In increasing number of interesting, challenging, and frustrating problems arising among a select number of affluent clients in this author's private practice has led her to suspect that this group of older persons is one which is victimized by great discrimination. There seems to be a tendency on the part of persons working with the elderly to think that all elderly people are economically deprived; therefore, those with few money worries are ignored. Also, there seems to be a belief that because money is readily at hand for this group, they have no worries or problems. Being old, according to this line of thinking is pleasurable. If this is so, why do we see in our office affluent clients (among whom are six multimillionaires) with enough problems to keep Norman Lear in production for a long time?
Not surprisingly, a literature search turned up scant recognition of the affluent elderly. Textbooks by leaders in the field give no information or at best onehalf page to the subject.1-3 Gerontological research seems mainly focused on the elderly poor with very little attention being given to the elderly affluent. Statistics are given in terms of lack of money, rather than in terms of acquisition of money. Havighurst4 is one of the few sociologists who has a glimmer of recognition for the potentials for the affluent elderly.
Electronic media in its news reports and documentaries tend to focus on the economically deprived. Human interest stories are mainly of poor old people needing the community's charity. If such stories are about the affluent elderly, the focus seems to be on some behavior considered deviant for older people. Possession of money itself by the elderly seems to be considered a deviant phenomenon.
Who are the affluent? Kirsten5 defines the affluent as those who are mainly free of economic worries, but makes the distinction between this group and the rich who have total economic freedom. Census information cites income in terms of middle- and low-income groups rather than in terms of the more affluent who are lumped into a group of "$15,000 income and above." Lundberg8 reports that in the United States in 1962 there were 200,000 households that were worth $500,000 or more. Unfortunately, the data were not presented by age groups. However, he does identify the names of those five men who, in 1957, were the wealthiest in the United States. These were: J. Paul Getty (age 65), H.L. Hunt (age 67), Arthur Vining Davis (age 90), Joseph P. Kennedy (age 69), and John Mecom (age 45). How interesting to note that these billionaires and millionaires were all elderly except one.
Are the affluent different? The answer to this question is of particular importance for nurses and other caregivers because, generally, they are not socialized to the life style of the affluent based upon their own lower and lower-middle income value systems. The affluent are, of course, different in some of their attitudes. Kirsten5 states that those with few economic worries can choose careers and life styles which afford considerable life satisfactions. Because of this economic freedom, their behavior patterns and general attitudes may vary from that of others. They may even be considered arrogant or imperious, especially by nursing personnel whom they may seem to order around. Some of this behavior is described in a delightful article by Breitung,9 one of the very few nursing journal articles to give any attention to the affluent elderly.
Lundberg8 also found that the affluent were just as vulnerable as any other group to consumer problems such as poor quality products and con games.
Our Mrs. G, an 83-year-old widow, is a good example of how one's health can be affected by trying to cope with fraud, deception, and crime. Upon the recommendation and urging of her apartment hotel's housekeeper, she hired a certain company to lay new carpet and make new draperies for her apartment. She found that she was grossly overcharged by the carpet layers and drapery makers, and that the work was not up to her expectations. At the same time this work was being done, a valuable porcelain figurine disappeared from a cabinet in her living room. She admitted to stomach pains as she wrote out the checks to the people who charged her triple for their poor work. She stated she was just too tired to fight for her rights and she also expressed fear of reprisal from the apartment housekeeper if she said anything.
Mr. T, age 73, became lost one evening when he had to detour to an unfamiliar road. A young man offered to drive him home for $20.00 plus cab fare. Two days later, this same man was back at Mr. T's home trying to extort money from Mr. T's wife, who, that very day was having problems of her own. She had just caught her housekeeper taking money out of her purse. Mrs. T's doctor wanted to put her on tranquilizers. She rejected this masking of her problem; consequently, she came to us for more realistic assistance in solving her problem.
Crimes against the elderly, as described, are not always so petty. White collar crimes of a very high order victimize the affluent elderly as well. Mrs. O, in an effort to protect her husband and herself, was reviewing the various trusts set up by her husband. When requested reports were not forthcoming from one bank, she investigated, and through sheer persistence she found evidence of collusion by the trust officer and Mr. O's son to handle the trusts in favor of the son and not Mr. and Mrs. O for whom the trusts were set. Legal aid was of no help because the lawyer reported the communication to the son. Even though she was the subject of much intimidation, Mrs. O moved the trusts to another bank. She was so emotionally drained by this experience that she came to us for supportive nursing care.
Another area in which the affluent elderly are different is in their attitude toward and use of the health care system. Poor health was cited by 1 1 percent of the Louis Harris study group as the second largest problem they had. l0 Lundberg8 was of the opinion that the "rich are especially enamored of medicine - and their faith in the powers of doctors at times passeth all understanding." Katchadourian and Churchill" found that the upper classes tend to be neurotic because they can afford to use a multiplicity of specialists; whereas, the lower classes tend to be psychotic which makes them eligible for state-supported mental health services. Even though her study was not really income-level oriented, Shanas12 wrote that retirement does not cause poor health, but poor health may cause retirement. Tallmer and Kutner13 state that morale related to life style and circumstances concerning health, income, widowhood, and retirement was often beyond the control of the individual no matter what his economic level. Voluntary disengagement tended to yield high morale, whereas stressful disengagement tended to be associated with hopelessness and despair.
Our own clients serve to illustrate the attitudes of the affluent elderly to the health care system and to disengagement. Mrs. G, because of the physical problems brought on by the stress of her multiple family problems, has frequently sought medical care for relief. One physician she visited always prescribed lab work and an EKG no matter how recently this was previously done or why she was seeking care. This doctor spent an average of three minutes with her to tell her there was nothing wrong with her. Her bill was always about $150.00. Once, when she tried to get the doctor to answer her questions, he simply told her she was an "old crock," which so upset her that she went home feeling very depressed, anxious, and rejected. Mrs. G, in her quest for well-being, goes from doctor to doctor around the world seeking relief. She is given pills in abundance, but little is done to help her cope with her real problems - a demanding family and her own arteriosclerotic condition. When she is in Dallas, we can help her cope, but as soon as the media identify some doctor somewhere presenting a new therapy, off she goes.
Mrs. G wants to disengage from some activities, but is called upon by her family to remain very much engaged through the many events of the social season. She becomes overly fatigued by all of these social obligations and wonders why she feels unwell. Our nursing care has been directed toward helping her to set priorities on her social calendar and to assist her to balance activity and rest.
Perhaps the biggest problem of all, which explains that the affluent elderly are different, lies in the determination of competency level in order to secure control of the older person's wealth. Stephenson,14 writing on estates and trusts, describes the mechanism for declaring a person incompetent and having a guardian appointed. There must first be a court proceeding with a jury (or commission in some states) verdict declaring the person incompetent and directing the court to appoint a guardian. The whole proceeding can be so complex, distasteful, embarrassing and drawn out, that the older person's property can be dissipated and misused as he tries unsuccessfully to manage for himself. The prime example of this was Howard Hughes who, fearing "a judge might question his mental competence, caused Hughes to go to any length, even risking his fortune, to avoid appearing in court."15
Physical and emotional ailments arising out of the mental competency level of the elderly are numerous in our practice. These situations are highly frustrating to our clients as well as to us. We have found that the legal profession has generally been unaware of gerontological theory and so are oriented to the same social values of "make way for the younger person" as those who are trying to deprive the affluent elderly of their dignity and property rights. We find that it is quite easy to have an older person declared incompetent. All one has to do is to overstress the individual and manipulate his environment so that he loses a grasp on reality. They then can take the poor soul to court where he will surely and certainly display his incompetence to the jury.
Two examples from our practice illustrate how older affluent people are often under considerable stress trying to continuously prove their competence or how they are manipulated into incompetence. Mrs. J, age 85, was declared incompetent because she was conned out of a large sum of money by her chauffeur and because she was having memory problems. The courtappointed guardian was supposed to keep her from having people take advantage of her, yet the guardians freely spend her money, ostensibly in her behalf. Mrs. J is given a weekly allowance, and if she needs any more money, she has to ask for it, something she had never done before and is demeaning to her now. Because of this, she began to hoard money around the apartment; her fear of not having money caused her to lose contact with reality. Our nursing efforts have been directed toward bringing Mrs. J back to reality and helping the guardians to give her more say in decision-making to keep her in contact with reality.
Mr. R, a 90-year-old multimillionaire, was having difficulty staying in contact with reality. A home visit uncovered no calendars or clocks in areas where Mr. R spent the greater part of his day. Newspapers were available, but his eyesight was too poor to enjoy them. No one, except the cook, took any real personal interest in him. No one felt Mr. R was capable of doing anything but existing. Yet, when this author persuaded his daughter-in-law to play checkers with him, he thoroughly enjoyed beating her. Mr. R tried unsuccessfully to engage people in the house in conversation, so he talked to himself, reminiscing about his past exploits which brought him so much wealth.
One of Mr. R's sons had Mr. R declared incompetent. Efforts were also made successfully to declare Mrs. R incompetent, too, eyen though she was not. The reasoning for this decision was that it was believed that no woman 85 years old was capable of handling wealth of millions of dollars. Her exclamations of outrageous indignation over this affront to her self-esteem were considered as further evidence of her inability to function in her own behalf. No matter that if this same indignant behavior had occurred in a younger person, it would not have been considered deviant at all.
The problem of maintaining and establishing competence when one is placed in a nursing home seems to be increasing in severity. Gaitz,16 at a film showing in Dallas, addressed this concern by stating that it was not too far-fetched to believe that old people going into nursing homes would have to name a guardian or advocate simply to protect their rights. Very often these rights are violated by well-meaning personnel who "report" all behavior of the older person to his/her children, especially if the older person should be widowed and is entertaining thoughts of marrying again, thus potentially depriving the children of their parent's money.
Kosberg17 studied whether or not economic class made a difference in the quality of care given residents of nursing homes. Results showed that the affluent could afford to purchase more of the comforts of life, so these could be provided. In one nursing home for the affluent, this author noted that the majority of residents all have personal maids who stay all day or who work an eight-hour shift. Yet, many of these elderly residents are disadvantaged in that everything is done for thembath, feeding, dressing, out of bed into a chair, etc. - but very little is done to stimulate them intellectually or to promote their socialization. Perhaps the attitude of these affluent elderly can be summed up by the remark of one resident who said, "I am 94 years old; I am not supposed to make decisions any more."
The following suggestions are offered to assist nurses and other caregivers to better recognize the affluent elderly's unique needs.
1. Money does not buy health and happiness. Wealth alone can bring as many problems to the affluent elderly as lack of money can bring to the impoverished elderly. The affluent elderly can be plagued by many of the same problems as any other socioeconomic group - crime, loneliness, family dysfunction, disengagement, etc. Therefore, nurses should be aware of these factors as. possible reasons for presenting behaviors and should assess accordingly.
2. Special attention must be given to the problems of the elderly as a result of their affluence. Every effort must be made to protect the older person's competency and privacy. An understanding of the legal rights of the elderly and the resources to protect these rights must be part of the nurse's store of knowledge. Personnel should not be quick to label a person incompetent because he does not make judgments in accordance with the staff's value system or if he simply makes a mistake. Give the older person the right to think differently from others and to make a few mistakes.
3. Recognition must be given to the fact that the family of the affluent elderly may be extremely harmful to their health. Family members may not have the best interests of their aged relatives at heart, so care must be taken to protect the individual's privacy and civil rights, especially before one runs and "tattles" to the family. Each gerontological professional must be very aware oí Family Codes and other pertinent laws affecting the elderly. Support staff must also be cautioned about unwittingly giving out privileged information. Strict protocols for the civil protection of the elderly must be developed in all facilities caring for the elderly and should be enforced, even in the face of intimidation by family and their lawyers.
4. Attention should be paid to the socialization needs of the affluent elderly. They must be helped to have. friends and assigned personnel who can speak with the same frame of reference as they do, have had experiences similar to theirs, and have similar values as they do. If nursing were truly individualized, those needs would be met.
5. Efforts must be made to correct society's erroneous thinking about the affluent elderly. Research in nursing and in the behavioral sciences must be conducted to obtain new data about the affluent elderly and to update the very little information available. Perhaps, in this way, society - and especially nursing - will view the affluent elderly as real people with many of the same problems as other socioeconomic groups, but colored with the unique factor of wealth.
The author wishes to express her thanks to Dr. Cora Martin, Codirector of the Center for Studies in Aging, North Texas State University, under whose direction this paper was written.
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