The Not-So-Golden Years: Caregiving, the Frail Elderly, and the Long-Term Care Establishment. Laura Katz Olson. Lanham, MD: Rowman & Littlefield, 2003, 304 pp. $29.95 paperback. .

Labels to give us pause. Read more.

Political scientist Laura Katz Olson recognizes it's a myth. Her latest book, The Not-So-Golden Years: Caregiving, the Frail Elderly, and the Long-Term Care Establishment, despite some odd omissions, offers a valuable critique of politics, society, and aging in the United States. Her sections on demographics and on the inadequacy of U.S. policy " are terrific. Yet she falls short in her discussion of comunity-based solutions -- and never really offers readers a convincing way out of the mess.

The book has a serious drawback: she fails to even notice the effort to pass the Medicaid Community Attendant Services and Support Act (MiCASSA) -- or to notice the work being done by groups like ADAPT. Aging policy needs to begin from the "grass roots," rather than being dictated from above. Olson recognizes the problem, but doesn't say -- as I think she should -- that it will need to be the cornerstone of any possible solution.

Focusing on people over 85 years in age -- the oldest of the old -- Olson writes that U.S. policy has been based on illusion. Medicare and Medicaid, she points out, never addressed long-term care. Talk of cures is misleading, she says; many people simply live with disabling conditions. And, she notes, the popular image of old people, once full of pity and charity, has shifted to an image of a greedy "special interest" which drains the public treasury.

She points out that most of the above 85's are women, and that the people most likely to serve either their own families or others' are women as well. This isn't intrinsically bad, but since it compounds discrimination and disadvantage in the workforce, it aggravates inequalities, she notes.

A system in which nursing homes become the "last resort" of the predominantly white upper-class, with an underpaid labor force that is increasingly immigrant and not white, aggravates inequalities, too. Latinos, Olson tells us, are much more likely than whites to be employed by institutions, but much less likely to live there.

Topics Olson explores include, in her words, "the gendered nature of care," elder abuse," "immigrant labor," "the nursing home hierarchy," assisted living" (community care for elders who can pay). "continuing care retirement communities" (community care for those who can pay even more), and "warehousing the frail" (nursing facilities).

But in a final chapter on "Toward a New Vision of Care Work," alongside themes like deprivatization and revaluation of care work, we have "revamping nursing homes." They would need to be "more patient-oriented," Olson says, but allows that "nursing homes are not inherently objectionable places for frail, dependent people."

I disagree. Any attempt to distinguish among categories of "dependent people" is likely to be made by others presuming to know "their interests," and creates a very dangerous slippery slope, which Olson seems to either be unaware of or to ignore. Olson aptly criticizes nursing homes as "a system run amok," yet doesn't seem to recognize that attempts to create the "good nursing home" are subject to the same dangers as attempts to create the "good war." WE create the good wars and good nursing homes, and THEY bear the consequences.

Prominent politicians extol "community care." By decentralizing authority, this might give people the equal right to sleep under bridges (to paraphrase Anatole France). Olson has a point in decrying the mood of denying national responsibility for social needs. Age, like disability, is used to attack a group as drains on the system, replacing or accompanying images of pity and dependence. Combating this will require a shift from leaner, meaner, more profitable policies, as Olson emphasizes. It also requires making connections to independent living, self determination, and least restrictive alternatives, all of which need to be underscored.

Five years after the Olmstead v L.C. and E.W. Supreme Court decision, a Los Angeles Times writer described implementation of the ruling as "sluggish" and "uneven." Two phrases from that June 22, 1999 opinion, written by Justice Ruth Bader Ginsburg are key: "most integrated setting" (from the Rehabilitation Act of 1973); and "least restrictive setting" (based on language from the Developmentally Disabled Assistance and Bill of Rights Act, also applicable to the "frail elderly"): Placement in an overly restrictive environment, in a setting that wasn't integrated, was considered "discrimination" prohibited by the Americans with Disabilities Act of 1990.

Lois Curtis and Elaine Wilson were 31 and 40, respectively, when the Supreme Court issued its opinion. Ginsburg's points may be even more compelling five decades from now.

Olson, though she never discusses the Olmstead decision, points out that aging policy is characterized by very restrictive settings, and by increasing segregation,. offering evidence and cases that are useful for people like me in pushing for MiCASSA and speedy implementation of Olmstead, both of which are becoming increasingly important as our population ages.

Why didn't Olson specifically mention Olmstead and MiCASSA? I hope it isn't her focus on older people. She writes at one point that she is "leaving it to others to address the equally important concerns of the younger disabled population." But to assume a disjunction between the needs of older people and disabled people is in this instance a real mistake. The central concern of both is the same: to receive assistance in an integrated setting, with a minimum of restrictions dictated by a drive for profit, or by bureaucratic imperatives. We would do well to be cautious of political leaders' simplistic rhetoric -- but we've got promising initiatives coming from the grass roots. Pushing profit out of the way should make room for choice and independent living. So it's puzzling that the last chapter of the book doesn't offer a convincing way out.

Even with MiCASSA and implementation of Olmstead, we'll need to confront rampant irresponsibility and inequality in the U.S. Men are part of the solution as well as part of the problem, and Olson writes about "normalizing men as carers." Many common U.S. cultural assumptions need to be rethought , she argues. I couldn't agree more.

Although I found a lot to like in The Not-So-Golden Years, this isn't the "one book" that's a "must read" -- perhaps people shouldn't look for one book to cover the entire topic, anyway. Aging policy is complex; one book likley can't cover it all. Laura Katz Olson's book, nonetheless, provides valuable insight on what's happening in the U.S., and what will likely happen unless fundamental changes are made.

Labels to give us pause

Discussions of aging use a plethora of terms, some inherited from or imposed by legislators or the nursing home industry. All carry powerful connotations. They can place us on a "slippery slope" on which people risk losing their autonomy.

Olson uses terms that may make readers pause. "Frail" is almost always used in combination with "elderly." Olson uses it for people who require assistance with at least one "activity of daily living," or ADL (in some legislation, requiring assistance with three ADLs is needed to be classified as "frail"). Someone requiring assistance with one or two ADLs may be classified as being "at risk."

Many countries have programs directed toward people who are "frail," determined by such criteria as whether the person leaves the house. Kansas's "frail elderly waiver" allows people to elect to live independently rather than in a nursing home. It's a frequent target for people who argue that the "frail elderly" should not be able to choose home assistance.

Olson's label "caregiver" describes people who frequently are abusers of the frail elderly. This is particularly disturbing because, as Olson points out, the prevalence of abuse is rising. Her occasional descent to use of the label "caretaker" implies that the person receiving personal assistance services must depend on others for care, not just for assistance with ADLs. Olson rightly argues that the concept of "care" requires revaluation, since our current system is based on a lack of choice trapping both the "frail elderly" and the "caregivers." She therefore "would argue for smaller facilities, integrated into communities, that can provide truly homelike environments. The frail elderly need not be warehoused, isolated, and tucked away from previous neighbors, friends, and the larger society."

I would add: "excluded from autonomy and control."

Posted 7/27/2004

Art Blaser chairs the political science department at Chapman University.

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