Recently, an administrator of a long-term care facility with a newly built "Special Care Unit" remarked that it was important to ensure that the unit maintain a quality of "gracious living." This comment was striking in its difference from the staff's view that the unit be optimally therapeutic. Upon further reflection the remark also seemed a good window into a broader exploration of the muddled and sometimes competing views of what constitutes optimal care for people with Alzheimer's disease and other irreversible dementias. Ultimately, the examination of our assumptions about quality of care and quality of life is important because these views will form the basis of our policy and treatment methods for a large segment of older adults.
The administrator's remark clearly underscores the fact that managers of long-term care facilities, while certainly interested in quality of care, must also be mindful of creating a unit that is a good marketing tool - not only to keep the beds on the special care unit full, but also to enhance the reputation of the entire facility and, thus, keep the beds in the entire facility occupied. Meanwhile, staff working with demented older adults might well be designing therapeutic activities that are in conflict with maintaining the presentation of "gracious living." Mounted busy boxes, gardening projects in styrofoam cups, displays of unsophisticated artwork, prominent visual cues to the location of toilets, and freestyle floor exercises may be interpreted by some as demeaning and devoid of the dignity older adults deserve.
The literature on humans' propensity to develop an attachment to place (Rowles, 1993) and some empirical support for the adaptive aspect of aging in place (Boschetti, 1990; Rowles, 1983; Rubenstein, 1989, 1990} provides an additional perspective. When demented older adults require a move to a more supportive environment such as a special care unit, current thinking is that physical, social and activity therapies should work to create an affinity for the place and a sense that the new unit is home. Residents are encouraged to bring in furniture, knickknacks, and pictures from their previous residence supposedly to transfer some of the significance of home to the new unit.
The three views of providing gracious living, an optimally therapeutic environment, and homelike atmosphere, all are reasonable and aspire to provide quality of life for the person with an irreversible dementia. Clearly, there is room to accomplish several agendas on a special care unit by complementing the need for certain stylish aspects of the unit with the need for certain therapies. Perhaps a gracious living room can be maintained and a therapy room can contain many of the sights and sounds not commonly seen in homes. Artwork can be framed to acknowledge the artist's efforts while blending the work into a more sophisticated ambience. The gracious living focus of some special care units provides an environment that is sophisticated and meets our societal views of successful aging. Active therapy programs engage the resident, enhance selfesteem, and optimize functioning. A homelike atmosphere may assist in creating a physical attachment to place and this may be adaptive.
But underpinning all of these issues seems to be a central question: What are the essential qualities of human dignity, dignified living, and quality of life for demented older adults? Rather than being divisive, the differing agendas and perceptions of those involved in providing quality long-term care for the demented, are a useful springboard for continuing to explore and think about the essential qualities of human dignity. There is a need to examine how these qualities of human dignity might change and evolve when a person suffers from an irreversible dementia, and how we as a culture, can limit human experience by narrowly defining human dignity or ascribing one set of standards to groups with a variety of differing needs. We need not only to explore the essential qualities of human dignity, but then, decide how we act on human dignity by providing programs, housing, etc., for demented older adults that reflect serious consideration of the needs of the demented person rather than some rigid views of proper behavior or functioning at a specific stage of development.
Missing from many discussions of what is best for the demented, is the perspective of older adults with a dementing illness. Their input is needed. Empirical studies validating the benefits of many interventions currently considered sacrosanct are also needed. There may be a need to abandon some illusions or exaggerated notions of the role of therapy, gracious living, and maintaining a sense of home to the quality of life of this group.
- Boschetti, M.A. (1990). Reflections on home: Implications on housing design for elderly persons. Housing and Society. 17(3), 57-65.
- Rowles, G.D. (1983). Place and personal identity in old age: Observations from Appalachia. Journal of Environmental Psychology. 3, 299-313.
- Rowles, G.D. (1993). Evolving images of place in aging and "Aging in Place." Generations. spring/summer, 65-70.
- Rubenstein, R.S. (1989). The home environments of older people: A description of the psychosocial process linking person to place. Journal of Gerontology: Social Sciences. 44(2), 45-53.
- Rubenstein, R.L. (1990). Personal identity and environmental meaning in later life. Journal of Aging Studies. 4(2), 131-147.