HISTORY113 - History of Eldercare

Given that Pat and I have recently moved into an independent living facility, with provisions for assisted living and memory care should/when we need it, I thought it might be interesting to research and write about the history of eldercare. 

 

After a short introduction, I will cover the history of eldercare from ancient times, in convenient chronological time periods, though today.  I will finish with what the future of eldercare may hold.

I will list my principal sources at the end.

 

Introduction

Even though people are living longer these days, in the United States, the term "elderly" is still generally associated with individuals aged 65 and older.  Of course there are many exceptions, and each person is different.  By the year 2030, one-fifth of the U.S. population will be over the age of 65. 

Eldercare encompasses the comprehensive services and support provided to older individuals who may require assistance with daily activities, medical needs, or social support.  This care has historically taken various forms, ranging from family-managed support to professional care in specialized facilities.  The societal role of eldercare is crucial as it reflects our values and the respect afforded to older generations.  Cultural perspectives on eldercare have varied greatly through the ages.

 

Ancient Times

The history of eldercare began in ancient civilizations, each with its unique approach reflecting their cultural values and societal structures.  Here are some distinct practices from notable ancient civilizations:

Ancient Egypt: Elders were revered, often involved in governance and knowledge dissemination, cared for by their families, with additional community support when needed.

Greece and Rome: Both cultures highlighted the respect for elders, although the level of care varied significantly depending on one's social and economic status.  Elders often played crucial roles in advising and leadership.

In ancient Greece, caring for the elderly was primarily the responsibility of their families, particularly their children. This duty was considered a sacred obligation.  Neglecting this responsibility could result in severe consequences, including the loss of citizenship or imprisonment. 

In ancient Rome, elderly care primarily fell on the family, particularly children, reflecting strong cultural values of respect and obedience.  While older individuals might have held respected positions in society, particularly those with wisdom and experience, those who became infirm or impoverished often relied on their families for support. 

Respected Roman Senator Lucius Licinius Crassus, speaks to the Senate.  It was common in the Roman Senate for the elderly to speak first.

In ancient Rome, the average life expectancy was around 22-33 years at birth, but this figure is skewed by high infant and childhood mortality rates.  If someone survived to adulthood, they could reasonably expect to live into their 60s and 70s, and some even reached their 80s or 90s. 

Across the Globe: Indigenous cultures typically revered their elderly as custodians of wisdom and tradition, integrating their care within the fabric of community life, where elders participated actively in teaching and governance.

Family members were primarily responsible for taking care of the elderly. This changed little over more than 1,000 years.

 

Middle Ages through Renaissance (6^th - 17^th century)

The Early Middle Ages (to about 1000 AD), were characterized in Europe by a decline in culture, intellectualism, and economic stability.  During this period, old age was often viewed as a “positive evil.”  Elderly people were often feared and denigrated.  Art conveyed a variety of religious themes that portrayed seniors as grotesque. 

However, unlike Europe, beginning in the 8^th century, the Islamic world experienced a period of significant intellectual, cultural, and territorial expansion, often referred to as the Islamic Golden Age.  This era, roughly spanning from the 8^th to the 13^th centuries, saw advancements in science, mathematics, medicine, and philosophy, and the flourishing of arts and architecture.

In 1025, the Canon of Medicine, a highly influential medical encyclopedia, was written by Ibn Sina.  It presented an overview of the contemporary medical knowledge of the Islamic world. The work covered various aspects of medicine, including anatomy, physiology, hygiene, and treatment of diseases.  Ibn Sina also addressed topics like aging, longevity, and the specific health concerns of older individuals, providing insights into how to maintain health and manage age-related ailments.  This made it an early source of information on elderly care.  The Canon was translated into Latin in the 12^th century and became a standard textbook in European universities for centuries. 

The Canon of Medicine, published by Ibn Sina in 1025, was an early source of information on elderly care.

Beginning in 10^th century Europe, the development of eldercare was predominantly influenced by the Christian Church.  The era saw the rise of monastic care where religious institutions provided refuge and care for the elderly.  This evolved into almshouses, charitable housing institutions that provided low-cost or free housing, primarily for the elderly, poor, or those in need. 

Initially set up to care for the poor, elderly, and infirm, almshouses were funded by charitable donations from the wealthy.  Innovations during the Renaissance (14^th-17^th century) introduced more structured community care with the emergence of organized charitable institutions dedicated specifically to the elderly, marking the beginning of what would evolve into modern-day social services.

By the middle of the 1500s, hundreds of almshouses were spread across Europe.  During the late 16^th century, European craft guilds founded many almshouses to provide care for the “elderly decayed” members in their declining years.  

 

17^th Century

In the 17^th century, the mission of almshouses in Europe began to broaden to include trying to manage poverty and provide for the destitute, including the elderly, mentally ill, blind, orphans, and the disabled.  In England, the Elizabethan Poor Law of 1598 laid the groundwork for managing poverty through local responsibility.  This landmark legislation established a system of parish-level taxation to fund relief for the "impotent poor."

The English Poor Law of 1601 particularly addressed the elderly poor by requiring parishes to provide relief, often in the form of almshouses or cash or sustenance.  The law also emphasized family responsibility, with children expected to care for their impoverished elderly parents. 

The "impotent poor" were to be cared for in almshouses, while the "able-bodied poor" might be sent to workhouses.  Workhouses were institutions where destitute individuals, primarily the poor, were offered food and shelter in exchange for work.  These institutions were intended to be a deterrent to seeking public assistance.  Families were often separated, and conditions were deliberately harsh to discourage reliance on the workhouse. 

Eldercare in the 17^th century was a complex system involving family and community support, alongside institutional care for the most vulnerable.   Attitudes towards the elderly varied, with both respect and negativity present.  While family played a crucial role, challenges like poverty, changing family structures, and inadequate institutional conditions posed significant obstacles for many elderly individuals. 

 

18^th Century

In the 18^th century, European eldercare continued with family and community support, with parishes offering limited assistance when families couldn't cope.  Almshouse and workhouses provided care for the destitute elderly, but conditions were often harsh.  

European approaches for eldercare spread to America early in the 18^th century.  In 1713, one of the earliest organizations designed specifically to care for the elderly, “Friends Almshouse of Philadelphia,” was founded by the city's Quaker leadership to help destitute members of the Society of Friends.

Friends Almshouse of Philadelphia in 1713.

The Industrial Revolution, beginning in about 1760, brought about significant social and economic changes, including urbanization and increased poverty.  Workhouses became more prevalent as a way to address the growing numbers of people in need. 

Alternatives for eldercare began to emerge.  Religious and fraternal organizations started opening nonprofit housing for the elderly, offering a more comfortable alternative to public institutions.  These early examples of senior housing provided room and board, and sometimes care, foreshadowing modern assisted living models.  But medical knowledge about aging and age-related diseases was limited, and specialized geriatric care was largely absent. 

 

19^th Century

In the 19^th century, care for the elderly in the U.S. continued to primarily fall to families and communities, with limited formal institutional options.  Almshouses and workhouses provided basic care for the destitute elderly, while some families hired nurses or doctors for home care. 

The government realized they had an obligation to make sure that the indigent elderly population had a place to live and enough food to eat.

More almshouses and workhouses (also called poorhouses) were constructed for seniors who had no means or family to take them in.  While these living facilities were meant to be charitable, they were terrible places to live.  Seniors who lived in these structures were known as inmates.  Both females and men were regulated by their gender, had to wear uniforms, and were forced to work in order to keep the property maintained.  Living conditions were barely tolerable and horrific in many cases.

In America, care started becoming more specialized but had not improved much.

A law was finally passed that disallowed housing orphans in workhouses.  Asylums were available for the mentally ill, and indigent senior residencies were in development. 

In 1817, the Indigent Widows’ and Single Women’s Society in Philadelphia was established to care for a growing population of poor and elderly woman who had lost their husbands.  This was one of the first senior living facilities in existence.

Elderly people were no longer forced to live in workhouses; however, the new homes were despotically institutionalized.  America was undergoing industrialization, and it was thought that a factory’s efficiency could also be applied to caring for the elderly population.

In the middle 1800s, the first pieces of the modern care system were in development.  Religious groups, tradesmen, and fraternal organizations were opening nonprofit housing for seniors as an alternative to state-run institutions.  Some examples include the Odd Fellows, Masons, Knights of Columbus, and the German Benevolent Society.   Younger members of these groups paid into a pool that operated similarly to the way our pension system does today.  Many of the homes were very nice places to live and some of them are still in operation

In 1862, Civil War pensions became the first major pension program in the U.S. to care for Union war veterans, their widows, and their dependents.

Toward the end of the century, Visiting Nurse Associations emerged to provide nursing care to the sick and elderly in their own homes, often for those with acute illnesses who could be discharged from hospitals.  But home care services were often limited by cost and availability, with the acutely ill receiving priority.  The first nursing homes and home care services began to emerge, though still limited in scope. 

At the end of 19^th century, Visiting Nurse Associations emerged to provide in-home care for the elderly.

Old age was sometimes associated with burden and uselessness, and elderly individuals often faced social stigma, particularly those in workhouses. 

 

20^th Century

Aging became an important area of study in the 20^th century.  During the first decade, the terms “geriatrics” (medical care for the elderly) and “gerontology” (a study of aging) were both coined.  During that same decade, Alzheimer’s disease was identified and described for the very first time.

The 20^th century marked a significant transition in the history of eldercare, moving towards more institutionalized forms.

Church Home Care.  In the early 1900s, churches started to feel guilty that the elderly were spending their last days in almshouses and workhouses, surrounded by paupers, criminals, mentally ill people, and “unsavory” individuals.  Various religions decided to step in and create homes specifically to care for the elderly.   In order to be accepted into one of these homes, the senior had to be a member of the faith, preferably attending that church.  Conditions here were far better than the almshouses, but we still had a long way to go.

Social Security. The U.S. Government saw the many issues with almshouses and workhouses, and wanted to change the system quickly.  The Social Security program in the United States was established by the Social Security Act, which was signed into law by President Franklin D. Roosevelt on August 14, 1935.  

President Franklin D. Roosevelt signed Social Security into law on August 14, 1935.

The Act aimed to address the economic hardship faced by many elderly Americans during the Great Depression.  It established a system of federal old-age benefits for retired workers aged 65 or older.  The system was funded by a payroll tax on both workers and employers.  Social Security taxes were first collected in January 1937.  The first one-time, lump-sum benefits were paid out in January 1937.  Regular, ongoing monthly Social Security benefits began in January 1940. 

While initially focused on individual retirement benefits, amendments in 1939 expanded the program to include benefits for dependents and survivors.  Early retirement benefits, allowing people to draw checks at age 62, were enacted in 1956 for women and in 1961 for men.  Disability payments were enacted in 1956 and initially were payable only to workers aged 50-64.  Payments to divorced wives began in 1965, and to divorced husbands in 1977.

The 1935 Social Security Act had a significant effect on workhouses in the U.S. - causing a rapid decline in these institutions.  While they didn't all close at once, most were gone by about 1950, with a few remaining until the 1970s.  The Social Security Act shifted the responsibility for caring for the poor and indigent from local institutions to the federal government.

Almshouses in the U.S. began to decline significantly. during the mid-20^th century.  While some almshouses may have lingered into the late 20^th century, the concept of the almshouse as a primary institution for the poor and vulnerable largely disappeared in the latter half of the century. 

Nursing Homes. The Hill-Burton Act of 1946, provided federal grants and loans to states for the construction and modernization of hospitals and other healthcare facilities.  In return for this funding, facilities were required to provide a reasonable volume of free or reduced-cost care to those unable to pay and ensure their services were available to everyone in the facility's service area. 

The Hill-Burton Act also provided grants for nursing homes that were built in conjunction with a hospital to provide clean, organized, and medically-proficient environments.  After World War II, nursing homes became widespread driven by medical advancements and increased life expectancy.  In the late 1950s, nursing homes could receive grants without being connected to a hospital.  The private nursing home industry grew quickly.

Medicare and Medicaid. In 1965, Medicare and Medicaid were created to ensure that seniors would have accessible medical care regardless of their financial situation.  Medicare provides health insurance to the elderly (65 and older) and disabled. Medicaid provides health coverage to low-income individuals and families, including children, pregnant women, seniors, and people with disabilities. 

President Lyndon Johnson signed Medicare/Medicaid into law on July 30, 1965.

These programs prevented private nursing homes from discriminating against lower-income seniors in need of care.  They also protected those who were unable to work conventional jobs and earn benefits.  Essentially, it placed all elderly people on a similar playing field in terms of insurance.

Independent Living and Memory Care. Growing dissatisfaction with the "institutional" nature of traditional nursing homes sparked the search for alternatives, particularly for seniors who needed some assistance but not the level of care provided in typical nursing facilities.  This search led to the conceptualization and development of assisted living facilities, which offered a more homelike environment with a focus on individual independence and respect.  The Park Place in Portland, Oregon, opened in 1981, and is considered a pioneer in the modern assisted living model, offering private rooms, community spaces, and 24-hour staffing for emergencies.

The first facility specifically designed for people with dementia, The Weiss Pavilion in Philadelphia, was established in the 1970s, though it was part of a nursing home.  Later, facilities like The Corinne Dolan Center in Ohio and Woodside Place in Pennsylvania focused on creating more residential-style environments for dementia care.

Throughout the 1980s and 1990s, the concept of assisted living expanded, leading to the development of various models that incorporated different levels of care, including memory care.  The "hybrid model" that emerged during this period combined residential settings with individualized services, emphasizing resident autonomy.  By the late 1990s, memory care assisted living gained significant popularity, attracting financial investment and influencing the construction and practices within these facilities. 

Continuing Care. Continuing Care Retirement Communities (CCRCs), have a history rooted in the early 20^th century, evolving from religious and fraternal organizations offering care to their aging members.  These communities provided a continuum of care, allowing residents to age in place as their needs changed.  Initially, CCRCs focused on providing basic care and shelter, but they have since grown to offer a wider range of services and amenities, including independent living, assisted living, and skilled nursing care. 

Scope of a continuing care retirement community.

The concept of CCRCs gained traction during the mid-20^th century due to increased life expectancy and a growing awareness of the needs of the elderly. 

In the 1990s, CCRCs began to emphasize lifestyle and wellness, offering a broader range of services and amenities to attract a wider range of seniors.  The term "Life Plan Community" has also become more common as a way to emphasize the proactive approach of these communities.  Today, CCRCs continue to evolve, with a growing focus on resident choice, personalized care, and a vibrant community atmosphere. 

Hospice Care. While hospice, as a concept of providing care for the ill and dying, has existed in various forms throughout history, the modern hospice movement emphasizes specialized care for terminally ill elderly patients, focusing on symptom management and improving quality of life. 

The first modern hospice in the United States was Connecticut Hospice, founded in 1974 in Branford, Connecticut.  It was modeled after St. Christopher's Hospice, the first modern hospice founded in London in 1967.  The concept of hospice care gained traction in the U.S. during the 1970s.

 

21^st Century

Nursing homes are still available, though their numbers have decreased in recent years, and access to them varies by location.  Many facilities are facing financial and staffing challenges, leading to closures, particularly in rural areas.  However, nursing homes remain a vital option for those needing 24-hour skilled nursing care. 

A variety of other senior care options are available across the U.S., due to the increased aging population and a need for alternatives to nursing homes. These include independent living, assisted living, memory care, continuing care retirement communities, and hospice care.

Another approach to elderly care in the 21^st century is evolving to emphasize aging in place and leveraging technology for remote care and community support.  In-home care allows elderly loved ones to live in their own home (or with their family).  Caregivers are hired by the family to visit the senior on a fixed schedule.  A caregiver can stop by for a few hours per day to help the elderly person get ready for the day, give them social interaction, take them on walks, and more.  Loved ones can age in place in their own home where they are comfortable with their environment.  This includes increased focus on home-based care options, telehealth, and utilizing the Internet of Things (IoT) to enhance communication and community within senior living facilities.  (IoT is a network of interconnected physical devices, appliances, industrial machinery, and other items embedded with sensors and software that enable them to collect and exchange data over the internet.)

Seniors increasingly prefer to remain in their homes and communities, prompting a shift towards expanded home-based care services.  Telemedicine and remote monitoring technologies are becoming vital for providing healthcare to seniors in remote areas or with mobility limitations.  IoT is being implemented to foster connections between residents, staff, and families in senior living communities, enhancing communication and a sense of community.

In-home elderly care is growing rapidly in the 21^st century.

However, challenges remain, such as the growing demand for services, financial strain on caregivers, and the need for proactive, holistic care for those with multiple chronic conditions. 

There's a growing emphasis on preventative care, care planning, and case management for seniors with multiple chronic conditions, focusing on maintaining independence and preventing hospitalizations. 

Ensuring access to affordable and quality care, including home care, is crucial for supporting seniors in their chosen living situations.  Addressing ageism and helping seniors maintain a sense of purpose and social connection are also important aspects of 21^st-century care. 

 

Future

Continuing care retirement communities will continue to grow, providing independent living to skilled nursing and memory care, with an increased emphasis on wellness - an active lifestyle that incorporates several components that affect health (physical, mental, and social wellbeing), including a wide range of dining options, physical fitness and recreation opportunities, specialty workshops, educational classes and lectures, entertainment, visits to local attractions, and even shopping excursions. 

The future of elderly care is also trending towards personalized, technology-driven, and community-integrated solutions.  This includes a greater emphasis on preventative care, remote monitoring, and support for aging in place, with a focus on maintaining dignity and quality of life. 

Supporting seniors to remain in their homes and communities for as long as possible through in-home care and technology is a growing trend. 

Top 6 trends in elderly care technology.

Remote consultations and monitoring through video calls and wearable devices can improve access to healthcare for those with mobility issues or living in remote areas. 

Artificial Intelligence is being used for predictive health analytics, cognitive aids, and personalized care plans.  Devices like fall detectors, automated lighting, and voice-activated systems can enhance safety and independence for seniors living at home.  Robots can assist with physical tasks, provide companionship, and even offer mental health support. 

By embracing technology, prioritizing personalized and preventative care, and fostering strong community and family support, the future of elderly care can ensure that older adults enjoy a fulfilling, dignified, and connected life. 

 

“No elderly person should be like an “exile” in our families.  The elderly are a treasure for our society.” - Pope Francis

Sources

My principal sources included: “Elderly Care,” Wikipedia.com; “The History of Senior Care,” generationshcm.com; “The Comprehensive History of Eldercare,” yodda.care; “A Brief History of Senior Care Through the Decades,” bzocare.com; “The History of Eldercare,” silverbellhomestead.com; plus, numerous other online sources.  I particularly want to recognize the use of online artificial intelligence ChatGPT summaries on many elements of this blog.