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Contents
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword by Robert N. Butler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Foreword by Robert H. McNulty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Section I

The World of Senior Living . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1

A History of Long-Term Care in the United States

Nancy Carman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 2

Public Health and the Built Environment

Pauline Abbott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chapter 3

Geographic Information Systems: Health and

Aging as a Spatial Construct
Kerry R. Brooks and Bob Scarfo . . . . . . . . . . . . . . . . . . . . . . . . . 33

Chapter 4

Nature-Related Contact for Healthy Communities:

From HunterGatherer to Horticultural Therapy
Angela C. Pappas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Section II

Supportive Environments in the Community, the

Neighborhood, and at Home . . . . . . . . . . . . . . . . . . . . . . . . 85

Chapter 5

The Evolution of Continuing Care Retirement

Communities: Not Your Grandmothers
Retirement Community
Frank R. Mandy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
v

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Chapter 6

Naturally Occurring Retirement Communities:

Thriving through Creative Retrofitting
P. Annie Kirk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Chapter 7

Cohousing and Shared Housing

Laura Bauer Granberry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Chapter 8

Outdoor Environments Supportive of Independence

and Aging Well
Jack Carman and Edward Fox . . . . . . . . . . . . . . . . . . . . . . . . . 163

Chapter 9

Technology and Aging: Adapting Homes and

Shopping Environments with Assistive Technologies
Emi Kiyota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Section III

Preparing for the Near and Distant Futures . . . . . . . . . . 223

Chapter 10

Collaboration as the Key to the Successful Future

of Aging
Bob Scarfo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

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The World of Senior Living

LIFE IS SYNONYMOUS WITH CHANGE. Sometimes the changes are slow and
sometimes they occur in a New York minute. The aging of the United
States, and for that matter of the global population, is only one of several
emerging trends that will soon influence how many people carry out their
daily routines in their neighborhoods. Peoples routines are already changing. The near-retiree cohort is redefining retirement, retiree, retirement community, and, for that matter, grandma and grandpa. Preparing for the coming of
age of baby boomers cannot be considered nor planned for in isolation. Rising energy costs due to oil depletion are impacting the costs of heating and
cooling homes and businesses, commuting routines, as well as food production, processing, and shipping, to name just a few effects. Health issues
associated with obesity and Type 2 diabetes are not only influencing individual well-being, community and business health care costs, and
employee and student absenteeism, but also community policies and planning practices and their subsequent design outcomes. It has become apparent that suburban sprawl contributes to weight gain, whereas pedestrianfriendly environments contribute to healthier people. Daily life in many
neighborhoods is being redefined by a need to downsize. These trends are
each first-time-ever events. Each is contributing to what will come to be
1

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known as daily life, active living, and healthy aging. Space, in terms of the
form, content, and character of neighborhoods, is in need of greater consideration in the research and literature on aging. That research, its interpretation and practical applications, calls for greater collaboration at each
stage along the theorypractice spectrum.
The attitudes and activities associated with retirement, retirees, and
retirement communities are also being redefined. Shifts in the three are
readily seen in Del Webbs Baby Boomer Survey throughout the 1990s and
the 21st century. Peoples attitudes, values, and behaviors are changing, as
well as the built environments to which they are being drawn. Given the
boomers increased longevity and their sheer numbers, their history of
influencing changes in landscapes, architecture, social systems, and institutions as their cohort has aged is not about to slow down. Being idle is no
longer their image of a retiree. Decade by decade, the boomers have caused
massive changes in schools and schooling, in the numbers and kinds of
advanced degrees in higher education, in housing and recreation, and in
industries and technologies. Their intellect and innovative spirit have
pushed the envelope in communications, space travel, medicine, aeronautics, film making, and more. Their ideologies have challenged presidents
and politics. Now, with so many baby boomers at the brink of retirement,
society must recognize and acknowledge that boomers will apply the same
energy, inquisitiveness, and innovation to their retirement.
Baby boomers tendency away from idleness and toward action aimed
at bettering communities is evident in a growing number of studies. A
2001 study conducted by the Fannie Mae Foundation and the Brookings
Institution Center on Urban and Metropolitan Policy Census found that 18
out of 24 downtowns saw increases in their populations. The authors identified one of the contributing factors as the influx of empty nesters, people
no longer responsible for dependent children. This growing restlessness is
reinforced in the 2003 Del Webb Baby Boomer Survey, which reported that
59% of those surveyed said they would move into a new residence in retirement. In the 1999 survey, only 31% of respondents, age 48 to 52 at the
time, said that they planned to move to another residence for retirement.
The influence of boomers on existing and proposed communities is noted in
the MetLife Foundation/Civic Ventures New Face of Work Survey:
This new survey of Americans aged 50 to 70 finds that they do not expect
to, or want to, put their feet up and not work at all in retirement . . .
Fully half of all adults age 50 to 70 (50%) say they are interested in taking jobs now or in the future to help improve the quality of life in their

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communities. Leading edge baby boomers are especially interested, with

6 in 10 (58%) indicating they would consider taking jobs now or in the
future that would serve their communities. (Civic Ventures, 2005, p. 6)

According to Rosabeth Moss Kanter, Professor of Business Administration

at the Harvard Business School,
Someday soon, going to a university at [age] 50 or 60 could be the norm.
Someday, every major university will have graduate schools designed
specifically for accomplished professionals who want to make the transition from their primary income-earning careers to their years of flexible
service. Someday, corporations will include tuition for these schools in
retirement packages and will support scholarships through their foundations. Someday, the federal government will offer tuition grants and tax
breaks for attending universities after 50, to support new forms of philanthropy and public service that truly solve problems. (Kanter, 2006)

The American Association of Retired Persons is already offering its Loan to

Learn program, which allows members to borrow anywhere between $2,000
and $50,000 a year for all education-related expenses up to $250,000.
The ability to age in place is developing a wrinkle. Although over
50% of those approaching retirement say that they wish to age in place,
they plan to move one last time. The two main attractors are an urban setting with diverse opportunities or near a university. The communities and
campuses to which older adults will relocate will need to change. Communities with good mass transit, readily accessible goods and services, diverse
recreational opportunities, and built environments that foster and sustain
social connectivity will attract the aging cohorts energy, entrepreneurial
and innovative spirit, and financial and political clout.
Architects and interior designers have given and continue to give buildings
and their interiors the design attention needed for the benefit of older people. Universal design relates to inclusive design. Although the goal of
universal design is to make goods, services, and environments useable by
many people, the principles of universal design are often applied to the
interior of houses and stop at the exterior wall when they should extend
into the community. Growing old is as much a process of maintaining ones
daily activities in the home as throughout the greater community. In
Chapter 1, A History of Long-Term Care in the United States, Nancy Carman brings to light the challenges that elders have faced over the centuries

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in various familial, state, and public and private institutional settings.

Early on, multi- and intergenerational care settings were not an issue.
Elders often remained with and were cared for by the family. Over time,
responsibility for their care shifted, from almshouses to private nursing
houses, to rest homes and convalescent homes, and, more recently, to continuing care retirement communities and assisted living residences. Latent
in the progression of caregiving settings has been a change in attitudes and
perceptions among older adults regarding where and how they will live.
Older adults have become increasingly more involved in the planning and
design of long-term care settings, which has resulted in the emergence of a
variety of retirement-housing options in the United States today.
In Chapter 2, Public Health and the Built Environment, Pauline
Abbott discusses the effects of housing and land-use patterns on mental and
physical health and the growing impacts on older adults, many of whom
would prefer to age in place. The built environment in which boomers have
reached adulthood, raised families, and become empty nesters is characterized by automobile-dependent suburban sprawl that soon may not allow
boomers to comfortably and safely live out their later years. Older Americans will face serious challenges in the very automobile-dependent suburban environments they so passionately sought and cherished.
Social connectivity is critical to longevity and aging in place. If social
interactions are primarily dependent on the use of an automobile, they will
be lost to many older adults who can no longer drive. Life in the suburbs,
in the homogeneous regions of sprawling houses separated from retail outlets, recreation, health care, and friends and family, will require changes in
community and land-use planning and zoning. Denser, mixed-use community settings will contribute to greater social connectivity, provide more
opportunities for walking as an integral part of daily life, and lower the
cost of living by decreasing or eliminating the use of a car (now costing
about $8,600 a year to own and maintain). Abbott asserts in her conclusion
that, City planners, public health departments, architects, designers,
builders, elected officials, and all others who are involved in shaping the
built environment must realize and understand their roles as guardians of
the future (p. 31). They must consider and plan for long-term livability
factors, which can best be achieved by accessing the growing resources at
hand on the impacts of community design on the health and quality of life
of older adults who want to age in place.
French philosopher Henri Lefebvres idea that space is a social product
gets to the heart of Chapter 3, Geographic Information Systems. Kerry

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Brooks and Bob Scarfo focus on the fact that social space, while often
ignored, can be made visible and in so doing can illuminate critical aspects
of the relationship between health and the built environment. An early
example of the visualization of social space was demonstrated in London in
1854 when Dr. John Snow and Reverend Henry Whitehead mapped the
incidents of cholera they treated. By making the cholera epidemic visible,
Dr. Snows map reinforced his belief that the deaths were related to the
neighborhoods drinking source, its public well (Johnson, 2006). Today
geographic information systems software (GIS) makes the mapping of the
invisible, visible.
As Graham Rowles aptly demonstrated in Prisoners of Space (1978),
ones surroundings contribute to the personal and social aspects of aging. It
is the diversity of those aspects that can be mapped via GIS technology as a
means of seeing their interrelationships. GIS technology also provides
ways to visualize the social equality that exists or does not exist in a community, specifically the extent to which the built environment supports
access to health care systems, goods, services, recreation, and education.
Access and availability are integral to successful and productive aging
and both can be made visible through GIS technology. Together, public
heath and city and urban planners can use GIS technology to identify the
extent to which a community can contribute to successful aging and
healthy aging in place.
Landscape architects have for some time promoted the idea that green
environments contribute to healthier living. Their argument has gained
evidence-based support wtith the growing involvement of the health sciences in discussions about the effects of the built environment on health.
To this growing body of information, Angela Pappas contributes a foundation for Nature-Related Contact for Healthy Communities in Chapter 4
that begins as far back as Paleolithic times (p. 53). Even with such
a long history, the restorative benefits of nature are often overlooked in
the design of communities. That may be changing, she argues, with the
growing body of research related to health and the built environment.
Pappas reviews four theories that each support the recuperative powers of
green environments: biophilia; cognitive, content and spatial perception;
psycho-evolutionary; and human environmental value. From calming children with attention-deficit/hyperactivity disorder to extending peoples
lives to supporting the psychological well-being of people, creating
restorative and revitalizing properties of green environments will require
greater collaboration across the environmental design, health care, and

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medical health professions for the benefit of the ill, the aging, and the
greater general public. Healthy people contribute to healthier communities and vice versa.

REFERENCES
Civic Ventures. (2005). New face of work survey. Retrieved January 2008, from
http://www.civicventures.org/publications/surveys/new-face-of-work.cfm.
Del Webb. (2004). Del Webb baby boomer survey: Empty nester syndrome. Retrieved
June 2007, from http://www.pulte.com/pressroom/2004BabyBoomer/Baby
BoomerDetailReport.pdf.
Johnson, S. (2006). The ghost map: The story of Londons most terrifying epidemicand
how it changed science, cities, and the modern world. New York: Riverhead Books.
Kanter, R. M. (2006). Back to college. AARP The Magazine. Retrieved January
2008, from http://www.aarpmagazine.org/lifestyle/back_to_college.html.
Lefebvre, H. (1991). The production of space. Cambridge, MA: Blackwell.
Rowles, G. (1978). Prisoners of space?: Exploring the geographical experience of older people. Boulder, CO: Westview.

Copyright 2008 by Health Professions Press, Inc. All rights reserved.

Charles F. Longino, Jr., Ph.D., Professor of Sociology &

Director of the Reynolda Gerontology Program, Wake Forest University

As Americans live longer and longer, what lifestyle options exist

beyond nursing homes and other institutional care facilities? This informative
book provides some answers: walkable neighborhoods with connections
to goods, services, and personal relationships and refreshing green space
among them. Planners, architects and landscape architects, and
health care professionals will all benefit from this book.
J. William Thompson, FASLA, Editor, Landscape Architecture

Re-creating Neighborhoods for Successful Aging provides a crucial foundation for

confronting the growing aging populations demands for appropriate housing and environments. This
current demographic shift is causing a transformation of attitudes and perspectives about growing
older, retirement, and senior housing. To ensure that physical environments meet the changing needs
of older adults, a reconception of housing, communities, and neighborhoods is required.
Drawing from the fields of gerontology, health sciences, community planning, landscape
architecture, and environmental design, this groundbreaking resource provides an in-depth
examination of current elder housing practices and strategies, alongside goals for the future.
Housing models, such as continuing care retirement communities (CCRCs), shared housing, and
co-housing, are evaluated, and best practice recommendations are presented.
Expert contributors also incisively explore interdisciplinary issues, including

the causal relationship between health and the environment

challenges posed by Americas automobile-dependent suburban communities

elder-friendly design principles, including universal design and defensible space

restorative benefits of nature and green environments

assistive technologies that support older adults independence

retrofitting of naturally occurring retirement communities (NORCs)

The book closes with an inspiring look at opportunities for future collaboration of health sciences and
planning and design professionals for the realization of supportive, life-affirming communities that
will result in healthy aging, active living, and continued community participation for older adults.
Forewords by
Robert N. Butler, M.D., & Robert H. McNulty, J.D.

www.healthpropress.com

Re-creating Neighborhoods for Successful Aging

Abbott,
Carman,Carman,
& Scarfo

The baby boom is retiring and will increasingly press for new, creative, and
interdisciplinary approaches that fit environments to the needs of older persons.
Re-creating Neighborhoods for Successful Aging is an eagerly awaited volume
that speaks to the personenvironment fit in old age, and does so brilliantly.