About The Book
Watching my parents' age has been quite disheartening, their illnesses slowly eating away at their ability to do simple things that are taken for granted by all of us. I have worked most of my adult life with the elderly and the disabled, and was quite unprepared to deal with the emotional connotations of my parents' situation. This brought me to the subject of how to improve my parents' daily life, prolong it, and enrich it.

In the last 23 years I have worked in the health-related field. I have worked in hospitals specializing in chronic and long-term illnesses. I have worked in nursing homes, I have spent years doing research for the World Health Organization (WHO), headed a geriatric department, and chaired and been part of many geriatric-related planning committees. Coming from this professional background, I feel knowledgeable enough to speak on the subject of quality of life during the later years. For a long time, I considered putting that knowledge into a book.

In the last few years I headed an agency providing home care. This allowed me to see the quality of daily life in different situations: that of an elderly person residing in a nursing home or in another institutional setting, and that of one residing in his or her own home. In this book I examine society's relationship to and with the elderly, as well as the organized cultural relationship with the aging population today. Evaluating the impact of today's family structure on the aged and their lifestyle, and how different this is from the familiar structure in the past, makes it clear how difficult it is to get older in these times.

One cannot discuss the subject of the aged without examining the economic implications on their lives. The policy makers at the state and the federal levels, as well as the city government level, at times are totally detached from the reality of everyday life of the elderly. How do we interrelate and consolidate all those aspects to produce a better, longer, and more fulfilling life for our elders, and how do we prepare ourselves for our own needs at the later years of our lives? Those are just a few of the topics that I will be discussing in this book.

Being in my late fifties myself gives me the ability to examine first-hand two totally different patterns of family practices and behavior: the life that my parents' generation practiced, and the one that my generation is practicing. The fact that I was born into European culture also colors my experiences. Fifty years ago, one's mobility (in terms of residence) was limited due to economic, technical, and cultural restrictions. One was predestined to live close to their family and, in most cases, die not far from the place he or she was born. Familiarity was the name of the game, and one did not venture out of his or her comfort zone too often.

Grandparents were an integral part of the family, in many ways, the foundation on which the family was built. The elders had direct input in everyday life, the customs, traditions, values, and religious practices.

The aging members of the family never needed to worry about where they would live in their later years or who would take care of them, when they would not be able to take care of themselves.

If we look back, just say, 100 or 200 years, the parents, as well as the grandparents always stayed in the family house, and one or more siblings were responsible for the care and well-being of the elders. There were no nursing homes or other formal arrangements to care for the elderly. The elderly, who did not have relatives, or anyone to take responsibility for their well-being, were usually cared for by nuns or other religious or philanthropic organizations. One took care of his or her elders the same way one was sure that they would be taken care of by their children when they would reach old age.

After World War II, this changed significantly. Suddenly opportunities opened up to more than the rich. Suddenly the middle class and the lower middle class, and even the lower class, had in their grasp the possibility to move throughout the country for education and for economic opportunities. If, years ago, it was part of your daily ritual to sit down for dinner every evening with all the members of your family, suddenly, your child was at school 2000 miles and one time zone away from you. Holidays and their importance to traditional and cultural behavior slowly changed. Your child, exposed to professional opportunities in and around the area of his schooling, was more than likely not to return to his childhood neighborhood. Most family communication now is through electronic channels, such as telephones, computers, etc.

These days, children are establishing their families far away from their parents, whom they might see no more than once a year. One might say that the considerably inexpensive airfares make it possible to travel to one's family with ease. Nonetheless, with the demands that our everyday lives put upon us, there is less and less time to do so. In my work, I see more and more elderly people who are on their own, trying not to burden their children with their problems, coping as best as they can.

In all fairness, many children do try to be an active component in their parents' lives, with more frequent visits; they are involved in their parents' decisions-making regarding health issues, financial issues, and other issues. Members of the extended family - i.e., cousins, nephews, and/or friends - sometimes fill the void children filled in the old times. But it is quite clear that the elderly are more on their own than ever before. And loneliness has become a given in their lives. In this book I shall discuss the options that our society offers to the elderly who are living on their own.

When we study the elderly and what ails them carefully, we see that the things that affect them most are: loneliness, isolation, hopelessness, helplessness, and lack of social contact and engagement in social and physical activities, bringing on boredom, and illness.

Many psychological studies show that the long-term effects of loneliness and isolation have a great impact on the health of the elderly: bringing on illness, prolonging recuperation from illness, complicating illness, and shortening life span. Not too many people will argue with the notion that one should not live alone and that loneliness and isolation are definitely not good for one's happiness and well being.

So what are the alternatives? The best one, of course, is for one to live at the later years of his or her life with or near family to provide an active support system. But if this is not possible, what then? In this book you will find many different options and the pros and cons for each, to make it easier for you or your parent to evaluate the most suitable option for you.

There is the good old nursing home, but maybe it's not always so good. Let's look at this option more closely. I worked for many years in nursing homes, and I agree that at times it is the only viable option for the elderly. But by all means, try every other avenue available before choosing that one. In general, one can say that being institutionalized in a nursing home deters an individual from being just that, an individual. All decision-making is removed, and institutionalized routines totally take over every aspect of one's life. I will consider this option in depth later in this book.

In the last 20 years more and more retirement shared-living situations have become available to the elderly. Some of them are quite good. Most of them are built on beautiful grounds; some include luxury suites, tennis courts, golf, pools, and recreational programs. In some, one can find fancy dining arrangements, a nurse on the premises, a social worker, etc., and luxury amenities. The drawbacks of such a place are that it is geared to higher functioning individuals, and in most cases very independent individuals. Some places do not accommodate wheelchairs, or people with disabilities that require special provisions such as wide corridors, ramps, or elevators. There is sometimes internal pressure on the residents to be active and partake in all activities, far beyond what some can or want to do. And above all, these places tend to be highly priced and out of reach for most retired individuals.

Such shared-living situations also demand the individual to readjust to a new situation, new people, new routines, and a totally new environment. Although it is partially independent living, it is still very structured and regulated. If the person coming into such a situation is a shy individual, he or she is likely to be lonely and unengaged. You will find more on that option in the chapter dealing directly with shared-living facilities.

Shared households are also an option, although not in significant numbers. This option is appropriate for a highly functioning individual. It basically provides for two or more individuals sharing a residential household, for economic and social considerations.

This option is actually quite good. Expenses are cut in half or more. One is not alone, there is always someone there, and household chores are shared, making life much easier. Social interaction is built in. But it also has some drawbacks.

Shared living has to be established with much care so several important components fit, with the understanding that if any one component is missing or unstable, it may cause the entire arrangement to fail. In the chapter dealing with the different residential options, this is explained in detail.

As said previously, the best of all possibilities is to remain at home. In the period when a person is not totally dependent on a caregiver, the elderly person may only require help with shopping, trips to the doctor's office, and some household chores. There are agencies that are available to step in for specified needs, i.e., Meals on Wheels, Access-a-Ride, etc. The problem with this set-up is that there is no coordination between sources of services, and the care is fragmented. This fragmentation may affect the care and be harmful to the senior, if, for example, one doctor does not know what medication other doctors are prescribing to him or her. With fragmented care, the well-being of the elderly, both psychological and physical, may be neglected.

In this situation, to provide a safe and nurturing environment for the elderly, a back-up support system should be in place. There should be a family member, a neighbor, or a friend to look in on the senior to make sure the needed help is provided. That designated person should be the one coordinating the different service providers, and making sure that all medical treatments are known among all specialists.

As we age, our decision-making becomes affected to some degree. That degree varies from person to person, and is directly related to age, health status, medication, and environment. Thus there is an essential need to have someone to help make important decisions, when one is unable to do so independently. But one must be careful to whom one designates to this role. Later in this book I will expand on the subject of power of attorney and health proxy, as well as the different trusts that are available and relate to the needs of the aged. The helpful ways to protect one's self are presented in the chapter dealing with legal considerations.

At some stage, most of the elderly will require greater care, as their ability to remain totally independent decreases. One of the choices is home care, which may be introduced as needed. An aide can be brought in to help with Activities of Daily Living (ADLs), as needed, for a few hours a day, only a few days a week, for example. Hours may be increased as the needs increase, eventually covering day and night care. If this is done through a qualified agency, it will come with a wide range of support systems.

This book was written with the premise to help you navigate through the landscape of health systems and guide you through the maze of options that are available to you. The idea is to make it easier for you to evaluate the best choices for your situation. I hope this book will guide you, and help you on this journey. For your convenience, the material has been arranged in chapters that concentrate on specific topics relating to aging, needs, and services. Throughout the book you will find cases of real clients of mine and their experiences.

I will try to answer the questions that we all ask, whether we are middle-aged children of aging parents, or just a population of people that are facing our own aging and preparing for the future. If anyone asked us how we see our lives in the later years, we would all say we'd like to be healthy, independent, socially and physically active, and not be a burden on our families. Well, let's explore the possibilities of maximizing our quality of life using what is available in the society we live in, regardless of the level of our independence or health status.

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