The Paradox of Aging in Place in Assisted Living, and: Reinventing Care: Assisted Living in New York City (review)

Concerns about population aging and increased longevity dominate many of our social policy debates. Ironically, despite all of the attention population aging receives, long-term care remains "largely off the political radar screen in any meaningful way" (Kane 2001). This is striking because, while older persons are healthier and have fewer disabilities than previous generations, there is a growing population of vulnerable older persons age eighty-five and over. Between 1970 and 2000, this population grew from 1.5 to 4.2 percent of the population over sixty-five. The number of persons age eighty-five and over is projected to triple by 2040 (Stone 1999). This so-called older-old population tends to be less healthy and more socially isolated and is more likely to have two or more chronic conditions, more likely to have at least one functional limitation, and more likely to have mobility and social activity limitations than persons between ages sixty-five and eighty-four. The growth of this vulnerable population demands closer attention to long-term care policies and services.

Currently, long-term care policy in the United States is biased in favor of nursing home care. Nursing homes, which are modeled on hospitals, place efficiency and routine ahead of individual preferences (Kane and Kane 2001). Residents of nursing homes typically express high levels of satisfaction in surveys, but older persons are filled with dread at the thought of moving into such a place. One survey found that 29 percent of older persons "would rather die than enter a nursing home" (ibid.: 114). As Jacquelyn Beth Frank explains, older persons "see nursing homes as a place they go to die, not to live; yet, the usual idea of home we tend to carry with us invokes life, contentment, and happiness" (24). Family members are often equally dismayed by the prospect of sending loved ones to a nursing home. Indeed, as Smith explains, the early pioneers of the assisted living movement were inspired to create an alternative for frail older persons because of their negative experiences with nursing homes.

Assisted living emerged in the 1980s as a response to the dominant model of long-term care. Assisted living aspires to create a homelike alternative to the institutional, medical model of the nursing home. Although assisted living arrangements remain largely out of reach for moderate and low-income older persons, the popularity of this alternative is reflected in the extraordinary growth of the private assisted living industry. The first assisted living sites did not appear until the early 1980s, but by the mid-1990s it had emerged as a $15 billion industry with 30,000 to 40,000 facilities in the United States.

The growing popularity of this model notwithstanding, there are few studies of assisted living, and our knowledge of how it works in practice is limited. Two new books, The Paradox of Aging in Place in Assisted Living by Jacquelyn Beth Frank and Reinventing Care: Assisted Living in New York City by David Barton Smith, seek to remedy this gap. Both books rely on qualitative, case study examinations of assisted living sites to explore the limitations and promise of assisted living. Frank emphasizes understanding assisted living from the perspective of residents and administrators. She contrasts the reality of assisted living with the ideal espoused by the advocates of this model. She also uses the concept of home developed in the anthropological literature as a normative standard against which to judge the success of this emerging industry. Smith contrasts the reality of assisted living in New York City with the ideal as well but spends more time placing the current debate about the role of assisted living into its historical context. Smith also places greater emphasis on the economic and...