Elder Care: Making The Right Choice

By John Greenwald

Marjorie Bryan's husband died 14 years ago. That was when she lived in Mississippi, and for some time afterward she went on living on her own. Now she's 82. A few years ago, she started having trouble with her balance and taking falls. Bryan has a grown son in Georgia, but moving in with him didn't seem like the answer. It's one thing to have a roof over your head. It's another to have a life. "I didn't want to live with my children," she says. "I think it would bore me to death. I don't drive anymore. If I'd stayed there, I'd be sort of a prisoner during the day."

So Bryan went looking at the alternatives. It turned out there were more than she had imagined. A couple of decades ago, seniors like her who were basically healthy but needed some assistance had limited choices. Among them, they could move in with their grown children, if they had any and were willing to risk the squabbling and sulking. Or they could be bundled off to a nursing home that was like a hospital, only less inviting. All that began to change in the early 1980s with the growth of a new range of living arrangements for older people who want to live as people, not patients, without the physical confinement and spiritual dead air of many nursing homes.

Eventually Bryan came upon the Gardens of Towne Lake in Woodstock, Ga., a landscaped complex where about two dozen seniors live in their own apartments and have round-the-clock staff members to help with daily tasks such as dressing and bathing. There are regular social events. There's a beauty shop. "I love living here," she says. "I got out that first day to learn names."

The late 20th century has done for the retirement years what it did for TV channels and fancy coffee. It multiplied the choices but also the consumer bewilderment. For seniors who want to stay in their homes as long as they can, there is home care for the masses--agencies everywhere that provide nurses and aides who either come by your place on a regular basis or live in. Traditional nursing homes are still widely used, though they are evolving away from long-term care and toward rehabilitative facilities, for short-term stays following hospitalization. The most popular new options are assisted-living facilities. There are an estimated 20,000 to 30,000 such places in the U.S., according to industry figures. Assisted-living complexes are home to one-fourth of the 2.2 million Americans who live in housing for seniors, according to the American Seniors Housing Association. Some are free-standing facilities. Some are part of continuing-care retirement communities, which offer increasing levels of help and medical supervision as residents move through the years.

"The assisted-living movement has really changed the way people age," says Karen Wayne, president of the Assisted Living Federation of America (ALFA), an industry trade group. "We've proved that people don't want to be in institutional settings." The facility provides each resident with a room or suite; meals, usually in a common dining room; and round-the-clock staff members who help with the no-big-deal chores of the day that can still defeat the mostly capable elderly--bathing, dressing, taking medication. Assisted living gives the elderly some measure of independence, a chance to socialize and needed privacy. Privacy for all sorts of things--sex has hardly disappeared from these seniors' lives. A survey released this month by the American Association of Retired Persons revealed that a quarter of those 75 or older say they have sex at least once a week.

The widening flood of Americans into later life--Tina Turner turns 60 this year!--guarantees that elder care will be a 21st century growth industry. The market, which was $86 billion in 1996, is expected to reach $490 billion by 2030. That potential is attracting such big developers as the Hyatt Corp. and Marriott International hotel operators. The 3,300 units of senior housing that Hyatt operates in 16 communities around the country are worth an estimated $500 million.

The old people that assisted living caters to are usually able to get out of bed and walk around. But their average age, estimated by ALFA, is 83, so they can also be frail. Almost half have Alzheimer's or some degree of cognitive impairment. (Alzheimer's patients tend to have their own, more closely supervised areas.) John Knox Village, in Pompano Beach, Fla., is a not-for-profit continuing-care operation on a landscaped campus with meandering walks and duck ponds. In an arrangement typical of such places, the elderly buy a residence--studio apartments are $48,500; two-bedroom "villas" are $142,500--and a continuing-care contract that sets a monthly maintenance fee covering all services. While they may begin life there in a mostly independent mode, taking an apartment with meals, they can later move to assisted-care rooms or even the on-campus nursing home for about the same monthly maintenance fee, usually a fraction of what a regular nursing home demands.

Carl Kielmann, 73, is a retired banker and the second generation of his family to live at John Knox in the Health Center. He and his wife Lillian moved there in 1985, joining his mother, who was also a resident. His mother's contract with Knox allowed her to spend her last six years in the village medical center without eating up her savings. "In a lot of ways," says Kielmann, "this type of place is your ultimate insurance policy."

Other assisted-care facilities can be a single building. Sunrise Assisted Living in Glen Cove, N.Y., is a 57,000-sq.-ft. soft yellow mansion with white gingerbread trimmings. The 83 seniors who live there each pay between $2,850 and $4,800 a month. On a recent day the buttery smell of fresh popcorn wafted through the vestibule. On the door of its suites, framed "memory boxes" display mementos of the lives of the people who live behind those doors--family photos, military dog tags and other souvenirs of long lives. In the special section for residents with Alzheimer's, one area is stocked with old tool kits, wedding gowns and a crib with several dolls, haunting but therapeutic props meant to engage the minds of people who have returned in fantasy to younger days when they worked and raised families. "We want to create pleasant days for these folks," says Jennifer Rehm, who runs the busy activity room. "This is not usually a neat place by the end of the day."

Keeping the elderly connected to the larger world is a big part of the idea behind assisted living. At the Munne Center in Miami, where family gatherings are featured, residents look forward to seeing their neighbors' grandchildren as eagerly as they do their own. Cecilia Struzzieri, 95, recently moved into Munne after living with her daughter. "I was getting feeble, and she wanted her freedom," Struzzieri says with a sigh. "Here I get all the attention I need." Miami developer Raul Munne, who built the place, is a Cuban immigrant. "Where I grew up," he jokes, "the elderly sat on the porch and fought with the neighborhood kids. It gave them incentive to get out of bed in the morning." But in the U.S., he says, "old folks are told, 'Don't open your door and go out at night. You might get mugged.' So, many of them have no one to talk to all day. They can only sit and watch television."

Later life lived this way doesn't come cheap. The Del Webb company, which made its name building luxury spas and retirement communities in the Sun Belt, last year opened a Sun City retirement community in Huntley, near frost-belted Chicago, an acknowledgment that seniors increasingly prefer to locate near longtime friends and family and not move to far-off sunny climes. Prices range from $130,000 for a single-level fourplex to $750,000 for customized estate homes that include home theaters, Jacuzzis and wine cellars, where an eminent Bordeaux can age along with its owners.

The typical assisted-living unit rents for about $2,000 a month, meals and basic services included. And prices can go much higher. Furthermore, assisted-living communities are not medical facilities, so their costs are not covered by Medicare or Medicaid, though 32 states do permit the limited use of Medicaid funds for assisted living. No wonder, then, that the average assisted-care resident has an income of $26,000 annually, while the typical retiree has $20,700.

The boomtown growth of the assisted-living industry has left it a bit rough around the edges. While nursing homes are federally regulated, assisted-living communities are overseen by the states and thus subject to widely varying standards. A federal study in four states (California, Florida, Ohio and Oregon) found "unclear or potentially misleading" language in sales brochures for about one-third of the 60 assisted-living homes surveyed. The most common problem was a failure to disclose the circumstances under which a resident can be expelled. One Florida home promised that seniors would not have to move if their health deteriorated, but the fine-print contract said physical or mental decline could be grounds for discharge.

Congress has begun poking into the problem, partly by way of its work to update the 1965 Older Americans Act, which provides penalties for scams on the elderly. "New services that meet the needs of our growing senior population are necessary and exciting," says Louisiana Senator John Breaux, ranking Democrat on the Senate Special Committee on Aging. "But the facilities are market driven and are susceptible to a bottom-line mentality that can lead to consumer fraud and abuse."

Of course, they are. Late-century American life is a social experiment in which we hope that market institutions can be fashioned to meet the most personal requirements. And sometimes they can be. New living arrangements for the elderly are still evolving. If that evolution isn't finished in time for all our parents to take advantage of, for many of us there will be a second chance--when it's our turn.

--Reported by Aixa M. Pascual/New York, Greg Aunapu/Miami, Leslie Everton Brice/Atlanta, Anne Moffett/Washington and Kermit Pattison/St. Paul

With reporting by Aixa M. Pascual/New York, Greg Aunapu/Miami, Leslie Everton Brice/Atlanta, Anne Moffett/Washington and Kermit Pattison/St. Paul