[Paleopsych] NYT: Under One Roof, Aging Together Yet Alone

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The New York Times > National > Under One Roof, Aging Together Yet Alone
http://www.nytimes.com/2005/01/30/national/30assisted.html
January 30, 2005

    By JANE GROSS

    STRATFORD, Conn., Jan. 28 - Everyone complains about the food. Nobody
    wants to sit with the misfits. There are leaders and followers, social
    butterflies and loners, goody-goodies and troublemakers. Friendships
    are intense and so are rivalries. Everybody knows everybody else's
    business.

    Except for the traffic jam of wheelchairs and walkers, the dining room
    at the Atria assisted living community here might as well be a high
    school cafeteria.

    Mary Mercandante, 88, has an explanation for the restive, gossipy
    environment when old people are forced to live under one roof, even in
    a top-notch place like this. "Nobody wants to be here," said Mrs.
    Mercandante, who has lived in the residence for all of its five years
    and has a gold key to prove it.

    Phil Granger, a chipper 84-year-old newcomer, agrees that no one
    welcomes assisted living's stark reminder of mortality. "There's
    everything anybody could want here," said Mr. Granger, who spreads
    good cheer by dispensing hard candy, except to diabetics and those
    with dementia, who might choke. "The only thing wrong with this place
    is that we're all old. We remember what we used to do and can't do
    anymore."

    When introduced in the mid-1980's in the United States, assisted
    living was hailed as a dignified alternative to nursing homes. Its
    chief attraction was a well-appointed private apartment rather than a
    fluorescent-lighted double room along a linoleum corridor. The monthly
    costs, which average $2,524 nationwide and thousands of dollars more
    here in Connecticut's wealthiest county, include a common dining room,
    transportation, housekeeping, activities meant to relieve isolation,
    and à la carte services for changing personal care and medical needs.

    In the last decade the number of elderly Americans in assisted living
    has tripled, to nearly one million, and industry experts say the
    residents, overwhelmingly widowed women with an average age of 85,
    have steadily grown older and frailer. A study by the National Center
    for Assisted Living, an industry group, shows that half the residents
    have some degree of cognitive impairment, three-quarters need help
    bathing, 8 in 10 cannot administer their own medication and more than
    90 percent can no longer cook or do housework.

    Residents who leave assisted living usually do so not because they die
    but because they run out of money, and go to nursing homes. There the
    impoverished, including middle-class men and women who have outlived
    their savings, are covered by Medicaid as they are not (except for a
    small percentage) in assisted living.

    The federal government has already made recommendations to improve
    quality control and correct misleading advertising in assisted living
    facilities. But only a few sociologists and public health researchers
    have studied the social organization and daily preoccupations of these
    communities. Dr. Catherine Hawes, a professor of health policy at
    Texas A&M University, is one. She describes them as "high school all
    over again, without the expectations."

    Keren Brown Wilson, who ran some of the nation's first assisted living
    homes, in Oregon, said that "naïve notions about the socialization of
    older adults" leave many residents wondering why they are not having
    as much fun as the happy people pictured in retirement brochures. The
    Atria brochure, by example, features photographs of people who look to
    be 60 to 70.

    "We pretend everything is wonderful," Dr. Brown Wilson said, "which is
    an unrealistic expectation at this stage in life."

    This stage in life, experts agree, is bleaker than most Americans
    admit. Humbled by the loss of control and fearful of the future, many
    older people complain incessantly, most often about the food. Also, in
    a cruel sorting process, they ostracize others more impaired than
    themselves. The hierarchy by disability "is really fear," said David
    Vail, executive director of Atria Stratford and president of the
    Connecticut Assisted Living Association, an industry group. "They
    don't want to look at what they might become." Both the crankiness and
    the cliques are on view in the dining room of the Atria Stratford,
    home to 120 residents, many of whom good-humoredly call themselves
    "inmates." But also on view are acts of exceptional kindness, budding
    friendships and sparks of romance between flirtatious women who dress
    for dinner and chivalrous men who hold their chairs.

    King of Crankiness

    The king of crankiness, by his own account, is Bill Haug, 87, who
    finds fault with just about everything. The chicken is dry and the
    soup lukewarm. The fitted sheet does not quite cover his bed. What the
    menu bills as cranberry juice is actually cranberry cocktail. His
    hotheaded letters to management are legendary. So are his tirades at
    meetings of the residents' council.

    Mr. Haug writes the letters on the same electric typewriter he uses
    for love poems, sent back to him unread by a woman he dated after his
    wife died. Bluster turns to tears in the privacy of his apartment,
    where only the typewriter and crossword puzzle books are his own. The
    shabby furnishings were borrowed from Atria's storeroom. Within
    months, Mr. Haug says, his nest egg will be gone, despite selling his
    house, car and possessions. Then he will have to go into a nursing
    home.

    To Mr. Haug's right at the dinner table is Mary Thompson, 85,
    statuesque, dressed to the nines and reluctantly resettled here by an
    adult daughter. Mrs. Thompson sometimes gets confused, insisting she
    is in a hotel while her home is remodeled. At meals, she bangs a spoon
    on her glass or hollers to get the waitress's attention.

    Mr. Haug pays her no mind. But it took lots of shuffled seating
    assignments to achieve this peculiar if peaceable arrangement. Most
    residents have no patience for either of them. Behind his back Mr.
    Haug is often called a windbag. Mrs. Thompson's behavior provokes
    cries of "Shut up!" from nearby tables, where fear of the future
    trumps empathy. Everywhere but the dining room, Mrs. Thompson is never
    more than inches away from Christine Schwinbold, 88, who is a full
    foot shorter and cheerfully forgetful. The pair, who even accompany
    each other to the ladies' room, are known as the Bobbsey Twins and are
    generally given a wide berth.

    Plans to Call a Cab

    Mrs. Schwinbold declares that her former home in Wisconsin is just
    down the block. Other residents were so tired of hearing about Beaver
    Lake that they showed her a map. It made no difference.

    Gwendolyn Lord, director of food services, separated the two women at
    meals because "they feed off each other's impairment," with one or the
    other hatching plans to call a cab and go home. This way, Ms. Lord
    said, Mrs. Thompson, a great beauty in her time, holds court with Mr.
    Haug and two other grumpy old men. And Mrs. Schwinbold is the perfect
    dinner companion for others who are similarly impaired but less perky
    about it.

    Ms. Lord's latest seating dilemma is which woman to put in the "ghost
    seat" occupied by Ann Cerino until her sudden death on Dec. 26.
    Leaving a chair empty after a funeral is a mistake, Ms. Lord said. So
    is an all-male table, a waste of scarce resources. "Men have a duty to
    flirt with the ladies because the desire to be admired doesn't go away
    with age," Ms. Lord said. "Plus, assuming responsibility for their
    female tablemates enhances their masculinity."

    Mrs. Cerino's wake and funeral drew a big crowd of residents,
    including Mr. Granger, in a new topcoat, who drove there in his
    souped-up 2001 Impala, mostly used to visit his own wife's grave.

    Mrs. Cerino was the queen bee here, holding court all day in the snack
    bar, known as the country kitchen. She also ran the all-important food
    committee - assisted living's equivalent to being president of the
    student government - which debates the merits of chunky versus smooth
    spaghetti sauce and whether the fish should be fried or broiled.
    Meanwhile her 90-year-old husband, Tony, a shy man, watched television
    in their apartment upstairs.

    Mr. Cerino was dazed in the weeks following the death of his wife of
    67 years, so Pete Piretti, 83, kept an eye on him. Mr. Piretti lives
    alone in a studio, while his wife, Millie, who has had Alzheimer's
    disease for 18 years, is upstairs in the dementia unit. Mr. Piretti
    had some homemade tomato sauce, Mrs. Cerino's recipe for polenta with
    beans and a jug of Chianti. The two men had a jolly evening in
    Apartment 306, neither directly mentioning the other's heartache.

    "He can cook better than I can because I didn't have to," Mr. Cerino
    said, obliquely referring to the many years Mr. Piretti cared for his
    wife and assumed all the housekeeping duties.

    The Pirettis, high school sweethearts, arrived at Atria Stratford on
    March 17, 2002, when Mr. Piretti said he was close to "the breaking
    point" and afraid he would strike out at his wife. He is not alone in
    knowing the precise month, date and year, a grim milestone that stays
    fixed in memory.

    For Mr. Granger it was Oct. 4, 2004, shortly after his wife died and
    he realized he "couldn't hack it" at home alone. Arline Brady, 87 and
    nearly blind, came a month earlier. She had taken a bad fall in her
    Florida condominium and, she said, her five children "told me I
    couldn't live alone anymore." Similarly, Helen Simics, 78, moved here
    at the insistence of her brother and sister-in-law, on June 21, 2000,
    after she broke a hip.

    Leaving an assisted living community, on average after two and a half
    years, is rarely voluntary. Three residents died at Atria Stratford in
    December. Others, when their assets are gone, will go to nursing
    homes, which charge 40 percent more on average but accept government
    reimbursement. The best known in these parts is Lord Chamberlain. The
    euphemism for winding up there is "being sent across the street."

    Most states in the last few years have begun small, experimental
    programs that permit Medicaid to pay a portion of the cost of assisted
    living: the personal care and medical services that are tacked on to
    the monthly charge, but not the rent itself. Nationwide, according to
    a 2002 study by the National Academy for State Health Policy, 102,000
    assisted living residents, or 11 percent of the total, received this
    benefit, double the number in 2000. But rarely is it enough to allow
    people to stay in an apartment for more than a few extra months.

    That is because of the traditional fee structure in assisted living.
    At Atria Stratford, for example, a studio costs $3,400 with no special
    services. Medication management adds $400 a month. Help bathing,
    dressing or eating can cost an additional $1,400 a month, for a total
    of $5,200. Of that amount $1,800 would be covered by Medicaid if Atria
    participated in Connecticut's tiny waiver program. It does not.

    Statewide, Mr. Vail said, there are 9,800 assisted living units and
    only 75 Medicaid waiver slots. So he advises families to calculate
    when their money will run out and move before that point, since
    nursing homes, if they have a high enough percentage of Medicaid
    patients, can push those with assets to the top of the waiting list.

    Mr. Piretti, a former gas station owner, currently pays $3,400 a month
    for his apartment and an additional $5,500 a month for his wife's care
    and accommodations, a stunning sum to him. "When we run out," he said,
    "she'll go on Title 19," as Medicaid is known in Connecticut, "and
    I'll go live with my daughter."

    It is a workable plan. Especially if Mr. Piretti remains as fit and
    independent as he is now, able to drive to stores that sell supplies
    for the log houses he builds from kits and the decoupage watering cans
    he decorates with magazine photos. He is among just 20 residents,
    mostly men, who need no assistance but meals and housekeeping, Mr.
    Vail said.

    The discrepancy seems to be a result of men moving here earlier than
    women, who want to stay home as long as possible, often until their
    adult children intervene. Men, by contrast, seem to willingly relocate
    when their wives have died or deteriorated to the point they cannot
    run a household anymore. Here they will be taken care of by a largely
    female staff and have the companionship of the female residents, who
    outnumber them 4 to 1.

    "I couldn't stay home alone," Mr. Granger said. "My wife was my life.
    I just didn't know that until she died."

    Big Men on Campus

    Now Mr. Granger is one of the big men on campus. He favors a tweed
    cap, has all his faculties and still drives, even after dark. But
    grief for his wife is fresh and his outings take him no farther than
    Riverside Cemetery, 4.1 miles away by his reckoning. The other
    candidate for romance is Pat Jordan, 94, whose wife died here last
    year. Mr. Jordan is a charmer. His arrival in the country kitchen or
    the arts and crafts room brings a blush to the faces of at least two
    women. One is Mrs. Brady, a well-to-do widow whom Mr. Jordan describes
    as "one classy gal." The other is Doris Mauri, 85, who never married
    and worked with computers. Mr. Jordan says Miss Mauri is "a quiet
    girl, a decent girl and my very best friend here."

    "I'm very fond of her," he added. "But I have no love interest in
    anyone. I don't think my Florence would like it."

    But Colleen Douglas, the activity director, has not given up hope. She
    is not the typical aerobics-instructor-type who is often hired to lure
    the old folks to the 9:30 a.m. seated exercise class. Residents love
    her faux leopard skin coat, red furry boots and year-round tan, as
    well as her sharp wit. Activity directors, more typically, are cloying
    or patronizing.

    The daily activities schedule here nevertheless has a cookie
    cutter-feel. On Dec. 28, for instance, the lobby signboard, headlined
    "Today's Opportunities to Engage Life," lists exercise, penny poker,
    word games, afternoon snacks and socializing, bingo, and a Gene
    Hackman movie, "The Heist." But outside the formal schedule, Ms.
    Douglas injects a bit of pizzazz.

    One recent day she baked apple pies, using a resident's recipe. She
    never pushes organized gaiety on loners, like Miss Simics, who prefers
    reading The Connecticut Post in the lounge each morning and then
    spending the rest of the day puttering in her apartment. Ms. Douglas
    gets a kick out of seeing Mr. Jordan return from the store with a
    six-pack of beer. And she does not tattle on a resident with no
    serious disabilities who has a forbidden hot plate.

    Mr. Jordan is her best shot at every activity director's dream: a
    wedding. "Nobody wants a romance in this building more than I do," Ms.
    Douglas said. "So if I'm moving in a woman who still has her mind and
    walks, I go to Mr. Jordan. So far he's still mourning his wife. But
    I'll keep trying."