September/October 2015

Boomers in Nursing Homes: Ready or Not, Here They Come
By James Siberski, MS, CMC, and Carol Siberski, MS, CRmT, C-GCM
Today's Geriatric Medicine
Vol. 8 No. 5 P. 18

From considerations regarding drugs, sex, rebellion, and rock and roll to end-of-life care issues, baby boomers will challenge long term care facilities to institute new policies.

Throughout their history, the baby boom generation by their sheer numbers has been prodigious. Remember Woodstock, where they were 400,000 strong and inundated the infrastructure? Presently, they are 75 million strong and will overwhelm society's ability to provide adequate care as they age. This article is not intended to address the looming shortage of medically trained personnel to dispense care nor to discuss the fiscal challenges the boomers pose to the government, their own children, and themselves as a result of the recent great recession.

The baby boomers were dependent on their parents who provided for them until approximately the age of 18. Many of them, in turn, eventually provided care to the generation who raised them. Now this cohort will require care from the generations that follow them as they become society's responsibility and create a strain on the social welfare system. Many of the baby boomers will require long term care (LTC) facilities. This article addresses LTC facilities such as skilled nursing homes, personal care facilities, and continuing care retirement communities, along with the many challenges those facilities will face in delivering the care baby boomers not only require but also demand.

Baby boomers will no doubt tax such facilities' ability to meet the institutional and service demands of the free-spirited baby boomers that must be considered when building a new facility, remodeling or expanding an existing facility, and staffing an LTC facility. Balancing boomers' needs and desires against the physical, fiscal, and time realities of caring for up to 75 million boomers will indeed be taxing (no pun intended). In preparing for this generational sonic boom(er), primary care specialists, including physicians, physician assistants, and nurse practitioners who treat these facilities' residents, as well as the staff members and the administrators of LTC facilities, need to answer several questions and engage in forward thinking and planning in order to provide good primary care and remain attractive to baby boomers so that facilities will have few empty beds and the residents will receive quality care.

Health Care and LTC Nuances
The boomer cohort, accustomed to being trendsetters throughout their lives, will continue to set trends whether or not they age in place. Embracing drugs, sex, rebellion, and rock and roll, the boomers have lived very differently from their parents. In their youth, many baby boomers used multiple types of drugs. Some smoked drugs like marijuana; some ingested drugs like psychedelic mushrooms; and some injected other drugs like heroin. This history should argue in favor of primary care professionals screening all baby boomers for hepatitis C, asking about previous and current drug use (including addictions), and inquiring about prescription medication and its possible abuse, all of which can exert a significant impact on individuals' current medical conditions and their response to treatment.

The baby boomers will be more independent than the previous generations of patients and will therefore want to be involved in their treatment and in their treatment choices. Primary care professionals will need to inquire whether a baby boomer engages in alternative or complimentary medicine or is seeking treatment from chiropractors, acupuncturists, or reflexologists, to name only a few alternative practitioners. A local chiropractor notes that baby boomers comprise 32% of his current practice.

Baby boomers often take over-the-counter medications and supplements promoted in advertisements and self-help literature. It's important to determine whether baby boomers take any vitamins such as E or D3, herbs such as St John's wort, hormones such as melatonin, or Emu oil for pain relief, as supplements can interfere with medications prescribed by health care professionals and can even result in dangerous situations. Clinicians will encounter patients with multiple chronic conditions who will want to understand available treatments and medications before giving informed consent. While the list of suggested questions is not all-inclusive, it attempts to make the point that "It's not your father's Oldsmobile"—ie, baby boomers are not traditional patients.

LTC Facilities: What to Expect
Statements from the younger baby boomers, who are currently in their mid-50s and 60s and voicing their complaints about LTC facilities, indicate that such facilities must undergo changes in various areas. It's the younger baby boomers who are most displeased at the restrictions in place in most LTC facilities. They object to being unable to leave a facility unescorted or being advised to sit when they'd prefer to walk and take the risk of falling. As baby boomers enter LTC facilities in greater numbers, those objections will increase in intensity, requiring changes in ways care is provided. The transition can be successful if providers anticipate and respond now to boomers' needs, desires, and lists of "must haves" rather than simply reacting to their unhappiness and dissatisfaction later.

LTC facilities will be confronted with issues that were nonexistent in residential facilities and care settings for previous generations. Just as the boomers wrote not only a new chapter but, in fact, a new book on living the American dream and uniquely influenced the nation's economy and culture, they will influence, if not transform, the LTC system. If home health care is not a viable option for a baby boomer, personal care and then assisted living facilities will become the preferred options. However, these facilities will need to display their flexibility as never before. One size will not fit all.

The boomers, who are ethnically, racially, and economically diverse, are better educated than their parents and previous generations and, until the great recession, were in reasonably good shape financially. Under current conditions, many boomers will have to prudently scrutinize their budgets, especially when considering the purchase of LTC. Many of the recommendations below do not apply to personal care and assisted living accommodations but rather to nursing homes, which boomers will attempt to avoid. The old saying, "Hell no, we won't go," once used to protest the war in Vietnam, will apply to baby boomers who don't want to slip into retirement, don't want to go to Florida, and will refuse to move into a nursing home unless they choose to do so. The generation who advised never to trust anyone over the age of 30 now asserts that 50 is the new 30 and that 70 is the new 50. Of course, circumstances will dictate living arrangements in certain situations and some baby boomers will require nursing homes. Many baby boomers will require care facilities initially for rehabilitation from strokes, illness, or injuries, and ultimately for LTC. However, as in the past, boomers will demand that their expectations are met, or they will choose another nursing home that will satisfy or even exceed their wishes.

What Boomers Want
When building a new facility or remodeling or expanding an existing facility, think private rooms. In years gone by, boomers may have shared their marijuana, their needles, and their beds. However, at this stage of their lives, a private room will be of singular importance. Boomers will want autonomy, and they will prefer to live the remainder of their years in a meaningful way where they control what they eat, when they go to bed and get up, and what activities are best suited to their interests.

LTC facilities administrators and staff should be prepared for boomers to be admitted with their transcutaneous electrical nerve stimulation (TENS) machines, paraffin heat baths, and biofeedback apparatus. They will likely request or bring their own mini-refrigerators for beer, wine, and other beverages of choice. Since boomers have been exposed to a wide variety of ethnic foods over the course of their lives, consider surveying residents to determine their food preferences and offer menus featuring international options for greater variety and opportunity for personal growth. It will be essential to satisfy boomers' food preferences, which may include sushi, tofu, and organic and gluten-free foods, as well as vegetarian options. According to Vegetarian Nation, individual dining preferences can lead consumers to become vegans, lacto vegetarians, ovo vegetarians, or lacto-ovo vegetarians, and the list goes on.

LTC facilities must likewise address baby boomers' psychosocial communication needs. Internet access keeps boomers in touch with family, friends, and social networks as well as the rest of the world. The next generation of residents will expect to be wired, so work now toward making your LTC facility a hotspot. Baby boomers will require Wi-Fi in order to tweet, video chat, surf the Internet, and have access to the cloud.

Other beneficial changes for LTC facilities will include saying goodbye to "Shine On Harvest Moon" and hello to "Dawning of the Age of Aquarius." The popular music of earlier generations swings toward more individualized preferences in this new cohort. Ideally, mix your Motown with your Jimi Hendrix and the Bee Gees. Facilities will need to deal with volume issues or perhaps provide headsets. Personal choice is important to boomer residents, making them more likely than the current population to demand flexible scheduling options. They will want to eat when they want to eat, rather than at prescribed times. They may want to eat alone or with others, but they will be making their own choices, and not conforming to the dictates of others.

Boomers have attained record levels of education with large numbers surpassing the educational status achieved by the previous generations. This can have positive effects because higher levels of education may postpone the onset of neurocognitive disorders due to Alzheimer's disease. On the other hand, this will certainly challenge any facility's activity staff because current birthday, Bible, and bingo routines may fall short of boomers' expectations. Baby boomers will expect autonomy with regard to their daily routines. They will not necessarily rely on medical care offered within a facility. They will appreciate access to transportation should they wish to leave a facility for outings such as physician appointments, shopping, or meeting friends. They will want to reside in a place that complements their lifestyles, with comfortable living and the ability to obtain good medical care for physical issues.

Facilities should consider hiring geriatric fitness trainers to help prevent injuries and creating exercise rooms with appropriate equipment as well as contracting with specialized elder care yoga and tai chi instructors. This yields the twofold advantage of assisting boomers to get into or stay in shape, which helps reduce medical costs.

Activities will need to change to meet baby boomers' expectations. When building a new facility or expanding or remodeling a current facility, it's important to add space for activities. Replacing a large activity room with smaller rooms that could become destinations for boomer residents is worth considering. A library, for instance, is a potential destination for all residents, which could offer listening stations for music, computers for education and recreation, books, and magazines. Educational sessions could be readily provided there for small groups of residents.

Other useful functions for desirable rooms or areas include a horticulture room; a nondenominational chapel; a Snoezelen therapy room (especially for advanced neurocognitive disorders); a store for shopping essentials; an outdoor patio for barbeques, social gatherings, Oktoberfest, and gardening; a swimming pool; a spa; and a fitness room with classes. All are potential destinations with appeal to varying tastes and abilities. These destinations could be used for activities, including group programing. When not being utilized for activity therapy, volunteers, family members, and the residents themselves can use the areas at times convenient for personal use and for club activities centered around hobbies and interests such as photography, bird watching, poker, bridge, and dance classes.

Boomers were revolutionary when it came to sexuality. In view of that fact, LTC facilities will need to think through sexuality questions sooner rather than later. Will baby boomers be permitted to have sexual relationships in care facilities—or will they even ask? Facilities will need to develop policies concerning sexuality. It is beyond the scope of this article to be specific, but consider how the facility will address sexual contact, condoms, and lesbian, gay, bisexual, and transgender rights as well as the reactions of staff and family members. What will be the facility's stance if a resident with a neurocognitive disorder chooses to have an intimate relationship with another resident, and what will staff tell a spouse or children when they visit? How will staff members respond to a resident's request for Viagra?

While there are numerous scenarios and policies to consider as the baby boomers begin to populate LTC facilities, the following suggestions may be helpful:

• Health care professionals and staff members of LTC facilities need to understand the concept of baby boomers and how to work with this population. Educate administrators and senior staff to enlighten those who care for baby boomers.

• Develop policies now to address issues of sexuality, marijuana, and other drugs baby boomers may be using. In addition, address Internet usage, personal possessions such as TENS units, vibrators, supplements, and screening tests that must be performed prior to admission.

• Consider how activities will meet boomers' recreational needs.

• When building, expanding, or remodeling facilities, consider boomers' expectations and plan for destinations to utilize residents' time purposefully and meet their psychosocial needs.

• Arrange for necessary outside services, such as Alcoholics Anonymous, Narcotics Anonymous, service clubs, chiropractors, yoga, and tai chi instructors.

• Decide on ways to incorporate the above into the budget.

As a vast number of baby boomers will require LTC services in the future, these considerations represent not only challenges but also opportunities. To transition successfully, it is critical for facilities to become more attuned to consumers and to individuals who have needs and desires and will demand control, individuality, and options in order to prosper and to continue to lead a meaningful life. Remember that baby boomers have a history of and reputation for indulging themselves, getting their way, and refusing to take no for an answer. The LTC revolution is upon us. Enjoy the challenges that lie ahead and "make love, not war."

— James Siberski, MS, CMC, is an assistant professor of gerontology and the director of the geriatric care management graduate certificate program at Misericordia University. He is also an adjunct faculty member at University of Scranton in Pennsylvania.

— Carol Siberski, MS, CRmT, C-GCM, is a geriatric care manager in private practice and participates in research in geriatrics and intellectual disabilities in Pennsylvania.