CENIE · 08 May 2023

Is cohousing the alternative to nursing homes? Short answer: no.

I am going to express here why I do not agree with certain approaches to so-called "cohousing". The idea of senior cohousing, which would be to live in a kind of "commune" in which we share a series of services and where we would go to live at the end of our lives (forgive the oversimplification) does not seem wrong to me. Who am I to tell people where they should or should not live. How could any idea that is based on the idea of creating community, on sharing, seem wrong to me. 

No, it's not that I think the idea, in the abstract, is bad. Not at all. My only issue is that cohousing, being an option or an interesting alternative to other models, does not respond to any specific need or, at least, does not respond to some of the issues to which it is presented as a useful alternative or tool. Let me explain. 

Lately, I see that cohousing tends to be presented as a care model, as an alternative model to nursing homes. It is true that, faced with certain problems in the home occupied by the elderly person or those related to the environment and accessibility (such as those I am referring to here), a change of home and habitat is necessary. This change, let us not forget, is strongly limited by the availability of a series of economic resources, advice, management skills and even psychological tolerance to changes that are very extreme. In the case of opting for cohousing, it is expected that the elderly person (or in the process of becoming one) will have a created, strong community on which to rely in a process that can last for years. Many years. This is not a minor point.

While cohousing may seem to me to be a good alternative (or simply one more) for people who are in good health, I consider that it does not meet the needs of a large part of the ageing population. This is the point where I raise the greatest resistance, because in the popular imagination and in certain speeches it sometimes seems to be understood that cohousing is an alternative to nursing homes. Approaches along these lines make me think that they are based on a very limited and somewhat (in fact, very much) idealised knowledge of the reality of the nursing home, the circumstances that have led a number of people to end their days there and the needs (type of care) of those who live there. My rejection or resistance to the cohousing approach is not at all because I do not understand that someone wants to provide an alternative to a reality that is horrible. Because, even if the nursing homes really did comply with the idea of Person-Centred Care, if they really did comply with the quality parameters that should be a requirement for them to obtain the appropriate licences, the meaning of the nursing home (the need for continuous care, the high level of dependency) is horrible. 

I understand that, faced with this reality, different alternatives to the issue of institutionalisation are sought. I have been in many nursing homes throughout my life and, moreover, at different stages of my own development, so I can understand the different reactions and views on the reality of institutionalisation. The first time I entered a nursing home, I still remember it very vividly, I was just a child. And I was afraid. I was afraid of those people who tried to grab me and who called out to me and smiled at me with incomplete dentures. Now, with the passing of time, I understand how excited those people must have been, so old and alone, in an environment that was probably hostile to them, to be visited by a little girl and to be able to somehow have that intergenerational relationship that I allude to so much.

I have also been to different nursing homes in my teenage years, when the prevailing smell would get stuck in my pituitary and I wished I was far away from there. I have spent hours in nursing homes when I was older or perhaps more mature enough to understand that I was supposed to be there. I have spent time in nursing homes to visit people who were not a part of me, in order to reduce their loneliness or isolation, but mostly I have spent time in nursing homes to visit the half-empty shell of someone who was important to me. Sometimes she was aware that I was there, with her, but never who I was: "How beautiful you are, madam" I will remember as one of the greatest compliments I have ever received, said by a grandmother who no longer knew that I was her granddaughter. 

The particular, isolated and hidden world that the residences represent continues to awaken in me an instinctive and visceral reaction of profound rejection. But I still, despite this, understand the necessity of their existence and why they cannot be replaced by models that do not take into account the specific needs of those who live there. The key question, even leaving for another post the criticisms of how care homes are managed (necessary criticisms) is very simple: why do we need care homes? If we are realistic about why they exist, our answers will be very different from those that give rise to the development of living models such as cohousing.  Even if we understand that the situation of institutionalised people is varied, the reasons that lead us to residential care are often health problems and a considerable lack of autonomy. 

Table: Health profile of people admitted to nursing homes.

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Source: https://www.inforesidencias.com/resources/public/biblioteca/documentos/s...

Co-morbidity, dementia and Alzheimer's will not find a correct treatment in the cohousing approach. It is important for me not to forget this reality, this specific point, because then we will not give idealised solutions that in reality do not respond to anything more than a wish, however laudable it may be.

It would be wonderful to think of a reality of ageing in which we do not need nappies and in which we do not forget who we are. I wish that this reality that characterises the last stages of some people's lives did not exist. But it does exist. That is why, rather than the existence of alternatives such as cohousing which, I insist, do not contemplate that reality of the nappy, there are two key issues that I would call for regarding nursing homes and possible alternatives. 

The first, along the lines of the alternative (so simple for me and so little considered), is greater attention to the physical conditions of the neighbourhoods in which we live. I would call for greater attention by public institutions to the structural conditions of the buildings and to ensure that the quality of our homes allows us to live in them for as long as possible and, if possible, until the end of our lives. I want the housing to be good enough so that we are not condemned to a nursing home before our time. In other words, older people often have to go into a nursing home as an alternative to staying in an environment that suddenly becomes hostile to them. And this particular issue is the fault of the administration (that entity), for not conceiving cities and environments in which we can all fit.

Sometimes, even if the housing conditions are adequate, the continuous need for care and, above all, the demand for specialised care means that nursing homes are the only real alternative. This is where the second key issue comes in: nursing homes must offer a decent quality of life. This implies sufficient carers, with a carer/resident ratio that is far removed from the realities we have now. It also implies that care needs to be well paid. Furthermore, we need to move beyond the view that anyone, at any time, can care. The care that people need throughout their lives must be provided by people with a certain level of knowledge.

I end this post by insisting that I understand cohousing for those who want it, old or young, but emphasising that it is not a magic solution and that there is a demand for care to which we need to respond in solidarity, from society, ensuring the quality of care and attention received in the nursing home, also guaranteeing the well-being of those who work there.

Under the framework of: Programa Operativo Cooperación Transfronteriza España-Portugal
Sponsors: Fundación General de la Universidad de Salamanca Fundación del Consejo Superior de Investigaciones Científicas Direção Geral da Saúde - Portugal Universidad del Algarve - Portugal