[2] There were other interesting projections—or estimates—made at the White House Conference as to the characteristics of the older population. These too are important for us in planning our programs of service. The number of persons over 75 will not double; it will triple. The persons in the “over-65” group will constitute more than ten percent of the total population, or even may be more than one in ten. The encouraging note—(if one is disinclined to think that living longer is in itself an unmixed blessing for this number of persons)—is that most of those between 65 and 75 years of age will have better health than their parents or grandparents enjoyed at the same chronological age. However, the most encouraging note is that which anticipates that what is called “social competence” is to remain high even at 65. Women will increasingly outnumber men at the upper age levels. The financial picture is not bright at present, for more than half of the elderly have incomes of less that $1,000 per year, and about half have assets of less than that amount.

[3] For those interested in the health needs of older people, these facts are relevant, for the Section on “Population Trends: Social and Economic Implications” also predicted that medical costs for this group will be approximately twice those for average members of the population. The present fact seems to be that persons over 65 now spend two and one-half times as much time in hospitals as persons under that age. There is no prediction as to whether this situation will continue to be as serious, as medical care for younger people in the population improves. Hopefully preventive measures, such as better use of available medical services, may be effective in reducing this high ratio of hospital use. For all members of the health professions, but especially for nurses these prophecies, based on currently known facts, have a very real meaning. More women, with a greater tolerance of morbidity than men, and more older women, widowed or single, will comprise a good part of the older population requiring service. Women’s income levels are, and will doubtless continue to be, lower than those of men, except for the famous “few rich widows” who control a high percentage of the country’s wealth. Also while women may not now use hospital facilities to the same extent as do men, they will nevertheless require some greater degree of service and probably for a longer time than the men of their families, simply because they are, or will be more of them.

[4] So far older people have not moved about the country in large numbers, despite the well-known movement of some older people to those states which make capital of their salubrious climates – Florida, Arizona and southern California. Now the Northwest is beginning to feel to some extent the effects of a fairly large number of older people settling in the states of Washington and Oregon. As one observes and attempts to analyze the movement it seems clear that the greatest amount of mobility is found in intra-state, rather than inter-state, changes. These seem to occur in shifts from a former farm or village resident to towns and cities not too remote from “home”. Also it seems reasonable to suggest that some of the movement may be stimulated by the lack of appropriate living accommodations for older people in the home communities of the present migrants. While there is slight evidence that efforts are now being made in some eastern and middle western communities to build desirable living units for these so-called “senior citizens”—private dwellings, or apartments, or homes for the aged or even retirement villages, it may be fair to conclude that if and when such accommodations are provided at rates which the low-middle and middle income groups can afford, there will be a more marked tendency to “stay at home.” on the part of those who are now trying out new places and new faces. It goes without saying, however, that once older people have pulled up their roots and have taken up residence in environments new and strange to them, their problems of adjustment to changing situations will be aggravated to a greater degree than they would be in surroundings familiar to them and in which they are known.

[5] In one sense, the dominant attitude toward older people is still the unfavorable one. It might be accurately stated that while nationally – and in some instances, locally – “the aging and the aged” are currently considered worthy of serious recognition and thought, and their needs sufficiently important to warrant community planning to meet them, there is still a noticeable lag in the development of a favorable attitude towards the individual old person. He – or she – generically speaking, is not yet really welcome in a family, in a group, in a house, in an agency, or in a hospital either because of his age or despite it. He is almost automatically endowed with all the unfavorable characteristics which tradition and habit have made almost universal, the minute “age” or “old age” is a factor in his situation. Yet, as one contemplates this circumstance which so often prevents genuine understanding either of the person or his needs, it is indeed paradoxical. No group in the entire population is comprised of so many rank individualists as is that group categorized as “the aging and the aged”. As we grow older we not only accumulate years, but we also acquire all the effects, good or bad, of all the events of a lifetime – each of us in his own “fashion.” So, in our work with older people, we are faced with a dilemma – the dual task of planning soundly for a large number of persons and simultaneously planning to so individualize relationships that they can help in resolving the personal problems of the man or woman for whom efforts are being made. This is not easy. For nurses this is nevertheless a cardinal principle on which nursing care must be firmly based, if elderly patients are to be served as they should be served.

Financial Trends
[6] It may seem far fetched to point out that one of the trends of the past quarter century that is definitely affecting not only who will have service, but where it will be given, and by whom, is that of the constant improvement in the social security programs—public assistance, social insurance for the retired for the disabled and for survivors of employed persons, and in the rapid growth of private pension programs. During this relatively short period of time, it has come about that practically no older person really must be without some money with which to meet his basic needs, either wholly or partially. That they are not met adequately for a great number of people is of course common knowledge, but there are funds available, and the formulae for determining their amount is in most places being upgraded. This ability to spend one’s own money for one’s own needs has brought about some very interesting changes. Even with the limitations imposed by public assistance through the requirement of relatives’ responsibility for support and often the requirement that families of several generations live under the same roof, the very obvious trend is for older people to continue to live independently of other members of the family so long as funds and health permit. Fortunately the institution is no longer the only alternative to living with one’s grown children or living at home with a slight handicap which can be supplemented by visiting services.

[7] This trend has a very real effect on current plans for housing older people. New construction for this new and rapidly growing market is going on at an almost frightening pace,—frightening because there seems to be so little time devoted to adequate planning either of accommodations or of selection of sites. It has become almost axiomatic that any accommodations which serve primarily older people should be so located that social and health services can reach them where they live, and where the older persons can reach them without undue strain on failing strength and faculties. Nevertheless the leadership that has been given by some public housing authorities—notably New York and Cleveland Ohio—there are new considerations of the requirements of the older population in both public and privately sponsored housing, whether commercially provided or under the sponsorship of non-profit groups.

Locale of Service to Older People
[8] What has this to do with health services in general, and nursing services in particular? It means that much of the required service will be given to individuals either in out-patient departments of hospitals, in doctors’ offices, or in their own or substitute homes on a visiting basis. Hence there is the movement to develop “organized home care programs,” administered by hospitals or visiting nurse services, or departments of public health, an expansion of visiting nurse services under both voluntary and public auspices, visiting housekeeper and homemaker services, “meals on wheels”, friendly visitors, and even visiting social workers. In my own parlance this is a “back-to-the-home” movement (long overdue) for professional personnel, from doctors to housekeepers and friends, for in the attempt to professionalize services everyone has become so “office” and “appointment” minded that it has been easy to forget the tremendous value personal knowledge of the actual home environment—physical, social and emotional—is in the understanding of any individual or family problem. Obviously this trend—with its shift in milieu of treatment and its involvement of a team of professional people—has been accelerated by the current plans for curtailing hospital stay to the barest minimum possible, even though today older people do remain in hospital on the average longer than do younger people. Yet it must also be remembered that even older people do not go to the hospital “to die” as once they did. A very high proportion of them improve sufficiently to return to their own or substitute homes where nursing care if indicated can be given.

Nursing Homes
[9] One of the facilities about which we hear the most—and much of what we hear is unfavorable—is the nursing home, today an essential facility in the gamut of medical care facilities in any community. This growing tendency to specialize and to limit the kinds of services given in any one institution, together with the shortage of places in which to care for the “long term patient” has brought the nursing home into being under proprietary or non-profit sponsorship under strong pressures from the community. One is apt to overlook the basic premise that the primary commodity a nursing home has to offer is “nursing care”. Yet in too many instances this is the care which is of the poorest quality. Hence it is important for anyone in the nursing profession to have personal knowledge of the nursing homes in her community—something of the quality of care given—and the physical and professional conditions under which it is given. Not all nursing homes are poor, but many of them are. Not all the nursing homes offer high grade care, but those which do ought not to suffer from the poor reputation of others in the community. It is a personal conviction of mine that if nurses who function in nursing homes will live up to the ethical practices and the high standards established by the profession, this alone will make a major contribution to the much needed improvement.

Homes for the Aged
[10] Homes for the aged, under both voluntary and public auspices, have for many years been regarded as hostelries for the so-called “well aged”. However the national trend indicates that owing this to the trend to independent living the average age at application for residence in such homes is rising to the neighborhood of 80 years. Further the average age at admission is above that mark. It is therefore logical to conclude that the average age of the resident population is bound to be somewhere in the middle eighties, if not higher. These facts alone provide the logic for pointing out that few “homes for the aged” are serving a resident group of well people, but rather one which is composed of infirm, feeble, and even chronically sick or chronically invalided persons. Therefore the growing need of these homes is for physical accommodations which will enable them to give care to their residents in accordance with modern medical and nursing practices, as well as for a staff equipped to undertake service to a group of this age and character. More and more homes for the aged are and will continue to in the market for professional nurses—registered and licensed practical nurses. This is another locale for nursing practice which is becoming increasingly important and demanding if standards of care are to [be] met. The major service of homes for the aged in the not too distant future may well be “nursing care”.

Trends in Nursing Care
[11] It is not so long since the appropriate care for an elderly patient was to keep him safely in bed, see that he was kept reasonably comfortable and clean, and help him face the unpleasant realities of a terminal illness. Today this is an outmoded an approach as the horse and buggy is as a mode of transportation in this astrojet and space age. The patient, no matter how young or old, is an individual, and if modern concepts are accepted, his age is not the factor that determines what can and will be done. Rehabilitative therapy has contributed much to this new look at patients, whatever their age. To it can be credited the tremendous change in the lives of many, many patients—not only as to their ability to remain alive, but their ability to “live so long as they are alive.” The potential of elderly patients for improving, for accomplishing what seems to be miraculous improvement when tested against result of past years—is a source constant amazement to doctors, nurses, to families, and even to patients themselves. But this again requires on the part of everyone, willingness and ability to see the patient as a person—not as a collection of years which have wrinkled his skin, made his hair turn gray or to disappear altogether, his eyesight poor, and his hearing even worse. It is the “will to live” which survives in most of us, and the strength of personality which with the help of the nurse (and the nurse is in my estimation the most important therapist in rehabilitative care—are the vital factors to call upon in treatment. And the strength of older people is too often unrecognized although it has been discovered to be of a quality to create very great surprise.

Mental Health or Illness
[12] It is my personal observation that when the subject of “mental health” is being discussed, it is usually mental illness rather than health which occupies the major attention of the discussants. But with older people a very hopeful trend is one which is teaching us that losing one’s wits is not an essential concomitant of old age. Also it is teaching us that often symptoms which indicate a person’s wits may be losing their acuity may actually be not signs of mental deterioration, but may well be physiological in origin. The new chemotherapy for some of the forms of mental illness that have been observed in older people has wrought some very encouraging changes in patients, but more meaningful ones in the attitudes of others toward these types of illness. It teaches us that the watchword given me by the late Dr. Ernst Boas — one of the ablest physicians the country has known in the treatment and understanding of chronic illness and chronically ill patients—is a good one to keep constantly in mind, whether in the treatment of physical, emotional or mental illness — “Never take anything for granted because of the age of the patient. “Whatever is the matter may be curable or capable of improvement.” So let us watch the trends in our hospitals and nursing homes caring for older people who exhibit varying degrees of abnormal behavior, which may be subject to very simple treatment—such as attention to physical and personal wants in a way that personalizes these. Let us remember that many of the older people who have found their way—or had it found for them—to mental hospitals are very often there for the lack of housing and the lack of relatives or friends to give them supervision, rather than for any real need of the kind of hospitalization these institutions offer.

Nursing Care
[13] Nursing care today seems to involve so much more than the immediate care of the sick person. Yet it is still my strong personal plea that nurses never once let themselves forget that the only reason for the existence of their profession is that people—real suffering people—are sick and many need their attentive and skilled care. Somehow the nurse has a relationship which can be so personal, even though professional—that much can be done to give an elderly patient that which he needs as much as “skilled care”— a desire to awaken in the morning after a night of sleep. This is not always possible for an older person. It is in helping the patient develop interests outside his own illness or handicap—things that can occupy his mind to the exclusion of self-interest which can be so absorbing—that a nurse can find the most vital part of her service. It is fortunate that one of the noticeable trends across the country is the realization that this attempt to rouse the patient “out of himself” is an essential part of nursing for all patients, but it is especially essential with older patients whose future, whether long or short in days and nights—may be deprived of those normal outlets for mental or physical activity which are thought to be desirable for most human beings.

[14] Since nurses are members of one of the professions in which one’s own age does not present a barrier to continuing to practice, there is great value in this for making them very sensitive to the needs of older people, and strong allies of families and friends in promoting better understanding of them. With maturity comes an understanding which can come in no other way, for as one delightful elderly lady once phrased it in her talk to a group of scientific gerontologists—“no one can forefeel old age!”

Community Activities
[15] Without reviewing in detail some of the community developments in the interest of older people, it may be well to note that one of the trends which is emerging very strongly is the concern of the organized church groups which is being expressed in training for pastoral counseling, for more religious guidance, and for responsibility for providing social outlets under church or religious auspices that go beyond the traditional ones of homes for the aged. It is to be hoped that nurses with their special training and understanding of older people will participate actively in the organization of these and other community sponsored activities. The understanding, acquired through direct personal experience and contact with those who need service and with those who respond so readily to the kind of help nurses are best equipped to give, will be a distinct asset in sound planning and development of those health services which will enable their elderly patients and friends to attain the three s’s thought to be essential to a contented old age—“Status, Security, and Serenity.”