Three Myths About Senior Living a Geriatrician Wants You to Drop

Over the last decade or so, the goal of “aging in place” has become a rallying cry for individuals, families, and institutions. Indeed, an AARP survey indicated that nearly four out of five older adults prefer to live out their elder years in a place of their choosing. Defining what we mean by “aging in place,” however, is far more difficult than it might seem. Navigating the variegated landscape of places where we could age is harder still. There are single-family homes and multi-family homes; there is “senior housing” and assisted living; and for some, there is consideration of long-term skilled nursing, memory care, or “continuing care retirement communities” (CCRCs) providing multiple levels of support. Once uncommon, senior housing cooperatives—constructed around the sharing of resources— are growing in popularity. “Aging in place” need not only mean remaining in the same home that we’ve inhabited for decades, alone or with a partner, until the twilight of life. It might instead mean transitioning to a small but beloved apartment close to one’s children, or joining a retirement or co-housing community.

There are many sources of confusion and consternation across our experiences of aging, but the question of where we age is perhaps chief among them. This is because where we age substantially affects how we age. The decision to age in a certain place reflects not only our preferences (over which we do have control), but also our specific needs (medical, social, and financial, over which we may not have control). And such decisions involve more than our own preferences and needs. We often also take into account those of our family members and of our friends, and may also consider community and natural resources in our decision-making. In other words, where and how to “age in place” may be one of the hardest choices we face across a lifetime.

As a geriatrician, I’ve accompanied thousands of patients and families as they struggle to find the best path for aging in place. The decisions they have faced are challenging enough, but nearly universally, such decisions are made all the more challenging by misinformation about what designations like “independent living,” “assisted living,” “memory care,” and “continuing care retirement communities” (among others) really mean. While it would take multiple book chapters to correct such misinformation comprehensively, below are three of the most important myths to dispel.

Myth #1: “Independent Living” is only for the independent

As we’ve noted in newsletters past, “independence” is actually a misnomer, no matter our age. We are, always and everywhere, interdependent, living in the space between ourselves and our loved ones, with mutual support. Our cultural (often default) preference for autonomy and safety can lead us to conclude that when we need more support, any place with the title “independent” is off-limits. So much, however, depends on one’s financial and social resources. Whether with family or paid in-home care, an older adult living with dementia may thrive better in an “independent” setting, such as their own home, than they would in a memory care community. Some housing cooperatives are designed so that members can support one another as they strive to live “independently” but with varying levels of need. Some older adults join CCRCs—expressly to be able to easily “move up” from independent to assisted living if needed—only to realize that they love their “independent” home and will do whatever it takes to remain there. For others, however, a memory or assisted care environment may represent the best balance of preference and needs.

Myth #2: “Assisted Living” will assist

It’s no secret: the ongoing explosion of assisted living facilities (ALFs) across the United States has led to a vast array of different options. To say “not all assisted living facilities are created equal” is an understatement. Minimally regulated (by states, not the federal government) and primarily for-profit, the myriad models for assisted living can bring boom or bust, and everything in-between. Given the title, many older adults and their families understandably approach assisted living as a place where they can receive assistance commensurate with their needs, however, it is essential to recognize that this may not be true. There are two important correctives to this myth. First, those who require levels of personal support on par with assisted living often have substantial medical needs, and assisted living facilities are neither designed to be, nor regulated to sustain themselves as, healthcare facilities. It can therefore be very difficult to access high-quality medical care in assisted communities. Secondly, the greatest cost for most ALFs is their labor. Whether for-profit or not-for-profit, and in a context where most states do not regulate staff-to-resident ratios, many (though not all) ALFs suffer from chronic understaffing relative to the need of their residents. When moving into an ALF, the assistance one expects to receive may be greater than the assistance that one actually receives, which often makes families wonder: why pay for these services? While this is not to say that assisted living is to be avoided, it is to say that it may not be right for all older adults who need certain levels of assistance. The same is true for memory care units, which are in most states organized in tandem with ALFs.

Myth #3: Perceived “level of support” is more important than the persons providing that support

If, proverbially, it takes a village to raise a child, then it certainly also takes a village to flourish through aging in place. But sometimes we can focus too much on the mechanics of support in a particular village, and too little on the people in our village who will surround us, day-by-day. A choice about whether to move into assisted living is often a case in point: we ask all kinds of good questions about level of care provided, about how the ALF organizes meals and other activities, and yet fail to ask about staffing levels, credentials, community involvement, and so on. As we’ve also noted in Alula newsletters past, the quality of social connection is central to thriving through the various stages of aging. The overall culture of our choice for aging in place—whether our longtime home, an ALF, a senior housing community, or a CCRC, is as critical (if not sometimes more critical) to our decision-making process as is any service or resource provided.