Cover of <em>Old Age in a New Age</em>

The following was posted in 2010.

Review of Old Age in a New Age: The Promise of Transformative Nursing Homes, by Beth Baker. Vanderbilt University Press, 2007, 236 pp.

Reviewed by Mary Meehan

Are you interested in radical transformation of nursing homes? How about letting residents set their own schedules for sleeping and eating? Inviting them to help plan the new décor for their surroundings? Offering them both a more homelike atmosphere and more involvement in the outside community? Giving more respect to nursing assistants and involving them in change efforts?

The transformed homes described in this book offer all of this. If you visit one, you are likely to see many houseplants inside and lovely gardens outside. The gardens may include one for vegetables, which residents help raise and then eat in their dining rooms. You may see a child-care center on the grounds and see seniors talking with the kids or playing with them. You will notice resident pets: perhaps a tabby cat, a dachshund or golden retriever, canaries and parakeets, a rabbit or parrot. The pets provide great companionship for many residents, even helping draw some out of depression or other ailments.

Many writers tell us what's wrong with the world, and many suggest how it might be set right. But rarely does anyone do both tasks as well as Beth Baker does in this splendid book.

A Maryland writer who has covered many aging issues, she has followed nursing homes closely for many years. Traditional homes, she says, "are often nondescript brick buildings with tidy grounds and no signs of life." She explains why this is so and why many homes overemphasize their medical mission and neglect so much that makes life worth living. A key culprit, she suggests, is "a U.S. culture that views old age as a disease to be prevented or conquered, rather than a life stage to be honored."

Over the past 20 years, though, many people have worked for radical change in nursing homes. Baker explains--with vivid examples--efforts to transform the homes through the Eden Alternative, the Green Houses, the Pioneer Network, and other change agents.

The folks involved have thought deeply about what they are doing, and many have wondrous creativity. Baker reports that a home in Bigfork, Minn., "has a wheelchair-accessible dock where residents can fish in the Bigfork River. It's a lovely spot, with wild rice growing on the banks and ducks coming in for a landing." A home in Bedford, N.H., has "a pine grove, with picnic tables scattered under the trees." When a Missouri home sent residents to a county fair, a 100-year-old woman rode a ferris wheel for the first time in her life. Residents from the same home have visited a pontoon boat for fishing, and a staff member said they "always want to do a fish fry afterwards."

Resident views her caged finches

Resident with her tiny finches (under card at far right)
Rolling Fields, Conneautville, Pa.

In these hard economic times, it is heartening to see Baker's comment that the transformed homes "prove that a high quality of life does not have to cost more." She notes that some "of the best homes in the nation serve primarily low-income people who are on Medicaid." How can this be? Well, traditional homes generally have high staff turnover, which is quite expensive. Successful transformation usually leads to much lower turnover and a major saving. It also tends to reduce falls, bedsores, the use of antipsychotic medicines--and the financial drain of all three. Transformed homes also attract more residents; with higher occupancy rates, they have higher incomes as well.

This isn't to say that radical change can be made easily or without fallout. Baker notes that staff turnover may actually increase at first because some staff dislike the upheaval of change or disagree with specific changes. Nurses, especially, may find it hard to adapt to new ways. As Baker says, the old system drives them to emphasize "enforcing regulations, holding to strict medication regimes, and running a tight ship."

Some nurses do not approve allowing residents to eat what they want, as they would if still in their own homes. Nurses do not want a diabetic, for example, to eat ice cream. A former nursing director said they find it difficult to accept that "we're not going to change habits of a lifetime." The administrator of another home noted that a dietician there told a 92-year-old resident, who wanted hot oatmeal every morning, that he needed more variety than that. But the administrator added, with great good sense, that possibly the resident had reached the age of 92 "because he had eaten oatmeal every day."

Staff who decide to stay through the transition tend to be happier in their work--thus the lower turnover. Nursing assistants receive more respect and often are assigned to help the same residents every day. This enables them to know the residents' needs better and to see them as persons rather than objects. Residents like this approach far more than impersonal care from an ever-changing cast of characters.

The architecture of traditional nursing homes is a great challenge for those who want to make a real home for residents. Staff often inherit long halls (hard for residents to negotiate without walkers or wheelchairs); large nursing stations (which encourage staff to talk to one another instead of spending time with residents); and huge dining rooms (which discourage conversation among residents). Such places look and feel much more like hospitals than genuine homes.

When change advocates can do so, they get rid of nursing stations, create small areas where residents can visit with one another, and break down institutional dining rooms into smaller and quieter rooms that encourage conversation. A home in Rochester, N.Y., had tried to feed 42 dementia patients in a large dining room; the administrator said the noise level and acting-out were "incredible." But after the room was broken down into three small dining areas: "Overnight, I kid you not, overnight it changed the whole environment on that unit." Everything improved.

Baker covers many other practical issues, including:

How to change from authoritarian management to genuine teamwork

How to improve relations between residents' family members and staff

How to go "beyond bingo" and provide more substance in activities

How to help the many residents who have Alzheimer's or other forms of dementia

Beth Baker has written an extremely valuable book--honest about the problems, hopeful and informative about solutions. If you are dissatisfied about conditions in your own nursing home, or that of a loved one, this book will show you how they can be changed. Media reporters and politicians, too, can learn much from Old Age in a New Age. Then, too, nearly everyone alive faces the possibility of needing care in old age. This book is for all of us.

Two elderly quilters

Quilters at work, Beacon Ridge, Indiana, Pa.