urge those who want to help their parents--and other elderly--to help overhaul old policies and develop some new ones, particularly with regard to:

RETIREMENT. Most people assume that to be old is to be finished or "over the hill," and at least half of all American workers are now employed by companies that have institutionalized this assumption by forcing their employees to retire at age 65, if not earlier. The effects of this involuntary idleness can be traumatic. "One day they have life, the next day nothing," says Margaret Mead of unwilling retirees. "One reason women live longer than men is that they can continue to do something they are used to doing, whereas men are abruptly cut off--whether they are admirals or shopkeepers."

Most companies claim that mandatory retirement is necessary to maintain efficiency, preserve profits and clear the way for younger employees. But gerontologists find the arguments unfair. There is no evidence that an individual's efficiency or creativity declines dramatically once he passes his 65th birthday; indeed, many people--from scientists to craftsmen to musicians* have done their best work during their declining years. Nor can it be assumed that most elderly Americans are too feeble to support themselves. At least half of those now over 65 are physically capable of doing a day's work. Mandatory retirement is, in fact, now under challenge. A former civil servant has filed suit to set aside the Federal Government's retirement policies. The American Medical Association has allied itself with him, insisting in a friend-of-the-court brief that there is no evidence that older workers are any less efficient than younger ones.

INCOME. It is pure romanticism, say most gerontologists, to assume that prudent people can provide adequately for their old age. Inflation in the 1970s can erode the value of the most liberal of pensions and shrink the worth of even the fattest savings accounts. Nor does Social Security, upon which most elderly Americans depend for at least a third of their income, enable most to live with any measure of financial security or comfort. A 65-year-old couple entering the plan this year and entitled to the maximum benefits, which they have paid for in taxes, draws only $474 a month. That inches them above the poverty line but hardly enables them to live beyond the bare-bones level. Besides, the average couple receives only $310 a month.

To alleviate the financial plight of the elderly, experts recommend placing a reasonable floor, pegged to the actual cost of living, under retirement incomes, either by increasing Social Security benefits or supplementing them from other state or federal funds. They also recommend reforms in both Government and private pension systems, to assure that all workers who contribute to a pension plan will derive at least some benefits from it.

MEDICAL CARE. Most medical plans are designed to care for the elderly once they become ill. Gerontologists believe that the emphasis should be on preventing illness and preserving health and keeping the aged in the community.

To accomplish this, New York's Montefiore Hospital 28 years ago inaugurated home care for the elderly with regular visits to the homebound by doctors, physical therapists and social workers. Since then, about 100 other hospitals across the country have set up similar programs. Three years ago, Montefiore branched out with an aftercare program, under which stroke, arthritis and cancer patients were brought to the hospital for follow-up treatments that doctors hope will eliminate the need for institutional care. Two years ago, the hospital helped set up a day-hospital program. It offers custodial care to those who have no one at home to watch over them during the day.

Dr. Isadore Rossman, who directs the Montefiore programs, hopes that the success of these pilot projects and the acceptance of others like them round the country will lead to the passage of legislation to create and buttress alternatives to institutional care. Such programs would prove an unexpected bargain. Montefiore's home-care costs about $12 a day, or a maximum of $4,380 a year. Even with an elderly person's rent and food bills--averaging at least $2,400 a year--added on, this makes staying out of a nursing home far cheaper than going in. The average cost of a modern New York nursing home is up to $42 a day, or a whopping $15,000 a year.

ATTITUDES TOWARD AGING. Americans, says Butler, take an unhealthy and often unrealistic attitude toward aging, assuming that old people have no further contributions to make to society and should be excluded from it. Many of the elderly share this view, occasionally attempting to conceal evidence of their advancing years and withdrawing from an active life. Butler and others believe that attitudes must change if the aged are ever to be treated fairly in the U.S. They urge society to recognize the basic rights of old people to independence and security. Gerontologists also urge society to make better use of the elderly, drawing on their experience and talents and giving them a greater voice in matters that concern them. It is ridiculous, they agree, to have panels of 35-year-olds determining the wishes of and setting policy for the aged when the aged are better equipped to do the job.

Improvements in these areas are on the way. Congress has moved--albeit not very far--to tap the reservoir of talents the elderly have accumulated during their lives. It has approved $45 million for a variety of projects, including the Foster Grandparent Program, which pays oldsters for supervising dependent and neglected youngsters; $17.5 million for the Retired Senior Volunteer Program (RSVP), which pays out-of-pocket expenses to 100,000 involved in such community activities as entertaining the handicapped and visiting homebound patients; and a skimpy $400,000 for the Senior Corps of Retired Executives (SCORE), which reimburses some 4,500 retired executives for expenses incurred while counseling small businesses and community organizations.

Other programs are under way.

One feeds the elderly, who often stretch their skintight budgets by subsisting on peanut butter sandwiches or skipping meals entirely. The nutrition section of the 1965 Older Americans Act, funded for $125 million this year, now provides 220,000 seniors with a hot meal a day through local nutrition centers or "Meals on Wheels" vans that deliver hot food right to the doors of the homebound aged.

More encouraging are the programs to keep the elderly in the community and out of institutions. Chicago, which set up the nation's first municipal office for the aged in 1956, sponsors some 600 senior citizens' clubs, where they can meet to talk out their problems and organize to get things done. It also operates some 62 nutrition centers, where an estimated 3,800 come for a low-cost hot meal and some companionship.

At present, these programs reach and benefit only a handful of the nation's elderly. But the prospects for their expansion and for the development of other new approaches toward aging are brightening. One reason for this improved outlook is the growing recognition by most Americans that the country has a lot of catching up to do in its treatment of the aged and the new desire to change what more and more agree is an intolerable situation.

This urge to change things has been inspired in large part by the realization that other countries have done so much more than the U.S. in caring for the elderly. Sweden, Denmark and Norway have used part of the mountain of taxes collected from their citizens (as high as 50% of most salaries in Sweden) to ease many of the burdens of aging. In Sweden, city governments run housing developments where the aged can live close to transportation and recreational activities. Denmark, with a population of 5 million, houses many of its more than 600,000 elderly in subsidized houses or apartments and helps those who want to remain in their own homes by providing them with day helpers and meals. Those who need nursing homes find them a considerable cut above most of their American counterparts: with their excellent design, many look like modern hotels.

Another force behind the new impetus for change is the growing political power and militancy of the elderly themselves. Many groups--blacks, young people, women--have realized how much political muscle their numbers provide and organized in recent years to demand and get attention and help from federal, state and local officials. The aged are following their lead. No longer content to pass their days playing checkers or weaving potholders at senior citizens' centers, a growing number of elderly Americans are banding together to make their wishes known. Several thousand of them have joined a five-year-old group known informally as the Gray Panthers, whose leader, a retired Philadelphia social worker named Maggie Kuhn, 69, is dedicated to altering U.S. attitudes toward the aged. The Panthers have agitated for better housing and medical care and more employment opportunities for the elderly. "Most organizations tried to adjust old people to the system," says Miss Kuhn, "and we want none of that. The system is what needs changing."

The system is changing, and it is likely to change even further. Politicians, aware that the elderly are more likely to register and vote than the young, are listening when senior citizens speak. So are younger people. The new interest is encouraging. Americans have for too long turned their backs on their old people. Now many are seeing them for the first time, recognizing their plight and moving to help them. The interest and action are both humane and pragmatic. Today, millions of Americans are wondering what to do about their parents. Tomorrow, their children will be wondering what to do about them.

* Giuseppe Verdi produced his great opera, the joyously exuberant Falstaff, at age 80; Justice Oliver Wendell Holmes Jr. crafted some of his most powerful opinions in his tenth decade.

This file is automatically generated by a robot program, so viewer discretion is required.