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Canadian Urbanism Uncovered

The Aging City

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The city is thousands of years old and, over this time, humans have learned many lessons—often through trial-and-error—around what makes a rich, meaningful built environment capable of sustaining ourselves over the course of our lives. Interestingly, the average life expectancy until the mid-nineteenth century remained under 40 years old, and over the course of the last century and a half we have seen this average virtually double around the world. As such, aging as we know it today, is a very new phenomenon. Although our knowledge of aging has increased considerably over the past decades with advances in medicine and public health, our understanding of what constitutes a ‘good’ built environment for an elderly population as the options for medicare assisted living facilities in Somerset County —psychologically, socially, as well as physiologically—is in its infancy. 

Simply put: old age is not the rarity that it once was and our society has yet to come to grips with what this means and how we ought to approach designing cities for a population with increasing numbers of individuals of advanced age. Including a few strong questions here would work well. Perhaps one from later in your original piece like: How can we design and build better urban environments that anticipate the needs that arise from the physical changes of age? How can we balance the autonomy of the individual with their needs as they age within the built environments we create for them? How can our communities foster engagement and offer support?

Stigmas around aging are ever-present in contemporary society—we tend not to acknowledge that we will age and that we will all eventually need help. Even though more than half of the typical lifespan of humans is spent aging (Thomas, 2004), understanding how the aging process unfolds and how people experience the later parts of their lives isn’t at the forefront of ongoing conversations (Check it out vitamin c serum amazon). As such, there is little societal impetus for discussing the adaptations to our built environments needed to accommodate this inevitability. Or worse still, if and how the design of cities can improve this process. Instead, contemporary society offers a view of old age that focuses on “disease, disability, dependence, decline, and ultimately death” (Thomas, 2004). To better understand aging and look beyond the stigma, it is important to understand those who make up what we consider to be an ‘older demographic’, and their psychological and physical needs.

In North America, we are experiencing the retirement of the baby boomer generation and the discussion of architecture for an aging population is more relevant than ever. Where, in the past, demographics would often be visually described as a triangle—with the largest segment at the bottom being those in the early stages of their lives and the narrow peak being those of advanced age—we are now observing more of a rectangular shape. (fig. available…a graphic would be great here)

There are far more equal numbers of individuals at every stage of their lives and we are therefore dealing with a much greater proportion of elderly persons (Gawande 2014). – the latter could be the caption of the image.

As we age, our bodies inevitably experience physiological changes and we begin to feel the limitations that this exerts on our quality of life (Unger et al., 1999). The built environment that, at one time in our lives, was suitable and enabled our ability to interact with others may, in turn, begin to have the opposite effect. As physical capabilities such as endurance, mobility, and balance become less certain, tasks such as climbing stairs are no longer effortless or sometimes even possible (Ball et al., 2004). Understanding the physical trajectory of aging is therefore a crucial part of understanding how we can better design for aging individuals. Health and well-being are more than just physiological, however, they include psychological, social, and cultural elements as well (George). And a built environment that truly accommodates aging—an Aging City—considers all these critical elements of human nature simultaneously. 

The elderly often face the reality of trading of their homes and the lives they have curated for ourselves over the years for an institutional impersonation of a community. The Aging City is empathetic towards the aging process: one too commonly seen as solely a series of losses. It requires us to look ahead and ask simple, fundamental questions of how our built environment can accommodate our inevitable selves as seniors. What will we need? Will we have created built environments that enable us? How can the built world—its distribution of spaces and activities—add meaning and richness to our lives?

With the large baby boomer cohort entering retirement and old age, now is time to take a critical look at the how our cities are providing for our aging citizens and start moving towards the creation of responsive, carefully considered built environments that foster holistic health: enabling us to lead lives worth living. The birth of the Aging City starts now (I’m not sure about this last sentence, but we need an impactful statement here.)

Let’s look more closely into what this means:

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PHYSIOLOGICAL:
Physiological changes are often what is thought of when considering the aging process. There are many theories that exist that each try to understand aging. Medical professionals have hypothesized many different reasons for the aging of the human body. Examples include the belief that aging is a gradual wearing down, while others believe there is a genetic limit written into our DNA (Gawande, Thomas). The reason, however, is not so important when considering physiological aging in regards to architecture and the city, only that indeed it is currently an inevitable process.

Understanding how the body ages provides a clearer picture of the abilities of the user group being designed for. It also gives an idea of how the body may change over time and how the built environment may be able to plan for these eventualities and continue to enable users for a longer period of time. Aging is a widely varied experience and each individual will exhibit elements of decline but at different rates and in different ways. Understanding the spectrum of change allows the architecture to remain flexible and provide a variety of appropriate solutions.

One of the greatest physical hazards that an aging individual is at risk of as a result of the declining physical body is the possibility of falls. This can be the result of weakened muscles, the reduced ability of the nervous system to send messages as quickly or as completely, and a decline of sensory systems – particularly the vestibular.

Falls can lead to disability, chronic pain, loss of independence, and a decrease in quality of life (Public Health Agency, 2005). Several provinces and territories have recognized the severity and magnitude of the issue and have labelled falls among seniors a serious public health issue (Public Health Agency, 2005).

Fall prevention is not only a medical issue to be managed by healthcare professionals. The built environments used by aging individuals can be an effective tool as part of preventing falls. Understanding the physiological issues behind falls can help designers to appropriately manage some of the causes of falls. This does not necessarily mean sanitizing environments and stripping them of all obstacles, only that architects must be aware of how their designs may be tricky for seniors to navigate. For example, rather than removing all such features, signaling them, or providing alternate paths and options around them can be a solution.

SOCIOLOGICAL:

The importance of providing environments where people can excel cannot be overstated. The previous section looked at the physiological changes that accompany the process of aging and ways to help support these changes so that seniors can continue to live well despite changes to mobility, sensory perception and motor control. But a physiological perspective is not enough, we must also consider the sociological. The multi-faceted nature of senior well-being is discussed by authors in the Handbook of Aging: “On an individual level, self-perceptions are related to individuals’ well-being, coping abilities, achievements and failures, relationships with others, health, and even mortality. On a social level, historical and cultural trends influence individuals’ self-concepts and collectively alter society.” (Giarrusso et al.) As designers we must create environments where people can succeed in order for them to feel positively about both physical and mental elements of their person in order to maintain good health. This well being then allows people to live better and more independently for longer therefore requiring less intensive care and support, and requiring less medicalized built environments. It’s a cyclical process that depends greatly on architecture.

We’ve come to realize that health is more than just a physical understanding of how a person is doing; their mental and emotional well-being is just as crucial. As Dr. Bill Thomas notes, “The upper limit of longevity may be defined by human genetics, but the experience of living into old age is defined almost exclusively by the customs and mores of one’s culture. An individual’s ability to live a long and bountiful life depends, most of all, on society’s aptitude for making such a life possible.” (Thomas) Looking at the needs of a senior beyond their physical needs and examining how architecture can help provide and support these needs is an integral piece of the puzzle.

In the examination of old age, much of the discussion of a senior’s health is focused on the physical. Needs have been considered entirely from a medical perspective. Dr. Atul Gawande explains:

“[f]or more than half a century now, we have treated the trials of sickness, aging, and mortality as medical concerns. It’s been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs. That experiment has failed. If safety and protection were all we seek in life, perhaps we could conclude differently. But because we seek a life of worth and purpose, and yet are routinely denied the conditions that might make it possible, there is no other way to see what modern society has done.” (Gawande)
Gawande also notes:

“[t]he problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of soul.”

Understanding the sociological needs and desires that make us unique and human allows us to see the senior as more than a patient, and in the case of architecture, it provides a way to make design decisions that focus on the senior as a user.
When the senior is considered a patient only, then the user instead becomes the medical and technical staff working in the institutions. The design question becomes about creating a place of work, not about creating a home for those who live there.

The sociological aspects of a seniors life and how they relate to the built environment are harder to quantify but no less important than the more straightforward physiological aspects previously discussed. Understanding a full spectrum of what keeps individuals healthy includes not only the physical, but the mental and emotional. In fact, many health professionals would argue that the sociological aspects are perhaps even more important than the physiological (Gawande, Thomas) due to their roll in decreasing stress and loneliness, and all round mitigating some of the physical ailments that would otherwise befall aging individuals.

GEOGRAPHICAL:

The examination of the physiological and the sociological has begun to give a picture of who the senior is as a user. The next stage is to examine the communities and built environments in which their lives unfold. Spatial relationships and how they respond to aging individuals determines the success with which seniors can interact with them and maintain quality of life.

Community and regional planner, Gerald Hodge, notes that Canada’s population is getting older but little focus has been put on the communities where seniors live. (Hodge) On the macro scale, understanding census-level trends can help paint a picture of where seniors live and provide a base of data to make decisions by. But it is the micro scale, understanding “the spatial patterns of seniors’ activities within their neighbourhoods and communities,”(Hodge) that gives tangible information from which to base a multitude of design decisions.

Based on recent statistics, it has been found that in Canada, “most seniors prefer to live in the largest metropolitan areas. Indeed, metropolitan areas housed 60 percent of all seniors in 2001.”(Hodge) This is likely due to the fact that larger urban centers are more likely to offer services and supports required by seniors such as specialized housing, health care, and transportation.(Hodge) Hodge notes that over the past several decades, the growth in the number of seniors living in Canadian metropolitan areas has been substantial, and in fact, “the senior population grew faster than the non-senior population in metropolitan areas.” This starts to give an idea of where aging individuals live but a more detailed look is important.

As individuals age, they continue the pursuit of activities that respond to their goals, needs, and aspirations that have spatial implications. The results of these activities and the patterns generated by them is the geography of everyday lives. For the aging individual, Hodge notes that this geography is dependent on a multitude of physiological and sociological factors of their life such as age, health, gender, background, experience, personal resources, marital status, etc. The geography of daily life is made up spatial environments, most of which are a direct result of the designer on a variety of scale levels.

Understanding the everyday activities of older individuals helps to discern spatial patterns associated with them which can be identified as life spaces. The activities chosen by seniors have specific physical environments associated with them and therefore, by observing which environments are occupied and associated with life spaces, a better understanding of the environmental press experienced by seniors can be developed.

BUILT ENVIRONMENT:

When considering the built environment for aging individuals, it is important to consider the full range of scales to ensure that use can be as seamless and enabling as possible. This means considering the planning principles in place, the landscape and urban environment, the architecture, and the details of the interior environment.

In his book, Livable Communities or Aging Populations, Scott Ball explores the urban environment and how it can empower older users. He notes that when considering an aging agenda in urban planning, it is important to examine larger physical, social, economic, and access issues and work down towards the scale of the community. He states that “[g]ood urbanism at the community level raises the quality of life for all residents, but for older adults it is more critical and may determine whether or not health and engaged lifes can be sustained in a community at all.”  Quality of life and an impression of holistic health can be understood to be highly dependent on environmental factors.

Architecture has already benefited from a large body of research on supportive environments for individuals with differing physical and cognitive abilities. As Diane Carstens notes, “[g]uidelines for indoor spaces are readily available, and the differences that these are making in the quality of life for elderly residents are evident in projects across the country.” Americans with Disabilities Act (ADA) guidelines and building code requirements ensure the safety and accommodation of individuals but are simply a baseline for good design for aging individuals.
Much of what makes one built environment superior to another when designing for the aging comes down to understanding the user group and the subtleties of their daily lives. It is for this reason that a comprehensive understanding of physiological, sociological, and geographical concerns is so important. Additionally, the nuance of the details and assemblies of a project go a long way in providing specialized environments for the aging that allow them to succeed.

HISTORY OF THE INSTITUTION:
-Source: Ball, 2012

Over the past century, the living environments for the elderly have changed dramatically. For those unable to continue working, support themselves, or live independently, the almshouse house was the solution. This dates back to the 17th CE and was still a model used in the early 20th CE. With the rise of modern medicine, however, there was a shift towards hospitals and early nursing homes to care for the elderly who were no longer independent. In these early institutions, the architecture was greatly shaped by the need of surveillance by the attendants caring for patients. Direct visual connection was required which led to “large, open multibed wards that were supervised from central nursing stations.” Eventually, however, greater levels of privacy were demanded which saw the introduction of smaller quad or double rooms and a change in the architecture again. Rather than open wards, institutions for the elderly now were organized into axial wings with double-loaded corridors and centralized nursing stations.
Over the years, “despite the fine care provided by many [nursing home entities], the nursing home became a symbol of institutionalized warehousing of old people.” The advent of social security along with the local locksmith in Scottsdale services brought regulation to the nursing home and with it concerns of safety and liability mitigation, and security were prioritized over dignity of the individuals living there. The regulations that were intended to prevent inhumane conditions often instead meant that the minimum standards enforced instead became the accepted standard resulting in undesirable living conditions, “further enhancing the public image of a nursing home as a fearful place to avoid at all cost.” This negative attitude still exists to some extent today and leads to a fearful image of what awaits us when we age and are no longer able to live independently.
In the past several decades, “[p]roviders have found that care environments that were more tailored to various types and degrees of needs could be more cost effective than the one-size-fits-all approach of the hospital-like nursing home.” These new care models offer more customized care and include assisted living, independent living, and supportive housing. Each of these models endeavours to “increase self-sufficiency through the provision of a limited range of nonmedical supportive services in a residential setting.” New regulations are acknowledging the inadequate results of the past and are accommodating more diverse housing and care options in an attempt to provide more appropriate and empathetic care for aging individuals.
With the “GI Generation” came a “sudden wave of relatively affluent, able-bodied retirees [that] led to the emergence of a new development facility type for seniors, the active adult community. These communities were the first fully urban approaches to provide specifically for aging across an entire community, and their early examples pioneered unique urban structures.” These communities were particularly concentrated in the Sun Belt of the United States due to warm weather and an active lifestyle offering leisure activities like golf and tennis that helped emphasize their difference from the institution. Real estate developers capitalized on the demand of active adult living and instances of these communities exploded, particularly in the southern United States.
The limitation of active adult communities, however, is that they typically become a stepping stone between the suburbs and the nursing home as the physical abilities of the individual decline. Rather than making multiple moves throughout old age to different facilities that each offered a different level of care, the idea of the continuum of care emerged. The facilities from  TrustedCare directory offer active adult housing as well as a variety of skilled nursing amenities on site so that more advanced care could be provided as required without requiring that the senior move to a different home or institution.
Another intermediate option between independent living and the institution emerged in the 1980s and came to be known as assisted living. Assisted living was conceived as “a way to provide a safer, more service-enriched environment than independent living, but less intensive than that of the nursing center.” The rooms or suites in assisted living were no longer patient rooms, but resident rooms instead. “Each had an adjoining toilet room with a shower and included a kitchenette to provide a semblance of the home the resident left behind.” This system was intended to be more private, offer greater levels of independence when possible, and be a more dignified care model than the nursing home. A specialized form of assisted living is also available to serve those who suffer from cognitive decline and is classified as memory support.
Parallel to assisted living is the Green House Replication Initiative which is based on the Eden Alternative conceived by Dr Bill Thomas. The model is based on the idea of neighbourhoods and houses where smaller houses with no more than ten residents are grouped into neighbourhoods (the large organizing facility) to facilitate more attentive care and a feeling of community. Ball writes that “[a]ll of these changes are intended to provide a more resident-centered form of care, wherein the residents’ needs and contributions are the center of attention and great care is made to place the pragmatics of staff and service delivery in the background.” This approach is key to making homes for people to live in rather than focusing on institutions for healthcare professionals to work in.
These more empathetic and community oriented schemes that place people at the forefront of care are now the dominate responses to living facilities for aging individuals.
Institutions in some form or another seem an inevitability as “the dependence on the assistance of others sharply escalates with age, since the health problems that limit functional autonomy also increase with age,” but the key to making them livable is to make them a home rather than an institution. A common roadblock to this goal, however, comes in the form of family who assists in the process of finding suitable living arrangements for seniors requiring assistance. It’s been found that “[w]e want autonomy for ourselves and safety for those we love” which creates a paradox when selecting a home for the senior. Further, “[m]any of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.” Gawande quotes Keren Wilson Brown, the creator of the first assisted living facility, who puts some of the blame on the elderly for this, however. She says “[o]lder people are in part responsible for this because they disperse the decision making to their children. Part of it is an assumption about age and frailty, and it’s also a bonding thing that goes on from older people to children.” As parents age, there’s often an unspoken understanding that the adult children become the decision makers and when this happens, safety of the parents in the new home is the priority. Due to this, institutions cater to that desire, and “[t]he elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care for.” Frankly, there is more to be expected from life than safety.
We saw this previously with the discussion of the three plagues of the nursing home. Medical and physical needs, as well as safety were carefully attended to at Chase Memorial, but the sociological was ignored entirely. As Thomas writes,
“[t]he plagues were relentless, remorseless, and too often fatal. Despite this, the organization devoted very few of its resources to alleviating them. Such passivity was hard for me to comprehend, given how committed the facility was to quality care and how seriously these afflictions were harming the people who lived there. … The true culprit was the system of long-term care itself.”
This led to the staff questioning whether Chase Memorial was an institution, or a home. In his examination of Chase Memorial, Gawande writes that “habits and expectations had made institutional routines and safety greater priorities than living a good life and had prevented the nursing home from successfully bringing in even a dog to live with the residents. He wanted to bring in enough animals, plants, and children to make them a regular part of every nursing home resident’s life.” Thomas sought to continue the legacy of safety and exceptional physical care while also making Chase Memorial into a home.
The really great thing is, we seem to have learned from the past. As Ball notes, “seniors housing development has made great strides in moving from hospital-like configurations to more familiar neighborhood forms.” We are allowing ourselves more imagination for what the built environment can look like when accommodating seniors. We are recognizing that living arrangements should  be home-like and provide more than safety. These environments should nurture individuals holistically and approach more than the physiological concerns of aging. There is still work to be done, but it is certainly moving in the right direction.

RESEARCH CONCLUSION:

Design consideration for aging individuals is a crucial element in creating hollistic communities that enable users. With general population aging and the baby boomer cohort entering retirement, the time is ripe for these explorations. This involves taking a comprehensive look at the aging user and all of the facets of their lives that affect design.
The physiological is perhaps the easiest to translate to the built environment as it is quantifiable and scientific in nature. The difficulty, however is in recognizing that physical decline symptoms manifest distinctly in each user and at different paces.The aging population is incredibly varied and no one solution will suit every user.
Like the physiological, sociological aspects of this user group are also highly varied. Each individual has a lifetime of experiences, memories, culture, and values that makes them who they are. Recognizing the individual and not the group is key here. Translating this to design means accounting for diverse interests and needs. To do this, design for the aging must foster autonomy and agency as much as possible while still recognizing the need for assistance as the inevitable symptoms of decline appear.
Another puzzle piece in designing for the aging is examining the communities and architecture where lives unfold. The decisions designers make have direct impact on the daily lives of users and the extent to which they enable or disable has immense impact on the aging user. All scales of the built environment are important to consider. The urban network, the formation of neighbourhoods, and the landscape design all facilitate autonomy outside of the home and can greatly extend the period of independence when well considered. The architecture, interior design, and detailing of a building has daily impact on the aging user and can facilitate competence and confidence. All scales must work together to create an enabling environment. Any gaps between scales can cause a collapse and have direct negative impacts on the capabilities of the user.
The built environments servicing older individuals have undergone drastic improvements over the past century, particularly in the field of housing. Those in charge of managing and designing these spaces have learned from the past and modified solutions in response to the changing needs and ideas surrounding aging. We now see a trend towards maintaining the idea of the community and home regardless of the level of assistance required by users in a facility.
There is a much more empathetic approach being employed when considering the aging individual. We can see this in the research being conducted, the facilities being designed, and even in the new suggestions of language to use.
Each piece of the research represents a different way to consider the aging user and forms the base for site investigation, and design exploration and intervention.

OTHER THOUGHTS:

The evolution of built environments used by older individuals is improving over time as the research here has shown. There is a substantial body of architectectural projects that cater to the transitions and phases of later life and the new expectations of those individuals making up this cohort. Many of the precedents, however, are focused on small-scale interventions intended to improve the lives of a handful of older individuals directly interacting with the project. This can be seen in both new and retrofitted individual residences or group living situations. What is missing though is the larger scale urban interventions and built elements that connect already existing projects. The discussion of what makes a city great for older individuals is still in its early stages. To create more complete communities and livable built environments for older users, a coordination of multiple scales of design intervention with the body of research undertaken for this project is essential. This requires understanding how the aging process unfolds, and then applying this knowledge beyond residential environments.

Design consideration for older users is a crucial element in creating holistic communities that enable our aging population. It is essential to acknowledge the realities of aging and start being more proactive in the approach we take to designing for this demographic.
We have all known older individuals who have struggled to navigate environments that didn’t account for their needs. And, at some point, we each come to recognize that we too will someday be in this position. We will be the unconsidered user managing with makeshift solutions unless we take a critical look at the built environments that architecture is providing for aging individuals.

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Some related sites:

https://ourworldindata.org/life-expectancy

https://www.archdaily.com/900713/how-to-design-for-senior-citizens/

 

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