Moving Beyond Place:
Aging in Community

by William H. Thomas and Janice Blanchard

In 1519, the Venetian scholar Antonio Pigafetta was among those who accompanied Captain Ferdinand Magellan on the three-year voyage that became the first known circumnavigation of the earth. During his travels, Pigafetta kept a detailed diary in which he noted that the lifespan of the average Brazilian Indian was between 124 and 140 years (a longevity he attributed to the Indians’ retention of what he called a primitive innocence similar to that of the Biblical patriarchs).[1] 

The standard for exaggerated claims had been set by Christopher Columbus 30 years earlier. In one of the explorer’s early letters he gushed over the seemingly limitless supply of food available in the New World, calling it “a veritable Cockaigne” or land of plenty.

Such observations were welcomed by rich and poor alike because they offered hope at a time when few people lived past the age of 40 and devastating famines were a common occurrence. Pervasive scarcity, back-breaking labor, and the prospect of early death led people to imagine a land where food and good health came effortlessly — to everyone. They dreamed of a utopia called Cockaigne, in which there was no need to work, the streams ran with water that restored the full bloom of youth, and the houses were roofed with meat pies.

Today, of course, the fanciful legends of Cockaigne can seem juvenile, encouraging us to believe that we have outgrown the need to console ourselves with imagined utopias. But such is not the case, certainly for many people growing old now.

Today’s Fear: Old Age in an Institution

The paradox of modern societies is that they provide the stability and affluence that enable many people to grow old, while at the same time denying older people a suitable role within the social order. Old age does not occur in a vacuum. How we define, experience, and perceive old age is influenced by a number of complex and interrelated factors, including social policies, politics, demographics, economics, and cultural values, as well as class, gender, and race/ethnicity. While theories of aging evolve over time within gerontology, it is apparent that social policy and public opinion are often slow to catch up. In public discourse and policy, aging is still largely defined by a biomedical perspective that emphasizes dependency, loss, and decline. Not surprisingly, the proposed solutions are rooted in the same soil. As a consequence, more than 70 percent of long-term-care dollars are spent on skilled nursing facilities, or nursing homes, that conform to the medical model.[2] 

At the beginning of the past century, an American could reasonably expect to die at home, surrounded by loved ones and consoled by the most familiar of surroundings. Today, most older adults die in unfamiliar and impersonal hospital and nursing home environments. While a relatively small percentage of older adults find themselves living in nursing homes on any given day (5 percent of the population over age 65), the risk for a 65-year-old of entering a nursing home for some period of time is 46 percent and increases with age. With the survival rate increased to age 65, it is estimated that the number of 65-year-olds who will spend some time in a nursing home will double by 2020.[3] 

People fear nursing homes. Indeed, when asked what they fear most, older people ranked loss of independence and placement in a nursing home above the fear of death.[4] 

Aging in Place: Still “Dreaming of Cockaigne”

This brew of fear and loathing inspires millions of older Americans to dream of growing old in their longtime homes, or “aging in place.” Indeed, the ideal of growing old in one’s own home has developed into a powerful idealized counternarrative, the opposite of a dreadful old age cursed with indignity, a loss of autonomy, and the looming terror of institutionalization. The power that animates “aging in place” as a concept is its implied promise of freedom from that which we fear most. Rather than experience a loss of independence, we remain masters of our own domain. Instead of being cared for by strangers, we are sheltered within the bosom of our families or at least come to rely on a trusted homecare aide. Instead of being placed in an institution, we stay safe, secure, and comfortable within the walls of our own homes. This is the most consoling of all the ideas that we associate with old age. We have come to believe that in all times and in all ways, “home is best.” Indeed, some 92 percent of Americans age 65 and older who participated in 2000 in an AARP survey said they wanted to live out their lives in their current homes; even if they should need help caring for themselves, 82 percent said they would prefer not to move from their current homes.[5]  With this idealized notion of the old age that awaits us, we are still “dreaming of Cockaigne.”

The bitter truth is that an older person can succeed at remaining in her or his own home and still live a life as empty and difficult as that experienced by nursing home residents. Feeling compelled to stay in one’s home, no matter what, can result in dwindling choices and mounting levels of loneliness, helplessness, and boredom.[6]  This difficulty is often compounded by the fear that someone (a state official or even a friend or family member) will discover the true state of affairs and enforce the ultimate sanction. Because it is fixated on a location (the private home) and pays little heed to the factors that make up actual quality of life, commitment to aging in place can turn out to yield benefits that are as mythical as those of Cockaigne, and may actually do harm.

Aging in Community: A Third Way

Our culture has constructed a continuum that positions institutional long-term care at one end of a spectrum, and an idealized vision of aging in place at the other. The challenge is to escape this false choice. An increasing number of Americans are searching for, and finding, a third way.

Historically, American cultural values of independence, self-reliance, and individual responsibility have supported the notion that elders can and should age in place. The New York Times columnist David Brooks recently challenged this ideal:

This individualist description of human nature seems to be wrong. Over the past thirty years, there has been a tide of research in many fields, all underlining one old truth — that we are intensely social creatures, deeply interconnected with one another, and the idea of the lone individual rationally and willfully steering his own life course is often an illusion.[7] 

The United States faces a range of issues that must be addressed cooperatively. Global warming, a faltering economy, a troubled healthcare system compound the challenges that come with an aging population. New responses to these challenges, from senior cohousing to shared households to cooperative urban “villages,” point to the emergence of a new doctrine: People working together can create mutually supportive neighborhoods to enhance well-being and quality of life for older people at home and as integral members of the community. This is the essence of “aging in community.”

We use the word community to refer to a small group of people who voluntarily choose to rely on each other and to be relied upon over an extended period of time. Aging in community presumes that those who embrace it have a high degree of interest in a way of life that offers daily opportunities for social connection in the context of smaller, clustered, village-like settings, whether urban or rural. The qualities of aging in community are highlighted below.

The Qualities of Aging in Community

  • Inclusive — People of all ages, race/ethnicities, and abilities, especially elders, are welcome.
  • Sustainable — Residents are committed to a lifestyle that is sustainable environmentally, economically, and socially. Size matters. People need to know each other, and scale determines the nature of human interaction. Small is better.
  • Healthy — The community encourages and supports wellness of the mind, body, and spirit and, to the same degree, plans and prepares programs and systems that support those dealing with disease, disability, and death.
  • Accessible — The setting provides easy access to the home and community. For example, all homes, businesses, and public spaces are wheelchair-friendly and incorporate universal design features. Multiple modes of transportation are encouraged.
  • Interdependent — The community fosters reciprocity and mutual support among family, friends, and neighbors and across generations.
  • Engaged — The community promotes pportunities for community participation, social engagement, education, and creative expression.

The concept is focused on building vital communities that engage people of all ages and abilities in a shared, ongoing effort to advance the common good. A useful analogy envisions the people who populate an “aging in community” setting as bricks and the relationships that develop between them as the mortar. Together, the bricks and mortar create “social capital.” In this society, the value (rising and declining) of financial capital is measured obsessively, while our stock of social capital earns surprisingly little attention. It is the web of informal, voluntary, reciprocal relationships found within the mundane routines of daily life that forms the core of any society’s social capital. Aging in community embraces strategies that help people intentionally create and deploy the resources of social capital alongside financial capital resources.

The current practice of institutionalizing elders in need of care is undesirable because it consumes large quantities of financial capital while it also destroys reservoirs of social capital. Aging in place, with its dwelling-centric approach, relies heavily on dollar-denominated professional and paraprofessional services while offering older people little or no opportunity to create or deploy reserves of social capital. Aging in community presents a viable and appealing alternative to both approaches.

Types of Communities

Today, as 78 million boomers turn 60 and beyond, we stand at a crossroad that will redefine the second half of life. The vanguard of this generation is already at work redefining core elements of the experience of aging. One facet of this cultural revolution in aging is the emergence of so-called intentional communities that address a constellation of desires — for a sense of place, sustainability, shared values and goals, diversity, and respect and support for elderhood as its own distinct life phase — a phase of life that lies beyond adulthood.

As work and family responsibilities shift and retirement looms in the future, some boomers are reflecting back on the peak experiences of their youth. They lived together in a variety of household settings with friends who shared the daily rhythms of life and who really cared for one another. Boomers bonded in ways unheard of by their parents with unrelated people outside their families.

A growing number seek to rekindle this vision of building custom communities with select friends and kindred spirits. Recent research found that about a quarter of boomers interviewed are interested in shared housing (“private living units with communal living areas”), and a third indicated interest in a “clustered living community” with a campus-like setting, private space for residents, and such shared amenities as a dining room, library, and laundry (this form of living is also referred to as cohousing). Some yearn for an urban, intergenerational, and diverse community, while others seek rural, back-to-the-land places.[8]  The boomer generation is likely to do for aging services what they did for the ice cream industry 40 years ago. Three flavors will no longer be enough.

Intentional Communities

“Intentional communities” are planned residential groupings, usually founded on similar spiritual, social, or political beliefs or other shared values or goals. Resources and responsibilities are often shared, although the degree varies significantly among different community models. Intentional communities include cohousing, communes, ecovillages, ashrams, kibbutzim, and cooperative housing. The fastest growing type of intentional community is cohousing, an arrangement of resident-designed-and-managed housing, usually in developments of about 30 homes that include shared facilities, require residents to share responsibilities and resources (but not incomes), and are not necessarily devoted to any particular age group. The concept was imported from Denmark in the early 1990s. From about 16 communities in 1995, the number of cohousing communities in the U.S. had grown to about 113 in 2008, with 111 currently in the planning stages, including several senior cohousing communities designed by and for adults 50 and older.[9] 

Elderspirit is one of the first senior cohousing communities, founded by former nuns who left their order in the 1960s over philosophical differences. Without the safety net of the convent, in retirement they wanted to build their own community dedicated to personal growth, mutual support, and spiritual deepening in later life. Elderspirit has 29 units. Residents are of mixed income levels and must be at least 55 years of age. The development is built along the scenic Virginia Creeper Trail, within easy walking distance of shops and downtown Abingdon, Virginia.

Hope Meadows is a mixed-income, intergenerational community in Rantoul, Illinois, founded in 1994 and dedicated to addressing the challenge of children living for years in foster care without permanent families. Hope Meadows illustrates that ordinary people are capable of extraordinary compassion, caring, and love, regardless of their age, class, or ability. The resident seniors serve as honorary grandparents and agree to volunteer at least six hours per week in exchange for reduced rental housing. Even more than their volunteer work, it is the caring relationships they develop with the children and other adults that has been identified as a key factor in healing the children and providing stability to the community, while also enhancing the lives of the elders. As the older residents age, the community is helping them to continue to live in their homes and stay connected.

Spontaneous Communities

Notably, the U.S. is home to many successful communities that developed spontaneously in already established places. Within small towns and suburban and urban areas in every state, one can find a community in which traditional ideas about caring for one’s neighbors still prevail. Often, however, as people age they may require more specialized support than other residents are able to offer on a regular basis. Established communities are developing new capacities to deal with this challenge.

The Beacon Hill neighborhood in downtown Boston is such a community. In 2001, several friends and neighbors came together to create a plan, the Beacon Hill Village, to help each other stay in their homes and remain meaningfully connected to the community. The Village model uses a nonprofit organization to vet and organize programs and services for older adult residents. To help defray costs, the organization charges residents a yearly membership fee, with discounts for those in financial need. Beacon Hill Village has received considerable media attention in recent years, resulting in thousands of inquiries about replicating the model. According to the Village-to-Village Network, 90 affiliated villages are “open” (as of August 2012), with another 130 in development, located in 38 states and the District of Columbia.

Cockaigne, the medieval mythical land of plenty, as portrayed by Pieter Bruegel the Elder (1567).


The Trillion Dollar Question

While our culture seems to revere the notion of aging in place, our public policy continues to favor institutionalization for those requiring long-term-care services. The conflict between what people say they want (to receive services in their own homes) and the way their tax dollars are spent has become especially acute. This situation exists despite studies showing that, on average, it costs about half as much to maintain an elder at home as compared to placement in a nursing home.[10]  Given that three-fourths of the nation’s long-term-care budget is spent on nursing homes, and Medicaid is the largest source of payment for that care (about half), the need for a rebalancing of the public funds committed to meeting the needs of frail elders becomes clear.

Because of its intense focus on independence, the concept of aging in place leads, rather directly, to an emphasis on the dollar; paid professional services are required to provide care that will allow individuals to remain in their own homes. The combination of an aging society with the enshrinement of the private home as the only acceptable locus for aging yields cost projections that boggle the mind. Consider the following: The post–World War II generation that is now approaching old age has about 70 million members. If we imagine making a trillion dollar investment in the care of that generation, simple arithmetic tells us that that provides a per capita amount of just under $15,000 dollars. That is not $15,000 a year but rather for the entire period that members of this generation will need care, barely enough to cover two years of in-home supportive services in 2005.

The cost of an independence-based public policy, centered on the concept of aging in place, lies far beyond what our society can afford. At the same time, the use of mass institutionalization to cope with the needs of frail older people is gradually being seen as morally unacceptable. It is in this context that a third way becomes increasingly attractive. We need a public policy that facilitates the blending of financial resources (such as personal savings, pensions, and money from government programs like Medicare and Social Security) with social capital (which is created and maintained by healthy families and communities). For this blend to occur, we will have to confront and overcome deeply held and highly negative preconceptions about age and aging.

Conventional wisdom holds that the aging of America is, by necessity, a bad thing. The inventory of losses and unwelcome burdens is long and has been detailed in scholarly journals and the mainstream media. Omitted from these calculations, however, is an accounting of what age and aging contribute to everyone. The virtues of aging remain invisible.

Occurring parallel to this phenomenon of a rapidly aging society are shifts in family patterns (particularly the trend toward smaller family size, childlessness, alternative families, and divorce); increased mobility of families; the growing number of women in the workforce; increased life expectancy past the age of 85; spiraling healthcare and long-term-care costs. Another factor is the increased social acceptance of age-segregated communities.

Still, new opportunities and hopeful paradigms are emerging: an increased interest in civic engagement in older adults; a conscious-aging movement that promotes a new vision of elderhood; and examples like Hope Meadows that show intergenerational community as a tool that can be used to address social challenges that young and old face.

At its most fundamental level, human longevity creates the possibility of multigenerational families and communities that contain three and sometimes even four or more generations. Because it is the multigenerational transmission of culture, values, and wisdom that is most essential to our humanity, strategies that strengthen interaction and ties between generations contribute enormously to our stock of social capital.

The concept of aging in community is presented here as a useful successor to the concept of aging in place because the former shifts the emphasis away from dwellings and toward relationships. As the models described above demonstrate, the aging-in-community idea will be replicable across the spectrum, from rural to urban. With a high value placed on economic sustainability, it is critical to explore ways to extend the opportunity to age in community to the broadest possible segments of the population.

United by the intention to create innovative alternatives to current housing choices, the new movement for aging in community promises to inspire the entire national conversation about aging and to engage the skills, spirit, and imagination of architects, planners, builders, and community activists of all ages.
 


William H. Thomas, M.D., is an international authority on geriatric medicine and eldercare from upstate New York. He is the founder of the Eden Alternative, a philosophy and program that has helped de-institutionalized nursing homes in all 50 states and worldwide over the past 20 years. A self-described “Nursing Home Abolitionist,” he is also creator of the Green House®, a radically new approach to long-term care where nursing homes are torn down and replaced with small, home-like environments where people can live a full and interactive life. He is the author of What Are Old People For? How Elders Will Save the World and Professor of Aging Studies and Distinguished Fellow, Erickson School, University of Maryland, Baltimore County, Baltimore, MD. Access the video, "Elderhood Rising: The Dawn of a New Age," at http://www.youtube.com/watch?v=ijbgcX3vIWs.

Janice M. Blanchard, M.S.P.H., is a gerontologist and nationally recognized writer, speaker, and consultant on aging issues. For 20 years she has worked on the cutting edge of public policy and programs promoting a new vision of elders as valuable members of our communities and of elderhood as a distinct phase of the human life cycle. Renowned for her seminal work in “aging in community,” Janice consults with government, non-profit, and private organizations to develop innovative housing and community-based solutions that strengthen the fabric of our communities, for all ages and all abilities — especially our elders. Contact Janice at 720-934-7985 or denverjanice@gmail.com.


Notes

1 This article is adapted with permission from an article of the same title published in Generations 33:2, Summer, 2009. Copyright @ 2009. American Society on Aging, San Francisco, California. http://www.asaging.org/.

2 Carroll Estes and Associates, Social Policy and Aging: A Critical Perspective (Thousand Oaks, CA: Sage, 2001).

3 B.C. Spillman and J. Lubitz, “New estimates of lifetime nursing home use: Have patterns of use changed?” Medical Care 40(10) (2002):965–75.

4Clarity, “Seniors fear loss of independence, nursing homes more than death.” November 12, 2007. marketingcharts.com/direct/seniors-fear-loss-of-independence-nursing-homes-more-than-death-2343/ (accessed August 31, 2012).

5 AARP, “Fixing to stay: A national survey of housing and home modification issues” (Washington, DC: AARP, 2000). http://assets.aarp.org/rgcenter/il/home_mod.pdf (accessed August 31, 2012).

6 W.H. Thomas, Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home — The Eden Alternative in Action (Acton, MA: Vanderwyk and Burnham, 1996).

7 David Brooks, “The Social Animal,” New York Times, September 11, 2008. nytimes.com/2008/09/12/opinion/12brooks.html (accessed August 31, 2012).

8 Metlife Mature Market Institute, AARP Health Care Options, and Mathew Greenwald and Associates, The Future of Retirement Living (Westport, CT: Metlife Mature Market Institute, 2004).

9 Donna Freiermuth, “A 2008 map of where cohousing communities exist.” cohousing.org/cm/article/map08 (accessed August 31, 2012).

10Social Policy and Aging.