Jack Aoyagi is doing what gerontologists call "aging in place."
For Aoyagi, that place is a little rambler in West Valley City, where his daughter once found him sitting in an empty bathtub with all his clothes on. During the day, Jack attends an adult day-care program, and when he's home, his children check up on him frequently, bringing frozen dinners, watering his lawn, making sure he gets a bath. He burned himself once, so they've disconnected his stove.
According to the Utah Division of Aging and Adult Services, most Utahns 80 and older live in their own homes, and by age 85 nearly half of them live alone. What the statistics don't tell us is how well these old people are doing.
The numbers don't differentiate between 83-year-old Lily Kunz, who manages just fine in her apartment who takes the bus to the grocery store, pulling the little cart she calls her "Cadillac convertible" and 85-year-old Aoyagi. Or the 84-year-old woman with Alzheimer's who needs someone to check in on her daily but who has no family nearby.
That's the one that haunts Heather Bittinger, a social worker with Millcreek Home Health and Hospice, who worked with the woman until Medicare stopped paying for physical therapy after hospitalization for an infection.
"The path I see for her is she'll probably get hurt in her home and require extensive hospitalization and then a nursing home," says Bittinger, who adds that she sees one or two old people a day "very marginally" making a go of it in their own homes.
The double-edged sword of aging in the 21st century is that there are more healthy seniors than ever before and also more frail ones living longer. In the early 1990s, Salt Lake County Aging Services' elderly clients mostly needed help with homemaking. Now, increasingly, they need help with bathing and dressing and other "activities of daily living" (ADLs).
Policymakers love the idea of the elderly aging in place at least in part because that means spending fewer taxpayer dollars on nursing home care. But keeping the elderly "independent" sometimes requires fancy footwork: family, friends, neighbors and volunteers willing to help out, or plenty of money to hire private caregivers for the kind of services that Medicare, nonprofits, governments and family don't provide to everyone who needs them. Bottom line: Sometimes it takes a village to help an old person live at home.
When part of her roof caved in, and a time when she fell and couldn't get back up, Margarete Hicken called Arthur Swindle for help. For rides to the doctor, the 102-year-old calls longtime friend Bonnie Evans. And when it's time to restock the pantry, she usually goes to the store with Maureen Madrian, who worked with her at Zions Bank almost 50 years ago.
This is the unofficial, often overlooked, sometimes under-appreciated part of the village. It's the kid next door who shovels an old man's sidewalk, the neighbor who makes sure an old woman has opened her drapes this morning, the woman who helps an elderly neighbor keep track of her bills.
Bonnie Evans' east-bench neighborhood is full of people who have moved together through life's stages, from child rearing to empty nesting and now old age. In gerontology-speak, the neighborhood is an NORC (naturally occurring retirement community). Of the 20 couples who once were part of a neighborhood dinner group, 15 of the women are now widowed. "We've known each other and borne each other's burdens," says Bonnie, who tries to be alert to needs for rides and friendship.
There are seniors, like Margarete, without families nearby, and seniors without any family at all. But even if family members are close by and diligent about helping a parent bringing dinner over, mowing the lawn, vacuuming every week notes Salt Lake geriatrician C. Edward Wyne, that parent probably spends 90 percent of each day alone, and maybe lonely. Sometimes what the village can do best is hunker down for a good conversation.
Sometimes the helpers get worn out, says Nancy Stallings, program director for Caregiver Support at Salt Lake County Aging Services. She occasionally fields calls from LDS Church bishops whose members have cheerfully volunteered countless hours offering rides, meals and other help to their elderly neighbors and have discovered that the needs are endless and sometimes hard to remedy. "There are five (LDS Church) stakes I know of that have gotten to the end of their ropes," Stallings says. "A bishop will call and say, 'There's a person out wandering around and we're worried he's going to fall and freeze to death."'
When Goldie Barron worked as a bank teller, she got to know the routines of her elderly customers. Some would come in regularly just to get change for a $5 bill or would deposit a pocketful of coins. "It's like middle-aged people who go to the bars," says Barron. "They would come into the bank just to talk to someone."
And then, one day, one of her regular customers came in looking sad, and after that she stopped coming in at all. So Barron and a friend called the woman's landlord, then went to her apartment. "There sat this little lady, in the dark, in the corner, dried-up food plates in the kitchen. She hadn't eaten in a long time. She was just going to sit there and die."
The experience was life-changing for Barron, who quit the bank and became a personal care aide. Fourteen years later, herself now 66, Barron spends her days with the people who are otherwise home alone. She does a little light house cleaning, makes meals, reminds her clients to take their medicines, does the crossword puzzle with them.
Families who pay for in-home services find that at $10 to $20 an hour (depending on the agency and whether the worker stays overnight), the money can add up fast, especially if the aide helps with "activities of daily living."
One local family hired a 24-hour personal care worker mainly to keep mom company. Left alone, she would misplace her mail, then blame it on bad guys who had sneaked into her house, a fear that sometimes sent her outside to wander the neighborhood. The $10,000-a-month round-the-clock care, though, was only doable because she had sold her house and moved into a smaller rental house, where she is now aging in place but not necessarily the place she prefers.
Families are often surprised to learn that Medicare provides only brief home health visits for a limited time, and usually not for help with ADLs. Long-term care insurance may cover home care, but it's estimated that only 5 percent of Americans own such policies.
Utah boasts that it has the very lowest percentage of its old people living in nursing homes. That's largely because of a culture of family helping family and, often, families that are large enough to spread the caregiving around. But while we say our old people belong at home, that's not where the state puts the bulk of its money. Utah spends its long-term-care Medicaid dollars for nursing home care, leaving only 4 percent for in-home services. States like Washington, Oregon and Vermont spend more than 50 percent for in-home services. In July, Utah froze its Medicaid funds for home-based care.
All programs that provide in-home services "have been historically underfunded," says Kelli Polcha, manager of Salt Lake County's state-funded Alternatives Program, which provides home health, homemaking and other help for frail seniors. The waiting list in Salt Lake County numbers 150.
Polcha and her colleagues field calls from adult children worried about parents who live alone. Sometimes the caller just wants advice on how to start the conversation with mom about needing assistance.
A whole aging-in-place industry has emerged to remodel or build houses that are senior friendly houses with wider doorways to accommodate wheelchairs and walkers; grab bars in strategic places; lowered countertops and sinks that can be raised up and down.
The National Association of Home Builders and AARP have teamed up to provide specialty certification for builders (known as CAPS, certified aging-in-place specialist). It's better to do these modifications before a fall leads to injury, advises AARP Utah state director Rob Ence.
Aging in place should reach into neighborhoods, says Ence, providing seniors easy access to shopping, clinics and social opportunities. Some communities are more senior-friendly than others think Sugar House compared to the suburbs of West Jordan with stores and medical services sometimes within walking distance. Salt Lake County offers rides to "essential" appointments, mostly doctor visits, but rides are not always available when you need them. And if you want to visit a friend in the hospital, you're on your own. County volunteers used to provide rides for social visits, but growing demand for critical services ended that, says Salt Lake County Aging Services planner Darrell Butler.
The elderly in rural Utah face huge challenges, especially transportation, says Vaughn Call, director of the gerontology program at Brigham Young University. Health care may be as far away as the Wasatch Front, and that can mean family or neighbors taking time off work to drive the old person, with perhaps an overnight hotel stay. "Get outside the I-15 corridor 50 miles in any direction, and you've got a major problem," Call says.
Technology has alleviated some of the transportation woes; the Internet is simplifying others. You may be able to sit in front of video conferencing equipment for a routine doctor visit, rather than traveling a few hundred miles. The Veterans Administration in particular is using telehealth for primary care and even tele-mental health, says Jill Atwood, spokeswoman. And Call says old people are embracing the Internet as a way to do many things, including some shopping and mail-order pharmacy.